Psychiatry · Trauma-Related Disorders
The facts most likely to be tested
Press 1–5 to rate · ↑↓ to navigate
Core symptom clusters are re-experiencing, avoidance, negative mood/cognition, and hyperarousal after a traumatic stressor.
PTSD requires symptoms lasting >1 month; the identical picture lasting 2 days to 1 month is acute stress disorder.
First-line pharmacotherapy is an SSRI (paroxetine or sertraline) combined with trauma-focused CBT.
Prazosin is specifically used to reduce trauma-related nightmares.
Pathophysiology involves a hyper-responsive amygdala with failed prefrontal and hippocampal fear extinction.
Benzodiazepines are generally avoided because they do not treat core symptoms and carry dependence risk.
Always screen for comorbid depression and substance use, which worsen prognosis and complicate treatment.
Vignette unlocked
A 29-year-old combat veteran presents 6 months after returning from deployment with recurrent nightmares, intrusive flashbacks, and avoidance of crowds and loud noises. He is hypervigilant with an exaggerated startle response and reports poor sleep and irritability. His symptoms have caused him to lose his job and withdraw from his family.
Which of the following is the most appropriate first-line pharmacotherapy?
An SSRI such as sertraline or paroxetine.
Symptoms persisting beyond 1 month with re-experiencing, avoidance, and hyperarousal meet criteria for PTSD, for which SSRIs plus trauma-focused psychotherapy are first-line. Prazosin can be added for nightmares, while benzodiazepines are avoided because they fail to treat core symptoms and carry dependence risk.
Full handout
High yield triage
Etiology / Epidemiology
Follows exposure to an overwhelming traumatic stressor (combat, assault, disaster); comorbid depression and substance abuse worsen the course.
Clinical Manifestations
Re-experiencing (flashbacks/nightmares), avoidance, negative mood/cognition, and hyperarousal (startle, hypervigilance).
Diagnosis
PTSD requires symptoms >1 month; acute stress disorder is the same picture lasting 2 days to 1 month.
Treatment
First-line SSRIs (paroxetine, sertraline) plus trauma-focused CBT; prazosin for nightmares.
Prognosis
Variable; worsened by comorbid depression and substance use.
Full handout
Epidemiology & Etiology
PTSD develops after exposure to an overwhelming traumatic stressor, combat, sexual assault, natural disaster (hurricane, earthquake), or serious accident, to which the person reacts with fear and helplessness. It is more common after interpersonal violence and in women, and risk rises with prior trauma, lack of social support, and pre-existing psychiatric illness. Comorbid depression and substance abuse are common and worsen the prognosis, so both must be screened for.
Pertinent Anatomy
PTSD reflects dysregulation of the fear circuit: an overactive amygdala with impaired prefrontal cortex inhibitory control and hippocampal dysfunction that disrupts contextual memory and fear extinction. Noradrenergic hyperactivity (driving hyperarousal and nightmares, and the rationale for prazosin, an alpha-1 antagonist) and dysregulated HPA-axis cortisol signaling characterize the neurobiology, alongside serotonergic abnormalities targeted by SSRIs.
Pathophysiology
Traumatic exposure produces a pathologically consolidated, poorly contextualized fear memory: the amygdala becomes hyper-responsive while prefrontal and hippocampal regulation fails, impairing extinction so that reminders trigger full re-experiencing. Sustained noradrenergic overactivity (locus coeruleus) drives hyperarousal, exaggerated startle, and trauma-related nightmares, explaining why the alpha-1 blocker prazosin reduces nightmares. SSRIs modulate serotonergic tone to attenuate the entire symptom cluster over weeks.
Clinical Manifestations
Following trauma, patients continually relive the event (intrusive memories, flashbacks, nightmares) and avoid reminders of it, alongside negative alterations in mood and cognition. Hyperarousal symptoms are prominent: exaggerated startle response, hypervigilance, sleep disturbance, irritability/anger outbursts, and difficulty concentrating. Symptoms cause significant functional impairment. The clinical picture is shared with acute stress disorder, with the key difference being symptom duration.
Diagnosis
Diagnosis is clinical and hinges on the relationship between symptom duration and the trauma. PTSD requires symptoms lasting more than 1 month after the event; acute stress disorder is the same symptom picture lasting from 2 days up to 1 month and occurring within 1 month of the trauma. Always screen for and address comorbid depression and substance use, since both worsen the diagnosis and complicate treatment.
Treatment
First-line pharmacotherapy is an SSRI, paroxetine and sertraline are FDA-approved, combined with trauma-focused psychotherapy (cognitive processing therapy, prolonged exposure). Prazosin is specifically used to reduce trauma-related nightmares. Relaxation techniques and supportive psychotherapy after the event help develop coping skills and acceptance. Benzodiazepines are generally avoided because they do not treat core PTSD symptoms and carry dependence risk in this high-comorbidity population.
Prognosis
The course is variable: many patients improve substantially with combined SSRI and trauma-focused therapy, but a significant minority develop a chronic, relapsing illness. Prognosis is worsened by comorbid major depression and substance use disorders, which must be treated concurrently. Strong social support and early intervention improve outcomes.
Differential Diagnosis
Acute Stress Disorder: identical symptom profile but lasting 2 days to 1 month within a month of trauma; PTSD is diagnosed only when symptoms persist beyond 1 month.
Adjustment Disorder: emotional symptoms following a non-life-threatening stressor that do not meet the full re-experiencing/hyperarousal criteria of PTSD.
Major Depressive Disorder: depressed mood and anhedonia predominate without trauma-specific re-experiencing or hyperarousal; often comorbid with PTSD.
Panic Disorder: recurrent unexpected attacks not tied to trauma reminders, lacking re-experiencing and avoidance of trauma cues.
Obsessive-Compulsive Disorder: intrusive thoughts are ego-dystonic obsessions relieved by compulsions rather than re-experiencing of a specific traumatic event.