PTSD:
trauma therapy first, medication as a support

1. What is post-traumatic stress disorder?

Post-traumatic stress disorder (PTSD) is one possible reaction to an event of exceptional threat — a serious accident, physical or sexual violence, war and displacement, a natural disaster, or witnessing such an event as a relative or as an emergency worker.^¹

The most important sentence first: PTSD is a treatable condition, not a weakness. It does not arise because someone is not resilient enough, but because an experience overwhelmed the normal way of processing things. The memory is then stored in fragments — it does not feel like the past, but like a present that can break in again at any moment.

From the outside this is hard to follow, and that is exactly what makes it lonely. Many describe “functioning” while an alarm runs constantly inside. Others feel ashamed because they think the event was “not bad enough”. Both are common — and a reason to get support.

2. The four symptom clusters

The symptoms fall into four groups. They almost never appear on their own, and their intensity can swing from week to week.^¹,²

Re-experiencing (intrusions)

Intrusive images, nightmares and flashbacks — moments in which what happened feels as though it were happening again right now. They are often set off by harmless cues: a sound, a smell, a tone of voice. Not understanding the trigger yourself is typical and is no sign that you are imagining things.

Avoidance

Places, conversations, people or thoughts that are reminders of the event get avoided. In the short term that brings relief; in the long term everyday life narrows — and the memory never gets the chance to settle into place. That is why avoidance is a central starting point in therapy.

Negative changes in thinking and mood

Persistent guilt and shame (“I should have done something”), deep mistrust, loss of interest, emotional numbness, estrangement from the people closest to you, and gaps in memory. This group is the one most often overlooked from the outside, because it is quiet.

Hyperarousal

Constant watchfulness, marked jumpiness, irritability, concentration problems, inner restlessness and sleep disorders. Physically this often shows up as a racing heart, sweating or tension: the body stays on alert even when there is no danger.

3. The timeline: acute reaction, PTSD, delayed onset

How much time has passed since the event is decisive for making sense of it — and it explains why treatment straight after a trauma is not the same as treatment for a long-standing condition.

• Acute stress reaction (hours to days): numbness, a sense of unreality, jumpiness, sleeplessness — a normal stress response that usually settles quickly. What helps here is safety, rest and reliable people.
• Up to about four weeks: if the symptoms persist and restrict everyday life, a professional assessment makes sense.
• PTSD (from about four weeks): if the symptoms carry on for longer than roughly a month, it is called PTSD. It responds well to treatment.
• Delayed onset: the symptoms can appear only months or years later, often triggered by a new strain or by retirement — that makes the connection no less real.
• Complex PTSD: after prolonged or repeated traumatisation, problems with emotional regulation, self-image and relationships are added; treatment then takes longer.

4. Who develops it — and why not everyone does

Whether PTSD follows a trauma depends on several factors. None of them is a question of blame:^¹,³

• The kind of event — deliberate violence caused by people leaves PTSD behind more often than accidents or natural disasters.
• Duration and repetition — one-off events are on average processed better than prolonged traumatisation.
• Closeness and loss of control — being in danger of your life yourself and the feeling of being completely at another's mercy raise the risk.
• What happens afterwards — social support is one of the strongest protective factors; isolation and blame work in the other direction.
• Earlier burdens — previous traumatisation as well as an existing depression or anxiety disorder; and ambulance work, policing and nursing all bring repeated contact with distressing events.

5. Diagnosis: how it is made

The diagnosis is made by a psychotherapist or a psychiatrist in conversation — not by a test on the internet and not by a laboratory value.

• A detailed conversation: which symptoms, since when, how restricting? You do not have to tell everything — for the diagnosis it is usually enough that the event is named.
• Structured questionnaires: they capture the symptom clusters and the severity and make the course measurable.
• Co-occurring conditions: depression, anxiety disorder, substance use and sleep disorders are recorded as well, because they shape the treatment.
• Physical work-up: thyroid values, a blood count and your current medication, so that physical causes of restlessness and exhaustion are not missed.
• Safety check: are there suicidal thoughts, or is there still contact with a dangerous situation? That is what determines the urgency.

A common misunderstanding: for the diagnosis the memory does not have to be complete — gaps in memory are actually part of the picture. Nor is any proof needed that the event was “bad enough”. What counts is how it was experienced.

6. Treatment: trauma-focused psychotherapy first

Here is the central message, and it runs against a widespread expectation: the guidelines recommend trauma-focused psychotherapy as first-line treatment — not a medicine.^¹ A tablet can support sleep and mood, but it does not put the traumatic memory in its place. That is exactly what psychotherapy does.

