Behavioral Health

Post-traumatic stress disorder: diagnosis and treatment

Clinical Overview and When to Suspect PTSD

— Lifetime US prevalence ~6–8%; women ~2× men

— Highest rates: combat veterans (10–30%), sexual assault survivors (up to 50%), refugees, first responders, ICU survivors

— Onset typically within 3 months of trauma but can be delayed (>6 months in ~15%)

— Veteran with insomnia, irritability, alcohol misuse presenting to primary care

— MVA survivor avoiding driving, hypervigilant in clinic

— Sexual assault survivor with new GI/pelvic complaints, sleep disturbance

— ICU survivor (especially post-ARDS, prolonged sedation) with nightmares

— Postpartum patient after traumatic delivery with intrusive flashbacks

— Acute Stress Disorder: same symptoms but 3 days–1 month post-trauma

— PTSD with dissociative subtype: prominent depersonalization/derealization

— Complex PTSD (ICD-11, not DSM): chronic interpersonal trauma with disturbed self-organization

— PC-PTSD-5 (5-item primary care screen; ≥3 positive → full assessment)

— PCL-5 (20-item self-report, score ≥31–33 suggests probable PTSD)

Definition: PTSD is a trauma- and stressor-related disorder characterized by persistent symptoms (>1 month) across four clusters—intrusion, avoidance, negative alterations in cognition/mood, and hyperarousal—following exposure to actual or threatened death, serious injury, or sexual violence (DSM-5-TR Criterion A).

Epidemiology:

Criterion A exposure must be direct, witnessed in person, learned of in a close family/friend (violent/accidental), or repeated occupational exposure to aversive details (e.g., child-abuse investigators). Key distinction: indirect media exposure (TV news) does not qualify except for work-related.

When to suspect on Step 3:

Subtypes:

Screening tools:

Board pearl: USPSTF has no specific PTSD screening recommendation, but VA/DoD and most primary care guidelines endorse annual PC-PTSD-5 in high-risk populations (veterans, post-deployment, post-ICU, sexual assault survivors). On Step 3, screening a veteran in ambulatory clinic with PC-PTSD-5 is the expected first step.

Presentation Patterns and Key History

— Intrusion (B): recurrent involuntary memories, nightmares, flashbacks, intense distress/physiologic reactivity to cues

— Avoidance (C): of internal reminders (thoughts/feelings) or external (people, places, conversations)

— Negative cognition/mood (D): dissociative amnesia for trauma, persistent negative beliefs ("world is dangerous"), distorted self-blame, anhedonia, detachment, inability to feel positive emotions

— Arousal/reactivity (E): irritability/anger, reckless behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance

— "Slams to the floor when a car backfires" → exaggerated startle

— "Refuses to drive on highway after collision" → avoidance

— "Cannot remember details of the assault" → dissociative amnesia

— "Feels emotionally numb toward spouse and children" → detachment

— Nightmares with recurrent thematic content of trauma

— Trauma type, timing, duration; single vs. repeated

— Prior trauma history (childhood abuse strongly increases risk)

— Substance use—especially alcohol, cannabis (self-medication for sleep/anxiety)

— Suicidal ideation (PTSD carries ~2× suicide risk)

— Comorbid depression (~50%), GAD, panic, TBI

— Sleep architecture: trauma-related nightmares, middle-of-night awakening

— Functional status: work, relationships, parenting

— Pre-trauma: female sex, prior psychiatric illness, childhood adversity, low SES

— Peri-trauma: severity, perceived life threat, peri-traumatic dissociation

— Post-trauma: lack of social support, ongoing life stressors

Four DSM-5-TR symptom clusters (need ≥1 intrusion, ≥1 avoidance, ≥2 negative cognition/mood, ≥2 arousal; ≥1 month; functional impairment):

Classic Step 3 vignette cues:

High-yield history elements:

Risk factors:

Board pearl: Symptoms <1 month = Acute Stress Disorder (treat with trauma-focused CBT; benzos contraindicated). Symptoms ≥1 month = PTSD. The 1-month threshold is a frequent Step 3 distractor.

Key distinction: Adjustment disorder lacks Criterion A trauma and the full symptom-cluster profile.

Physical Exam Findings and Mental Status Assessment

— Hypervigilant—scanning the room, sitting facing the door, startles at door knock

— Guarded affect, poor eye contact, or conversely, intense fixed gaze

— Signs of self-neglect in chronic disease

— Resting tachycardia, mild hypertension reflecting sympathetic hyperarousal

— Diaphoresis, tremor when discussing trauma cues

— Key distinction: persistent tachycardia/HTN warrants ruling out hyperthyroidism, stimulant use, pheochromocytoma before attributing to PTSD alone

— Self-inflicted scars, cigarette burns, healed fractures in interpersonal trauma victims

— Tattoos covering scars; bruises in various stages (intimate partner violence)

— Document carefully—forensic implications

— Screen for comorbid TBI in combat/MVA patients (cognitive testing, cranial nerves, gait)

— Sleep deprivation may produce mild attentional deficits

— Mood/affect: anxious, dysphoric, constricted, or flat

— Thought content: intrusive recollections, survivor guilt, hopelessness; assess SI/HI explicitly

— Perception: flashbacks (re-experiencing as if reoccurring) are dissociative, not psychotic—no fixed delusions, no formal thought disorder

— Cognition: intact orientation; concentration often impaired

— Insight/judgment: variable; often preserved insight regarding symptoms

— PHQ-9 (comorbid depression), AUDIT-C (alcohol), C-SSRS (suicide risk), PC-PTSD-5

PTSD has no pathognomonic physical findings—the exam goal is to (1) detect comorbid medical sequelae, (2) screen for self-harm, (3) rule out mimics.

General appearance:

Vital signs and autonomic findings:

Skin/musculoskeletal:

Neurologic:

Mental Status Exam (the highest-yield "exam"):

Screening instruments to administer:

Step 3 management: Always perform a suicide risk assessment at the index visit—PTSD roughly doubles suicide attempt risk, and combined with depression or substance use, risk multiplies. Document a safety plan and lethal-means counseling (firearm storage—particularly relevant for veterans).

