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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Post-traumatic stress disorder

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Trauma-related crisis with immediate danger

Suicidal intent, violent danger, ongoing abuse, trafficking, severe dissociation with unsafe wandering, psychosis, inability to care for dependants or acute intoxication or withdrawal requires immediate safety action before routine trauma processing.

Action: Establish current location and threat, use ABCDE for injury or intoxication, assess suicide and access to means, and create a risk-management and safeguarding plan. Involve emergency, crisis and specialist services and trusted supports as appropriate without requiring a detailed trauma narrative during crisis.

Overview

Recognise post-traumatic re-experiencing, avoidance, threat and negative mood changes, assess complex needs and risk, and sequence active monitoring, trauma-focused CBT, EMDR and preference-based medication according to timing and presentation.

PTSD is not defined by exposure alone, and diagnostic systems organise the syndrome differently. ICD-11 requires an extremely threatening or horrific event followed by re-experiencing in the present, deliberate avoidance and a persistent sense of current threat, lasting at least several weeks and causing significant impairment. DSM-5 uses broader intrusion, avoidance, negative cognition or mood and arousal clusters for more than one month after qualifying trauma. Re-experiencing may be visual, sensory, emotional or bodily and feel as though the event is occurring now. Establish onset, duration and functional effect, distinguish a flashback from voluntary remembering, and state which framework supports the diagnosis rather than mixing thresholds silently.

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PsychiatryOriginal SBA

Early clinically important symptoms

An adult develops acute stress disorder with intrusive memories, avoidance and marked impairment two weeks after a traumatic assault. Which treatment should be offered?

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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG116 PTSD recommendationsAssessment, early monitoring, trauma-focused CBT, EMDR, medication and debriefing recommendations.
  • NHS post-traumatic stress disorder overviewCurrent UK patient information on symptoms, urgent risk and available treatments.
  • Sertraline tablets summary of product characteristicsLicensed adult PTSD dose, titration, maximum and safety information.
  • NICE NG116 rationale and impactEvidence reasoning for active monitoring, debriefing and trauma-focused interventions.
  • WHO ICD-11 clinical descriptions and diagnostic requirementsCurrent ICD-11 PTSD and complex PTSD core features, duration and functional-impairment requirements.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Assessment covers the event and current context without requiring a full narrative. Determine whether danger is over or ongoing, identify injury, pain, sleep disruption, dissociation, depression, suicide risk, substance use, psychosis, traumatic brain injury and safeguarding. ICD-11 complex PTSD requires all PTSD diagnostic requirements plus severe and pervasive affect-regulation difficulty, a persistent negative self-concept and persistent relationship disturbance; those features alone after trauma are not sufficient. Complexity influences engagement, session number and support needs but does not justify withholding an effective trauma-focused intervention automatically.

Timing matters. NICE advises active monitoring for subthreshold symptoms within one month and follow-up within one month. Adults with acute stress disorder or clinically important PTSD symptoms during that month should be offered individual trauma-focused CBT. More than one month after trauma, offer individual trauma-focused CBT such as cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy or prolonged exposure. Treatment is usually eight to twelve sessions, with more when clinically needed for multiple traumas, and includes safety planning, memory and meaning processing and restoration of ordinary function.

Offer EMDR to adults presenting more than three months after non-combat trauma and consider it between one and three months when the person prefers it. EMDR should use a validated manual, trained supervision and a phased protocol with psychoeducation, self-calming, target-memory processing and repeated bilateral stimulation. Supported trauma-focused computerised CBT is limited to selected adults without severe symptoms, especially dissociation, and without risk of harm. When an adult prefers drug treatment, consider venlafaxine or an SSRI such as sertraline and keep trauma-focused psychological treatment available rather than implying medication must be an adjunct. Medicines should not be offered to prevent PTSD.

Key points

  • Name the diagnostic framework: ICD-11 PTSD follows an extremely threatening or horrific event and requires re-experiencing in the present, deliberate avoidance and persistent current threat for at least several weeks with impairment; DSM-5 uses broader symptom clusters lasting more than one month after qualifying trauma.
  • Ask about flashbacks, nightmares, bodily reliving, trauma reminders, avoidance, shame, guilt, detachment, sleep, startle and hypervigilance without forcing a detailed account at the first contact.
  • Within one month, actively monitor subthreshold symptoms with follow-up within one month; offer individual trauma-focused CBT to adults with acute stress disorder or clinically important PTSD symptoms.
  • After one month, offer individual trauma-focused CBT; NICE also offers EMDR after more than three months for non-combat trauma and considers it at one to three months when preferred.
  • Trauma-focused CBT is usually eight to twelve sessions and includes psychoeducation, arousal and flashback strategies, memory and meaning processing, overcoming avoidance, safety planning and functional recovery.
  • Do not offer psychologically focused debriefing and do not use medication, including benzodiazepines, to prevent PTSD after trauma.

