Psychiatry/Behavioral · PANCE / PANRE

Post-Traumatic Stress Disorder (PTSD)

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

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

Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.

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?
  • APost-traumatic stress disorder
  • BBipolar I disorder
  • CSchizophrenia
  • DAntisocial personality disorder
Reveal answer & full explanation
Correct answer: A — Post-traumatic stress disorder
  • APost-traumatic stress disorder✓
  • BBipolar I disorder
  • CSchizophrenia
  • DAntisocial 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.
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, 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
Reveal answer & full explanation
Correct answer: A — Trauma-focused psychotherapy
  • ATrauma-focused psychotherapy✓
  • BBuspirone maintenance therapy
  • CBrief supportive psychotherapy
  • DScheduled benzodiazepine therapy

Why Trauma-focused psychotherapy is correct

  • Six months of re-experiencing (nightmares, flashbacks), hyperarousal (hypervigilance, exaggerated startle), and avoidance after combat exposure with functional decline meets criteria for 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
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Risk factors

  • 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
  • Negative cognition/mood: inability to recall key aspects, persistent negative beliefs, distorted blame, persistent negative emotional state, anhedonia, detachment, inability to experience positive emotions
  • Arousal/reactivity: irritability/anger, reckless or self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance
  • Dissociative subtype: depersonalization or derealization

Signs / physical exam

  • Hyperarousal observable as exaggerated startle, scanning behavior, irritability in interview
  • PCL-5 score >=33 supports probable PTSD

Differential diagnosis

  • Acute stress disorder — Same symptom clusters within first 3 days to 1 month after trauma
  • Adjustment disorder — Stressor not meeting PTSD trauma criterion; subthreshold symptoms
  • 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) — Prolonged interpersonal trauma plus disturbances in self-organization (affect dysregulation, negative self-concept, relational disturbance)
  • 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

ClusterMin #Examples
B Intrusion1Flashbacks, nightmares, distress on cues
C Avoidance1Avoiding thoughts, places, people
D Negative cognition/mood2Negative beliefs, anhedonia, detachment
E Arousal/reactivity2Hypervigilance, 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 and paroxetine (FDA-approved), fluoxetine, escitalopram
  • SNRI — venlafaxine XR
  • Combine medication with trauma-focused therapy in moderate-to-severe symptoms

Second-line / adjunct

  • Prazosin — alpha-1 antagonist for trauma-related nightmares (mixed evidence in recent VA trials but still widely used)
  • Mirtazapine, nefazodone for sleep and depressive overlap
  • Atypical antipsychotic augmentation (risperidone, quetiapine) for refractory cases or psychotic features
  • AVOID benzodiazepines — worsen PTSD trajectory, interfere with extinction learning, dependence risk

Complications

  • Suicide — substantially elevated risk, particularly with comorbid depression
  • Substance use disorders (alcohol, opioids, cannabis)
  • Comorbid depression, panic disorder, chronic pain
  • Relationship and occupational disruption
  • Cardiovascular morbidity

PANCE pearls

  • Trauma criterion (A) is specific — vague life stressors (divorce, job loss) do not qualify; consider adjustment disorder instead.
  • Benzodiazepines are contraindicated in PTSD per VA/DoD guidelines — they impair fear extinction and worsen long-term outcomes.
  • Single-session psychological debriefing immediately after trauma does NOT prevent PTSD and may be harmful — avoid.
  • Screen veterans and survivors of interpersonal violence routinely with PC-PTSD-5 or PCL-5.

References

  • VA/DoD 2023 — VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder (2023)
  • APA 2017 — American Psychological Association Clinical Practice Guideline for the Treatment of PTSD in Adults (2017)
  • DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)

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Commonly confused with

vs Panic Disorder

Related Psychiatry/Behavioral diagnoses

Major Depressive Disorder (MDD)Bipolar I DisorderGeneralized Anxiety Disorder (GAD)Panic DisorderObsessive-Compulsive Disorder (OCD)SchizophreniaBorderline Personality Disorder (BPD)Antisocial Personality Disorder (ASPD)Attention-Deficit/Hyperactivity Disorder (ADHD)Autism Spectrum Disorder (ASD)Alcohol Use Disorder (AUD)Opioid Use Disorder (OUD)Stimulant Use DisorderAnorexia Nervosa

Differentials & related conditions

Adjustment Disorder

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.