Board pearl: Flashbacks ≠ hallucinations. The patient experiences the event reoccurring; reality testing returns. Misclassifying as psychosis and starting antipsychotics is a classic wrong-answer trap.

Diagnostic Workup — Initial Evaluation and Labs

— CAPS-5 (Clinician-Administered PTSD Scale): gold standard structured interview

— PCL-5: self-report, score ≥31–33 suggests probable PTSD; useful for tracking treatment response

— PC-PTSD-5: primary care screen

— CBC, CMP (baseline LFTs, renal function for SSRI dosing)

— TSH—hyperthyroidism mimics arousal symptoms (tachycardia, insomnia, irritability)

— Vitamin B12, fasting glucose, HbA1c if cognitive complaints

— Urine toxicology if substance use suspected

— Pregnancy test (β-hCG) in reproductive-age women before SSRI/SNRI

— Lipid panel and ECG baseline if planning prazosin (orthostatic risk) or considering TCAs

— Not routine, but obtain if starting TCAs, considering high-dose citalopram (>40 mg, QT risk; >20 mg if >60 yo), or if palpitations/syncope present

— No role in routine PTSD diagnosis

— Consider non-contrast head CT or MRI if comorbid TBI suspected, focal neurologic findings, or atypical features (late-onset cognitive decline, seizures)

— Polysomnography if witnessed apneas, refractory nightmares, or suspected REM sleep behavior disorder—OSA is highly comorbid in veterans and worsens PTSD nightmares

— Depression (PHQ-9), GAD-7, AUDIT-C, DAST-10

— Suicide risk (C-SSRS)

— Intimate partner violence screen

PTSD is a clinical diagnosis—DSM-5-TR criteria, not lab- or imaging-based. The workup's role is to (1) exclude medical mimics, (2) identify comorbidities affecting treatment selection, (3) baseline labs before pharmacotherapy.

Structured diagnostic instruments:

Baseline labs to consider before initiating pharmacotherapy:

ECG:

Imaging:

Sleep evaluation:

Comorbidity screening (essential):

Key distinction: Acute Stress Disorder (3 days–1 month post-trauma) does not require a lab workup unless clinically indicated; PTSD diagnosis simply requires symptoms ≥1 month with functional impairment.

Step 3 management: In ambulatory primary care, the correct initial workup for a veteran with positive PC-PTSD-5 is: (1) full DSM-5-TR symptom review, (2) PHQ-9 and AUDIT-C, (3) C-SSRS suicide assessment, (4) baseline TSH and CMP, (5) referral to mental health for trauma-focused psychotherapy. Imaging is rarely the answer.

Diagnostic Workup — Advanced and Differential-Driven Studies

— Indicated when comorbid TBI suspected (post-deployment, post-MVA, post-assault with LOC)

— Domains affected: attention, working memory, executive function

— Distinguishes PTSD-related concentration deficits from post-concussive syndrome or early dementia

— Polysomnography: refractory nightmares unresponsive to therapy + prazosin, suspected OSA, parasomnias

— REM sleep behavior disorder (RBD) can mimic PTSD nightmares—dream enactment in older men should prompt sleep neurology referral (associated with α-synucleinopathies)

— TSH, free T4 → hyperthyroidism

— Plasma/urine metanephrines → pheochromocytoma (paroxysmal HTN, palpitations, sweating)

— Cortisol testing only if Cushing features

— Echocardiogram or stress testing if exertional chest pain (panic vs. ischemia—older veterans have high CAD burden)

— Holter if recurrent palpitations

— MRI brain if focal deficits, seizures, atypical cognitive decline

— Research findings (not diagnostic): reduced hippocampal volume, hyperactive amygdala, hypoactive medial PFC—do not order functional MRI clinically

— Urine drug screen, blood alcohol, hair testing if needed

— PEth (phosphatidylethanol) for chronic alcohol use—useful in monitored populations

— In assault cases: photographic documentation, evidence collection (SANE exam within 96–120 hours), STI/pregnancy prophylaxis—occurs at the index trauma encounter, not at later PTSD diagnosis

Advanced testing is driven by differential considerations, not by PTSD itself.

Neurocognitive testing:

Sleep studies:

Endocrine workup if atypical:

Cardiac evaluation:

Neuroimaging:

Substance use confirmation:

HPA axis research note: PTSD is paradoxically associated with low cortisol and enhanced negative feedback—of theoretical interest only; no clinical testing indicated.

Forensic documentation:

Board pearl: A 68-year-old man with "PTSD nightmares" who physically acts out dreams (kicks, punches partner) likely has REM sleep behavior disorder, not PTSD—order polysomnography and screen for parkinsonism. This is a classic distractor.

Key distinction: Genetic, biomarker, and neuroimaging tests have no role in routine PTSD diagnosis on Step 3. Picking "fMRI" or "cortisol level" is always wrong.

Risk Stratification and First-Line Management Logic

— First-line: trauma-focused psychotherapy (TF-CBT, Prolonged Exposure [PE], Cognitive Processing Therapy [CPT], EMDR)

— First-line pharmacotherapy: SSRIs (sertraline, paroxetine) or SNRI (venlafaxine)

— Combined therapy + medication: when severe symptoms, comorbid depression, or partial response

— Patient preference is paramount

— Trauma-focused psychotherapy is preferred over medication as monotherapy when available (stronger and more durable effect sizes)

— Medication first if: severe depression, suicidality, inability to engage in therapy, or therapy unavailable

— Mild symptoms (PCL-5 <33), recent trauma: watchful waiting + supportive care + sleep hygiene

— Moderate–severe: structured trauma-focused therapy ± SSRI

— Refractory: augmentation strategies, specialty referral

— Brief trauma-focused CBT reduces progression to PTSD

— Do NOT use benzodiazepines—they worsen PTSD development and impair fear extinction

— Critical incident stress debriefing is harmful and contraindicated (may increase PTSD incidence)

— PTSD + depression + substance use = highest risk triad

— Active SI with plan/intent → emergency psychiatric evaluation, possible hospitalization

