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psych.ptsd.core.v1PRODUCTION
psych.ptsd.core.v1

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)

psychiatrychronicacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 PTSD criteria — trauma exposure (criterion A) + intrusion (B) + avoidance (C) + negative cognition / mood (D) + arousal / reactivity (E); ≥1 mo duration (F43.10); functional impairment; not better explained by SUD / medical / TBI / bipolar / panic / OCD. Distinguish from ASD F43.0 (3 d – 1 mo) and complex PTSD ICD-11 6B41 (DSM-5-TR 2022; APA 2017 PMID 28291938; VA/DoD 2023)

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PTSD criteria met and bipolar / TBI / panic / OCD ruled out

Patient inputs (20)

Drug selection + dose; pediatric (FDA black-box adolescent suicidality 2004; AACAP 2010; Cohen TF-CBT); geriatric (Beers 2023 AVOID benzo, lower SSRI start dose; VA/DoD 2023)

SSRI choice (sertraline preferred for lactation; paroxetine AVOIDED FDA Category D); MFM coordination if severe (APA reproductive psychiatry; VA/DoD 2023)

DSM-5-TR PTSD criterion A — direct experience / witnessed / learned / repeated exposure to actual or threatened death, serious injury, or sexual violence; trauma-type axis drives setting + cross-routing (combat → VA, sexual assault → SANE / forensic considerations, childhood → cPTSD)

PFA <3 d / ASD 3 d – 1 mo / acute PTSD 1-3 mo / subacute 3-12 mo / chronic >12 mo — drives treatment selection: PFA + watchful waiting in PFA window; brief TF-CBT in ASD; first-line PE / CPT / EMDR in PTSD (DSM-5-TR 2022; VA/DoD 2023)

PHQ-9 — 50-70% comorbid MDD in PTSD (VA/DoD 2023); Q9 flags suicidality; informs SNRI vs SSRI choice (Kroenke 2001 PMID 11556941)

Prior trauma-focused psychotherapy / SSRI / SNRI response determines next step in ladder; treatment-resistant gateway = ≥2 SSRI/SNRI + ≥1 TF-therapy course failed (VA/DoD 2023; APA 2017 PMID 28291938)

Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; STEP-BD via psych.bipolar-disorder.core.v1 sibling)

Comorbid SUD 30-50% (AUD especially); integrated concurrent treatment more effective than sequential (Back COPE 2019 NEEDS_SOURCE_REVIEW; Najavits Seeking Safety); AVOID benzo in active SUD (VA/DoD 2023; FDA 2016 black-box benzo+opioid)

CV / renal / hepatic / seizure / sleep apnea affect drug choice + workup; cardiovascular morbidity elevated in chronic PTSD (Edmondson NEEDS_SOURCE_REVIEW; VA/DoD 2023)

MAOI washout 14 d; serotonergic load (SSRI + SNRI + tramadol + linezolid risk); CYP interactions; QTc; benzo + opioid overdose synergy (FDA 2016); SSRI + NSAID bleeding; antipsychotic dose if augmenting

Hyperthyroidism mimics anxiety / hyperarousal — baseline before initiating SSRI; LR+ ≈20 if TSH suppressed + free T4 high (VA/DoD 2023)

C-SSRS — PTSD substantially elevates completed-suicide risk (4-7× general population; veterans 1.5× non-veteran predominantly firearm); FDA 2004 black-box adolescent surveillance; mandatory at intake + first 4 wk of any new antidepressant (Posner 2011 PMID 22193671; VA/DoD 2023)

PCL-5 stratifies severity → TF-psychotherapy + SSRI/SNRI intensity (Blevins 2015 PMID 26606250; cutoff ≥33; VA populations may use higher 38-44)

GAD-7 — PTSD-anxiety overlap common (panic, GAD); informs comorbidity routing (Spitzer 2006 PMID 16717171; psych.anxiety-disorders.core.v1 cross-route)

VA eligibility + combat exposure (OEF/OIF Hoge NEJM 2004 PMID 15229303) — drives VA evidence-based program access (PE / CPT / EMDR / VA CBT-I); firearm means-restriction emphasis (veterans 1.5× completed-suicide rate predominantly firearm; VA/DoD 2023)

mTBI screen in combat veterans (LOC / AOC / PTA + symptom checklist); mTBI-PTSD symptom overlap; concurrent cognitive rehabilitation referral if positive (Hoge NEJM 2008 PMID 18234750; VA/DoD 2023)

