A 19-year-old male United States Army veteran presents to the outpatient clinic.

He recently
returned from combat in Iraq where he was assigned to the infantry. While on patrol 1 month
ago, he witnessed several friends killed by a road-side bomb. Since that time he has had
difficulty sleeping, with frequent awakenings after recurrent nightmares about the event. He
finds himself “jumpy” at times, especially with loud noises. He stayed in his parents’ house
around the July 4th holiday, and he became acutely anxious when hearing firecrackers. He has
not spent time with friends or family. He refuses to watch any television or listen to the radio for
fear of hearing
news of more casualties. He complains of a sense of “numbness” and gets easily distracted. He
denies suicidal ideation but sometimes feels that “my life ended over [in Iraq].” 

The patient is experiencing symptoms consistent with PTSD. Untreated, only approximately
30%
of patients completely recover, 60% continue to have mild-to-moderate symptoms, and 10%
remain unchanged or worsen. A rapid onset, short duration of symptoms, good premorbid
functioning, strong social supports, and absence of other psychiatric or medical illnesses predict
a better prognosis.
Sertraline, and the other SSRIs, are very effective and well-tolerated treatments for PTSD. SSRIs
have been shown to improve all of the symptom clusters of PTSD (i.e., reexperiencing
symptoms, avoidance of stimuli, and increased arousal). Based on their efficacy, tolerability,
lack of abuse potential, and safety in overdose, they are considered to be first-line agents for
treating PTSD. Administering amobarbital, or an amytal interview, has been used sometimes in
conjunction with psychotherapy to help individuals work through their traumatic event. It has not
been used as a treatment alone, however, given its addicting potential and lethality in overdose.
Antipsychotics such as haloperidol have little evidence supporting their use in treating PTSD
symptoms, but they may be used acutely to manage agitation or violence. Lorazepam can also be
used in a similar manner, but given the high comorbidity of substance abuse in patients with
PTSD, this is not recommended as a solo treatment. Trazodone, in lower doses, can be used to
help treat insomnia in these individuals. Treatment of the PTSD symptoms, however, would
likely require a full antidepressant dose, which carries significant side effects, such as daytime
sedation and orthostasis.