Post-Traumatic Stress Disorder (Acute)MANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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721 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp62

Immediate safety assessment

›Life-threatening presentations requiring urgent action

›Active suicidal ideation with plan or intent

›PTSD is an independent risk factor for suicidal ideation and completion

›Immediate psychiatric evaluation and safety planning

›Remove access to lethal means

›Homicidal ideation or imminent violence risk

›Duty-to-warn obligations per jurisdiction

›Security notification if in ED setting

›Severe dissociative episode with safety impairment

›Depersonalization or derealization preventing self-care

›Dissociative amnesia with disorientation

›Acute psychotic symptoms

›Distinguish flashbacks from command hallucinations

›Flashbacks are trauma-linked and ego-dystonic; hallucinations may lack trauma context

›Concurrent medical emergencies requiring simultaneous management

›Acute intoxication or withdrawal

›Alcohol withdrawal seizure risk

›Opioid intoxication with respiratory depression

›Concurrent traumatic brain injury

›Persistent disorientation or focal deficits favor TBI over PTSD

›Overlapping symptoms: irritability, concentration difficulty, sleep disturbance

›Sympathetic hyperarousal mimicking medical emergency

›Tachycardia and hypertension from autonomic dysregulation

›Rule out cardiac and pulmonary causes before attributing to PTSD

Stabilization priorities

›Environment and de-escalation

›Quiet, low-stimulation room

02History/hx113

Trauma exposure

›Nature of traumatic event

›Direct personal experience

›Combat or military trauma

›Sexual assault or interpersonal violence

›Motor vehicle collision or physical trauma

›Natural disaster or mass casualty event

›Witnessing event happening to others

›Degree of graphic exposure

›Relationship to victim

›Learning of event affecting close family member or friend

›Sudden violent or accidental death

›Occupational exposure to aversive details

›First responders, healthcare workers, military personnel

Symptom characterization

›DSM-5-TR Criterion B — Intrusion symptoms

›Unwanted distressing memories of traumatic event

›Frequency and duration of intrusions

›Degree of distress during intrusions

›Recurrent trauma-related nightmares

›Sleep disruption frequency

›Night sweats or nocturnal arousal

›Dissociative flashbacks

›Feeling or acting as if trauma is recurring

›Duration and triggers of flashback episodes

›Intense psychological distress to trauma reminders

›Internal cues (thoughts, feelings)

›External cues (places, people, smells, sounds)

›Physiological reactivity to trauma reminders

›Palpitations, sweating, tremor on exposure to cues

›DSM-5-TR Criterion C — Avoidance symptoms

›Internal avoidance

›Avoidance of trauma-related thoughts or feelings

›External avoidance

›Avoidance of people, places, activities, situations

›Social withdrawal and isolation

›DSM-5-TR Criterion D — Negative cognitions and mood

›Inability to recall important aspect of trauma (dissociative amnesia)

›Persistent negative beliefs about self or world

›Persistent blame, guilt, or shame related to trauma

›Emotional numbing or inability to experience positive emotions

›Persistent negative emotional states

›Fear, horror, anger, guilt, shame

›Diminished interest or participation in activities

›Feelings of detachment or estrangement from others

›DSM-5-TR Criterion E — Alterations in arousal and reactivity

›Irritability and anger outbursts

›Physical or verbal aggression

›Reckless or self-destructive behavior

›Hypervigilance

›Constantly scanning for threat

›Exaggerated startle response

›Concentration difficulties

›Sleep disturbance

›Difficulty falling or staying asleep

›Symptom duration and timing

›Onset after index trauma

›Symptoms persisting >1 month required for PTSD diagnosis

›Symptoms 3 days to 1 month suggest acute stress disorder

›Functional impairment caused by symptoms

›Occupational impairment

›Social and relationship impairment

Risk factors and vulnerability

›Demographic and personal risk factors

›Female sex

›Odds ratio approximately 2.2–2.3 for PTSD development

›Women affected twice as often as men across most trauma types

›Younger age at time of trauma

›LGBTQIA+ identity

›Higher rates of trauma exposure

›Lower socioeconomic status or lower educational attainment

›Minority racial or ethnic identity

›Trauma-related risk factors

›Interpersonal violence exposure

›Sexual assault carries highest conditional probability of PTSD

›Physical assault, combat exposure

›Cumulative trauma exposure

›Dose-response relationship between number of traumas and PTSD risk

›Peritraumatic dissociation at time of event

›Perceived life threat during trauma

›Pre-trauma vulnerabilities

›Prior psychiatric history

›Depression, anxiety disorders, prior PTSD

›Childhood adversity or adverse childhood experiences (ACEs)