Baseline before therapy; rule out anemia / occult illness

Baseline electrolytes + glucose; SIADH risk on SSRI in elderly (Beers 2023 NEEDS_SOURCE_REVIEW; APA 2017)

Hepatic-cleared agents; duloxetine LFT monitoring (APA 2017; VA/DoD 2023)

QTc baseline before citalopram >20 mg (FDA 2012) or atypical-antipsychotic augmentation (quetiapine); cardiac r/o in chronic-PTSD-elevated-cardiovascular-morbidity (VA/DoD 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseveresevere_ptsd_with_suicidal_ideation
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_resistant_ptsd_after_psychotherapy_plus_ssri
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomorbid_substance_use_disorder_in_ptsd
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredissociation_severe_or_dissociative_subtype
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateveteran_with_combat_ptsd_va_resources
    VA-eligible veteran or active-duty / National Guard / Reserves member with combat-related PTSD — VA-specific evidence-based programs (PE / CPT / EMDR / VA CBT-I); PCL-5 + CAPS-5 routine measurement; mTBI screen (Hoge NEJM 2008 PMID 18234750); firearm means-restriction emphasised (veterans 1.5× non-veteran completed-suicide rate predominantly firearm — Bullman/Kang 1996 NEEDS_SOURCE_REVIEW); ACT-tracked outcomes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_ptsd_with_caregiver_involvement
    Pediatric / adolescent (6-17) PTSD presenting for treatment — TF-CBT FIRST-LINE per AACAP 2010 (NEEDS_SOURCE_REVIEW) + Cohen TF-CBT RCTs (NEEDS_SOURCE_REVIEW); caregiver inclusion essential; school + family-system intervention; SSRI second-line (sertraline / fluoxetine — both off-label for pediatric PTSD though FDA-approved for pediatric OCD / MDD) only if psychotherapy inadequate or comorbid MDD; FDA 2004 black-box monitoring Q1-2 wk × 4 wk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_with_ptsd_medication_decision
    Pregnancy with PTSD medication decision — psychotherapy preferred (PE / CPT / EMDR / WET); sertraline acceptable SSRI if needed; paroxetine AVOIDED (FDA Category D cardiac teratogenicity); valproate / long-term benzo NEVER; coordinate with MFM if severe disease
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenightmares_persistent_despite_treatment
    Persistent trauma-related nightmares despite first-line trauma-focused psychotherapy + SSRI/SNRI — Image Rehearsal Therapy (IRT — Krakow 2001 PMID 11519951) first-line; prazosin trial as adjunct (low-strength after PACT 2018 PMID 29414272 negative for overall PTSD; VA/DoD 2023 retains for nightmares); sleep-quality impact assessment + CBT-I
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildacute_stress_disorder_within_1mo_of_trauma
    PTSD-spectrum symptoms within 3 days – 1 month post-trauma — DSM-5-TR 2022 Acute Stress Disorder F43.0. Brief trauma-focused CBT first-line (VA/DoD 2023; NICE NG116 2024); pharmacotherapy NOT first-line; do NOT use benzodiazepines (Mellman 2002 NEEDS_SOURCE_REVIEW — worsens PTSD-development risk); do NOT use routine single-session critical incident stress debriefing (CISD) — harmful (Cochrane Rose 2002 PMID 11869658). Reassess at 1 mo for PTSD transition with PCL-5
