Patient handout

PTSD (DSM-5-TR F43.10 acute / chronic / dissociative subtype + Acute Stress Disorder F43.0 + ICD-11 6B41 Complex PTSD) — trauma-focused psychotherapy first-line + SSRI/SNRI stepwise (APA 2017 PMID 28291938; VA/DoD 2023; NICE NG116 2024; ISTSS 2018)

PRODUCTION

1. Your condition

This handout is for ptsd (dsm-5-tr f43.10 acute / chronic / dissociative subtype + acute stress disorder f43.0 + icd-11 6b41 complex ptsd) — trauma-focused psychotherapy first-line + ssri/snri stepwise (apa 2017 pmid 28291938; va/dod 2023; nice ng116 2024; istss 2018). Your care team identified this based on: intrusive memories / flashbacks / nightmares / intense distress on trauma reminder (dsm-5-tr 2022 ptsd criterion b; f43.10).

Other reasons your team may use this plan: persistent avoidance of trauma-related stimuli (internal cues or external reminders) (dsm-5-tr 2022 ptsd criterion c; f43.10); negative alterations in cognition and mood — persistent negative beliefs, distorted blame, persistent negative emotional state, anhedonia, detachment (dsm-5-tr 2022 ptsd criterion d; f43.10); marked alterations in arousal and reactivity — irritability, reckless behaviour, hypervigilance, exaggerated startle, concentration / sleep disturbance (dsm-5-tr 2022 ptsd criterion e; f43.10).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
sertraline	25 mg PO daily × 1-2 wk → 50 mg → titrate	PO	once daily	FDA-approved for PTSD; preferred in pregnancy + lactation; among most effective + tolerable in Cipriani 2018 NMA PMID 29477251; VA/DoD 2023 strong recommendation
paroxetine	10 mg PO daily × 1 wk → 20 mg → titrate	PO	once daily	FDA-approved for PTSD (the only SSRI with both PTSD and panic FDA labels); AVOID in pregnancy (FDA Category D cardiac teratogenicity) + tamoxifen co-Rx (FDA 2011 CYP2D6); significant discontinuation syndrome (highest withdrawal burden — Horowitz 2019 NEEDS_SOURCE_REVIEW)
venlafaxine	37.5–75 mg PO daily (XR)	PO	once daily	VA/DoD 2023 strong recommendation for PTSD; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (Horowitz 2019 NEEDS_SOURCE_REVIEW)
fluoxetine	10–20 mg PO daily (mornings to avoid insomnia)	PO	once daily	APA 2017 PMID 28291938 conditional recommendation; long half-life buffers missed doses + reduces discontinuation syndrome; FDA-approved for pediatric MDD + OCD (not PTSD); AACAP 2010 aligned for adolescent PTSD off-label
citalopram	10–20 mg PO daily	PO	once daily	Effective; FDA 2012 QTc warning caps dose 20 mg in elderly; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
escitalopram	5–10 mg PO daily	PO	once daily	Most effective SSRI for anxiety per Cipriani 2018 NMA PMID 29477251; QTc concern at higher doses; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
duloxetine	30 mg PO daily × 1 wk → 60 mg	PO	once daily	SNRI with neuropathic-pain + fibromyalgia indication; less PTSD-specific evidence than venlafaxine; LFT monitoring (APA 2017)

Plan: PTSD stepwise pharmacotherapy — Step 1 SSRI/SNRI → Step 2 switch → Step 3 augmentation → Step 4 research-program (VA/DoD 2023; APA 2017 PMID 28291938; NICE NG116 2024)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — PCL-5 <31, no SI, functioning at baseline (VA/DoD 2023; APA 2017)

If you have:

Intrusive symptoms / nightmares / avoidance / hyperarousal at low baseline (DSM-5-TR 2022)
Sleep + appetite + concentration intact (DSM-5-TR 2022)
No suicidal thoughts (C-SSRS; Posner 2011 PMID 22193671)
Engaging with usual activities and relationships (VA/DoD 2023)

Do this:

Take SSRI / SNRI as prescribed every day — do not stop suddenly (VA/DoD 2023; APA 2017)
Continue trauma-focused psychotherapy attendance — homework, exposure tasks, cognitive restructuring as instructed (VA/DoD 2023; APA 2017 PMID 28291938)
Continue grounding + coping practices — 5-4-3-2-1 senses grounding, breathing exercises, safe-place imagery (VA/DoD 2023)
Keep follow-up appointments (VA/DoD 2023)
Keep crisis line numbers (988 US; 988 press 1 Veterans Crisis Line) available even when feeling well (VA/DoD 2023)
Maintain consistent sleep-wake schedule; minimise alcohol and recreational drugs; AVOID cannabis as PTSD treatment (VA/DoD 2023; ISTSS 2018)

YELLOW — Caution — PCL-5 rising or symptoms returning, increased nightmares / flashbacks / avoidance / hypervigilance, passive SI without plan (VA/DoD 2023)

If you have:

Increased intrusive memories / flashbacks / nightmares (DSM-5-TR 2022)
Increased avoidance of trauma reminders or expanded avoidance pattern
Increased hypervigilance / startle / irritability / concentration disturbance (DSM-5-TR 2022)
Sleep / appetite / concentration declining (DSM-5-TR 2022)
Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011 PMID 22193671)
Increased alcohol or substance use, or self-medicating with leftover benzodiazepines or cannabis (VA/DoD 2023)
Withdrawal from supports (VA/DoD 2023)
Dissociative episodes increasing in frequency or intensity

Do this:

Use grounding strategies — 5-4-3-2-1 senses, box breathing or 4-7-8 breathing, cold water on face, named-object focus, call a support person (VA/DoD 2023)
Use trauma-focused therapy skills — challenge stuck-point thoughts (CPT), exposure homework (PE), bilateral stimulation if EMDR (VA/DoD 2023; APA 2017)
Contact your provider for an early appointment — within 1 week (VA/DoD 2023)
Review medication adherence with provider — consider dose increase or augmentation if at adequate dose ≥8-12 weeks (VA/DoD 2023; APA 2017)
Avoid means of self-harm — lock or remove firearms (FIRST priority for veterans); secure or limit medications to short supply (VA/DoD 2023; Mann JAMA 2005 NEEDS_SOURCE_REVIEW)
Do NOT self-escalate benzodiazepine — call provider first to discuss; chronic benzo worsens PTSD (VA/DoD 2023; FDA 2016 black-box)
Do NOT use cannabis as PTSD treatment — associated with worse outcomes (VA/DoD 2023; ISTSS 2018)

Call your provider if:

Symptoms not improving after 2 weeks of self-care (VA/DoD 2023)
PCL-5 rises by ≥10 points (Blevins 2015 PMID 26606250)
Any thoughts of suicide become more frequent (VA/DoD 2023)
Functioning at work / home declines (VA/DoD 2023; APA 2017)
Considering self-escalating benzodiazepine dose or using cannabis (VA/DoD 2023)

RED — Medical alert — active SI with intent or plan, severe dissociative crisis with safety risk, recent suicide attempt, severe agitation with safety risk (VA/DoD 2023; APA 2017 PMID 28291938)

If you have:

Specific thoughts of how to end your life (C-SSRS; Posner 2011 PMID 22193671)
Access to means — firearms (CRITICAL for veterans), large-quantity meds (VA/DoD 2023)
Recent self-harm or attempt (VA/DoD 2023; APA 2017)
Severe dissociative episode with safety risk — unable to stay grounded / re-orient / keep yourself safe
Severe panic attack with chest pain in middle-aged / older adult — could be cardiac, treat as cardiac until proven otherwise (APA 2017; AHA / ACEP)
Severe shaking, confusion, hallucinations, sweating, racing heart after stopping or reducing benzodiazepines suddenly — possible life-threatening withdrawal (rare for PTSD patients but applies if benzo-dependent)
Inability to keep yourself safe (VA/DoD 2023)

Do this:

Call 988 (US) / Veterans Crisis Line (988 press 1 for veterans) / your local crisis line / emergency services NOW (VA/DoD 2023)
Go to the nearest emergency department; do not be alone (VA/DoD 2023)
Hand any means (firearms FIRST for veterans, pills) to a trusted person before going (VA/DoD 2023; Mann JAMA 2005 NEEDS_SOURCE_REVIEW)
Tell someone you trust what is happening (Stanley-Brown 2012)
Do not use alcohol or non-prescribed substances (VA/DoD 2023)
If severe benzo withdrawal suspected — do NOT abruptly stop further; go to ED + bring medication list

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (VA/DoD 2023; APA 2017)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in PTSD patient — PTSD elevates completed-suicide risk 4-7× general population (Bullman/Kang 1996 NEEDS_SOURCE_REVIEW); veterans 1.5× non-veteran rate predominantly firearm (VA/DoD 2023). Active SI routes to ED + psych.suicidality.ed.core.v1
Treatment-resistant PTSD = failure of ≥2 adequate trials of SSRI/SNRI from different classes at adequate dose × adequate duration (8-12 wk — PTSD responds slower than MDD) AND ≥1 trauma-focused therapy course completed (PE / CPT / EMDR / WET). Pseudo-resistance (subtherapeutic / inadequate duration / non-adherence / unrecognised bipolar / medical mimic — TSH, mTBI, cardiac, substance) ruled out FIRST
Comorbid SUD (AUD ~30-50%, OUD, stimulant) with PTSD — integrated concurrent treatment more effective than sequential (Back COPE 2019 NEEDS_SOURCE_REVIEW; Najavits Seeking Safety; VA/DoD 2023); routes to psych.alcohol_withdrawal.core.v1 OR psych.opioid_use_disorder.core.v1 if applicable; AVOID benzodiazepine in active SUD due to overdose synergy (FDA 2016 benzo + opioid black-box) and PTSD-worsening effects (VA/DoD 2023; ISTSS 2018; Guina 2015 NEEDS_SOURCE_REVIEW)
DSM-5-TR 2022 PTSD dissociative subtype (depersonalization + derealization) OR severe dissociation predominant in chronic PTSD or complex PTSD ICD-11 6B41 — responds less well to standard PE; CPT or schema-focused / phase-based therapy preferred (Cloitre ISTSS 2018 NEEDS_SOURCE_REVIEW); psychoeducation about dissociation + grounding skills; trauma-focused stabilization BEFORE exposure

5. Follow-up

Continue treatment ≥12 mo after remission for first episode (VA/DoD 2023; APA 2017); ≥2-3 yr or indefinite if recurrent / chronic; trauma-focused psychotherapy relapse-prevention; lifestyle (sleep hygiene, exercise 3-5×/wk × 30 min, alcohol reduction, social engagement, mindfulness / yoga as adjunct per VA/DoD 2023 low-strength)

6. Sources

Guideline: APA Clinical Practice Guideline for PTSD 2017 (PMID 28291938) + VA/DoD PTSD CPG 2023 (most-current US-government guidance) + NICE NG116 PTSD (2018, last updated 2024) + ISTSS 2018 Prevention and Treatment Guidelines + DSM-5-TR 2022 F43.10 / F43.0 / dissociative subtype + ICD-11 6B41 Complex PTSD