Trauma exposure plus intrusion, avoidance, negative cognition/mood, and arousal symptoms >1 month.
Also known as: PTSD, post-traumatic stress disorder, trauma response
Overview
A trauma- and stressor-related disorder developing after exposure to actual or threatened death, serious injury, or sexual violence (directly experienced, witnessed, learned about a close person, or repeated indirect exposure), characterized by intrusion, avoidance, negative alterations in cognition/mood, and alterations in arousal/reactivity persisting >1 month with functional impairment.
Epidemiology
Lifetime prevalence ~6-8% in the US; ~10% in women, ~4% in men. Higher in combat veterans (~10-20%), sexual assault survivors, refugees. Conditional probability after exposure varies by trauma type (highest for interpersonal violence).
Try two board-style Post-Traumatic Stress Disorder questions
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Question 1PsychiatryEasy
A 9-year-old girl is brought in after disclosing repeated sexual abuse by an adult relative over the past year. She has been having nightmares, school refusal, and new-onset enuresis. A child protective services report has been filed and she is in a safe placement. Which of the following long-term complications is she most likely to develop?
ASchizophrenia
BPost-traumatic stress disorder
CBorderline personality disorder
DBipolar I disorder
EAntisocial personality disorder
Reveal answer & full explanation
Correct answer: B — Post-traumatic stress disorder
ASchizophrenia
BPost-traumatic stress disorder✓
CBorderline personality disorder
DBipolar I disorder
EAntisocial personality disorder
Why post-traumatic stress disorder is correct
Repeated childhood sexual abuse is a major adverse childhood experience and one of the strongest known risk factors for later psychiatric morbidity.
PTSD is the most common long-term psychiatric complication of childhood sexual abuse; her nightmares (intrusion), school refusal (avoidance), and regressive new-onset enuresis are typical early trauma responses in a school-age child.
Depression and anxiety disorders are also frequent sequelae, but among the listed disorders PTSD has the strongest and most direct causal link to sexual trauma.
Why the others are wrong
Bipolar I disorder — a strongly heritable mood disorder; abuse is not its predominant cause and there are no manic features here. Trap: confusing trauma-related mood lability and irritability with mania (confused-with-bipolar).
Schizophrenia — risk is driven largely by genetics and early neurodevelopment; childhood adversity only modestly raises psychosis risk and there are no psychotic features. Trap: buzzword-matching severe trauma to severe (psychotic) illness.
Antisocial personality disorder — more strongly linked to childhood physical abuse, neglect, and early conduct disorder, predominantly in boys, and it cannot be diagnosed before age 18. Trap: anchoring on the intuition that abuse inevitably leads to antisocial behavior.
Borderline personality disorder — many adults with this disorder report childhood sexual abuse, but that statistic runs backward: most abused children never develop it, and its causes are multifactorial with a substantial heritable component, whereas PTSD is the far more common outcome. Trap: reversing a well-known association (abuse is common in the histories of borderline patients, but borderline personality is not the usual outcome of abuse).
Question 2PsychiatryMedium
A 28-year-old combat veteran presents with 6 months of recurrent nightmares about his deployment, intrusive daytime flashbacks, hypervigilance, and an exaggerated startle response. He avoids news coverage of the conflict and crowded places that remind him of his service, feels emotionally numb and estranged from his family, and his job performance has declined. He takes no medications and does not use substances. Which of the following is the most appropriate first-line treatment?