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildacute_traumatic_event_for_screening_or_psychological_first_aid
    Recent traumatic event (<3 days post-trauma window) — Psychological First Aid (PFA — NCTSN / WHO 2011); do NOT prescribe benzodiazepines (Mellman 2002 NEEDS_SOURCE_REVIEW — worsens PTSD-development risk); do NOT use routine single-session critical incident stress debriefing (CISD) — harmful (Cochrane Rose 2002 PMID 11869658); observe at 1 mo for PTSD transition with PCL-5
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: ptsd_stepwise_pharmacotherapystep 1 - Step 1 — SSRI or SNRI first-line when pharmacotherapy chosen (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 conditional recommendation)
Selected step "Step 1 — SSRI or SNRI first-line when pharmacotherapy chosen (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 conditional recommendation)" — PCL-5 ≥33 OR clinical-diagnostic PTSD with functional impairment, no prior failure, no contraindication; trauma-focused psychotherapy preferred-first if available + patient willing/able (VA/DoD 2023)
  • sertraline
    first line
    SSRI
    25 mg PO daily × 1-2 wk → 50 mg → titrate • PO • once daily (max: 200 mg/day)
    triggers: FDA_approved_for_PTSD, pregnancy, lactation, comorbid_MDD, pediatric_PTSD_off_label
    FDA-approved for PTSD; preferred in pregnancy + lactation; among most effective + tolerable in Cipriani 2018 NMA PMID 29477251; VA/DoD 2023 strong recommendation
    rxcui 36437
  • paroxetine
    first line
    SSRI
    10 mg PO daily × 1 wk → 20 mg → titrate • PO • once daily (max: 50 mg/day)
    triggers: FDA_approved_for_PTSD
    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)
    rxcui 32937
  • venlafaxine
    first line
    SNRI
    37.5–75 mg PO daily (XR) • PO • once daily (max: 300 mg/day for PTSD)
    triggers: comorbid_MDD_dual_indication, comorbid_neuropathic_pain, SSRI_intolerant
    VA/DoD 2023 strong recommendation for PTSD; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (Horowitz 2019 NEEDS_SOURCE_REVIEW)
    rxcui 39786
  • fluoxetine
    second line
    SSRI
    10–20 mg PO daily (mornings to avoid insomnia) • PO • once daily (max: 60 mg/day)
    triggers: adolescent_PTSD_off_label_AACAP_aligned, desired_long_half_life
    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
    rxcui 4493
  • citalopram
    second line
    SSRI
    10–20 mg PO daily • PO • once daily (max: 40 mg/day (20 mg if >60 yr or CYP2C19 poor metaboliser per FDA 2012 QTc))
    Effective; FDA 2012 QTc warning caps dose 20 mg in elderly; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
    rxcui 2556
  • escitalopram
    second line
    SSRI
    5–10 mg PO daily • PO • once daily (max: 20 mg/day)
    triggers: comorbid_anxiety_disorders
    Most effective SSRI for anxiety per Cipriani 2018 NMA PMID 29477251; QTc concern at higher doses; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
    rxcui 321988
  • duloxetine
    second line
    SNRI
    30 mg PO daily × 1 wk → 60 mg • PO • once daily (max: 120 mg/day)
    triggers: comorbid_neuropathic_pain, fibromyalgia_chronic_pain
    SNRI with neuropathic-pain + fibromyalgia indication; less PTSD-specific evidence than venlafaxine; LFT monitoring (APA 2017)
    rxcui 72625