— Lethal means counseling—firearm safe storage is a high-yield Step 3 item, especially for veterans

— PTSD + MDD → SSRI treats both

— PTSD + AUD → integrated treatment; sertraline + naltrexone evidence-based

— PTSD + chronic pain → avoid opioids and benzos; consider venlafaxine (dual action)

— PTSD + insomnia/nightmares → prazosin (mixed evidence but commonly used); CBT-I

Treatment hierarchy (VA/DoD 2023 and APA guidelines):

Choosing between psychotherapy vs. pharmacotherapy:

Stepped-care framework:

Acute Stress Disorder (<1 month):

Risk stratification for suicide:

Comorbidity-directed treatment:

Step 3 management: For an Iraq-war veteran with moderate PTSD presenting in primary care, the correct initial step is: (1) safety assessment, (2) refer to evidence-based trauma-focused psychotherapy (CPT or PE) through VA mental health, (3) offer sertraline if patient prefers medication or has comorbid MDD, (4) treat insomnia with CBT-I ± prazosin.

Board pearl: Benzodiazepines are contraindicated in PTSD—they worsen outcomes, impair extinction learning, and add addiction risk. Picking lorazepam or alprazolam is always wrong.

Pharmacotherapy — First-Line Drug Regimens

— Sertraline: start 25–50 mg daily, titrate to 50–200 mg; preferred in cardiac disease, postpartum, breastfeeding

— Paroxetine: 20–60 mg daily; avoid in pregnancy (category D, cardiac malformations), elderly (anticholinergic, sedation), and patients with weight concerns

— Fluoxetine: 20–60 mg; long half-life useful for nonadherence; activating

— Venlafaxine XR: 75–300 mg; check BP at higher doses (dose-dependent HTN); useful with comorbid pain

— Therapeutic effect: 4–6 weeks; full benefit by 8–12 weeks

— Continue for at least 6–12 months after symptom remission; many patients require chronic therapy

— GI upset, headache, sexual dysfunction (30–50%), insomnia or somnolence, weight changes

— FDA black box: increased suicidality in patients <25 → close follow-up first weeks

— Serotonin syndrome risk with MAOIs, linezolid, methylene blue, tramadol, triptans

— Hyponatremia (SIADH), especially in elderly

— Bleeding risk—caution with NSAIDs/anticoagulants

— Prazosin 1 mg qhs, titrate to 2–15 mg, for trauma-related nightmares; monitor orthostasis (first-dose phenomenon); recent VA Cooperative Study showed mixed efficacy but remains commonly used

— CBT-I preferred for insomnia over hypnotics

— Trazodone 50–100 mg qhs—pragmatic sleep option

— Mirtazapine (sleep, appetite, fewer sexual side effects)

— Topiramate (some evidence for hyperarousal, comorbid AUD)

— Atypical antipsychotics (e.g., risperidone, quetiapine)—reserved for refractory cases with severe hyperarousal/dissociation; weigh metabolic side effects

— Benzodiazepines (contraindicated)

— Cannabis—mixed evidence, worsens outcomes

— Bupropion as monotherapy—weak evidence for PTSD

FDA-approved for PTSD: only sertraline and paroxetine. Venlafaxine is strongly recommended off-label by VA/DoD.

First-line SSRIs:

First-line SNRI:

Onset and titration:

Adverse effects to counsel:

Adjuncts for specific symptoms:

Second-line and augmentation:

Avoid:

Emerging therapies: MDMA-assisted psychotherapy (FDA review pending/rejected 2024); ketamine (rapid but transient); stellate ganglion block (investigational).

Step 3 management: Start sertraline 25 mg → 50 mg after 1 week → titrate by 25–50 mg every 1–2 weeks based on response/tolerability. Reassess at 4, 8, and 12 weeks using PCL-5.

Board pearl: Paroxetine in pregnancy = wrong answer; sertraline is the preferred SSRI in pregnancy/lactation.

Psychotherapy and Non-Pharmacologic Management

— Prolonged Exposure (PE): 8–15 weekly 90-min sessions; in vivo and imaginal exposure to trauma memories/avoided situations; activates fear extinction

— Cognitive Processing Therapy (CPT): 12 sessions; identifies and restructures "stuck points" (maladaptive cognitions about safety, trust, power, esteem, intimacy)

— EMDR (Eye Movement Desensitization and Reprocessing): 6–12 sessions; bilateral stimulation during trauma recall; equivalent efficacy to PE/CPT

— Trauma-Focused CBT (TF-CBT): preferred in children/adolescents (ages 3–18)

— Stress Inoculation Training, Present-Centered Therapy

— Useful when patient declines trauma exposure or has severe dissociation

— Adjunctive; helpful for veterans (peer support), sexual assault survivors

— Not a substitute for individual TFP in moderate–severe PTSD

— Mindfulness-based stress reduction

— Yoga, exercise (aerobic 3×/week reduces hyperarousal)

— Service animals (modest evidence; insurance/VA coverage variable)

— CBT-I: first-line for insomnia

— Imagery Rehearsal Therapy (IRT): evidence-based for chronic nightmares—patient rewrites the nightmare narrative and rehearses the new version

— Seeking Safety (manualized) and concurrent PE for PTSD + SUD

— Treat both simultaneously—sequential treatment historically failed

— VA's PE Coach, CPT Coach apps; PTSD Coach

— Telehealth-delivered CPT and PE have equivalent efficacy to in-person

— rTMS: emerging evidence

— Stellate ganglion block: investigational

— ECT: not indicated unless severe comorbid depression

Trauma-focused psychotherapies (TFPs)—first-line, strongest evidence:

Non-trauma-focused (second-line):

Group therapy:

Adjunct modalities:

Treating comorbid insomnia/nightmares:

Substance use integration:

Digital/telehealth options:

Neuromodulation (refractory cases):

Step 3 management: When a patient declines medication, refer to CPT, PE, or EMDR—any of these is correct. Choose based on availability and patient preference (some prefer not to recount trauma in detail → CPT; others want exposure → PE).

Board pearl: Critical incident stress debriefing (CISD) immediately after trauma is harmful—it may increase PTSD risk. Routine post-trauma debriefing is contraindicated; offer psychological first aid and watchful waiting instead.

