Residency · Residency · Psychiatry
Post-Traumatic Stress Disorder: Diagnosis and Integrated Treatment
Diagnosis
DSM-5-TR Criteria (Adults)
Criterion A -- Trauma exposure: direct experience, witnessing, learning about (close family/friend), or repeated/extreme exposure to aversive details (first responders) Qualifying events: combat, sexual assault, physical assault, accidents, natural disasters, childhood abuse/neglect. Does NOT include events experienced only through media (unless work-related) Criterion B -- Intrusion symptoms (>=1): intrusive memories, nightmares, flashbacks (dissociative reactions), psychological distress at reminders, physiological reactivity to reminders. Criterion C -- Avoidance (>=1): avoidance of trauma-related thoughts/feelings, or avoidance of external reminders (people, places, activities) Criterion D -- Negative cognitions and mood (>=2): inability to recall key trauma features, persistent negative beliefs, distorted blame, persistent negative emotional state, diminished interest, detachment, inability to experience positive emotions. Criterion E -- Arousal and reactivity (>=2): irritability/aggression, reckless/self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance. Duration >1 month; causes functional impairment. Specifiers: with dissociative symptoms (depersonalization/derealization), with delayed expression (>=6 months post-trauma)
Differential Diagnosis
Acute stress disorder (symptoms <1 month post-trauma) Adjustment disorder (subthreshold symptoms, non-qualifying stressor) MDD (overlapping symptoms: anhedonia, insomnia, concentration problems) Panic disorder (physiological arousal symptoms overlap) TBI (especially in combat/accident populations -- overlapping cognitive and emotional symptoms) Complex PTSD (ICD-11 entity; discussed in Topic 73)
Trauma-Focused Psychotherapies
Cognitive Processing Therapy (CPT)
Developed by Patricia Resick; originally for sexual assault survivors, now broadly applied. Identifies and challenges maladaptive "stuck points" -- beliefs developed as a result of trauma (e.g., "It was my fault," "The world is completely dangerous," "I can never trust anyone") Protocol: 12 sessions, individually or in groups. Components: psychoeducation, written impact statement, Socratic questioning of stuck points, worksheets (Challenging Beliefs Worksheet), revised impact statement. Option: CPT with or without written trauma account (CPT-C = cognitive-only version, without written account; shown to be equally effective) Effect sizes: large (d = 1.0-1.5 for PTSD symptom reduction)
Prolonged Exposure (PE)
Developed by Edna Foa; based on emotional processing theory. Protocol: 8-15 sessions (typically 90 minutes each) Components: Psychoeducation about PTSD and treatment rationale. Breathing retraining (relaxation, though not the active ingredient) In vivo exposure: graduated approach to avoided real-world situations. Imaginal exposure: repeated, detailed recounting of the trauma memory during sessions; recorded and listened to between sessions. Habituation occurs as the patient processes the trauma memory without the expected catastrophic consequences. Effect sizes comparable to CPT.
Eye Movement Desensitization and Reprocessing (EMDR)
Developed by Francine Shapiro; involves bilateral stimulation (eye movements, tapping, or tones) while processing trauma memories. 8-phase protocol: history taking, preparation, assessment, desensitization, installation, body scan, closure, reevaluation. Mechanism of action debated: the bilateral stimulation component may not be the active ingredient (the exposure and cognitive processing elements may account for efficacy) Efficacy: comparable to CPT and PE in most head-to-head trials and meta-analyses. May be preferred by patients who find imaginal exposure too distressing (less explicit narrative retelling)
Choosing Among Trauma-Focused Therapies
| Feature | CPT | Prolonged Exposure (PE) | EMDR |
|---|---|---|---|
| Sessions | 12 | 8-15 (90 min each) | 8-12 |
| Core mechanism | Cognitive restructuring of stuck points | Habituation via imaginal + in vivo exposure | Bilateral stimulation during trauma processing |
| Homework | Worksheets, impact statements | Listening to session recordings; in vivo exposure | Minimal |
| Narrative required | Optional (CPT-C without) | Yes (detailed repeated retelling) | Less explicit retelling |
| Effect size | Large (d = 1.0-1.5) | Large (d = 1.0-1.5) | Large (d = 1.0-1.5) |
| Dropout rate | ~20-25% | ~25-30% | ~20-25% |
| Best for | Patients with prominent cognitive distortions | Patients with high avoidance | Patients distressed by explicit narration |
APA, VA/DoD, and NICE guidelines all recommend CPT, PE, and EMDR as first-line treatments. Choice often guided by patient preference, therapist availability, and specific symptom profile. All three have strong evidence; no therapy is clearly superior to the others. Dropout rates: approximately 20-30% across all trauma-focused therapies.
Pharmacotherapy
First-Line
SSRIs: sertraline and paroxetine are the only FDA-approved medications for PTSD. Response rates: ~60% (vs. ~40% placebo); remission rates: ~20-30%. Pharmacotherapy is generally less effective than trauma-focused psychotherapy for PTSD. Recommended as first-line when psychotherapy is unavailable, patient declines psychotherapy, or as adjunct.
