Many of the people I evaluate for trauma symptoms open with a disclaimer. They describe what happened, then immediately explain why it should not have affected them this much. Someone else had it worse. It was years ago. It was only a car accident. The apology arrives before the history does.
That instinct is worth naming early, because it is one of the main reasons post-traumatic stress in adults goes untreated for years. People measure their symptoms against how dramatic the event was rather than against how they are actually functioning. The diagnostic criteria do not work that way, and neither does the nervous system.
The Event Is Not the Diagnosis
PTSD is not scored on the severity of what happened. It is defined by what persists afterward: a specific pattern of intrusion, avoidance, altered mood and thinking, and heightened arousal that continues beyond a month and interferes with ordinary life. Two people can walk away from the same collision and only one develops PTSD.
That difference is not about character or toughness. It reflects prior exposure, what happened in the hours and days afterward, how much sleep was lost early on, how much support was available, and a great deal that medicine still cannot predict in advance.
The question is not whether the event was bad enough. It is whether the alarm ever switched off.
The comparison trap carries a real cost. People who decide their trauma does not qualify tend to wait years before mentioning it to anyone. They often arrive instead with insomnia, unexplained irritability, or a depression that never quite responds to antidepressants, and the trauma history only surfaces when someone asks a direct question.
Where Adult PTSD Actually Comes From
Combat is the association most people carry, and military trauma is real, specific, and worth specialized attention. But across the general adult population it accounts for a modest share of cases. The more common sources are ordinary in the worst sense of the word.
Motor vehicle collisions
Among the most common causes of PTSD in the civilian population, and among the most consistently dismissed by the people who experience them. Symptoms frequently do not appear until weeks after the insurance claim is settled and everyone has stopped asking about it.
Assault and interpersonal violence
Physical assault, sexual assault, domestic violence, robbery. Harm caused deliberately by another person tends to produce more persistent symptoms than impersonal events, because it damages the working assumption that other people are broadly safe.
Medical trauma
An intensive care admission, a cardiac arrest, emergency surgery, a cancer diagnosis, a delivery that went badly. Waking up intubated and restrained is a threat experience whether or not anyone intended harm. Post-traumatic stress following a frightening birth is common and is very rarely asked about at the six-week visit.
Sudden bereavement
A death that arrives without warning, particularly one the person witnessed or discovered. Grief and trauma can run together, and when they do, the trauma often has to be addressed before the grief can move at all.
Childhood adversity
Trauma in childhood shapes a developing nervous system rather than interrupting a formed one. In adulthood it often presents as chronic hypervigilance, difficulty with trust and closeness, and emotional swings that get misread as a personality problem rather than a learned threat response.
Occupational exposure
Nurses, paramedics, dispatchers, emergency physicians, police, firefighters, social workers, and child protection staff absorb other people's worst days as a condition of employment. No single shift qualifies as the event. The exposure accumulates anyway.
What the Symptoms Actually Look Like
Diagnostic language is abstract. What patients describe is more concrete.
Intrusion
Rarely the cinematic flashback. More often unwanted images that arrive the moment the day goes quiet, nightmares that repeat a theme rather than a scene, and a full-body jolt at a sound, a smell, or a particular quality of light.
Avoidance
Driving ten minutes out of the way to skip an intersection. Not booking the follow-up scan. Declining to discuss it, including with the people best positioned to help. Avoidance is the symptom that most reliably keeps PTSD in place, because it prevents the nervous system from ever gathering evidence that the threat has passed.
Changes in mood and thinking
Persistent guilt or self-blame, often organized around something the person could not realistically have controlled. A flattened capacity to feel good things. A settled conviction that the world is fundamentally unsafe. Patchy memory for the event itself.
Arousal and reactivity
Exaggerated startle, irritability that arrives faster than the situation warrants, trouble concentrating, sitting where the exits are visible, and sleep that either will not start or will not hold.
Why Sleep Usually Breaks First
Sleep is often the first thing to go and the first thing patients ask about. A nervous system holding a threat posture does not power down on a schedule. That produces difficulty falling asleep, waking in the early hours fully alert, and nightmares that make sleep itself feel unappealing.