Special Populations — Elderly and Renal/Hepatic Impairment

— Late-life PTSD may be reactivated by retirement, bereavement, medical illness, or institutionalization (especially WWII/Korea/Vietnam veterans)

— Symptoms may masquerade as cognitive impairment, depression, or "difficult behavior" in nursing facilities

— Differential: delirium, dementia (especially Lewy body—visual hallucinations), MDD, late-onset GAD

— Avoid paroxetine—high anticholinergic burden, sedation, falls (on Beers Criteria)

— Sertraline preferred (cleaner CYP profile, fewer drug interactions)

— Start at half adult dose: sertraline 12.5–25 mg, titrate slowly

— Hyponatremia (SSRI-induced SIADH) risk markedly elevated—check sodium at 2–4 weeks, then periodically

— Bleeding risk with concomitant NSAIDs, antiplatelets, anticoagulants

— Prazosin: heightened orthostatic risk; start 1 mg qhs, check standing BP

— QTc monitoring with citalopram (max 20 mg in >60 yo)

— Avoid TCAs (anticholinergic, orthostasis, arrhythmia)

— Avoid benzodiazepines absolutely (falls, delirium, cognitive decline)

— Sertraline, paroxetine, fluoxetine: minimal dose adjustment in CKD

— Venlafaxine: reduce dose ~25–50% in CrCl <30; monitor BP (renal patients have CV comorbidity)

— Duloxetine: avoid if CrCl <30

— Prazosin: dose-adjust cautiously

— Sertraline: use lower doses, titrate slowly in Child-Pugh B/C

— Paroxetine: reduce dose

— Avoid duloxetine in significant hepatic disease or chronic alcohol use

— Monitor LFTs at baseline and periodically

— TFP (PE, CPT, EMDR) is effective and well-tolerated

— May require longer sessions, accommodations for hearing/cognition

— Telehealth has expanded access for mobility-limited patients

Elderly patients with PTSD:

Pharmacologic caveats in older adults:

Renal impairment:

Hepatic impairment:

Psychotherapy in elderly:

Step 3 management: A 78-year-old WWII veteran in a SNF with new nightmares, agitation, and resistance to care: rule out delirium and dementia, screen with PC-PTSD-5, initiate sertraline 25 mg (not paroxetine, not benzodiazepine), refer to geriatric mental health for modified CPT, and check sodium in 2 weeks.

Board pearl: Late-onset PTSD reactivation in a nursing home patient is a classic Step 3 stem—the wrong answers are antipsychotic for "agitation" or benzo for "anxiety." Right answer: trauma-informed care and an SSRI.

Special Populations — Pregnancy, Pediatrics, and Veterans

— Untreated PTSD increases risk of preterm birth, low birth weight, postpartum depression, impaired maternal–infant bonding

— Sertraline = first-line SSRI in pregnancy and breastfeeding (low milk transfer, extensive safety data)

— Avoid paroxetine (FDA category D—cardiac septal defects, especially first trimester)

— Late-trimester SSRI use: counsel about transient neonatal adaptation syndrome (jitteriness, feeding issues) and small absolute risk of PPHN

— Trauma-focused psychotherapy is the preferred first-line modality in pregnancy—CPT, PE, EMDR all safe and effective

— Screen postpartum patients after traumatic delivery (PTSD prevalence ~4–6% postpartum; up to 15% after severe obstetric events)

— DSM-5-TR has separate criteria for children ≤6: lower symptom threshold, behaviorally expressed (re-enactment in play, regressive behaviors, separation anxiety, sleep disturbance)

— First-line: TF-CBT (developed by Cohen and Mannarino)—evidence-based across ages 3–18

— Avoid SSRIs as first-line in children—evidence weak; FDA black box for suicidality; use only when comorbid MDD or refractory

— If pharmacotherapy needed: sertraline preferred; start 12.5–25 mg

— Mandatory reporting: suspected child abuse must be reported to CPS regardless of caregiver wishes

— Screen at every primary care visit with PC-PTSD-5 (annual minimum per VA)

— High comorbidity: TBI, chronic pain, AUD, OUD, suicide risk

— Firearm safety counseling and lethal means restriction—document

— Refer to VA mental health, Vet Centers, or community providers in TRICARE

— VA disability evaluation may incentivize symptom reporting; remain trauma-informed

— Acute care: SANE exam, STI/HIV PPx, emergency contraception, forensic evidence

— Follow-up at 1–2 weeks: screen for ASD/PTSD

— Refer to rape crisis advocacy and trauma-focused therapy

— High prevalence (up to 30%); often multiple traumas

— Culturally adapted therapy; Narrative Exposure Therapy (NET) is evidence-based

— Language-concordant care; trained interpreters (not family)

Pregnancy and lactation:

Pediatric PTSD:

Veterans (high-yield Step 3 population):

Sexual assault survivors:

Refugees and asylum seekers:

Board pearl: Pregnant patient with PTSD + new pregnancy → sertraline + CPT/EMDR; paroxetine and benzodiazepines are wrong answers.

Complications and Adverse Outcomes

— Major depressive disorder (50% lifetime comorbidity)

— Suicide: PTSD ~2× attempt risk; up to 5× in veterans with comorbid depression

— Substance use disorders: AUD (lifetime ~50%), opioid, cannabis, stimulant

— Panic disorder, GAD, social anxiety

— Dissociative disorders

— Eating disorders (especially after sexual trauma)

— Interpersonal violence (perpetration and victimization)

— Occupational impairment, unemployment, disability

— Homelessness (overrepresented in veterans)

— Legal problems, incarceration

— Impaired parenting and intergenerational trauma transmission

— Cardiovascular disease: PTSD associated with ~50% increased incidence of CAD, MI, stroke—mediated by HPA dysregulation, inflammation, behavioral risk factors

— Hypertension, metabolic syndrome, type 2 diabetes

— Chronic pain syndromes: fibromyalgia, low back pain, headache

— GI disorders: IBS, functional dyspepsia

— Autoimmune disease (epidemiologic association)

