PTSD and acute stress disorder — assessment and trauma-focused management (MEQ)

(i) Diagnosis and differentials. Working diagnosis: post-traumatic stress disorder following a qualifying Criterion A occupational trauma, duration greater than 1 month (here 8 weeks), with intrusion, avoidance, negative cognitions (guilt), numbing and hyperarousal, plus alcohol use as self-medication and comorbid depressive symptoms. ASD is excluded by duration greater than 1 month. Differentials: major depressive disorder alone (does not capture trauma-linked intrusions/avoidance); adjustment disorder (threshold exceeded); substance-induced sleep/mood disturbance (alcohol contributes but does not erase PTSD); prolonged grief if loss was personal (here professional exposure); primary psychosis unlikely without other features. Discriminators: temporal link to trauma, re-experiencing quality, avoidance of trauma cues.^[5]

(ii) Assessment. Trauma-informed pacing; establish ongoing safety and work capacity; full risk assessment expanding passive death wishes (intent, plan, means, protective factors, alcohol-related impulsivity); substance history and withdrawal risk; MSE including dissociation; collateral if available; occupational health interface. Measures: PCL-5 for baseline severity and monitoring; consider CAPS-5 if specialist diagnostic confirmation needed. Baseline labs/ECG before antidepressant if chosen; pregnancy status if relevant. Capacity and voluntary care preferred if safe.^[4]

(iii) Psychological treatment. First-line trauma-focused psychotherapy — e.g. prolonged exposure: imaginal exposure to the trauma memory and in vivo exposure to avoided safe cues to promote extinction and processing; alternatives CPT (stuck points), TF-CBT/cognitive therapy (Ehlers–Clark appraisals), or EMDR depending on availability and preference. Typically multi-session protocol with measurement of PCL-5. Address alcohol in parallel (motivational work; may need stabilisation if dependence severe).^[1][5]

(iv) Medication if therapy declined. Example: sertraline 50 mg orally each morning (consider 25 mg start if anxious/sensitive), review early for activation/suicidality and side-effects, titrate toward 100–150 mg as tolerated, assess response over about 6–12 weeks at therapeutic dose. Monitor sexual side-effects, GI symptoms, sleep, alcohol interactions conceptually, and mood/risk. Paroxetine or venlafaxine XR are alternatives with PTSD evidence.^[2]

(v) Prazosin. May be considered for prominent trauma nightmares based on noradrenergic rationale and earlier positive studies, but the large multi-site veteran RCT did not show benefit over placebo — counsel equipoise, monitor BP/falls if trialled, and do not substitute for trauma-focused treatment of core PTSD.^[3]