Aetiology

01

Traumatic exposure

Direct exposure, witnessing, learning about close others or repeated occupational exposure to extreme details can precede the syndrome.

02

Vulnerability and context

Prior trauma, mental illness, injury, limited support and continuing adversity can increase persistence without making PTSD inevitable.

03

After-event conditions

Ongoing threat, blame, displacement, pain, sleep loss and fragmented practical support can prevent recovery and sustain defensive responses.

Pathophysiology

  1. 1
    Poorly contextualised memory

    Sensory trauma fragments are easily triggered as present experience because their time, place and ending are insufficiently integrated.

  2. 2
    Persistent threat appraisal

    Beliefs about permanent damage, guilt, danger or mistrust maintain defensive arousal after the original event has ended.

  3. 3
    Avoidance and arousal cycle

    Avoiding memories and reminders blocks updating, while sleep disruption and hypervigilance increase cue detection and emotional reactivity.

Clinical features and red flags

Re-experiencing

Intrusive memories, nightmares, flashbacks or intense bodily and emotional reactions create a sense that the past threat is present.

Trauma avoidance

Thoughts, feelings, people, places and activities linked to the event are restricted to prevent distress and memory activation.

Persistent threat

Hypervigilance, startle, irritability, insomnia and concentration difficulty continue after objective danger has ended.

Negative meaning

Guilt, shame, emotional numbing, detachment and broad beliefs about permanent damage or an unsafe world sustain impairment.

ICD-11 complex PTSD

All core PTSD requirements are met together with severe, pervasive affect-regulation difficulty, negative self-concept and relationship disturbance requiring adapted pacing and broader support.

Red flags requiring action

  • A current suicide plan, recent high-lethality attempt, severe hopelessness or access to weapons requires urgent crisis assessment and means-safety action.
  • Ongoing domestic abuse, exploitation, stalking, trafficking or unsafe housing means present danger must be addressed rather than treating all hypervigilance as a memory problem.
  • Severe dissociation, amnesia, collapse, seizure, psychosis or substance withdrawal requires medical and psychiatric differential assessment before trauma-focused work.

Investigations

  1. 01
    Trauma-informed clinical assessmentFirst step
    Why
    Define exposure, symptom clusters, timing, triggers, meanings, impairment and current safety.
    Interpretation and limitations
    Diagnosis depends on the whole syndrome and course; a trauma history or elevated questionnaire alone is insufficient.
  2. 02
    Risk and safeguarding formulation
    Why
    Assess suicide, violence, ongoing abuse, exploitation, dependants, housing and access to means.
    Interpretation and limitations
    A specific safety plan is required when risk is significant, and current external danger should not be reframed as pathological hypervigilance.
  3. 03
    Dissociation and mental-state review
    Why
    Identify depersonalisation, derealisation, amnesia, depression, mania, psychosis and cognitive change.
    Interpretation and limitations
    Severe dissociation affects treatment format and computerised-care eligibility; altered consciousness or neurology broadens the medical differential.
  4. 04
    Physical and substance assessment
    Why
    Detect injury, pain, sleep disorder, traumatic brain injury, intoxication and withdrawal.
    Interpretation and limitations
    Untreated physical symptoms and substance cycles can reproduce arousal and memory problems and require parallel care.
  5. 05

Differential diagnosis

01

Acute stress response

Early distress may resolve naturally; timing, clinically important symptom clusters and impairment determine monitoring or active trauma-focused care.

02

Depression or grief

Pervasive anhedonia, loss-focused yearning or guilt may dominate without reliving and trauma-cue avoidance, although conditions can coexist.

03

Brain injury or psychosis

Cognitive change, seizure, altered consciousness or fixed beliefs unrelated to reliving requires neurological, substance and psychiatric differential assessment.

Management

01First monthMatch early care to symptom severityFirst stepA person presents within one month of a traumatic event.+
  1. 1Provide practical and emotional support, assess current danger and risk, normalise common reactions without predicting either inevitable disorder or rapid recovery.
  2. 2Use active monitoring with follow-up within one month for subthreshold symptoms and provide a clear route back if symptoms or safety worsen.
  3. 3Offer individual trauma-focused CBT to an adult with acute stress disorder or clinically important PTSD symptoms and do not use debriefing or preventive medication.
02Established PTSDOffer trauma-focused psychological treatmentAn adult presents more than one month after trauma with PTSD or clinically important symptoms.+
  1. 1Offer a validated individual trauma-focused CBT and agree safety, target memories, meanings, avoidance, arousal strategies and functional goals.