— Dementia—PTSD nearly doubles late-life dementia risk (large VA cohort data)

— Chronic insomnia, nightmares, sleep apnea (under-recognized)

— Sleep deprivation perpetuates and worsens core PTSD symptoms

— Sexual dysfunction (both disorder- and medication-related)

— Pelvic pain, dyspareunia in survivors of sexual assault

— Pregnancy complications: preterm birth, hyperemesis, postpartum depression

— Benzodiazepine dependence (a recurrent failure mode in PTSD care)

— Opioid dependence when chronic pain treated reflexively with opioids

— Polypharmacy: PTSD patients average 3–5 psychotropics in some series

Psychiatric complications:

Behavioral and functional:

Medical sequelae (PTSD is a CV risk factor):

Sleep complications:

Reproductive/sexual:

Iatrogenic harms:

Step 3 management: At every visit, screen for the "deadly comorbidities" of PTSD—suicide, substance use, intimate partner violence, and cardiovascular risk. Document and address each. Use SBIRT (screening, brief intervention, referral to treatment) for substance use.

Board pearl: PTSD is an independent cardiovascular risk factor—aggressive lipid, BP, glycemic, and tobacco management are part of PTSD care, especially in middle-aged veterans. This integration of behavioral and chronic-disease care is a quintessential Step 3 theme.

When to Escalate — Inpatient, ED, and Specialty Consultation

— Active suicidal ideation with plan or intent

— Homicidal ideation

— Acute psychosis (rare in PTSD alone—reconsider diagnosis)

— Severe self-neglect, inability to care for self

— Severe substance intoxication or withdrawal requiring detox

— Catatonia or grossly disorganized behavior

— Acute agitation endangering self or others

— Mental illness AND

— Imminent danger to self, others, or grave disability

— Standard process: physician/psychiatrist evaluation + court process within 72 hours (state-specific)

— Psychiatry: medication-refractory PTSD, complex comorbidity, suicide risk

— Psychology/LCSW: trauma-focused therapy delivery

— Addiction medicine: comorbid moderate–severe SUD

— Pain medicine: comorbid chronic pain, opioid stewardship

— Sleep medicine: refractory insomnia, suspected OSA or RBD

— Neurology: comorbid TBI, seizures, atypical features

— Highest suicide risk in first 30 days post-psychiatric discharge

— Schedule outpatient follow-up within 7 days of discharge (CMS quality metric)

— Safety planning intervention (Stanley-Brown) before discharge—evidence-based

— Caring contacts (calls/texts) reduce post-discharge suicide

— Endorses suicide plan during visit

— Cannot contract for safety, refuses voluntary care, and meets commitment criteria

— Acute psychosis or severe agitation

Emergency department referral / psychiatric hospitalization indicated for:

Involuntary commitment criteria (vary by state but generally):

Specialty consultation (outpatient, urgent):

CCS pearl: For an inpatient veteran admitted after a suicide attempt with PTSD + AUD: initial orders should include (1) 1:1 sitter and contraband/sharps removal, (2) CIWA-Ar protocol with scheduled diazepam taper (note: benzos here are for withdrawal, not PTSD), (3) thiamine 100 mg IV before glucose, folate, multivitamin, (4) C-SSRS reassessment, (5) psychiatry consult, (6) hold home SSRI initially if QTc prolonged, otherwise continue, (7) social work for safety planning and firearm storage at discharge, (8) lethal means counseling documented before discharge.

Transitions of care—high risk window:

When to send to ED from outpatient clinic:

Board pearl: A patient with PTSD who voluntarily seeks help and reports passive SI without plan/intent does not require hospitalization—create a safety plan, restrict lethal means, intensify outpatient care, and schedule close follow-up. Reflexive hospitalization is often the wrong answer.

Key Differentials — Same-Category (Trauma/Stressor and Anxiety) Disorders

— Same symptom domains as PTSD but duration 3 days to 1 month post-trauma

— Treat with brief trauma-focused CBT; avoid benzos

— ~50% progress to PTSD if untreated

— Emotional/behavioral symptoms within 3 months of an identifiable stressor (not necessarily Criterion A trauma—e.g., job loss, divorce)

— Lacks full PTSD symptom clusters

— Resolves within 6 months of stressor termination

— Treatment: supportive psychotherapy

— Persistent excessive worry about multiple domains for ≥6 months

— No trauma exposure required; no intrusion/avoidance/dissociation

— Treatment: SSRI/SNRI, CBT

— Recurrent unexpected panic attacks + anticipatory anxiety

— PTSD patients can have trauma-cued panic—key distinction: PTSD panic attacks are cued by trauma reminders; panic disorder attacks are uncued

— Fear of social scrutiny; avoidance of social situations

— PTSD avoidance is trauma-cue-driven, not socially-driven

— Circumscribed fear; can follow trauma (e.g., driving phobia after MVA) without full PTSD criteria

— Ego-dystonic obsessions and compulsions

— PTSD intrusions are trauma memories, not obsessions; compulsions are absent

— Persistent yearning, identity disruption, avoidance ≥12 months after bereavement

— Death must be Criterion A (violent/accidental) for PTSD; non-traumatic loss → prolonged grief

— Dissociative amnesia, depersonalization/derealization disorder, DID

— PTSD with dissociative subtype overlaps; primary dissociative disorders lack the core PTSD symptom clusters

— Anhedonia and negative cognitions overlap with PTSD cluster D

— Key distinction: MDD lacks Criterion A trauma exposure, intrusion symptoms, and trauma-specific avoidance

— Frequently comorbid—diagnose both when criteria met

Acute Stress Disorder (ASD):

Adjustment Disorder:

Generalized Anxiety Disorder:

Panic Disorder:

Social Anxiety Disorder:

Specific Phobia:

Obsessive-Compulsive Disorder:

Complicated Grief / Prolonged Grief Disorder (DSM-5-TR new):

Dissociative Disorders:

Major Depressive Disorder:

Board pearl: ASD vs. PTSD is purely a duration distinction—<1 month = ASD, ≥1 month = PTSD. Choice of treatment (trauma-focused therapy in both; avoid benzos in both) is similar, but only PTSD warrants chronic SSRI consideration.

