Anxiety disorder: post-traumatic stress disorder
Overview
Differentiating trauma-related disorders
| Feature | Acute stress disorder | PTSD |
|---|---|---|
| Symptom duration | < 4 weeks post-trauma | > 4 weeks post-trauma |
| First-line treatment | Trauma-focused CBT | TF-CBT or EMDR |
| Second-line (if CBT fails) | SSRI (e.g. sertraline) | Sertraline or paroxetine (SSRI); venlafaxine (SNRI) |
Presentation
Four symptom clusters - must persist > 4 weeks and cause significant distress/functional impairment:
•Intrusion - flashbacks, nightmares, distress on exposure to trauma cues
•Avoidance - avoiding trauma-related thoughts, feelings, people, or places
•Negative cognition/mood - guilt, shame, emotional numbing, detachment, dissociative amnesia
•Hyperarousal - hypervigilance, exaggerated startle, insomnia, irritability, poor concentration
•Comorbidities - depression, alcohol/substance misuse, and suicidality are common and must be screened for
Management
🥇 First-line
•Trauma-focused CBT (TF-CBT) - 8-12 sessions; addresses trauma memory via exposure, cognitive restructuring, and anxiety management
•First-line (equal alternative): EMDR - bilateral stimulation while recalling trauma; facilitates memory processing, reducing emotional intensity
•Second-line (adults only): sertraline or paroxetine (SSRIs) - when patient declines therapy, cannot access it, or significant delay to referral; review every 2-4 weeks in first 3 months
•Second-line alternative: venlafaxine (SNRI) - if SSRIs not tolerated or ineffective
•Drug treatment is NOT recommended in under 18s - psychological therapy only
•Benzodiazepines - short-term only for acute agitation/severe sleep disturbance; not recommended long-term due to dependence risk