Complications

01

Suicide and self-harm

Shame, guilt, insomnia, depression, pain and substance misuse can combine to increase risk across both acute and chronic phases.

02

Substance and physical morbidity

Alcohol or sedatives used to suppress sleep and memory symptoms can create dependence, while pain and neglected injury reinforce disability.

03

Relationship and role loss

Avoidance, irritability, emotional numbing and mistrust can disrupt intimacy, parenting, education, employment, housing and community connection.

Monitoring and follow-up

  • For active monitoring within one month, arrange follow-up within one month and give an earlier route back for worsening risk, sleep, dissociation or function.
  • During therapy, review suicide and safeguarding safety, flashbacks, nightmares, avoidance, dissociation, substance use and restoration of social and occupational function.
  • Monitor distress and dissociation within sessions and adjust pacing collaboratively without using avoidance of all memory work as the long-term plan.
  • After starting medication, arrange early age- and risk-appropriate review for activation, agitation, suicidal thinking, adherence and adverse effects.
  • At treatment end, plan for trauma anniversaries, future triggers, booster sessions, relapse signatures and named access to urgent and routine support.

Special situations

Danger can be current

Hypervigilance is not necessarily distorted when abuse, stalking or insecure accommodation persists, so social safety work may be the immediate intervention.

Memory detail needs consent

Initial assessment can establish the syndrome and risk without compelling an exhaustive narrative that the person is not ready to provide.

Avoidance is broad

Suppressing feelings, emotional numbing and substance use can avoid internal reminders even when the person still visits the physical location.

Complexity changes dose

Multiple traumas, dissociation and social instability may require more sessions and coordination, not automatic exclusion from trauma-focused treatment.

Common pitfalls

  1. 01

    Requiring a detailed chronological trauma account before establishing consent, safety and the purpose of assessment.

  2. 02

    Treating ongoing external danger as if it were only a distorted memory-based threat appraisal.

  3. 03

    Offering one-session psychologically focused debriefing to everyone after a traumatic event.

  4. 04

    Using benzodiazepines or antidepressants to prevent PTSD instead of applying the symptom- and timing-based pathway.

  5. 05

    Withholding trauma-focused therapy indefinitely because any distress during memory work is mistaken for treatment failure.

For an adult who prefers drug treatment for established PTSD, consider venlafaxine or an SSRI such as sertraline while continuing safety, social and substance care.
A child or dependent exposed to violence, neglect or an acutely unwell caregiver requires proportionate safeguarding and coordinated family support.
Baseline symptom and function measure
Why
Record re-experiencing, avoidance, threat, mood, relationships and role participation.
Interpretation and limitations
Repeated validated measures support review, but current safety, personally valued function and therapy engagement remain essential outcomes.
  • 2PreferredOffer EMDR after more than three months for non-combat trauma, or consider it between one and three months when preferred, using a phased manualised approach.
  • 3Review progress and barriers across eight to twelve sessions or more when clinically indicated, planning booster work and significant-date support where needed.
    • 03Complex needsRemove barriers without abandoning trauma focusRisk, dissociation, repeated trauma, substance misuse, instability or major social need complicates engagement.+
    1. 1Prioritise immediate safety, housing, substance withdrawal, physical health and emotional regulation needs that would prevent safe session participation.
    2. 2Adapt duration, communication, pacing and support and coordinate services while retaining a plan for evidence-based trauma memory and meaning work.
    3. 3When the adult prefers drug treatment, consider venlafaxine or an SSRI such as sertraline; seek specialist review for severe refractory symptoms, psychosis or complex pharmacology.
    Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
    An SSRI option NICE suggests considering when an adult with established PTSD prefers drug treatment rather than trauma-focused psychological treatment alone.

    Sertraline oral

    For licensed adult PTSD treatment, give 25 mg by mouth once daily for one week, then 50 mg once daily; increase by 50 mg at intervals of at least one week to a maximum of 200 mg daily if needed.

    Monitor activation, akathisia, suicidal thinking, mania, hyponatraemia, bleeding, sexual dysfunction and serotonergic interactions; it does not prevent PTSD after trauma and should be tapered gradually when discontinued.