Key Differentials — Other-Category Causes

— Stimulant intoxication (cocaine, methamphetamine, high-dose caffeine): hyperarousal, insomnia, paranoia

— Cannabis use disorder: anxiety, panic, sleep disturbance; chronic use can blunt fear extinction

— Alcohol withdrawal: tremor, tachycardia, insomnia, hyperarousal mimic PTSD

— Corticosteroids, interferon-α, isotretinoin can produce neuropsychiatric symptoms

— Order urine toxicology in atypical or new-onset presentations

— Hyperthyroidism: tachycardia, tremor, insomnia, anxiety, irritability—obtain TSH

— Pheochromocytoma: paroxysmal HTN, palpitations, headache, diaphoresis

— Cushing syndrome: mood lability, depression, anxiety

— Hypoglycemia (insulinoma, post-bariatric): adrenergic surges

— Traumatic brain injury (especially mild TBI/concussion): overlaps with PTSD—irritability, sleep disturbance, concentration deficits; common comorbidity in veterans and MVA survivors

— Temporal lobe epilepsy: déjà vu, dissociative episodes, autonomic auras—flashback mimic

— Delirium in hospitalized/elderly patients: acute, fluctuating, with disorientation

— Frontotemporal dementia: personality change, disinhibition

— REM Sleep Behavior Disorder: dream enactment in older men → polysomnography

— Arrhythmias (paroxysmal SVT, AF) presenting as "panic attacks"—Holter monitoring

— Pulmonary embolism, acute MI: rule out before attributing chest pain to panic

— Schizophrenia, brief psychotic disorder—flashbacks vs. hallucinations distinction (flashbacks are dissociative re-experiencing, not psychotic)

— Persecutory delusions in schizophrenia ≠ hypervigilance in PTSD

— Affective instability, dissociation, identity disturbance, often with trauma history

— Frequently comorbid with PTSD; treat both (DBT + trauma-focused therapy)

— Particularly relevant in disability evaluations (VA compensation)

— Inconsistencies between reported and observed function; symptom exaggeration

— Maintain trauma-informed, nonconfrontational stance

Substance/medication-induced:

Endocrine:

Neurologic:

Cardiovascular:

Psychotic disorders:

Borderline Personality Disorder:

Factitious disorder / malingering:

Step 3 management: New "panic attacks" in a 55-year-old veteran with no prior history—obtain TSH, ECG, and rule out ACS/arrhythmia before attributing to PTSD. Anchoring on PTSD without medical workup is a Step 3 trap.

Board pearl: TBI and PTSD frequently coexist in veterans and MVA survivors; symptoms overlap substantially. Both should be treated; cognitive rehab + trauma-focused therapy + SSRI.

Secondary Prevention, Discharge Planning, and Long-Term Pharmacotherapy

— Continue SSRI/SNRI for at least 6–12 months after symptom remission

— Chronic PTSD or relapse after taper → consider indefinite maintenance

— Tapering: gradual over 4–8 weeks to avoid discontinuation syndrome (especially paroxetine, venlafaxine)

— Continue trauma-focused therapy "booster" sessions as needed

— Identify and plan for personal triggers and anniversary reactions

— Maintain social support, employment, structured daily routine

— BP, lipids, HbA1c, BMI at baseline and annually

— Tobacco cessation (high prevalence in PTSD)

— Statin per ASCVD risk; ACE-I/ARB or thiazide per BP

— Aerobic exercise 150 min/week

— Ongoing AUDIT-C; if positive, integrated treatment

— Naltrexone or acamprosate for AUD; buprenorphine for OUD—both compatible with SSRI

— Avoid prescribing benzodiazepines and opioids whenever possible

— Continue CBT-I principles; reassess insomnia; titrate or discontinue prazosin based on response

— Treat OSA aggressively—improves PTSD symptoms

— Follow-up appointment scheduled within 7 days (CMS quality measure; reduces suicide and readmission)

— Written safety plan (Stanley-Brown)

— Lethal means restriction documented—firearm storage, medication lockboxes

— Caring contacts (postcards, calls, texts) reduce post-discharge suicide

— Medication reconciliation; ensure 30-day supply

— Communication with outpatient providers

— VA service-connection evaluation for veterans

— SSDI for severely impaired civilians

— Trauma-informed documentation

— Psychoeducation; involve partners in therapy when appropriate

— Screen partners/children for secondary trauma

Duration of pharmacotherapy:

Relapse prevention:

Cardiovascular risk reduction (PTSD-specific secondary prevention):

Substance use:

Sleep:

Discharge from psychiatric hospitalization:

Vaccinations and preventive care: Often neglected; bring up to date as part of holistic PTSD care.

Disability and benefits navigation:

Family and caregiver support:

Step 3 management: At every primary care visit for a PTSD patient: reassess PCL-9 or PCL-5, screen for SI, alcohol, intimate partner violence, sleep, medication adherence/side effects; update BP, weight, A1c, lipids; reinforce lethal means safety; coordinate with mental health provider.

Board pearl: Premature SSRI discontinuation (especially patient-initiated within 3–6 months of remission) is a leading cause of PTSD relapse. Counsel on the 6–12 month minimum continuation at initial prescription.

