Clinical Guide > Neuropsychiatric Disorders > PTSD

Posttraumatic Stress Disorder

Authors: Francine Cournos, MD; and Milton Wainberg, MD
January 2011

Chapter Contents


Symptoms of posttraumatic stress disorder (PTSD) can develop after exposure to a traumatic event. A traumatic event may be a single instance, such as a car accident or experience of a natural disaster, or an ongoing pattern of events, such as continuous neglect, physical or sexual abuse, or chronic exposure to war or violent conflict. PTSD causes intrusive memories, hyperarousal, and psychological numbing or avoidance, among other symptoms. It may impair an individual's psychological and physical functioning, decreasing immune system function and increasing susceptibility to illness. Untreated PTSD can increase the risk of HIV transmission or acquisition and worsen the course of HIV treatment.

Individuals with PTSD may experience depression, anxiety, social isolation, impairments in trust and attachments, and feelings of anger, and PTSD often coexists with depression, anxiety, or other psychiatric illnesses. PTSD may be associated with increased risk-taking behavior (e.g., substance abuse, unsafe sex).

The rate of PTSD among individuals with HIV infection (in whom the lifetime prevalence is possibly as high as 42%) is higher than that of the general population (1.3%-7.8%). Women experience PTSD at a higher rate than men. The likelihood of developing PTSD increases in relation to the severity of or proximity to the traumatic event. A history of traumatic experiences may increase an individual's risk of developing PTSD after a new trauma. Although a diagnosis of HIV may trigger PTSD symptoms, a history of trauma or abuse often is present as well. A personal or family psychiatric history may increase the likelihood of developing PTSD.

PTSD is diagnosed, as in HIV-uninfected individuals, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV (see "References," below). It is treatable through diverse therapies and psychopharmacology.

S: Subjective

The following reflect DSM-IV diagnostic criteria; include them in the history.

Other complaints may include the following:

The patient may experience the following:

Also screen for the following:

O: Objective

A: Assessment

A differential diagnosis may include the following:

P: Plan


Perform the following tests:


Once other diagnoses have been ruled out and the diagnosis of PTSD is established, several treatment options are available.


Options include individual cognitive-behavioral therapy, dialectical-behavioral therapy, interpersonal therapy, exposure therapy, a stress-management group, relaxation therapy, visualization, guided imagery, supportive psychotherapy, and psychodynamic psychotherapy. Long-term psychotherapy may be indicated if experienced professionals are available and the patient is capable of forming an ongoing relationship. If possible, refer to an HIV-experienced therapist. The specific psychotherapy often depends on the skills and training of the practitioners available in a given health care system or region. In addition, refer the patient to available community-based support.



Most antidepressants should be started at low dosages and gradually titrated upward to avoid unpleasant side effects. Therapeutic effects may not be noticed until 2-4 weeks after starting a medication. If there is no improvement in symptoms in 2-4 weeks, and there are no significant adverse effects, the dosage may be increased. Before prescribing a medication, always remember to check for drug-drug interactions, particularly with concurrent antiretrovirals (ARVs). See "Potential ARV Interactions," below, and chapter Major Depression and Other Depressive Disorders for further information about antidepressants, including possible adverse effects and interactions with ARVs.


Antianxiety medications have not been shown to be effective treatments for PTSD when used alone but may be effective, as adjunctive therapy, in reducing anxiety symptoms. Treatment may include intermediate half-life benzodiazepines such as oxazepam (Serax)10 mg PO Q6H or lorazepam (Ativan) 0.5 mg PO Q8H. Longer-acting benzodiazepines such as clonazepam (Klonopin) may be useful at dosages of 0.25-0.5 mg PO BID. Levels of many benzodiazepines may be increased by certain protease inhibitors and nonnucleoside reverse transcriptase inhibitors; see "Potential ARV Interactions," below.

Benzodiazepines can reduce anxiety rapidly, often within hours, but may have counterbalancing side effects early in the course of their use that include sedation and incoordination. In addition, physical dependency may develop in patients who use them for more than a few weeks. Benzodiazepines are not recommended for people who have a history of alcohol abuse or dependence. Benzodiazepines ideally would be used only briefly and intermittently to quell acute and severe anxiety symptoms.

Buspirone (BuSpar) is a nonaddictive anxiolytic. It usually must be taken for at least 1-2 weeks before anxiety symptoms begin to lessen. Starting dosage is 5 mg PO TID. If symptoms persist, the dosage can be increased by 5 mg per dose each week to a maximum of 10-15 mg PO TID (for a total daily dosage of 30-45 mg). Low-dose benzodiazepines may be used during the initial weeks of buspirone therapy, until the effects of buspirone are felt. The major potential adverse effects of buspirone are dizziness and lightheadedness.


Mood stabilizers such as valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), and topiramate (Topamax) may be added for patients with a partial response to an antidepressant. They may be particularly helpful for those who have considerable irritability, anger, or hostility, as well as those with reexperiencing symptoms (e.g., flashbacks, intrusive memories). Gabapentin (Neurontin) 200-400 mg BID or QID sometimes helps to diminish anxiety. Treatment with these agents usually should be done by or in consultation with a psychiatrist.


Older and newer antipsychotics (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) may be suitable for individuals with psychotic features of PTSD or those who have a comorbid psychotic illness. These medications also may be helpful for some individuals who have not benefited from medications indicated for PTSD. Adverse effects may include dyslipidemia, hyperglycemia, weight gain, and sudden cardiac death. Consultation with a psychiatrist is recommended.

Other medications

A variety of other medications have been used as adjunctive treatment when insomnia and nightmares persist despite adequate use of psychotropic medications. Research is still quite limited, but suggests that the antihypertensive drugs clonidine (Catapres) and prazosin (Minipress) may help with the insomnia and nightmares of PTSD.

Patients with advanced HIV disease, as with geriatric patients, may be particularly vulnerable to the CNS effects of certain medications. Medications that affect the CNS should be started at low dosage and titrated slowly. Similar precautions should apply to patients with liver dysfunction.

Potential ARV Interactions

Interactions may occur between certain antiretrovirals and agents used to treat PTSD. Some combinations may be contraindicated and others may require dosage adjustment. Refer to medication interaction resources or consult with an HIV expert or pharmacist before prescribing.


  • Levels of many SSRIs and SNRIs may be increased or decreased by certain PIs or NNRTIs. These interactions generally are not clinically significant, but most agents should be started at low dosages and titrated cautiously while monitoring efficacy and adverse effects. See chapter Major Depression and Other Depressive Disorders.
  • Tricyclic levels can be increased substantially by ritonavir. If they are used for patients taking ritonavir or ritonavir-boosted PIs, they should be started at low dosage, patients should be followed closely, and tricyclic levels should be monitored.


  • Protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors may raise blood concentrations of many benzodiazepines. If benzodiazepines are used, they should be started at low dosage, and other CNS depressants should be avoided. Consult with a clinical pharmacist before prescribing. See chapters Anxiety Disorders and Insomnia for additional information.
    • Midazolam (Versed) and triazolam (Halcion) are contraindicated for use with all PIs and with delavirdine and efavirenz.
  • Buspirone levels may be increased by ritonavir-boosted PIs and may be decreased by CYP inducers. Monitor patients for adverse effects and for efficacy


  • Most anticonvulsants may have significant interactions with certain ARVs and other medications; check for drug-drug interactions before prescribing


  • Potential interactions vary according to the specific medications used; consult with a pharmacist or psychiatrist.

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