›Childhood abuse, neglect, family dysfunction

›Prior suicide attempts

›Prior traumatic brain injury

Alarm features

›High-risk clinical features requiring urgent assessment

›Suicidal ideation

›Passive (wish to be dead) vs. active (plan and intent)

›Access to lethal means

›Prior attempts increase risk substantially

›Homicidal ideation or aggressive behavior

›Specific plan or identifiable victim

›Severe dissociative episodes impairing safety

›Active psychosis

›Command hallucinations vs. trauma-linked flashbacks

›Inability to care for self or maintain basic functioning

›Concurrent TBI with persistent confusion

Comorbidities and collateral history

›Common psychiatric comorbidities

›Major depressive disorder

›Most common comorbidity with PTSD

›Shared negative cognition symptoms require differential attention

›Generalized anxiety disorder and panic disorder

›Substance use disorders

›Alcohol most commonly used as self-medication

›Worsens sleep, increases impulsivity, reduces treatment response

›Borderline personality disorder

›Overlapping emotional dysregulation

›Somatic presentations

›GI symptoms

›Nausea, abdominal pain, IBS-type symptoms

›Cardiovascular symptoms

›Palpitations, chest tightness from hyperarousal

›Chronic pain and musculoskeletal complaints

›Headaches and dizziness

03Physical Exam/exam51

Vital signs

›Autonomic and hemodynamic findings

›Tachycardia from sympathetic hyperarousal

›Heart rate > 100 beats/min at baseline or with minimal provocation

›Elevated blood pressure

›Persistent hypertension associated with chronic arousal

›Tachypnea during anxiety or flashback states

›Temperature — fever should prompt medical evaluation for organic cause

General appearance and mental status

›Behavioral observations

›Hypervigilance

›Constant scanning of room or exits

›Startles to sudden movements or sounds

›Psychomotor findings

›Agitation, restlessness, or conversely flat affect

›Guarded or constricted body posture

›Eye contact and interpersonal engagement

›Avoidance of eye contact

›Emotional detachment or dissociation during interview

›Formal mental status exam components

›Orientation

›Time, place, person — impairment suggests concurrent TBI or psychosis

›Mood and affect

›Anxious, dysphoric, irritable, numb

›Restricted, labile, or hyperreactive affect

›Thought content

›Intrusive memories, guilt, shame, worthlessness

›Suicidal ideation — passive vs. active with plan

04Differential Diagnosis/ddx48

Primary psychiatric differential

›Acute stress disorder (ASD)

›ICD-10: F43.0

›Same DSM-5-TR symptom clusters as PTSD

›Duration criterion: 3 days to 1 month post-trauma

›Approximately 50% of ASD patients progress to PTSD

›Trauma-focused CBT during ASD phase reduces PTSD progression

›Major depressive disorder (MDD)

›ICD-10: F32.x / F33.x

›Shares negative cognition and mood symptoms with PTSD

›Lacks intrusion, re-experiencing, and avoidance symptoms

›Highly comorbid — both diagnoses can coexist

›Generalized anxiety disorder

›ICD-10: F41.1

›Chronic worry not linked to specific trauma

›No intrusion or avoidance symptoms

›Panic disorder

›ICD-10: F41.0

›Spontaneous panic attacks without trauma-specific triggers

›No avoidance of trauma reminders specifically

Trauma-related mimics

›Traumatic brain injury

›ICD-10: S09.90XA

›Overlapping symptoms: irritability, concentration difficulty, sleep disturbance, emotional dysregulation