Second-Line and Augmentation
Venlafaxine XR: evidence comparable to SSRIs; not FDA-approved but recommended in VA/DoD guidelines. Mirtazapine: some evidence; useful if insomnia and weight loss are prominent. Atypical antipsychotics: quetiapine and risperidone for augmentation in partial responders; FDA off-label. Topiramate: some evidence for hyperarousal symptoms; not first-line.
Prazosin for Nightmares -- The Controversy
Prazosin: alpha-1 adrenergic antagonist; blocks norepinephrine-mediated activation during sleep. Initial evidence (Raskind et al. 2003, 2007): promising RCTs showed significant reduction in trauma-related nightmares and improved sleep in combat veterans. RASKIND VA Cooperative Study (2018): large, definitive VA trial failed to show superiority of prazosin over placebo for nightmares in veterans with PTSD. Possible explanations for discrepancy: patient population differences, lower baseline nightmare severity, placebo response rate, dose differences. Current status: some guidelines still recommend prazosin as an option; others have downgraded it; clinical experience suggests benefit in some patients. Pragmatic approach: trial of prazosin remains reasonable for PTSD nightmares when first-line treatments are insufficient; titrate to 6-15 mg at bedtime; monitor for orthostatic hypotension.
Medications NOT Recommended
Benzodiazepines: no evidence for PTSD; may worsen outcomes (impair fear extinction, increase risk of PTSD development post-trauma) Typical antipsychotics: no evidence. Bupropion: no evidence for PTSD.
Complex PTSD (Brief Introduction)
ICD-11 entity (not in DSM-5-TR): PTSD + disturbances in self-organization (affect dysregulation, negative self-concept, interpersonal difficulties) Typically associated with prolonged, repeated trauma (childhood abuse, captivity, domestic violence) May require phase-based treatment: stabilization before trauma processing. Full discussion in Topic 73.
<image> A comparison diagram of the three first-line trauma-focused psychotherapies for PTSD. Three columns for CPT, PE, and EMDR. For each, show: theoretical basis, number of sessions, key therapeutic components (cognitive restructuring for CPT, imaginal/in vivo exposure for PE, bilateral stimulation with trauma processing for EMDR), homework requirements, effect sizes, and dropout rates. Use consistent formatting to facilitate comparison. Include a bottom row showing that all three are equally recommended by major guidelines. Clean clinical reference format. </image>
<image> A diagram illustrating the cognitive model underlying CPT for PTSD. Show how a traumatic event leads to natural emotional reactions (fear, horror) AND to maladaptive "stuck points" (assimilation: "It was my fault" or over-accommodation: "The world is always dangerous, no one can be trusted"). Show how stuck points maintain PTSD symptoms. Then show the CPT intervention: Socratic questioning and worksheets challenge stuck points, leading to more balanced beliefs and symptom reduction. Include examples of common stuck points in safety, trust, power/control, esteem, and intimacy themes. Clinical education style. </image>
<image> A treatment algorithm for PTSD. Start with "PTSD diagnosed." First-line: trauma-focused psychotherapy (CPT, PE, or EMDR) with or without pharmacotherapy (SSRI). If psychotherapy unavailable or declined: SSRI monotherapy (sertraline or paroxetine). For partial response: augment with prazosin for nightmares (noting controversy), atypical antipsychotic for persistent symptoms. For treatment-resistant: combine modalities, consider intensive outpatient programs. Include a warning box: "Do NOT prescribe benzodiazepines for PTSD." Show assessment points using PCL-5. Color-coded flowchart. </image>
Clinical Pearls
Trauma-focused psychotherapy (CPT, PE, or EMDR) is the most effective treatment for PTSD -- pharmacotherapy alone produces modest response rates. Benzodiazepines are contraindicated in PTSD -- they do not treat the disorder and may impair fear extinction learning that is necessary for recovery. SSRIs are first-line pharmacotherapy, but response rates (~60%) and remission rates (~25%) are modest compared to psychotherapy. The prazosin-for-nightmares evidence is mixed after the negative 2018 VA Cooperative Study -- a pragmatic trial remains reasonable, but it is no longer a slam-dunk recommendation. Screen for PTSD in all patients with depression, anxiety, substance use, and chronic pain -- PTSD is commonly comorbid and frequently missed. CPT can be delivered without a written trauma account (CPT-C) with equivalent efficacy -- this may reduce dropout for patients who find narrating the trauma too distressing. Avoidance is the engine that maintains PTSD -- treatment must ultimately address avoidance through exposure or cognitive processing.
References
- Resick PA, et al. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol. 2008;76(2):243-258.
- Foa EB, et al. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. 2nd ed. Oxford University Press; 2019.
- Raskind MA, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-517.
- VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Version 3.0. 2023.
- Shapiro F. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. 3rd ed. Guilford Press; 2018.