outpatient playbook — drug actions (4)

  1. 1. sertraline OR paroxetine OR venlafaxine XR
    Sertraline 25 → 200; paroxetine 10 → 50 (AVOID pregnancy); venlafaxine XR 37.5-75 → 300 for PTSD (HTN monitor) • PO • daily
    trigger: PCL-5 ≥33 + functional impairment OR clinical-diagnostic PTSD (DSM-5-TR criteria) when pharmacotherapy chosen (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 conditional recommendation)
    First-line SSRI / SNRI per VA/DoD 2023 + APA 2017; sertraline + paroxetine FDA-approved for PTSD; venlafaxine VA/DoD 2023 strong recommendation; trauma-focused psychotherapy preferred-first if available + patient willing/able
  2. 2. switch class (SSRI → SNRI or within-class SSRI switch)
    Per agent • PO • daily
    trigger: Failure / intolerance at adequate dose × 8-12 wk (PTSD responds slower than MDD — full 12 wk often needed)
    STAR*D-style framework adapted to PTSD; pseudo-resistance ruled out FIRST (subtherapeutic / inadequate duration / non-adherence / unrecognised bipolar / medical mimic) (VA/DoD 2023; APA 2017)
  3. 3. augmentation
    Prazosin 1 mg QHS → 5-15 mg (nightmares only; orthostatic BP monitor); quetiapine 25-50 → 100-300 mg (metabolic monitor); topiramate 25 → 100-400 mg (cognitive SE); trazodone 25-100 mg QHS (sleep); mirtazapine 7.5 → 45 mg QHS (sleep + appetite) • PO • daily
    trigger: Treatment-resistant after ≥2 adequate SSRI/SNRI trials of different classes (VA/DoD 2023; APA 2017)
    VA/DoD 2023 + APA 2017 augmentation options; psychiatry referral mandatory at this stage; consider research-program MDMA-AT / ketamine-AT if available (Step 4)
  4. 4. short-term benzodiazepine — ACUTE CRISIS ONLY, NEVER chronic
    Lorazepam 0.5-1 mg PO/SL PRN — single dose for acute-crisis containment only • PO/SL • PRN acute crisis only
    trigger: Severe acute dissociative crisis / panic-attack overlay with safety risk — NEVER long-term, NEVER in acute-stress-disorder window (VA/DoD 2023; ISTSS 2018; Guina 2015 NEEDS_SOURCE_REVIEW; Mellman 2002 NEEDS_SOURCE_REVIEW)
    CRITICAL anti-pattern: benzo for chronic PTSD worsens outcomes + dependence + interferes with extinction learning; acute-crisis single-dose only; AVOID in active SUD + elderly (Beers 2023 NEEDS_SOURCE_REVIEW; FDA 2016 benzo + opioid black-box)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Intrusive memories / flashbacks / nightmares / intense distress on trauma reminder (DSM-5-TR 2022 PTSD criterion B; F43.10); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**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)** (psych.ptsd.core.v1).
Phenotype framing: Adjustment disorder vs Acute Stress Disorder F43.0 vs PTSD F43.10 vs PTSD with dissociative subtype vs Complex PTSD ICD-11 6B41 vs MDD with trauma-related features vs panic disorder vs GAD vs bipolar-mixed-features vs hyperthyroidism vs mTBI vs substance-induced (DSM-5-TR 2022; APA 2017 PMID 28291938; VA/DoD 2023)
Scope: Confirm DSM-5-TR 2022 PTSD criteria — trauma exposure (criterion A) + intrusion (B) + avoidance (C) + negative cognition / mood (D) + arousal / reactivity (E); ≥1 mo duration (F43.10); functional impairment; not better explained by SUD / medical / TBI / bipolar / panic / OCD. Distinguish from ASD F43.0 (3 d – 1 mo) and complex PTSD ICD-11 6B41 (DSM-5-TR 2022; APA 2017 PMID 28291938; VA/DoD 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — SSRI or SNRI first-line when pharmacotherapy chosen (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 conditional recommendation)".
1. sertraline 25 mg PO daily × 1-2 wk → 50 mg → titrate PO once daily (SSRI, first line) — FDA-approved for PTSD; preferred in pregnancy + lactation; among most effective + tolerable in Cipriani 2018 NMA PMID 29477251; VA/DoD 2023 strong recommendation
2. paroxetine 10 mg PO daily × 1 wk → 20 mg → titrate PO once daily (SSRI, first line) — 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)
3. venlafaxine 37.5–75 mg PO daily (XR) PO once daily (SNRI, first line) — VA/DoD 2023 strong recommendation for PTSD; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (Horowitz 2019 NEEDS_SOURCE_REVIEW)
4. fluoxetine 10–20 mg PO daily (mornings to avoid insomnia) PO once daily (SSRI, second line) — 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
5. citalopram 10–20 mg PO daily PO once daily (SSRI, second line) — Effective; FDA 2012 QTc warning caps dose 20 mg in elderly; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
6. escitalopram 5–10 mg PO daily PO once daily (SSRI, second line) — Most effective SSRI for anxiety per Cipriani 2018 NMA PMID 29477251; QTc concern at higher doses; less PTSD-specific evidence than sertraline / paroxetine / venlafaxine
7. duloxetine 30 mg PO daily × 1 wk → 60 mg PO once daily (SNRI, second line) — SNRI with neuropathic-pain + fibromyalgia indication; less PTSD-specific evidence than venlafaxine; LFT monitoring (APA 2017)