›Persistent disorientation or confusion favors TBI

›Re-experiencing and avoidance symptoms favor PTSD

›Both diagnoses can coexist following physical trauma

›Adjustment disorder

05Laboratory Tests/lt35

Baseline metabolic assessment

›Complete blood count

›Baseline prior to medication initiation

›Anemia contributing to fatigue and concentration difficulties

›Leukocytosis if concurrent infection suspected

›Comprehensive metabolic panel

›Glucose and electrolyte abnormalities mimicking anxiety and mood symptoms

›Hypoglycemia producing diaphoresis, palpitations, anxiety

›Hyponatremia producing confusion and cognitive impairment

›Renal function baseline before SSRI/SNRI initiation

›Hepatic panel

›If substance use suspected or pharmacotherapy planned

›Baseline AST, ALT, bilirubin

Endocrine and toxicology

›Thyroid-stimulating hormone

›Thyroid dysfunction mimics

›Hyperthyroidism mimics hyperarousal, anxiety, insomnia, palpitations

›Hypothyroidism mimics depression, emotional numbing, fatigue

›TSH screen indicated before attributing symptoms to PTSD

›Urine drug screen

›Concurrent substance use detection

›High comorbidity between PTSD and substance use disorders

›Cocaine and stimulants may cause hyperarousal and paranoia

›Cannabis use associated with worsened PTSD outcomes despite self-reported benefit

›Opioids: detect use prior to initiating any sedating medications

›Blood alcohol level

›If acute intoxication suspected

›Intoxication can mask or worsen PTSD symptoms

06Diagnostic Tests/dt58

Scoring Systems

›PCL-5 (PTSD Checklist for DSM-5)

›Primary validated screening and severity tool

›20-item self-report questionnaire

›Score range 0–80; threshold for probable PTSD is >=33

›Sensitivity approximately 83%; specificity approximately 86% at cutoff 33

›Use at initial assessment and each follow-up visit to monitor trajectory

›VA/DoD 2023 CPG recommends PCL-5 for ongoing monitoring

›PC-PTSD-5 (Primary Care PTSD Screen for DSM-5)

›Five-item ultra-brief screen for high-throughput settings

›Sensitivity 91%; specificity 72% at threshold of 3/5

›Validated in civilian primary care populations

›Positive screen warrants full diagnostic evaluation

›Appropriate for ED-based screening after trauma exposure

›Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

›Gold standard diagnostic instrument; not typically ED-based

›Structured interview administered by trained clinician

›30-item instrument covering all DSM-5-TR symptom domains

›Required for definitive PTSD diagnosis in research settings

›Score >=25 consistent with PTSD diagnosis

›Columbia Suicide Severity Rating Scale (C-SSRS)

›Structured suicidality assessment tool

›Distinguishes passive ideation from active ideation with plan and intent

›Guides safety planning and disposition decisions

›Recommended at every encounter for patients with PTSD

MRI

›Brain MRI in PTSD evaluation

›Not routinely indicated for PTSD diagnosis

07Disposition/dispo35

Admission criteria

›Psychiatric inpatient admission indications

›Active suicidal ideation with plan, intent, or inability to contract for safety

›Involuntary admission criteria if patient refuses and imminent danger exists

›Document clinical reasoning and jurisdiction-specific legal basis

›Active homicidal ideation with identifiable victim or plan

›Severe psychotic symptoms or dissociative episodes impairing capacity for self-care

›Inability to maintain basic self-care (not eating, not sleeping, complete social withdrawal)

›Acute intoxication or withdrawal requiring medical management prior to psychiatric stabilization

›Medical admission indications

›Concurrent TBI requiring observation or intervention

›Withdrawal syndrome requiring inpatient detoxification

›Self-harm injuries requiring surgical or medical treatment

Discharge criteria

›Safe for ED discharge

›No suicidal ideation or passive ideation with protective factors intact

›Robust social support network

›Adequate insight and willingness to engage with treatment

›Access to lethal means restricted or removed

›Safe living environment

›No ongoing domestic violence or acute safety threat

›Stable housing

›Outpatient follow-up confirmed

›Primary care or behavioral health appointment within 1–2 weeks

›Crisis line number provided

›ED return precautions clearly communicated

Observation indications

›Short-stay observation considerations

08Treatment/t89

Psychotherapy — first-line treatment

›Trauma-focused psychotherapy

›Strongly recommended over pharmacotherapy as first-line

›VA/DoD 2023 Clinical Practice Guideline: strong recommendation

›APA 2025 Clinical Practice Guideline: conditionally recommended

›Superior long-term maintenance of gains vs. pharmacotherapy alone

›Prolonged Exposure (PE)