“Trauma-focused” means the experience is worked through deliberately instead of being skirted around. That sounds frightening at first — which is why good trauma therapy is built up in stages.

So it begins with safety and stabilisation: as long as a threat continues, ending it comes before any trauma work. Added to that is psychoeducation — understanding why the body sounds the alarm takes much of the force out of the fear of your own symptoms — and techniques for anchoring yourself in the present during flashbacks.

7. Medication: what supports, what harms

Medicines have a clearly defined place in PTSD: they can improve sleep, mood and tension and so create the strength for therapy. They do not dissolve the traumatic memory. The choice and the dose are always set by the treating practice.

The best studied are the serotonin reuptake inhibitors; sertraline is the preparation used most often, and venlafaxine is a possible alternative. Important for your expectations: the effect does not set in straight away but over several weeks, and inner restlessness may increase at first — a known pattern, not a sign that the medicine is wrong for you.

Alcohol, too, works like an instant sedative: it worsens sleep, intensifies nightmares and raises the risk of dependence — combined with medicines, further risks are added, see Medications and alcohol. Drinking regularly to get through the evening is a symptom that belongs in the treatment.

8. Nightmares and sleep

Sleep is affected almost every time — and at the same time it is one of the most effective places to start, because with better sleep all the other symptoms are easier to bear. Two patterns dominate: not being able to fall asleep, and waking from recurring nightmares.

Nightmares after a trauma are not a side issue but a complaint in their own right that can be treated specifically. Behavioural approaches work on deliberately rewriting the dream and rehearsing the new version while awake; for some of those affected this changes the burden at night considerably. In individual cases medication support is added — a decision for a specialist.

What helps day to day: fixed sleeping times, no alcohol as a sleep aid, getting up briefly at night rather than brooding — and writing your sleep down, because otherwise changes go unnoticed. The basics are under Sleep disorders.

9. Co-occurring conditions

PTSD rarely comes alone — and an untreated co-occurring condition can make trauma therapy harder.

• Depression — a lack of drive and hopelessness very often occur alongside it, see Depression.
• Anxiety and panic disorders — the lasting hyperarousal often turns into generalised anxiety or panic attacks, see Anxiety disorders.
• Substance use — alcohol and sleeping or sedative tablets often serve to calm things down; this is exactly where the course frequently gets worse.
• States of exhaustion — the line between this and burnout is blurred; what matters is whether re-experiencing is in the foreground.
• Physical symptoms — chronic pain and palpitations are common and are often investigated as purely physical for a long time.

10. Bridging the wait: where to turn

One problem should not be glossed over: in many places the wait for a psychotherapy place runs to months — particularly bitter when you have just brought yourself to ask for help. Even so, that time can be bridged.

• The appointment service (Terminservicestelle) on 116 117: it arranges appointments for the psychotherapy consultation session across Germany — the official way in, and quicker than searching on your own.
• The psychotherapy consultation session: a first assessment appointment that every practice licensed by the statutory health insurance offers. Acute treatment can follow from it, without a full therapy place having to be free.
• Trauma outpatient clinics: at many hospitals, some with appointments at short notice. After violent crime the federal states cover the cost of prompt initial care.
• Your GP practice: for an assessment, a sick note and referrals — it can coordinate things when you do not have the energy for the search.
• The social psychiatric service and self-help: the service can be reached free of charge and without an appointment at every public health office (Gesundheitsamt), including by relatives; self-help groups work against isolation.
• Telefonseelsorge, the German emotional support helpline: round the clock, free of charge and anonymous on 0800 111 0 111 and 0800 111 0 222, and also by chat and email.

11. Everyday life with PTSD

• Know your triggers, but do not arrange your life around them — recognising triggers helps; avoiding all of them makes everyday life narrower and narrower.
• Structure and movement — fixed times give the overstimulated system a frame, and moderate exercise lowers the level of tension.
• Keep a record — note tension, sleep, nightmares and medicines over weeks. That shows up progress that gets lost in how you feel from day to day; strategies in the guide Chronic illness in everyday life.

For the people close to you a single sentence helps: “If I seem absent, I just need a moment of quiet, it is not about you.” And for relatives: stay available without pushing. Questions like “Why can't you get over it?” shift the responsibility onto the person affected; what helps more are concrete offers — coming along to the appointment, making the phone call, taking something off their hands in daily life.

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