Setting playbook (outpatient) — Trauma-focused psychotherapy first-line (PE / CPT / EMDR / WET) ± SSRI / SNRI stepwise pharmacotherapy with serial PCL-5 + PHQ-9 + GAD-7 + AUDIT-C + C-SSRS surveillance to remission and ≥12-month maintenance (VA/DoD 2023; APA 2017 PMID 28291938; NICE NG116 2024; ISTSS 2018)
8. sertraline OR paroxetine OR venlafaxine XR Sertraline 25 → 200; paroxetine 10 → 50 (AVOID pregnancy); venlafaxine XR 37.5-75 → 300 for PTSD (HTN monitor) PO daily — PCL-5 ≥33 + functional impairment OR clinical-diagnostic PTSD (DSM-5-TR criteria) when pharmacotherapy chosen (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 conditional recommendation) (First-line SSRI / SNRI per VA/DoD 2023 + APA 2017; sertraline + paroxetine FDA-approved for PTSD; venlafaxine VA/DoD 2023 strong recommendation; trauma-focused psychotherapy preferred-first if available + patient willing/able)
9. switch class (SSRI → SNRI or within-class SSRI switch) Per agent PO daily — Failure / intolerance at adequate dose × 8-12 wk (PTSD responds slower than MDD — full 12 wk often needed) (STAR*D-style framework adapted to PTSD; pseudo-resistance ruled out FIRST (subtherapeutic / inadequate duration / non-adherence / unrecognised bipolar / medical mimic) (VA/DoD 2023; APA 2017))
10. augmentation Prazosin 1 mg QHS → 5-15 mg (nightmares only; orthostatic BP monitor); quetiapine 25-50 → 100-300 mg (metabolic monitor); topiramate 25 → 100-400 mg (cognitive SE); trazodone 25-100 mg QHS (sleep); mirtazapine 7.5 → 45 mg QHS (sleep + appetite) PO daily — Treatment-resistant after ≥2 adequate SSRI/SNRI trials of different classes (VA/DoD 2023; APA 2017) (VA/DoD 2023 + APA 2017 augmentation options; psychiatry referral mandatory at this stage; consider research-program MDMA-AT / ketamine-AT if available (Step 4))
11. short-term benzodiazepine — ACUTE CRISIS ONLY, NEVER chronic Lorazepam 0.5-1 mg PO/SL PRN — single dose for acute-crisis containment only PO/SL PRN acute crisis only — Severe acute dissociative crisis / panic-attack overlay with safety risk — NEVER long-term, NEVER in acute-stress-disorder window (VA/DoD 2023; ISTSS 2018; Guina 2015 NEEDS_SOURCE_REVIEW; Mellman 2002 NEEDS_SOURCE_REVIEW) (CRITICAL anti-pattern: benzo for chronic PTSD worsens outcomes + dependence + interferes with extinction learning; acute-crisis single-dose only; AVOID in active SUD + elderly (Beers 2023 NEEDS_SOURCE_REVIEW; FDA 2016 benzo + opioid black-box))

