Updated October 2025

PTSD | Rapid Recognition and Evidence-Based Treatment

Post-traumatic stress disorder: recognition and treatment

PTSD is common, often under-recognized in medical settings, and highly treatable. Prioritize validated screening, DSM-5 diagnostic confirmation, suicide and safety assessment, and first-line trauma-focused psychotherapies. SSRIs/SNRIs are pharmacologic options when psychotherapy is unavailable or declined. Use guideline-based care and monitor outcomes with standardized scales.

Clinical question

In adults with suspected PTSD, how should clinicians recognize, diagnose, and manage PTSD using current evidence and guidelines?

PTSDTraumaMental HealthPrimary CarePsychiatryEvidence-Based Medicine

Key points

PTSD often presents in medical disguise

Somatic complaints, insomnia, chronic pain, and frequent medical visits can mask PTSD; targeted screening improves recognition ^[1].

Confirm diagnosis with DSM-5 criteria

Use an exposure history plus intrusion, avoidance, negative cognitions/mood, and arousal/reactivity clusters with duration ≥1 month and impairment ^[7], ^[8].

First-line is trauma-focused psychotherapy

Trauma-focused CBT and EMDR yield moderate symptom reductions and do not worsen symptoms mid-treatment ^[3], supported by international guidance ^[4].

Pharmacotherapy when indicated

SSRIs/SNRIs are options when psychotherapy is unavailable or declined; align with VA/DoD guideline pathways ^[6], ^[5].

Prioritize safety and comorbidities

Assess suicidality, substance use, depression, and sleep problems; coordinate care and monitor outcomes over time ^[6], ^[4].

Evidence highlights

Trauma-focused CBT or EMDR ^[3]

First-line therapy

Trauma-focused therapy: g = −0.57 (95% CI −0.79, −0.35) vs controls ^[3]

Effect at post-treatment

No symptom exacerbation: g = −0.16 (95% CI −0.34, 0.03) ^[3]

Mid-treatment safety

Recognition and Diagnostic Confirmation

From suspicion to diagnosis

PTSD is frequently missed in general medical settings; structured screening and DSM-5 criteria improve detection and treatment initiation.

Elicit a focused trauma and symptom history

Ask about exposure to actual or threatened death, serious injury, or sexual violence. Screen for intrusion, avoidance, negative mood/cognition, and arousal symptoms, duration ≥1 month, and functional impairment ^[7], ^[8].

Use validated screening tools

Tools such as brief PTSD checklists can identify high-risk patients in primary care; positive screens require diagnostic confirmation with DSM-5 criteria ^[1], ^[7], ^[8].

Differentiate acute stress disorder vs PTSD

Symptoms <1 month suggest acute stress disorder; persistent symptoms ≥1 month with impairment meet PTSD criteria and warrant treatment ^[7], ^[8], ^[6].

Assess risk and comorbidity

Evaluate suicidality, depression, anxiety, substance use, chronic pain, and sleep disturbance. These conditions commonly co-occur and influence treatment sequencing ^[1], ^[6], ^[4].

Management Strategy

Evidence-based treatment plan

Prioritize trauma-focused psychotherapy; integrate pharmacotherapy when indicated; monitor outcomes and safety.

First-line psychotherapies

Trauma-focused CBT (prolonged exposure, cognitive processing therapy) and EMDR are first-line. At post-treatment, g = −0.57 (95% CI −0.79, −0.35) vs controls; no mid-treatment exacerbation g = −0.16 (95% CI −0.34, 0.03) ^[3].

Therapies can be effective even when initiated months to years after trauma ^[10].

Educate that trauma-focused therapy is safe and effective; set expectations for transient distress without net worsening ^[3], ^[10].

Medications

Consider SSRIs (e.g., sertraline, paroxetine) or SNRIs (e.g., venlafaxine) when psychotherapy is unavailable, declined, or for partial response augmentation, following guideline algorithms ^[6], ^[5].

Target insomnia/nightmares with adjuncts (e.g., prazosin for trauma nightmares per guideline context), while monitoring blood pressure and daytime sedation ^[6].

Avoid initiating benzodiazepines for core PTSD symptoms due to limited benefit and risk of dependence; consider only short-term, time-limited, and with caution if used for severe anxiety crises ^[6].

Monitoring and measurement-based care

Track symptoms every 4–6 weeks using standardized scales; adjust therapy intensity or add pharmacotherapy based on response ^[6], ^[5].

Define response (≥30% reduction on validated scale) and remission thresholds; if nonresponse by 8–12 weeks, reevaluate diagnosis, comorbidity, and treatment fidelity ^[6].

Safety and stabilization

Screen for suicidality at intake and at transitions; create a safety plan and restrict lethal means when indicated ^[6].

Manage comorbid depression, SUD, and sleep disorders in parallel; coordinate with addiction and pain services when needed ^[6], ^[4].

Special populations and settings

Primary care: PTSD commonly presents with somatic complaints and insomnia; integrate collaborative care models to improve uptake of psychotherapy ^[1], ^[6].

Humanitarian and conflict settings: Use WHO mhGAP-aligned, scalable, non-specialist care pathways with supervision; prioritize safety and access ^[4].

Complex trauma presentations: Consider phased, skills-first approaches before intensive trauma processing; tailor interventions to dissociation and instability features ^[2].

Engagement and psychoeducation

Normalize post-trauma reactions while clarifying PTSD criteria; emphasize that evidence-based treatments are effective and safe ^[1], ^[3], ^[10].

Set collaborative goals and address barriers (transport, stigma, scheduling); consider telehealth delivery of trauma-focused therapies per guideline practice ^[6], ^[5].

References

Source material

Primary literature that informs this article.