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Q1: Diagnosis (2 min)
"A soldier returns from combat 6 weeks ago with nightmares, flashbacks, avoidance of crowds, irritability, insomnia, and a sense the world is dangerous. Diagnosis?"
- POST-TRAUMATIC STRESS DISORDER (PTSD) — DSM-5 trauma- and stressor-related disorder.
- Discriminator vs acute stress disorder (ASD): duration. ASD is 3 DAYS to 1 MONTH after trauma; PTSD is MORE THAN 1 MONTH. This is 6 weeks — PTSD.
- Four symptom clusters reproduced verbatim: intrusion (at least 1); avoidance (at least 1); negative cognition/mood (at least 2); arousal/reactivity (at least 3). All present here.
Q2: DSM-5 criteria in full (3 min)
"Walk me through the DSM-5 PTSD criteria."
- A — Exposure (qualifying trauma): actual/threatened death, serious injury, or sexual violence; via direct experience, witnessing in person, learning it happened to a close other (violent/accidental), or repeated extreme exposure to aversive details (first responders).
- B — Intrusion (at least 1): intrusive memories, traumatic nightmares, dissociative flashbacks (feeling event is recurring), psychological distress at reminders, physiological reactivity at reminders.
- C — Avoidance (at least 1): avoiding internal memories/thoughts/feelings OR external reminders (people, places, activities).
- D — Negative cognition/mood (at least 2): dissociative amnesia for key aspects; negative beliefs ('world is dangerous'); distorted blame; persistent negative emotions; diminished interest; detachment; inability to feel positive emotions.
- E — Arousal/reactivity (at least 3): irritability, recklessness, hypervigilance, exaggerated startle, concentration problems, sleep disturbance.
- F — Duration more than 1 month. G — clinically significant distress/impairment. H — not substance/medical.
- Specifiers: with dissociative symptoms (depersonalisation, derealisation); with delayed expression (full criteria not met until at least 6 months after trauma).
Q3: Differential and the can't-miss mimics (2 min)
"Distinguish PTSD from acute stress disorder, adjustment disorder, and major depression."
- ASD: same picture, duration 3 days to 1 month; many recover; if persists, reclassify as PTSD.
- Adjustment disorder: stressor does NOT meet Criterion A (not life-threatening injury, death, or sexual violence); symptoms within 3 months of stressor; resolve within 6 months of stressor ending; no intrusion cluster.
- Major depression: low mood/anhedonia dominant; no intrusive re-experiencing and no trauma-cue trigger; always take a trauma history — comorbidity with PTSD is ~ 50 percent.
- Other mimics to mention: panic disorder (panic attacks not trauma-cue-specific), GAD (diffuse worry), OCD (intrusions are ego-dystonic repetitive thoughts, not trauma memories), substance withdrawal (sympathomimetic), borderline personality disorder (Complex PTSD overlap).
Q4: First-line treatment (3 min)
"What is the first-line treatment for established PTSD, and what is its mechanism?"
- FIRST-LINE: TRAUMA-FOCUSED PSYCHOLOGICAL THERAPY — trauma-focused CBT (TF-CBT), prolonged exposure (PE), or EMDR. 8 to 12 weekly sessions.
- Mechanism (Ehlers and Clark model): repeated controlled exposure to the trauma memory allows FEAR EXTINCTION (the cue is relearned as safe) and MEMORY RECONSOLIDATION (the memory is integrated into autobiographical memory and updated with new information), so it is experienced as a memory of the past rather than a current threat. Cognitive restructuring corrects the negative appraisals ('world is entirely dangerous').
- EMDR eight-phase protocol: history/planning; preparation/resourcing; assessment (SUDs, VoC); desensitisation (bilateral stimulation while attending to memory); installation; body scan; closure; re-evaluation. Evidence equivalent to TF-CBT.
- Response rates 50 to 70 percent.
Q5: Pharmacotherapy (2 min)
"Which drugs would you use, and at what doses?"
- SSRIs are first-line pharmacotherapy. ONLY two FDA-approved: SERTRALINE (start 25 to 50 mg PO mane, titrate to 50 to 200 mg/day) and PAROXETINE (start 20 mg PO mane, titrate to 20 to 60 mg/day). Allow 4 to 8 weeks for full effect.
- VENLAFAXINE (37.5 to 225 mg/day) is an effective SNRI alternative supported by VA/DoD.
- PRAZOSIN 1 mg at night, titrate to 6 to 10 mg for trauma-related NIGHTMARES (alpha-1 blockade of noradrenergic locus coeruleus hyperactivity); warn of first-dose syncope. Raskind 2018 NEJM showed mixed overall efficacy; weak recommendation in 2023 VA/DoD; reserved for nightmare-predominant PTSD.
- AVOID: benzodiazepines (no efficacy, impair fear extinction, dependence); single-session debriefing (harmful); cannabis/cannabinoids (not supported).
Q6: Special scenario — Complex PTSD (2 min)
"A 30-year-old woman presents with chronic self-harm, unstable relationships, intrusive memories of childhood sexual abuse, intense shame, and difficulty regulating emotion. What is the diagnosis and management?"
- Complex PTSD (ICD-11) — caused by prolonged, repeated, inescapable INTERPERSONAL trauma (childhood abuse).
- Three defining features on top of PTSD core: (1) AFFECT DYSREGULATION (outbursts, dissociation when stressed); (2) NEGATIVE SELF-CONCEPT (worthlessness, shame, guilt); (3) DISTURBANCES IN RELATIONSHIPS (mistrust, withdrawal, difficulty sustaining relationships).
- Management: PHASE-BASED THERAPY — Phase 1 safety and stabilisation (skills: emotion regulation, grounding, harm reduction, safety in relationships); Phase 2 trauma processing (TF-CBT or EMDR for index traumas); Phase 3 integration and reconnection (identity, relationships, meaning). STAIR Narrative Therapy is one evidence-based phase-based approach.
- NEVER label as 'just' borderline personality disorder without recognising the underlying Complex PTSD; personality features may improve once the trauma is treated.