Non-pharmacologic actions:
- Trauma-focused psychotherapy FIRST-LINE — PE (Prolonged Exposure; Foa) / CPT (Cognitive Processing Therapy; Resick) / EMDR (Shapiro) / WET (Written Exposure Therapy; Sloan) — preferred over pharmacotherapy when available and patient willing/able (VA/DoD 2023 strong recommendation; APA 2017 PMID 28291938 strong recommendation; NICE NG116 2024)
- Phase-based therapy with stabilization-before-exposure for complex PTSD / dissociative subtype (Cloitre ISTSS 2018 NEEDS_SOURCE_REVIEW)
- CBT-I first-line for residual insomnia (>90% of PTSD patients have sleep disturbance) — Sleepio / Somryst FDA-cleared; AVOID chronic benzo (AASM 2017; VA/DoD 2023)
- Image Rehearsal Therapy (IRT) for trauma-related nightmares (Krakow JAMA 2001 PMID 11519951) — first-line; prazosin trial as adjunct if IRT insufficient
- Sleep hygiene, exercise prescription 30 min × 3-5 days/week moderate-intensity aerobic (VA/DoD 2023 — adjunct anxiolytic / mood effect); reduce alcohol; address substance use disorders concurrently (Back COPE 2019 NEEDS_SOURCE_REVIEW; Najavits Seeking Safety; VA/DoD 2023)
- Psychoeducation on medication course — 8-12 weeks to full onset (PTSD responds slower than MDD); ≥12 mo after remission first episode (VA/DoD 2023; APA 2017)
- Family / caregiver involvement with consent — particularly important for veterans and pediatric PTSD (VA/DoD 2023; AACAP 2010 NEEDS_SOURCE_REVIEW)
- Horowitz hyperbolic taper plan documented at the moment any SSRI / SNRI discontinuation is considered — receptor-occupancy-anchored 50% step-downs (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW); paroxetine and venlafaxine highest withdrawal burden — taper over ≥4 weeks minimum
- Firearm means-restriction counseling for ALL veterans with PTSD + any SI history — lock-box / off-site storage / family transfer; large-quantity-medication-restriction; vehicle / sharp-object review (Mann JAMA 2005 NEEDS_SOURCE_REVIEW; Stanley-Brown 2012; VA/DoD 2023 — veterans 1.5× non-veteran completed-suicide rate predominantly firearm)
- Stanley-Brown 2012 safety-plan documented and reviewed at every visit for any patient with current or historical SI — 6 steps: warning signs / internal coping / people-for-distraction / people-for-support / professionals-and-agencies / means-restriction
- MDQ administered before every SSRI initiation in patient with no prior antidepressant trial history AND at every visit during induction in patients with any risk indicator (family-history bipolar / early-onset MDE / atypical features / antidepressant-induced switch history) — avoids antidepressant-induced manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW)
- Social-determinants-of-health screen + referral (housing, food security, transportation, employment, social isolation, IPV / abuse, financial stress) — all are PTSD prognostic factors and modifiable via care-navigator / social-work referral (VA/DoD 2023)
- Mindfulness-based stress reduction (MBSR) + yoga + acupuncture — VA/DoD 2023 low-strength adjunctive recommendation; NOT first-line
- Explicit recommendation against cannabis as PTSD treatment — observational evidence shows associated with worse outcomes (VA/DoD 2023; ISTSS 2018)
- Explicit recommendation against routine single-session critical incident stress debriefing (CISD) — Cochrane Rose 2002 PMID 11869658 demonstrates harm or ineffectiveness; VA/DoD 2023 + NICE NG116 2024
- Relapse-prevention plan documented at remission — continuation phase ≥12 mo first episode; ≥2-3 yr or indefinite recurrent / chronic (VA/DoD 2023; APA 2017)
- Patient education on 988 Suicide & Crisis Lifeline + Veterans Crisis Line (988 press 1 for veterans) — both available for all PTSD patients in green / yellow / red zones

AVOID / contraindication checks:
- MAOI_washout_14_days_before_after (APA 2017; FDA)
- No_routine_long_term_benzodiazepine_for_ptsd (VA/DoD 2023; ISTSS 2018; Guina 2015 NEEDS_SOURCE_REVIEW)
- No_benzodiazepine_in_acute_stress_disorder_window (Mellman 2002 NEEDS_SOURCE_REVIEW; VA/DoD 2023)
- No_routine_single_session_debriefing_post_trauma_HARMFUL (Cochrane Rose 2002 PMID 11869658; VA/DoD 2023; NICE NG116 2024)
- No_cannabis_as_ptsd_treatment (VA/DoD 2023; ISTSS 2018)
- Benzo_plus_opioid_overdose_synergy_avoid_FDA_2016_black_box
- Paroxetine_avoid_pregnancy_first_trimester (FDA Category D; APA reproductive psychiatry)
- Citalopram_QTc_dose_cap_20mg_elderly (FDA 2012)
- Horowitz_hyperbolic_taper_mandatory_for_any_SSRI_SNRI_discontinuation (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW)
- Serotonin_syndrome_avoid_combo_serotonergic_SSRI_SNRI_tramadol_MAOI_linezolid (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW; APA 2023)
- SSRI_NSAID_anticoag_bleeding_caution (APA 2017)
- SSRI_hyponatremia_elderly_SIADH (Beers 2023 NEEDS_SOURCE_REVIEW; APA 2017)
- Fluoxetine_paroxetine_tamoxifen_CYP2D6_avoid (FDA 2011; APA 2017)
- Atypical_antipsychotic_only_as_augmentation_not_first_line (VA/DoD 2023; APA 2017)
- Prazosin_adjunct_only_for_nightmares_not_monotherapy_for_PTSD (Raskind PACT 2018 PMID 29414272; VA/DoD 2023)
- Prazosin_first_dose_effect_syncope_give_QHS_and_monitor_orthostatic_BP
- Topiramate_renal_dose_adjust_and_cognitive_side_effects
- Quetiapine_metabolic_monitoring_weight_A1c_lipids_QTc
- Beers_2023_AVOID_benzodiazepine_in_elderly_geq_65
- MDQ_screen_before_initiating_SSRI_in_suspected_bipolar (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; CANMAT 2014)
- C_SSRS_at_first_4_weeks_of_any_new_antidepressant (FDA 2004 black box adolescent reassessment)
- Firearm_means_restriction_for_veterans_with_any_SI_history (VA/DoD 2023; Mann JAMA 2005 NEEDS_SOURCE_REVIEW)