Follow-Up, Monitoring Parameters, and Rehabilitation

— Initial pharmacotherapy: follow-up at 1–2 weeks (especially patients <25, suicide risk assessment), then every 2–4 weeks until stable, then every 3 months

— Psychotherapy: weekly sessions × 8–15 weeks for course of CPT/PE/EMDR

— Stable maintenance: every 3–6 months

— PCL-5 every 4–8 weeks during active treatment; target ≥10–20 point reduction; remission goal PCL-5 <33 (preferably <20)

— PHQ-9 (depression), GAD-7 (anxiety), AUDIT-C (alcohol)

— C-SSRS suicide assessment

— Medication adherence and side effects (sexual dysfunction, weight, sleep)

— Sleep diary; nightmare frequency

— Functional status (work, relationships, self-care)

— Sodium at 2–4 weeks if elderly on SSRI

— BP at every venlafaxine dose increase

— LFTs annually if hepatic risk

— Metabolic panel and lipids if atypical antipsychotic augmentation

— Annual HbA1c, lipid panel, BP, BMI (CV risk)

— Response: ≥30% PCL-5 reduction

— Remission: PCL-5 <20–33 and no longer meets DSM criteria

— Non-response after 8–12 weeks at adequate dose → switch, augment, or add psychotherapy

— Supported employment programs (especially veterans, IPS model)

— Vocational rehabilitation through VA or state agencies

— Occupational therapy for ADL/IADL impairment

— Service animal evaluation for select patients

— Cognitive-Behavioral Conjoint Therapy for PTSD (Monson)—evidence-based

— Reduces partner distress and improves relationship satisfaction

— VA Peer Specialists, Vet-to-Vet, sexual assault survivor groups

— Reduces isolation, improves treatment engagement

— Aerobic exercise, sleep hygiene, limit alcohol/caffeine, mindfulness practice

Visit cadence:

Monitoring metrics at each visit:

Laboratory monitoring:

Treatment response definitions:

Rehabilitation and vocational support:

Family/couples therapy:

Peer support:

Lifestyle:

Step 3 management: Use measurement-based care—track PCL-5 systematically and adjust treatment when not meeting response targets at 8–12 weeks. "Just keep doing the same therapy" without measurement is the wrong answer in board stems implying non-response.

Board pearl: Post-psychiatric-hospitalization follow-up within 7 days is both a quality measure (HEDIS, CMS) and a suicide prevention intervention—high-yield Step 3 item.

Ethical, Legal, and Patient Safety Considerations

— Standard HIPAA protections apply

— Mandatory exceptions:

— Imminent danger to self or others (Tarasoff duty in most US states—warn identified victim, notify law enforcement)

— Suspected child, elder, or dependent adult abuse → mandatory CPS/APS report

— Some states: mandatory reporting for intimate partner violence with serious injury or weapon use (state-variable—generally NOT reportable in competent adults; offer resources)

— PTSD typically does not impair decisional capacity

— Severe dissociation, acute suicidality, or comorbid psychosis may transiently impair capacity—assess with the four-component model (understand, appreciate, reason, communicate)

— Document capacity assessment when patient refuses recommended care in high-risk situations

— Requires mental illness + imminent danger to self/others or grave disability

— Use least restrictive setting; voluntary admission preferred when possible

— Patient retains right to legal review (commitment hearing within state-specified window)

— Ethically and clinically obligatory in PTSD, especially veterans and patients with SI

— Document discussion; encourage off-site storage, gun locks, removal of firearms during high-risk periods

— Federal law (Lautenberg amendment) restricts firearm possession after qualifying domestic violence misdemeanors—relevant in IPV cases

— Child abuse, elder abuse, dependent adult abuse: universal

— Gunshot/stab wounds: most states require reporting to law enforcement

— Sexual assault of adult: patient-driven—respect autonomy; do not report against patient wishes unless other mandatory criteria met

— Post-psychiatric-discharge 30 days: highest suicide risk window—schedule follow-up within 7 days, safety plan, lethal means counseling, caring contacts

— Medication reconciliation errors at transitions

— Communication breakdown between inpatient and outpatient teams—use warm handoffs

— Maintain dual role transparency (treating vs. examining clinician); when possible, separate the roles

— Symptom validity testing in forensic contexts only

— Address race, gender, sexual orientation, immigration status as trauma context

— Use trained interpreters (not family members) for non-English speakers

— Avoid retraumatization—offer choice, control, predictability in encounters

Confidentiality and exceptions:

Capacity and informed consent:

Involuntary hospitalization:

Firearm safety counseling:

Mandatory reporting:

Transition-of-care risks (Step 3 high-yield):

VA disability evaluations:

Cultural humility and trauma-informed care:

Board pearl: A patient discloses childhood sexual abuse during a PTSD evaluation, with the alleged perpetrator no longer having access to children. Is this reportable? State-dependent, but most states require reporting even if the abuse occurred years ago when there is any potential ongoing risk to minors—when uncertain, err on the side of reporting and consult your state CPS hotline.

Step 3 management: Always document a safety plan, lethal means counseling, and follow-up plan at every high-risk visit—both ethically and medicolegally protective.

High-Yield Associations and Rapid-Fire Clinical Facts

— 4 symptom clusters: intrusion (B), avoidance (C), negative cognition/mood (D), arousal (E)

— Duration ≥1 month; functional impairment required

— Subtypes: dissociative subtype, with delayed expression (>6 months)

— Lifetime prevalence ~6–8% US; women 2× men

— Combat veterans 10–30%; sexual assault 30–50%

— Suicide risk ~2× baseline

— Comorbid MDD ~50%; AUD ~50%

— PTSD increases CAD risk ~50%; doubles dementia risk

— 6–12 months minimum SSRI continuation after remission

— Psychotherapy: PE, CPT, EMDR, TF-CBT

— Medications: sertraline, paroxetine (FDA-approved); venlafaxine (recommended)

— Benzodiazepines (always wrong on Step 3)

— Critical Incident Stress Debriefing (CISD)

— Cannabis as treatment

— Sertraline: preferred in pregnancy, lactation, elderly, cardiac disease

— Paroxetine: avoid in pregnancy (D), elderly (anticholinergic), withdrawal-prone

— Venlafaxine: BP monitoring; useful with pain

— Prazosin: nightmares; titrate from 1 mg qhs; orthostatic hypotension

— Citalopram >40 mg or >20 mg (>60 yo): QT prolongation risk

— PC-PTSD-5: primary care, ≥3 positive

— PCL-5: 20-item, ≥31–33 suggests probable PTSD

— CAPS-5: gold standard clinician interview

— Flashback (dissociative) ≠ hallucination (psychotic)

— ASD (<1 mo) vs. PTSD (≥1 mo)

— Adjustment disorder = no Criterion A trauma

— REM Sleep Behavior Disorder mimics PTSD nightmares in older men

— MDD, SI, AUD/SUD, TBI, OSA, chronic pain, IPV, CV risk

— Firearm storage, medication lockboxes—document at every high-risk visit

— TF-CBT first-line; behaviorally expressed in children ≤6

— Annual PC-PTSD-5 screening; VA disability; firearms; TBI screening

— Reduced hippocampal volume, hyperactive amygdala, hypoactive medial PFC

— Low cortisol with enhanced negative feedback

DSM-5-TR essentials:

High-yield numbers:

First-line treatments:

Contraindicated/harmful:

Drug-specific pearls:

Screening tools:

Distinctions to memorize:

Comorbidities to screen at every visit:

Lethal means counseling:

Pediatric:

Veteran-specific:

Neuroscience facts (low yield clinically, occasional buzz):

Board pearl: When in doubt on a Step 3 PTSD question, choose: sertraline + trauma-focused psychotherapy + safety planning—this combination is correct in the vast majority of stems.