›Involves imaginal and in-vivo exposure to trauma-related stimuli

›Typically 8–15 sessions

›Strong recommendation in VA/DoD 2023 CPG

›Cognitive Processing Therapy (CPT)

›Targets maladaptive beliefs about trauma and its consequences

›Typically 12 sessions

›Strong recommendation in VA/DoD 2023 CPG

›Eye Movement Desensitization and Reprocessing (EMDR)

›Bilateral stimulation during trauma recall

›Strong recommendation in VA/DoD 2023 CPG

›Written Exposure Therapy (WET)

›Briefer alternative — 5 sessions

›Feasible in primary care and time-limited settings

›For acute stress disorder (< 1 month)

›Trauma-focused CBT reduces risk of progression to PTSD

›Early intervention within weeks of trauma preferred

Pharmacotherapy — first-line medications

›SSRI therapy — FDA-approved agents

›Sertraline

›FDA-approved for PTSD

›Starting dose 25 mg orally once daily

›Titrate to 50–200 mg/day over 2–4 weeks

›Reassess at 8–12 weeks at maximum tolerated dose before switching

›Paroxetine

›FDA-approved for PTSD

›Starting dose 20 mg orally once daily

›Titrate to 20–50 mg/day

›Higher discontinuation rate due to sexual dysfunction and withdrawal syndrome

›Reassess at 8–12 weeks before switching

›SNRI therapy

›Venlafaxine

›Off-label for PTSD; strong evidence base; equivalent to SSRIs

›Starting dose 37.5 mg orally once daily

›Titrate to 75–225 mg/day

›Monitor blood pressure — hypertensive effect at higher doses

›Significant discontinuation syndrome; taper over weeks when stopping

›SSRI non-responders: switching to venlafaxine preferred over augmentation

Pharmacotherapy — adjunctive and second-line

›Prazosin for trauma-related nightmares

›Alpha-1 adrenergic antagonist

›Starting dose 1 mg orally at bedtime

›Titrate to 1–15 mg at bedtime over 2–4 weeks

›Improves nightmares but mixed evidence for overall PTSD symptom improvement

›Monitor for orthostatic hypotension — particularly in geriatric patients

›Systematic review 2025: efficacy heterogeneous; responders tend to have higher nightmare frequency at baseline

