Brooke Harbor Health System
PMHNP Clinical Learning Environment
Condition Guide
Trauma- and stressor-related presentations require careful attention to exposure, timing, symptom pattern, dissociation, safety, function, co-occurring conditions, and the person's readiness for treatment. Trauma-informed care supports choice, collaboration, predictability, and emotional and physical safety throughout the process.
Clinical application
Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.
Diagnostic Features
DSM-5-TR diagnoses require the full clinical pattern and relevant exclusions. Exposure alone, an elevated ACE score, or a positive PTSD screen does not establish a disorder.
Qualifying exposure is followed by intrusion, avoidance, negative cognition or mood, and arousal/reactivity symptoms meeting cluster thresholds, lasting more than one month and causing distress or impairment, with substance and medical exclusions.
After qualifying trauma exposure, at least nine symptoms across intrusion, negative mood, dissociation, avoidance and arousal begin or worsen and persist from three days through one month, with significant distress or impairment.
Emotional or behavioral symptoms are disproportionate to the stressor and/or cause significant impairment, do not meet another disorder or represent normal bereavement, and generally resolve within six months after the stressor or consequences end.
After death of a close person at least twelve months earlier in adults or six months in youth, intense yearning or preoccupation plus the required associated symptoms occur most days, exceed cultural expectations, and cause impairment.
A child shows emotionally withdrawn behavior toward caregivers with persistent social-emotional disturbance, developmental age of at least nine months, onset before age five, and a history of extreme insufficient care that is presumed causal.
A child actively approaches unfamiliar adults with at least two defining behaviors, beyond impulsivity alone, following extreme insufficient care; developmental age is at least nine months.
Rating Scales & Screening Tools
Select tools according to the exposure, symptom pattern, setting, and purpose of assessment; the VA National Center for PTSD provides additional professional assessment resources. For guidance on selecting, administering, and interpreting these tools, see the Toolbox's Rating Scales & Screening. When trauma intersects with threats, stalking, weapon access, or violence concerns, see Violence Risk, Threat Assessment, and Forensic Psychiatry.
Brief primary-care screen for probable PTSD. A positive result indicates the need for further assessment.
Twenty-item self-report measure used to assess DSM-5 PTSD symptoms and monitor severity. Interpretation depends on setting and purpose.
Clinician-administered structured interview for PTSD diagnosis and severity; requires appropriate training and access.
Ask directly about depersonalization, derealization, amnesia, identity disruption, triggers, frequency, function, and safety. The DSPS can support assessment of dissociative symptoms associated with PTSD.
Key Differential Considerations
A trauma history is common and does not by itself explain the current symptoms. Establish what else could produce the same picture, and what else may be producing it alongside the trauma.
Traumatic brain injury and post-concussive syndrome, obstructive sleep apnea, thyroid disease, focal seizures with dissociative or experiential features, delirium, chronic pain, anemia, and cardiac or vestibular conditions that produce arousal and startle symptoms.
Stimulants, decongestants, high caffeine intake, corticosteroids, and beta-agonists can drive hyperarousal. Alcohol, sedative, and opioid withdrawal produce arousal, nightmares, and autonomic symptoms. REM rebound after reducing alcohol or a benzodiazepine can be mistaken for worsening PTSD nightmares.
Major depression, panic disorder, generalized anxiety, OCD, ADHD, bipolar disorder, psychotic disorders, and dissociative disorders. Distinguish intrusive trauma memories from obsessions, flashbacks from hallucinations, and arousal-driven irritability with disrupted sleep from mania with reduced sleep need.
Acute stress disorder and PTSD are separated by timing, not by severity. Adjustment disorder applies when the stressor does not meet the exposure criterion or the pattern does not reach threshold. Prolonged grief applies when the stressor is a death and yearning or preoccupation predominates. Reactive attachment and disinhibited social engagement disorders require the care history and a developmental age of at least nine months.
Depersonalization, derealization, and amnesia occur in panic, substance intoxication and withdrawal, seizures, migraine, and severe sleep deprivation as well as in PTSD. Establish onset, duration, triggers, substance timing, and neurologic features before attributing dissociation to trauma alone.
