PTSD dossier — APA Clinical Practice Guideline for PTSD 2017 (PMID 28291938) + VA/DoD PTSD CPG 2023 + NICE NG116 2024 + ISTSS 2018 + DSM-5-TR 2022 + ICD-11 6B41 Complex PTSD Covers PTSD F43.10 (acute F43.11 + chronic F43.12, lifetime ~6-7%), PTSD with dissociative subtype (depersonalization + derealization), Complex PTSD ICD-11 6B41, Acute Stress Disorder F43.0 (3 d - 1 mo post-trauma); combat veterans ~12-20% (Hoge NEJM 2004 PMID 15229303), sexual-assault survivors ~50%, refugees ~40% Step 1 SSRI/SNRI when pharmacotherapy chosen: sertraline 25 → 200 (FDA-approved-for-PTSD; pregnancy + lactation preferred); paroxetine 10 → 50 (FDA-approved-for-PTSD; AVOID pregnancy FDA Cat D); venlafaxine XR 37.5-75 → 300 (VA/DoD 2023 strong recommendation; HTN monitor); fluoxetine 10-20 → 60 (APA 2017 conditional rec; long half-life; AACAP 2010 aligned for adolescent off-label); citalopram + escitalopram + duloxetine second-line Trauma-focused psychotherapy FIRST-LINE per VA/DoD 2023 + APA 2017 PMID 28291938 + NICE NG116 2024: PE (Prolonged Exposure; Foa) / CPT (Cognitive Processing Therapy; Resick) / EMDR (Shapiro) / WET (Written Exposure Therapy; Sloan) — stronger and more durable evidence than pharmacotherapy alone; combination acceptable Step 2 switch: SSRI ↔ SNRI cross-class OR within-class SSRI switch; PTSD responds slower than MDD — full 12 wk often needed before declaring failure Step 3 augmentation: prazosin 1 → 15 mg QHS (nightmares ONLY; low-strength after PACT 2018 Raskind NEJM PMID 29414272 negative); quetiapine 25-50 → 100-300 mg (metabolic monitor); topiramate 25 → 100-400 mg (renal dose; cognitive SE); trazodone 25-100 mg QHS (sleep); mirtazapine 7.5 → 45 mg QHS (sleep + appetite); psychiatry referral mandatory Step 4 research-program: MDMA-AT (Mitchell Nature Med 2021 PMID 33972795 Phase 3; FDA decision pending 2024-2025); ketamine-AT (off-label; esketamine FDA-approved-for-TRD-MDD only); stellate ganglion block (research-stage); psilocybin-AT (Phase 2) — all via specialty / research-program access only Acute crisis ED axis: cardiac r/o if panic-attack overlay (workup.chest_pain registered umbrella) + medical r/o → grounding + de-escalation FIRST → single-dose lorazepam 0.5-1 mg PO/SL ONLY if grounding fails + safety risk → outpatient bridge ≤24-72 h → NO long-term benzo prescription at discharge CRITICAL anti-patterns: NEVER long-term benzodiazepine for chronic PTSD (worsens outcomes, dependence, interferes with extinction learning — VA/DoD 2023; ISTSS 2018; Guina 2015 NEEDS_SOURCE_REVIEW); NEVER benzo in acute-stress-disorder window (Mellman 2002 NEEDS_SOURCE_REVIEW — worsens PTSD-development); NEVER routine single-session critical incident stress debriefing CISD (Cochrane Rose 2002 PMID 11869658 HARMFUL); NEVER cannabis as PTSD treatment (VA/DoD 2023); NEVER prazosin as monotherapy (adjunct for nightmares only after PACT 2018 PMID 29414272) Severity triggers (10): acute_stress_disorder_within_1mo_of_trauma (mild — brief TF-CBT first-line; do NOT use benzo or routine CISD), severe_ptsd_with_suicidal_ideation (severe — routes to psych.suicidality.ed.core.v1; firearm means-restriction for veterans), treatment_resistant_ptsd_after_psychotherapy_plus_ssri (severe — Step 3 augmentation; Step 4 research-program MDMA-AT / ketamine-AT), comorbid_substance_use_disorder_in_ptsd (severe — integrated COPE / Seeking Safety; routes to psych.alcohol_withdrawal / psych.opioid_use_disorder), veteran_with_combat_ptsd_va_resources (moderate — VA evidence-based program; mTBI screen; firearm focus), pediatric_ptsd_with_caregiver_involvement (moderate — TF-CBT first-line per AACAP 2010 + Cohen; SSRI second-line off-label), pregnancy_with_ptsd_medication_decision (moderate — psychotherapy preferred; sertraline acceptable; paroxetine AVOIDED), dissociation_severe_or_dissociative_subtype (severe — phase-based stabilization-before-exposure; CPT preferred over PE; Cloitre ISTSS 2018), nightmares_persistent_despite_treatment (moderate — IRT first-line Krakow PMID 11519951; prazosin adjunct low-strength after PACT), acute_traumatic_event_for_screening_or_psychological_first_aid (mild — PFA NCTSN/WHO 2011; do NOT prescribe benzo; do NOT routine CISD) Two setting playbooks: outpatient psychiatry / outpatient psychology / VA evidence-based program (PCL-5 + PHQ-9 + GAD-7 + AUDIT-C + C-SSRS cadence; trauma-focused psychotherapy first-line; SSRI/SNRI ladder; sleep adjuncts; Horowitz hyperbolic taper; MDQ pre-SSRI for suggestive features; firearm means-restriction for veterans; benzo taper plan if dependent) + acute ED (medical