Monitoring

Regimen monitoring:
- PCL-5 at 4 8 12 weeks then Q3 months (VA/DoD 2023; APA 2017 PMID 28291938)
- PHQ-9 at every visit for comorbid MDD tracking and SI flag (Kroenke 2001 PMID 11556941; VA/DoD 2023)
- GAD-7 at every visit if anxiety comorbid (Spitzer 2006 PMID 16717171)
- AUDIT-C Q3 6 months for AUD comorbidity (VA/DoD 2023)
- C SSRS at first 4 weeks of new antidepressant (FDA 2004 black-box; VA/DoD 2023)
- Side effect screen q visit (APA 2017; VA/DoD 2023)
- Sodium at 2 4 weeks in elderly on SSRI (Beers 2023 NEEDS SOURCE REVIEW; APA 2017)
- BP on SNRI especially venlafaxine (APA 2017; VA/DoD 2023)
- LFT at baseline and 3 mo on duloxetine (APA 2017)
- Orthostatic BP on prazosin titration (PACT 2018 PMID 29414272)
- Metabolic monitoring q3 6 mo on quetiapine augmentation weight A1c lipids QTc (APA 2017; ADA-APA 2004)
- Continue >=12mo after remission first episode (VA/DoD 2023; APA 2017 PMID 28291938)
- Continue >=2 3yr or indefinite if recurrent or chronic (VA/DoD 2023; APA 2017)

Setting (outpatient) monitoring:
- PCL-5 at 4, 8, 12 weeks then Q3 months (VA/DoD 2023; APA 2017)
- PHQ-9 q visit for comorbid MDD tracking + SI flag (Kroenke 2001 PMID 11556941)
- GAD-7 q visit if anxiety comorbid (Spitzer 2006 PMID 16717171)
- AUDIT-C Q3-6 months for AUD comorbidity (VA/DoD 2023)
- C-SSRS at every visit for first 4 weeks of any new antidepressant (FDA 2004 black-box; VA/DoD 2023)
- Side-effect screen q visit (APA 2017; VA/DoD 2023)
- Sodium at 2-4 weeks if elderly on SSRI (Beers 2023 NEEDS_SOURCE_REVIEW; APA 2017)
- BP on SNRI especially venlafaxine (APA 2017; VA/DoD 2023)
- Orthostatic BP on prazosin titration (PACT 2018 PMID 29414272)
- Metabolic monitoring Q3-6 months on quetiapine augmentation — weight, A1c, lipids, QTc (APA 2017; ADA-APA 2004 NEEDS_SOURCE_REVIEW)

Follow-up plan: 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)
- Close-out criterion: Maintenance plan in place

Monitoring phase: PCL-5 at 4, 8, 12 weeks then Q3 months (VA/DoD 2023); PHQ-9 + GAD-7 at every visit for comorbid MDD / anxiety tracking; AUDIT-C Q3-6 months; C-SSRS at every visit during first 4 wk of any new antidepressant (FDA 2004 black-box); side-effect screen (sexual, GI, sleep, weight, hyponatremia in elderly); response = ≥10-point PCL-5 reduction; remission = PCL-5 <31 + functional recovery