The loop is self-sustaining. Lost sleep lowers next-day tolerance for everything, which raises baseline arousal, which further degrades the following night. Clinically this matters because sleep is frequently the most workable entry point. Restoring it does not treat the PTSD, but it can return enough capacity for the rest of the work to be possible at all.
What Medication Does and Does Not Do
Medication does not process a memory. What it can do is lower the physiological alarm far enough that trauma-focused therapy becomes tolerable, and keep sleep and mood from collapsing while that therapy does its work.
Sertraline and paroxetine are the two medications carrying formal FDA approval for PTSD. Venlafaxine has solid supporting evidence without the label. All of them take weeks rather than days, and the first few weeks can be the least comfortable, which is precisely when people stop. For trauma nightmares specifically, prazosin, a non-controlled blood pressure medication, is widely used, though the evidence is more mixed than its popularity suggests.
Worth noting what is absent from that list. Benzodiazepines have obvious intuitive appeal for panic and broken sleep, and they perform poorly in PTSD specifically. Practice guidelines recommend against them for this condition, and there is reasonable evidence they interfere with the extinction learning that trauma therapy depends on. A medication that blunts the anxiety of a therapy session can quietly undercut the purpose of the session. This is one of the clearer cases in psychiatry where the obvious drug is the wrong one, and it is a large part of why trauma care here starts elsewhere.
The Prescriber Is Not the Whole Treatment
Trauma-focused psychotherapy is first-line treatment for PTSD. Cognitive processing therapy, prolonged exposure, and EMDR all have substantial evidence behind them. Medication is an adjunct to that work, not a substitute for it, and any prescriber who tells you otherwise is overselling what a prescription can do.
When someone comes to me already working with a therapist, the arrangement is straightforward. The therapist holds the therapeutic relationship and does the trauma work. I handle the medication that makes that work survivable, and the two of us stay in contact about it. That division is the entire point of the referral arrangement, and it works best when it is explicit from the first visit rather than negotiated later.
If you are not in therapy yet, that is usually my first recommendation rather than a second prescription.
Trauma Care by Telehealth in Washington
Trauma work translates well to secure video. Some people distinctly prefer it: they are in their own home, they control the environment, and there is no waiting room to sit in beforehand. The practical requirements are simple. You need to be an adult physically located in Washington State at the time of the appointment.
Initial evaluations run a full sixty minutes, which for a trauma history is the difference between a symptom checklist and an actual account of what happened. Follow-ups are thirty. For what the practice treats more broadly, see the trauma and PTSD care page, the anxiety and sleep page, and the pricing section.
Frequently Asked Questions
Can you have PTSD without a life-threatening event?
Yes. The diagnosis requires exposure to actual or threatened death, serious injury, or sexual violence, but that exposure includes witnessing it, learning it happened to someone close to you, and repeated occupational exposure to the aftermath. Many people who clearly meet criteria never believed their experience counted, and that belief is often what delayed treatment.
How is PTSD different from anxiety?
Generalized anxiety tends to run forward into possible futures. PTSD is anchored to something that already happened, and carries features anxiety does not: intrusive re-experiencing, deliberate avoidance of reminders, and a startle response calibrated to a threat that has passed. They frequently coexist, and treating one without recognizing the other is a common reason progress stalls.
Does medication treat PTSD on its own?
Usually not well. Medication can reduce hyperarousal, improve sleep, and treat co-occurring depression, which often makes therapy possible for someone who could not otherwise tolerate it. Trauma-focused psychotherapy remains the treatment with the strongest evidence for the core condition. The realistic goal of medication is to make that work accessible.
Do you prescribe benzodiazepines for PTSD?
Not as a treatment for PTSD. Controlled medications are within my scope and prescribed conservatively when genuinely indicated, but benzodiazepines specifically are recommended against in PTSD by practice guidelines, and they can interfere with the therapy that actually resolves the condition. I will not start one at a first visit or on request. If one is ever warranted, it comes with a Prescription Monitoring Program review and a clear agreement about how we use it.
When to Book a Consultation
If something happened and you have not been the same since, that is enough to make a phone call about. You do not need to have decided it qualifies, and you do not need to be ready to describe it in detail. The free fifteen minutes exist to work out whether this is the right practice, not to start the trauma history.