ATrauma-focused psychotherapy
BBuspirone maintenance therapy
CBrief supportive psychotherapy
DScheduled benzodiazepine therapy
EStructured psychological debriefing
Reveal answer & full explanation
Correct answer: A — Trauma-focused psychotherapy
ATrauma-focused psychotherapy✓
BBuspirone maintenance therapy
CBrief supportive psychotherapy
DScheduled benzodiazepine therapy
EStructured psychological debriefing
Why Trauma-focused psychotherapy is correct
Six months of intrusion (nightmares, flashbacks), avoidance (news coverage, crowds), negative alterations in cognition and mood (emotional numbness, estrangement from family), and hyperarousal (hypervigilance, exaggerated startle) after combat exposure with functional decline meets all four DSM-5-TR symptom clusters of post-traumatic stress disorder (PTSD)
Trauma-focused psychotherapy — prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing (EMDR) — is the first-line treatment, recommended over medication per current VA/DoD and APA guidance
Selective serotonin reuptake inhibitors (sertraline, paroxetine) are FDA approved for PTSD and are added when therapy is unavailable, declined, or insufficient
Prazosin is a targeted option specifically for trauma-related nightmares
Why the others are wrong
Buspirone maintenance therapy — buspirone has no established efficacy in PTSD; it tempts learners who buzzword-match anxiety symptoms to an anxiolytic without integrating the full post-traumatic syndrome
Brief supportive psychotherapy — supportive counseling is not trauma-focused and underperforms exposure-based therapies in PTSD; it sets the right-modality-wrong-intensity trap of defaulting to the gentlest-sounding option
Scheduled benzodiazepine therapy — benzodiazepines impair fear extinction, do not treat core PTSD symptoms, and are associated with worse outcomes; this catches anchoring on hypervigilance and poor sleep as simple anxiety or insomnia
Structured psychological debriefing — a structured retelling of the traumatic event sounds trauma-focused, but debriefing is an early post-incident intervention that has not been shown to prevent or treat PTSD, may worsen symptoms, and is recommended against; it sets the sounds-trauma-focused trap of mistaking event review for an evidence-based course of exposure or cognitive processing therapy
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Pre-trauma: prior psychiatric illness, childhood adversity, female sex, lower SES, family history
Peri-trauma: severity, perceived life threat, peritraumatic dissociation, interpersonal violence
Post-trauma: lack of social support, additional life stressors, ongoing threat
Pathophysiology
Dysregulated fear learning and extinction with amygdala hyperreactivity, reduced ventromedial prefrontal control, and hippocampal volume reduction. Elevated noradrenergic tone, altered HPA-axis with paradoxically low cortisol in some patients.
Clinical presentation
Symptoms
Intrusion: recurrent intrusive memories, distressing dreams, flashbacks, intense distress or physiological reactivity to cues
Avoidance: of trauma-related thoughts/feelings or external reminders
Major depressive disorder — May coexist; PTSD requires trauma exposure and intrusion phenomena
Panic disorder — Spontaneous panic attacks not tied to trauma cues
Complex PTSD (ICD-11) — ICD-11 only (not in DSM-5-TR): all core PTSD symptoms plus disturbances in self-organization (affect dysregulation, negative self-concept, relational disturbance), usually after prolonged interpersonal trauma; BPD instead centers on abandonment fear, an unstable self-image, and recurrent self-harm
TBI — Confounding cognitive symptoms; can co-occur
Substance-induced mood/anxiety — Symptoms in context of use or withdrawal
Diagnostic workup
Diagnostic criteria
DSM-5-TR: (A) Trauma exposure as defined; (B) >=1 intrusion symptom; (C) >=1 avoidance symptom; (D) >=2 negative cognition/mood symptoms; (E) >=2 arousal symptoms; (F) Duration >1 month; (G) Significant distress/impairment; (H) Not attributable to substance/medical condition. Specify dissociative subtype or delayed expression (>=6 months after event).
Labs
TSH, CBC, BMP; urine drug screen if substance use suspected
Sleep evaluation for nightmares and insomnia
Imaging
Not routinely indicated
Diagnostic algorithm
Cluster
Min #
Examples
B Intrusion
1
Flashbacks, nightmares, distress on cues
C Avoidance
1
Avoiding thoughts, places, people
D Negative cognition/mood
2
Negative beliefs, anhedonia, detachment
E Arousal/reactivity
2
Hypervigilance, startle, sleep disturbance
DSM-5-TR PTSD symptom clusters and minimum thresholds.
Treatment
First-line
Trauma-focused psychotherapy — prolonged exposure (PE), cognitive processing therapy (CPT), or eye movement desensitization and reprocessing (EMDR)
SSRI — sertraline or paroxetine (the only FDA-approved agents; recommended by VA/DoD 2023); fluoxetine has weaker guideline support
SNRI — venlafaxine XR
Trauma-focused psychotherapy is preferred over medication (VA/DoD 2023); use an SSRI/SNRI when psychotherapy is unavailable, declined, or insufficient — evidence for routinely combining medication with psychotherapy is insufficient
Second-line / adjunct
Prazosin — alpha-1 antagonist for trauma-related nightmares (mixed evidence in recent VA trials but still widely used)
Mirtazapine — off-label option for comorbid insomnia or depressive symptoms; evidence for PTSD itself is insufficient (VA/DoD 2023)
Atypical antipsychotic augmentation (risperidone, quetiapine) is NOT recommended — VA/DoD 2023 suggests against it given unproven benefit and metabolic/EPS harms; treat a comorbid psychotic disorder on its own terms
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.