r/o, grounding first, single-dose lorazepam last-resort, bridge ≤24-72 h, no long-term benzo at discharge, mTBI screen for combat veterans) Action plan green/yellow/red includes trauma-trigger coping (5-4-3-2-1 grounding, box / 4-7-8 breathing, safe-place imagery), trauma-focused therapy homework, firearm means-restriction warning for veterans, benzo self-escalation warning, cannabis warning, cardiac-red-flag chest-pain rule, Stanley-Brown safety plan, 988 lifeline + 988-press-1 Veterans Crisis Line Sibling differentiation: psych.depression.core.v1 (~50-70% comorbid MDD; SNRI dual-indication especially venlafaxine), psych.anxiety-disorders.core.v1 (PTSD-anxiety overlap; trauma criterion A distinguishes), psych.suicidality.ed.core.v1 (active SI cross-route; compose not replace; PTSD 4-7× completed-suicide; veterans firearm-predominant), psych.alcohol_withdrawal.core.v1 (30-50% comorbid AUD; integrated COPE/Seeking Safety), psych.opioid_use_disorder.core.v1 (CRITICAL: NEVER benzo + opioid per FDA 2016 black-box), psych.bipolar-disorder.core.v1 (MDQ before SSRI; switch caution) Front-end note: no existing PTSD-specific panel surface in src/components/panels/ob-peds-psych/ today; this dossier is the back-end pathway pack. PCL-5 / CAPS-5 / IES-R panel surfaces flagged for future wire-up batch. Workup IDs all resolve to registered umbrellas in clinical-tools-registry — workup.suicide_risk + workup.severe_agitation + workup.hyperthermic_toxidromes + workup.chest_pain + workup.insomnia + workup.head_injury. Calculator IDs all resolve to registered tools — calc.phq9 + calc.gad7 + calc.audit_c + calc.ckd_epi_2021. calc.pcl5 + calc.caps5 + calc.cssrs + calc.mdq + calc.ies_r flagged for future clinical-tools-registry batch — referenced via narrative + workup.suicide_risk for now. Phenotype matrix (subtype × trauma_type × time_since_trauma × treatment_history × comorbidity × suicidality_cssrs × veteran_status × pregnancy_lactation × age_strata) is encoded indirectly via severity_triggers + setting_playbooks + sibling_differentiation. First-class TS field for phenotype matrix is schema-blocked — see docs/framework-audit/shard-5-obped-id-state.md Schema-blocked queue. Bayesian linkage (PCL-5 ≥33 LR+ ~5-7 per Blevins 2015 PMID 26606250; CAPS-5 LR+ ~15+ gold-standard per Weathers 2018 PMID 29577636; PHQ-9 + PCL-5 simultaneous detects 50-70% MDD comorbid per VA/DoD 2023; MDQ LR+ ~7 in psych outpatients; C-SSRS gradient anchors disposition + PTSD 4-7× completed-suicide; TSH suppression LR+ ~20 for hyperthyroid mimic; mTBI screen LR+ ~3-5 in combat veterans per Hoge PMID 18234750; T_treat = PCL-5 ≥33 + functional impairment OR clinical-diagnostic PTSD; T_test = PCL-5 <31 + no functional impact; T_switch = 8-12 wk adequate dose; T_augment = ≥2 SSRI/SNRI failed + ≥1 TF-therapy course; T_research_program = treatment-resistant; T_taper_benzo = 10-25% Q2-4 wk hyperbolic-style; T_taper_SSRI = Horowitz hyperbolic; cross-dossier routing to psych.depression + psych.anxiety-disorders + psych.suicidality.ed + psych.alcohol_withdrawal + psych.opioid_use_disorder + psych.bipolar-disorder + workup.hyperthermic_toxidromes + workup.chest_pain + workup.head_injury documented in co-located research bundle). ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). PRODUCTION blockers / open gaps: (1) RxCUIs not yet validated via scripts/research/rxnav-validate.ts; (2) manifest reuses psych.depression.core.v1.ts pointer per peds.febrile-infant / psych.bipolar / psych.alcohol_withdrawal / psych.suicidality / psych.anxiety-disorders precedent — dedicated manifest out-of-shard-scope; (3) calc.pcl5 + calc.caps5 + calc.cssrs + calc.mdq + calc.ies_r not in clinical-tools-registry — referenced via workup.suicide_risk + narrative; (4) VA/DoD PTSD 2023 + NICE NG116 2024 + ISTSS 2018 + AACAP 2010 + Cohen TF-CBT + Back COPE 2019 + Najavits Seeking Safety + Guina 2015 + Mellman 2002 + Horowitz Lancet Psych 2019 + Hirschfeld MDQ 2000 + Beers 2023 + Boyer NEJM 2005 + Stanley-Brown 2012 + Mann JAMA 2005 + Bullman/Kang veterans + Cloitre ISTSS 2018 + Cipriani 2018 + Foa PE + Resick CPT + Shapiro EMDR + Sloan WET PMIDs NEEDS_SOURCE_REVIEW — referenced by label only; not added to evidence.pmids per verification rule; (5) targeted test file pending (relies on dossier-contract.test.ts); (6) panel→dossier wire (PCL-5 / CAPS-5 / IES-R panel) not authored — flagged for future wire-up batch; (7) MDMA-AT FDA regulatory decision pending 2024-2025 — referenced as research-program option; (8) stellate ganglion block + psilocybin-AT emerging / research-stage; not in core regimen.