Post Traumatic Stress Disorder

PTSD is a trauma related disorder following exposure to actual or threatened death, serious injury or sexual violence, with intrusion, avoidance, negative cognitions and hyperarousal for over one month.

• Lifetime prevalence 6 to 8%, higher in women (2:1), refugees, combat veterans and assault survivors.
• Risk factors: severity and interpersonal nature of trauma, prior trauma, early life adversity, lack of support, peritraumatic dissociation.
• Complex PTSD (ICD-11) adds affect dysregulation, negative self concept and relational difficulties after prolonged trauma.
• Comorbid depression, substance misuse, anxiety, suicidality, chronic pain.

• Intrusive memories, flashbacks, nightmares; avoidance of reminders.
• Negative beliefs, guilt, anhedonia, detachment; irritability, hypervigilance, startle, poor sleep and concentration.
• Dissociative symptoms; delayed onset in a minority.
• Red flags: suicidality, psychosis, severe substance misuse, ongoing abuse.

• Clinical interview, CAPS-5 (gold standard) or PCL-5 (33 or more suggests probable PTSD); Trauma history assessment.
• Exclude traumatic brain injury, acute stress disorder (under 1 month), adjustment disorder, psychosis, substance withdrawal, panic disorder.
• Assess suicide risk, safety and comorbidities.

• Trauma focused psychotherapy is first line: prolonged exposure, cognitive processing therapy, trauma focused CBT or EMDR (8 to 16 sessions), with response in 60 to 70%.
• Pharmacotherapy: sertraline 50 to 200 mg daily, paroxetine 20 to 60 mg, venlafaxine XR 75 to 225 mg; continue 12 months or more.
• Nightmares: prazosin 1 mg at night titrated to 3 to 15 mg (evidence mixed), imagery rehearsal therapy.
• Adjuncts: risperidone 1 to 3 mg or quetiapine for refractory hyperarousal or psychosis; topiramate 25 to 200 mg.
• Avoid benzodiazepines (worsen outcomes) and psychological debriefing.
• Stabilisation first in complex PTSD; treat substance misuse concurrently; MDMA assisted therapy remains investigational.