›Second-line agents for refractory PTSD

›Mirtazapine 15–45 mg at bedtime

›Reserved for treatment-refractory cases

›Sedating properties helpful for sleep disturbance

›Amitriptyline 25–150 mg at bedtime

›Tricyclic antidepressant; monitor for anticholinergic effects

›Cardiac monitoring recommended at higher doses

›Imipramine 25–150 mg at bedtime

›Tricyclic antidepressant; similar limitations to amitriptyline

Pharmacotherapy — contraindicated or recommended against

›Benzodiazepines

›Strongly recommended against by VA/DoD 2023 CPG

›Associated with misuse and dependence in PTSD population

›Decreased effectiveness of concurrent psychotherapy

›Adverse cognitive and memory effects

›No evidence of benefit for PTSD symptoms

›May be used briefly for acute agitation in ED only

›Cannabis and cannabis-derived products

›Recommended against — VA/DoD 2023 CPG

›Lack of RCT evidence

›Potential cognitive harms and increased psychosis risk

›Medications with insufficient evidence or potential harm

›Divalproex — recommended against for overall PTSD

›Guanfacine — recommended against for overall PTSD

›Ketamine — insufficient evidence for PTSD; may worsen dissociation

›Risperidone — recommended against as monotherapy or augmentation

›Tiagabine — recommended against; adverse event profile

Sleep and comorbidity management

›Sleep disturbance treatment

›CBT for insomnia (CBT-I) recommended before sedative-hypnotics

›Addresses hyperarousal-driven sleep fragmentation

›Sleep restriction, stimulus control, relaxation techniques

›Screen for and treat obstructive sleep apnea

›High prevalence in PTSD population

›Untreated OSA worsens nightmares and PTSD severity

›Concurrent comorbidity management

›Major depressive disorder

›Treat concurrently; do not delay PTSD treatment

›SSRI/SNRI address both conditions

›Substance use disorders

›Treat concurrently; abstinence not required before PTSD treatment initiation

›Integrated dual-diagnosis treatment preferred

09Special Populations/sp80

Pregnancy

›PTSD in pregnancy — unique considerations

›Prevalence and trauma context

›Intimate partner violence and sexual trauma are common precipitants in reproductive-age women

›Childbirth trauma can precipitate new PTSD onset

›Pre-existing PTSD associated with adverse perinatal outcomes

›Screening

›PC-PTSD-5 or PCL-5 recommended in prenatal care

›Mandatory reporting considerations if domestic violence is ongoing

›Pharmacotherapy in pregnancy

›Sertraline

›Most data in pregnancy; preferred SSRI when pharmacotherapy required

›Generally considered low-risk in second and third trimesters

›Neonatal adaptation syndrome risk with third-trimester use

›Paroxetine

›Category D for first trimester — associated with cardiac septal defects

›Avoid in pregnancy; transition to sertraline if possible

›Venlafaxine

›Limited data; use with caution; neonatal adaptation syndrome risk

›Prazosin

›Insufficient safety data in pregnancy — use with caution

›Potential fetal hypotension risk

›Benzodiazepines

›Avoid — neonatal benzodiazepine withdrawal syndrome risk

›Psychotherapy in pregnancy

›Prolonged Exposure and CPT preferred over pharmacotherapy

›No fetal risk from psychotherapy

›Modify exposure hierarchy to avoid trauma involving obstetric themes if triggering

Geriatric

›PTSD in older adults — modified approach

›Epidemiology and presentation

›Lifetime trauma exposure often remote (e.g., World War II, Korean War, historical abuse)

›May present with late-onset exacerbation triggered by health decline or loss

›Somatic presentations more common; may present as medically unexplained symptoms

›Cognitive decline can complicate symptom reporting

›Pharmacotherapy modifications

›Sertraline

›Preferred SSRI in older adults — favorable tolerability profile

›Start at 25 mg; titrate slowly (every 2–4 weeks) to minimize side effects

›Paroxetine

›Avoid in older adults — strong anticholinergic effects

›American Geriatrics Society Beers Criteria: potentially inappropriate

›Venlafaxine

›Use with caution — hypertensive effects and falls risk from dizziness

›Prazosin

›Significant orthostatic hypotension risk in older adults

›Start at 0.5–1 mg and titrate very slowly if used

›Monitor sitting-to-standing BP before each dose increase

›Benzodiazepines

›Avoid — Beers Criteria: high fall risk, paradoxical agitation, cognitive impairment

›Psychotherapy in older adults

›Prolonged Exposure and CPT effective across age groups

›May require modified pacing — fewer sessions per week

›Hearing, vision, and cognitive accommodations as needed

Pediatrics

›PTSD in children and adolescents

›Developmental considerations in presentation

›Young children (< 6 years): Separation anxiety, repetitive trauma-related play, regression (bedwetting, thumb-sucking), frightening dreams without trauma content

›School-age children: Re-enactment through play, trauma-specific fears, concentration impairment affecting school performance

›Adolescents: Adult-like PTSD presentation; increased risk of substance use, self-harm, risk-taking behaviors

›DSM-5-TR PTSD preschool subtype applies to children < 6 years

›Modified criteria: avoidance and cognition criteria have fewer required items

›Pharmacotherapy in pediatrics

›SSRIs

›No FDA-approved medication for pediatric PTSD

›Sertraline most commonly used off-label; start 12.5–25 mg/day

›Black box warning: increased suicidal ideation in children and adolescents

›Weekly monitoring initially after initiation

›Clinical monitoring at weeks 1, 2, 4, 8, and 12 after initiation

›Prazosin

›Limited pediatric data; used for trauma-related nightmares off-label

›Weight-based dosing; start at 1 mg at bedtime

›Psychotherapy in pediatrics — first-line

›Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

›Gold standard for children ages 3–18

›Includes caregiver sessions — parental component critical

›Typically 12–25 sessions

›Strongly recommended by multiple pediatric guidelines

›Child-Parent Psychotherapy (CPP)