Distress after trauma or loss is common and frequently self-limited. Prolonged grief disorder requires a reaction that exceeds expected social, cultural, and religious norms for the person's own context, so the comparison is to their reference group rather than to a general expectation. Where that judgment carries the diagnosis, use a structured cultural assessment; see the Toolbox's Psychiatric Interview & History.
For a structured approach to targeted evaluation, see the Toolbox's Ruling Out Medical Causes.
Medication Classes
Medication decisions should follow diagnostic clarification, shared decision-making, and the treatment recommendations in the VA/DoD Clinical Practice Guideline for PTSD. For support with actual-use histories, interactions, and monitoring, see the Toolbox's Medication Reconciliation & Monitoring.
Sertraline and paroxetine have FDA indications for PTSD. Other SSRIs may be considered using current guideline evidence and patient-specific factors.
Venlafaxine is supported by guideline evidence for PTSD. Monitor response, tolerability, blood pressure, discontinuation risk, and interactions.
Prazosin may be considered for PTSD-associated nightmares in selected patients. Assess blood pressure, falls risk, other medications, and individual response.
Benzodiazepines are generally discouraged for PTSD. Review co-occurring substance use, sleep conditions, bipolar-spectrum symptoms, pregnancy, and medical contributors before selecting medication.
Psychotherapy Modalities
Treatment should reflect safety, readiness, symptom pattern, co-occurring conditions, access, and clinician competence. SAMHSA's trauma-informed approaches guidance describes principles for creating safer and more collaborative services. For help matching evidence-based approaches to the clinical presentation, see the Toolbox's Psychotherapy Modalities.
Structured trauma-focused treatment addressing beliefs and meaning related to the traumatic event.
Structured treatment using supported engagement with trauma memories and avoided situations.
Trauma-focused psychotherapy integrating memory processing with bilateral stimulation.
Present-centered, skills-based, family, group, or substance-use treatment may be part of care. Match timing and intensity to safety, readiness, comorbidity, and clinician competence.
Supplements & Mind-Body Approaches
Adjunctive practices should support defined treatment goals and be adapted when they increase dissociation, hyperarousal, avoidance, or physical discomfort. For guidance on coordinating these approaches with the broader plan of care, see the Toolbox's Treatment Planning.
May support present-moment awareness, emotion regulation, and distress management. Adapt carefully when inward focus worsens dissociation or hyperarousal.
Graded physical activity, sleep support, and restoration of daily routines can strengthen recovery and function when medically appropriate.
Can reduce physiologic arousal for some people. Teach choice, pacing, and alternatives for patients who find these exercises activating.
No dietary supplement is an established first-line treatment for PTSD. Review product quality, interactions, adverse effects, pregnancy considerations, and the risk of delaying effective care.
Clinical Practice Guidelines & Sources
PTSD guidance is comparatively current, but the major guidelines weigh the evidence differently, particularly on EMDR and on the role of medication relative to trauma-focused psychotherapy. Read more than one, and interpret each alongside current product labeling and individualized shared decision-making.
Evidence-based recommendations for assessment and management of PTSD and acute stress disorder, with detailed treatment sequencing.
Open guideline ↗Updated in 2025, drawing on fifteen systematic reviews and a broader set of outcomes than the 2017 version it replaces.
Open guideline ↗UK guidance published in 2018 covering recognition, assessment, and treatment of PTSD in children, young people, and adults.
Open guideline ↗Current FDA labeling for the specific medication and formulation being prescribed.
Open labeling ↗Assessment instruments, treatment summaries, and materials written for patients and families.
Open resource ↗Related Resources
Structured suicide and self-harm assessment, formulation, means-safety counseling, and collaborative safety planning. Open resource →
Plan targeted evaluation for medical, neurologic, medication-related, and substance-related contributors. Open resource →
Address co-occurring substance use, withdrawal states that mimic arousal symptoms, and integrated treatment sequencing. Open guide →
Clarify overlapping negative cognition and mood symptoms, and treat co-occurring depression alongside trauma-focused care. Open guide →
Evaluate nightmares, insomnia, and sleep-disordered breathing, which both mimic and worsen trauma-related symptoms. Open guide →
Use developmentally informed assessment, collateral, consent and assent, and pediatric treatment principles. Open resource →