Disposition

Current setting: outpatient — Trauma-focused psychotherapy first-line (PE / CPT / EMDR / WET) ± SSRI / SNRI stepwise pharmacotherapy with serial PCL-5 + PHQ-9 + GAD-7 + AUDIT-C + C-SSRS surveillance to remission and ≥12-month maintenance (VA/DoD 2023; APA 2017 PMID 28291938; NICE NG116 2024; ISTSS 2018)

Disposition criteria:
- Continue current step if responding — ≥10-point PCL-5 reduction (VA/DoD 2023; APA 2017)
- Step up if inadequate response at adequate dose / duration 8-12 wk (VA/DoD 2023; APA 2017)
- Refer to psychiatry if at Step 3 augmentation or beyond, complex comorbidity, pregnancy, treatment-resistance, or Step 4 research-program consideration (VA/DoD 2023; APA 2017 PMID 28291938)
- Refer to VA evidence-based program for VA-eligible veterans (VA/DoD 2023; Hoge NEJM 2004 PMID 15229303)

Escalation triggers (move to higher acuity):
- Active SI with intent / plan / means → ED + cross-route to psych.suicidality.ed.core.v1 (Posner 2011 PMID 22193671; VA/DoD 2023)
- Severe dissociative crisis with safety risk → ED + Stanley-Brown safety plan + consideration of inpatient admission
- Antidepressant-induced manic switch → discontinue antidepressant + mood-stabiliser bridge + cross-route to psych.bipolar-disorder.core.v1
- Serotonin syndrome features → ED + workup.hyperthermic_toxidromes (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW)
- Pregnancy / postpartum with severe PTSD → urgent reproductive psychiatry + OB consult (APA reproductive psychiatry; VA/DoD 2023)
- Functional collapse with safety concern → partial-hospital / IOP or inpatient psychiatry (VA/DoD 2023; APA 2017)
- Treatment-resistant PTSD (≥2 SSRI/SNRI + ≥1 TF-therapy course failed) → psychiatry specialist referral; consider MDMA-AT / ketamine-AT in research program if available (VA/DoD 2023; Mitchell Nature Med 2021 PMID 33972795)

Patient Action Plan

**PTSD action plan + trauma-trigger coping + Stanley-Brown 2012 safety plan (VA/DoD 2023; APA 2017 PMID 28291938; NICE NG116 2024)**
Personalised values: baseline_PCL5, baseline_PHQ9, baseline_GAD7, current_medication_list, identified_supports, crisis_line_numbers_988_and_988_press_1_veterans, reasons_for_living, means_restriction_steps_firearms_first_for_veterans, identified_trauma_triggers, grounding_strategies.

**Doing well — PCL-5 <31, no SI, functioning at baseline (VA/DoD 2023; APA 2017)** (green):
Triggers:
- 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)
Actions:
- 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)

**Caution — PCL-5 rising or symptoms returning, increased nightmares / flashbacks / avoidance / hypervigilance, passive SI without plan (VA/DoD 2023)** (yellow):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- 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)

**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)** (red):
Triggers:
- 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)
Actions:
- 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
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (VA/DoD 2023; APA 2017)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] 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
- [SEVERE] 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
- [SEVERE] 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)

Citations

- 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 [PMID:28291938](https://pubmed.ncbi.nlm.nih.gov/28291938/)
- Cited evidence (PMID 22193671) [PMID:22193671](https://pubmed.ncbi.nlm.nih.gov/22193671/)
- Cited evidence (PMID 11556941) [PMID:11556941](https://pubmed.ncbi.nlm.nih.gov/11556941/)
- Cited evidence (PMID 16717171) [PMID:16717171](https://pubmed.ncbi.nlm.nih.gov/16717171/)
- Cited evidence (PMID 33972795) [PMID:33972795](https://pubmed.ncbi.nlm.nih.gov/33972795/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:28291938
  • Cited evidence (PMID 22193671) — PMID:22193671
  • Cited evidence (PMID 11556941) — PMID:11556941
  • Cited evidence (PMID 16717171) — PMID:16717171
  • Cited evidence (PMID 33972795) — PMID:33972795