›For children under 5 and their caregivers

›Relationship-based model addressing attachment disruption

›Mandatory reporting

›Child abuse or neglect as precipitating trauma requires mandatory report

10Background/b71

Epidemiology

›Prevalence and incidence

›Lifetime PTSD prevalence approximately 6% in the general population

›Women affected twice as often as men across most studies

›Women lifetime prevalence approximately 9–12%; men approximately 3–6%

›Conditional probability of PTSD varies by trauma type

›Sexual assault: 30–65% conditional probability

›Combat exposure: 10–30% conditional probability

›Natural disaster: 3–5% conditional probability

›Most trauma-exposed individuals recover without developing PTSD

›Approximately 10% of trauma-exposed individuals develop PTSD

›Resilience is the modal response to trauma

›Transition from acute stress disorder to PTSD

›ASD defined as same symptom clusters lasting 3 days to 1 month post-trauma

›Approximately 50% of ASD patients progress to PTSD

›Most PTSD patients were never formally diagnosed with ASD

›Early intervention during ASD phase can reduce PTSD progression

›Trauma-focused CBT in ASD reduces PTSD conversion rate

Pathophysiology

›Neurobiological mechanisms

›Fear conditioning and extinction failure

›Amygdala hyperactivation in response to threat-related stimuli

›Medial prefrontal cortex hypoactivity — failure of fear extinction regulation

›Hippocampal dysfunction — impaired contextualization of fear memories

›Hypothalamic-pituitary-adrenal (HPA) axis dysregulation

›Paradoxically low cortisol in many PTSD patients — contrast with depression

›Enhanced negative feedback sensitivity of glucocorticoid receptors

›Sustained corticotropin-releasing factor (CRF) elevation

›Sympathetic nervous system dysregulation

›Elevated norepinephrine at baseline and in response to trauma cues

›Elevated resting heart rate and blood pressure

›Elevated catecholamines explain prazosin efficacy for nightmares

›Memory consolidation and reconsolidation

›Trauma memories encoded with heightened emotional arousal

›Impaired hippocampal-mediated contextualization leads to time-independent re-activation

›DSM-5-TR diagnostic criteria summary

›Criterion A — Exposure to actual or threatened death, serious injury, or sexual violence

›Criterion B — One or more intrusion symptoms

›Criterion C — One or more avoidance symptoms

›Criterion D — Two or more negative cognitions/mood alterations

›Criterion E — Two or more arousal/reactivity alterations

›Criterion F — Duration > 1 month

›Criterion G — Functional impairment

›Criterion H — Not attributable to substance or medical condition

›Specifiers: With dissociative symptoms; with delayed expression (onset > 6 months)

Therapeutic Considerations

›Evidence base for treatment selection

›Psychotherapy demonstrates superior long-term outcomes vs. pharmacotherapy alone

›Network meta-analysis (JAMA Psychiatry 2019): psychotherapy superior to pharmacotherapy on symptom reduction

›Comparative effectiveness trial (JAMA Psychiatry 2025): PE and CPT equivalent in primary care settings

›EMDR efficacy equivalent to PE in meta-analyses

›Combined pharmacotherapy and psychotherapy

›Additive benefit not consistently demonstrated over psychotherapy alone

›May improve access when psychotherapy waitlists are prolonged

›Treatment of PTSD in the context of substance use

›Integrated treatment superior to sequential treatment

›Abstinence requirement prior to trauma therapy is not recommended

›Early intervention and prevention

›Psychological first aid for acute trauma survivors

›Promote safety, calm, connectedness, self-efficacy, hope

›Not equivalent to trauma-focused psychotherapy; does not replace formal treatment

›Single-session psychological debriefing

›Cochrane review: no benefit and potential harm from mandatory single-session debriefing

›Not recommended as universal intervention following trauma

›Propranolol for PTSD prevention — not recommended

›Cochrane review 2024: no evidence that early pharmacological interventions prevent PTSD

