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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- PTSD requires qualifying trauma exposure plus intrusion, avoidance, negative cognition/mood, and arousal clusters
- Duration >1 month; acute stress disorder lasts 3 days to 1 month
- First-line: trauma-focused psychotherapy such as prolonged exposure, CPT, trauma-focused CBT, or EMDR
- SSRIs/SNRIs such as sertraline, paroxetine, fluoxetine, or venlafaxine can be used
- Avoid benzodiazepines because they worsen outcomes and dependence risk
Overview
PTSD develops after exposure to actual/threatened death, serious injury, or sexual violence and causes persistent re-experiencing, avoidance, negative mood/cognition, and hyperarousal. Exposure may be direct, witnessed, learned about in a close relation, or repeated occupational exposure to trauma details.
Epidemiology
Risk rises after interpersonal violence, combat, childhood adversity, disasters, limited social support, prior trauma, depression, substance use, and severe exposure. Patients may present with insomnia, irritability, chronic pain, somatic symptoms, or substance use rather than naming trauma.
Clinical Features
Symptoms
Intrusive memories, flashbacks, nightmares, or distress at reminders
Avoidance of thoughts, conversations, places, people, or activities
Guilt, shame, detachment, emotional numbing, negative beliefs
Hypervigilance, startle, irritability, reckless behavior, insomnia
Suicidality, homicidality, unsafe dissociation, psychosis, or severe substance use
Signs
Hyperarousal, scanning exits, exaggerated startle, guardedness
Dissociation or depersonalization during recounting
Intoxication, withdrawal, self-harm, or ongoing violence requiring immediate safety plan
Investigations
First-line
Trauma-informed assessmentConfirm DSM-5-TR trauma exposure, symptom clusters, duration, impairment, and safety
Suicide/substance/IPV screenAssess suicide risk, alcohol/drug use, weapons, ongoing abuse, safe housing
Medical assessment as indicatedTBI, sleep disorders, pain, pregnancy, medication/substance contributors
Second-line
PCL-5Baseline and monitoring
Comorbidity screenMDD, panic, GAD, SUD, TBI, dissociation, pain
Differentiate acute stress disorder3 days to 1 month; PTSD >1 month
Specialist
Trauma-focused psychotherapy referralPreferred first-line when available
Psychiatry referralSevere suicidality, psychosis, dissociation, complex trauma, refractory nightmares, or SUD
1
Safety and stabilization
- Assess immediate safety, suicide, ongoing trauma exposure, weapons, intoxication, and supports
- Treat sleep deprivation, pain, withdrawal, and acute medical issues
- Use grounding before trauma processing in highly dysregulated patients
2
First-line psychotherapy
- Prolonged exposure, cognitive processing therapy, trauma-focused CBT, and EMDR
- Build consent and control; do not force premature detailed disclosure
- Address avoidance through graded structured work
3
Medication/comorbidity
- SSRI/SNRI: sertraline, paroxetine, fluoxetine, or venlafaxine
- Prazosin may help trauma-related nightmares; monitor orthostasis
- Treat SUD, pain, TBI, insomnia, and depression concurrently
Complications
- Suicide:
- Alcohol/sedative/opioid/stimulant use disorder:
- Functional avoidance:
- Dissociation:
- Chronic pain, insomnia, headaches, GI symptoms:
USMLE Step 2 CK Exam Tips
- 1PTSD duration >1 month; acute stress disorder is 3 days to 1 month
- 2Trauma exposure is required
- 3Nightmares + hypervigilance + avoidance after combat/assault = PTSD
- 4First-line is trauma-focused therapy
- 5Benzodiazepines are not first-line
- 6Prazosin is a classic answer for trauma-related nightmares
practicetest your knowledge on post-traumatic stress disorderApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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