Board Question Stem Patterns

Iraq veteran, 6 months post-deployment, presenting with insomnia, nightmares, irritability, hypervigilance, avoiding crowds, drinking 6 beers nightly.

— Best initial step: PC-PTSD-5 → full DSM assessment + AUDIT-C + C-SSRS

— Best treatment: refer to CPT/PE/EMDR + sertraline; firearm safety counseling

— Wrong answers: alprazolam (benzo contraindicated), antipsychotic first-line

Patient 2 weeks after rollover collision with intrusive memories, avoidance of driving, hyperarousal.

— Diagnosis: Acute Stress Disorder (not PTSD—duration <1 month)

— Best treatment: brief trauma-focused CBT

— Wrong answers: SSRI initiation, benzodiazepines, CISD

78-year-old WWII vet with new nightmares, agitation, resistance to bathing.

— Workup: rule out delirium, dementia; obtain TSH; screen PC-PTSD-5

— Treatment: trauma-informed care; sertraline 25 mg; modified CPT

— Wrong answers: paroxetine (Beers), benzo, antipsychotic for "agitation"

28-week pregnant patient with PTSD from prior assault; worsening symptoms.

— Best treatment: CPT or EMDR; if medication needed, sertraline

— Wrong answers: paroxetine (category D), benzodiazepines, defer all treatment until postpartum

Veteran on sertraline 200 mg with persistent trauma-related nightmares.

— Best next: add prazosin starting 1 mg qhs and titrate; consider Imagery Rehearsal Therapy

— Wrong answers: zolpidem chronically, quetiapine first-line, benzodiazepine

Patient discharged 5 days ago after suicide attempt with PTSD + MDD; missed first appointment.

— Best action: outreach call same day; arrange in-person visit within 7-day window; reassess SI; caring contacts; safety plan reinforcement

70-year-old man "with PTSD nightmares" who punches and kicks during sleep.

— Diagnosis: REM Sleep Behavior Disorder, not PTSD

— Next step: polysomnography; screen for parkinsonism

6-year-old with regressive behavior, re-enacts trauma in play.

— Reporting: mandatory CPS report

— Treatment: TF-CBT (not SSRI first-line)

Patient with PTSD and AUD wants treatment.

— Best approach: integrated concurrent care—sertraline + naltrexone + Seeking Safety or concurrent CPT/PE

Stem 1 — The Veteran in Primary Care:

Stem 2 — Post-MVA at 2 Weeks:

Stem 3 — The Older Veteran in SNF:

Stem 4 — Pregnant Survivor:

Stem 5 — Refractory Nightmares:

Stem 6 — Post-Discharge Suicide Risk:

Stem 7 — Dream Enactment in Older Man:

Stem 8 — Pediatric Sexual Abuse:

Stem 9 — PTSD + AUD:

Step 3 management: When stems ask for the best initial step, the answer is usually a screening tool, a safety assessment, or a referral—not immediate medication. When stems describe an established diagnosis, the answer is usually trauma-focused psychotherapy + SSRI (sertraline).

Board pearl: If "benzodiazepine" is an answer choice in a PTSD question, it is essentially always wrong (except for treating concurrent alcohol withdrawal—a different indication).

One-Line Recap

PTSD = ≥1 month of intrusion, avoidance, negative cognition/mood, and hyperarousal symptoms after Criterion A trauma exposure with functional impairment, best treated with trauma-focused psychotherapy (PE, CPT, EMDR) ± sertraline/paroxetine/venlafaxine, never with benzodiazepines, and always with safety planning, lethal means counseling, and integrated management of suicide risk, depression, substance use, sleep, and cardiovascular comorbidities.

Diagnosis: Clinical, DSM-5-TR criteria, ≥1 month duration, four symptom clusters; screen with PC-PTSD-5, confirm with PCL-5 or CAPS-5; rule out hyperthyroidism, TBI, REM Sleep Behavior Disorder, substance use, and arrhythmia mimics.

First-line treatment: Trauma-focused psychotherapy (PE, CPT, EMDR, or TF-CBT in children) is preferred; pharmacotherapy with sertraline, paroxetine, or venlafaxine; combine for severe disease or comorbid MDD; prazosin for trauma-related nightmares; never benzodiazepines, never CISD.

Special populations: Sertraline in pregnancy/lactation and elderly (avoid paroxetine); TF-CBT first-line in children; veterans need annual PC-PTSD-5, firearm safety, and TBI/OSA/AUD/CV co-screening; late-life reactivation in nursing facilities is under-recognized.

Safety and longitudinal care: Assess suicide at every visit (PTSD doubles risk); 7-day follow-up after psychiatric discharge; continue SSRI ≥6–12 months after remission; measurement-based care with PCL-5; address PTSD as a cardiovascular and dementia risk factor; mandatory reporting for child/elder/dependent abuse; trauma-informed, autonomy-respecting care for adult sexual assault survivors.

Board pearl: When the Step 3 stem describes a PTSD patient, the correct management almost always combines (1) trauma-focused psychotherapy, (2) an SSRI—sertraline first, (3) explicit safety planning and lethal means counseling, and (4) scheduled measurement-based follow-up—and the wrong answer almost always involves a benzodiazepine, paroxetine in pregnancy, or hospitalization of a patient with only passive ideation who can safely engage in outpatient care.