›Hydrocortisone post-trauma — insufficient evidence; not standard care

›Monitoring and treatment response

›PCL-5 at each visit to track symptom trajectory

›Clinically meaningful change defined as >=10-point reduction in PCL-5 score

›Consider switching strategy if < 10-point reduction at 8–12 weeks at maximum tolerated dose

›Adequate trial parameters

›Minimum 8–12 weeks at maximum tolerated dose before switching medication

›Non-responders to SSRI may respond to venlafaxine

11Patient Discharge Instructions/pdi38

copy discharge instructions

›PTSD discharge instructions for patient

›What is PTSD?

›PTSD stands for Post-Traumatic Stress Disorder

›It is a normal brain response to an abnormal event

›PTSD is a treatable condition — most people improve with proper treatment

›Having PTSD does not mean you are weak or that something is wrong with your character

›Your symptoms may include

›Flashbacks or intrusive memories of what happened

›Nightmares related to the trauma

›Avoiding reminders of the event

›Feeling constantly on guard or easily startled

›Feeling emotionally numb or disconnected

›Difficulty sleeping or concentrating

›What you should do now

›Keep your follow-up appointment with your doctor or mental health provider within 1–2 weeks

›If a referral was arranged, contact that provider this week to confirm your appointment

›If medication was prescribed, take it as directed — effects may take 4–8 weeks to feel fully

›Do not stop medication without speaking with your doctor

›What helps recovery

›Evidence-based talk therapy (such as PE, CPT, or EMDR) is the most effective treatment

›Regular sleep, meals, and physical activity help stabilize symptoms

›Connecting with trusted family members or friends provides an important protective factor

›Avoid alcohol and drugs — they worsen PTSD symptoms and interfere with treatment

›What does NOT help

›Alcohol or cannabis used to manage anxiety or sleep — these worsen PTSD over time

›Completely avoiding all reminders of the trauma — avoidance makes symptoms worse long-term

›Return to the emergency department if you experience

12References/r41

Guidelines and key sources

›VA/DoD Clinical Practice Guideline for PTSD and Acute Stress Disorder 2023

›Schnurr PP, Hamblen JL, Wolf J, et al. Synopsis of the 2023 VA/DoD CPG. Ann Intern Med. 2024

›Benzodiazepines strongly recommended against

›PE, CPT, EMDR strongly recommended

›Sertraline, paroxetine, venlafaxine recommended for pharmacotherapy

›American College of Surgeons Best Practices Guidelines — Mental Health in Acute Trauma Patients 2022

›Brasel KJ, deRoon-Cassini TA, Bernard A, et al.

›Screening and intervention guidance for ED and trauma settings

›APA Clinical Practice Guideline for PTSD 2025

›Zoellner LA, Schulz PM, Campbell-Law L, et al.

›Conditionally recommends PE, CPT, EMDR as first-line

›Updated recommendations for pharmacotherapy

Key trials and systematic reviews

›DSM-5-TR Diagnostic Criteria

›Jeste DV, Lieberman JA, Fassler D, et al. DSM-5-TR. American Psychiatric Association. 2022

›Defines PTSD Criteria A through H with specifiers

›Preschool subtype for children under 6 years

›Pharmacotherapy evidence

›Sartor Z, Kelley L, Laschober R. PTSD: Evaluation and Treatment. Am Fam Physician. 2023

›Comprehensive review of pharmacotherapy options and evidence levels

›Bajor LA, Balsara C, Osser DN. Evidence-Based Psychopharmacology for PTSD. Psychiatry Res. 2022

›Updated treatment algorithm and evidence review

›Merz J, Schwarzer G, Gerger H. Network meta-analysis of pharmacological and psychotherapeutic treatments. JAMA Psychiatry. 2019

›Psychotherapy superior to pharmacotherapy for PTSD

›Seales S, Seales P. Pharmacotherapy for PTSD. Am Fam Physician. 2022

›Prazosin and sleep

›Mendes TP, Pereira BG, Coutinho ESF, et al. Prazosin for nightmares in PTSD. Prog Neuropsychopharmacol Biol Psychiatry. 2025

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