PTSD After Sexual Assault

Clinical Scenario

Lauren Mitchell, 28, a paramedic, attends requesting sleeping tablets. She is irritable and guarded from the outset. She was sexually assaulted 6 months ago following a night out and did not report it to the police. She has been experiencing nightmares, flashbacks, hypervigilance, emotional numbing, and avoidance of social situations. She has not told anyone except one close friend. She is drinking more to help her sleep and has been calling in sick to work. She becomes angry when she feels her autonomy is being challenged.

What This Case Tests

Recognising PTSD symptoms in a patient presenting with a different request; creating a trauma-informed consultation environment; understanding that anger and irritability are PTSD symptoms rather than difficult behaviour; navigating sensitive disclosure without re-traumatising; knowing NICE-recommended treatments for PTSD; respecting patient autonomy around police reporting

Common Mistakes Trainees Make

The three most common mistakes are: responding to Lauren's anger and irritability as 'difficult patient' behaviour rather than recognising these as core PTSD symptoms — her hostility is a protective response, not rudeness; asking intrusive questions about the assault itself, which risks re-traumatisation and is not clinically necessary for diagnosis or initial management; and advising her to report to the police, which breaches her autonomy — the decision to report is entirely hers.

The Consultation Challenge

Lauren has come for sleeping tablets. She has not come to discuss the assault or her mental health. Respecting this while gently creating space for disclosure is the core skill.

Her irritability is a clinical sign, not a personality trait. When she is short or abrupt, do not match her energy or become defensive. Stay calm, warm, and steady: 'I can hear you're frustrated, and I want to help. Let's start with the sleep problems and go from there.'

Explore the sleep disturbance: when did it start, what happens (nightmares? difficulty falling asleep? early waking?), what has she tried? The timeline will point to 6 months ago. Ask gently: 'Did anything happen around the time the sleep problems started?' This is an open door — she can walk through it or not.

If she discloses, respond with calm validation: 'Thank you for telling me that, Lauren. What happened to you was not your fault, and I can see the impact it's having on you.' Do not react with shock or excessive emotion — she needs you to be steady. Do not ask for details of the assault.

Screen for PTSD symptoms without being interrogative: nightmares, flashbacks, avoidance, emotional numbing, hypervigilance, difficulty concentrating. Ask about the alcohol increase — this is self-medication and needs addressing without judgement. Ask about her work — calling in sick as a paramedic suggests significant functional impairment.

For management, explain that what she is experiencing has a name — PTSD — and that it is treatable. NICE recommends trauma-focused CBT or EMDR as first-line treatments, not medication. Sleeping tablets are not appropriate as they do not address the underlying condition and risk dependency. However, you can offer short-term support: sleep hygiene advice, reducing alcohol (which fragments sleep), and a low-dose sedating antidepressant (mirtazapine) if sleep is severely disrupted, which also has antidepressant properties.

Refer to specialist trauma services or IAPT with a trauma pathway. Signpost to Rape Crisis and Victim Support. Do not push police reporting — say: 'That's entirely your decision. If you ever want to explore that option, I can help you understand the process, but there's no pressure.'

Time check: Minutes 1-3 on exploring sleep and creating a safe environment. Minutes 3-6 on allowing disclosure and responding with validation. Minutes 6-9 on PTSD screening and understanding functional impact. Final 3 minutes on treatment options, referral, and safety-netting.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you recognise the PTSD symptom cluster from the sleep presentation, explore symptoms systematically without being intrusive, and identify the alcohol misuse as self-medication. They look for assessment of functional impact (work absence, social withdrawal) and risk screening (self-harm, suicidal ideation) conducted sensitively. Crucially, you should not ask for details of the assault itself.

Clinical Management and Medical Complexity: Examiners evaluate whether you explain PTSD as a diagnosis, know the NICE-recommended treatments (trauma-focused CBT or EMDR, not medication as first-line), and handle the sleeping tablet request appropriately. Offering a comprehensive plan — specialist referral, signposting to Rape Crisis, addressing alcohol, and appropriate pharmacological support if needed — shows clinical depth. Not prescribing hypnotics demonstrates good prescribing practice.

Relating to Others: This is the most heavily weighted domain. Examiners look for trauma-informed communication: not reacting to anger, not asking intrusive questions, validating the disclosure without excessive emotion, and explicitly respecting her autonomy on police reporting. The patient should leave feeling heard and empowered, not pathologised or pressured.

Example Opening

Strong opening: "Hello Lauren, thanks for coming in. I can see you've booked in about sleep problems. Tell me what's been going on — and take as much time as you need."

After disclosure: "Lauren, thank you for trusting me with that. What happened to you was absolutely not your fault, and the symptoms you're describing — the nightmares, the flashbacks, feeling on edge all the time — these are your mind's way of processing something traumatic. There's a name for it, and more importantly, there's effective treatment."

Avoid: "Can you tell me what happened that night?" — this risks re-traumatisation and is not necessary for diagnosis or management. The details of the assault are not clinically relevant at this stage.

How This Appears in the SCA

PTSD following sexual assault tests your ability to provide trauma-informed care, recognise that anger and avoidance are clinical symptoms rather than difficult behaviour, and manage a sensitive disclosure without re-traumatisation. Examiners value candidates who respect autonomy while offering comprehensive support.

Key Statistic

Approximately 50% of people who experience sexual assault develop PTSD. The average delay between trauma and seeking help is over 10 years, making early identification in primary care critical for better outcomes.

Relevant Guidelines

• NICE NG116: Post-traumatic stress disorder
• NICE CG123: Common mental health problems
• Rape Crisis National Service Standards
• NHS England IAPT programme — trauma pathway.

Frequently Asked Questions

How do I differentiate PTSD from depression after sexual assault?

PTSD and depression frequently co-exist after sexual assault, but PTSD has specific features: re-experiencing (flashbacks, nightmares of the event), avoidance (of places, people, or situations that trigger memories), hyperarousal (hypervigilance, exaggerated startle, irritability), and emotional numbing. Depression features low mood, anhedonia, hopelessness, and worthlessness without the trauma-specific re-experiencing. In practice, screen for both — the treatment pathways differ. PTSD requires trauma-focused therapy; depression alone may respond to antidepressants and generic CBT.

Should I prescribe sleeping tablets for a patient with PTSD?

No. Hypnotics (zopiclone, zolpidem) do not address the underlying trauma, risk dependency, and are specifically not recommended in NICE NG116 for PTSD-related sleep disturbance. If sleep is severely disrupted, a low-dose sedating antidepressant such as mirtazapine 15mg at night can improve sleep while also addressing low mood. The definitive treatment for PTSD nightmares is trauma-focused therapy. In the SCA, declining the sleeping tablet request while offering an appropriate alternative demonstrates good prescribing practice.

What is trauma-informed care in the GP consultation?

Trauma-informed care means: ensuring the patient feels safe and in control throughout the consultation; asking permission before sensitive questions; not requiring them to recount traumatic details; recognising that anger, avoidance, and distrust are symptoms rather than difficult behaviour; offering choices rather than directives; and being transparent about what will happen next. Practically, this means sitting at the same level, maintaining a calm tone, avoiding sudden movements or interruptions, and checking in: 'Is it OK if I ask about...?'

What are the NICE-recommended treatments for PTSD?

NICE NG116 recommends trauma-focused CBT (TF-CBT) or eye movement desensitisation and reprocessing (EMDR) as first-line treatments for PTSD in adults. These are typically delivered over 8-12 sessions. Medication is not first-line but venlafaxine or an SSRI (sertraline is most commonly used) can be offered if the patient declines psychological therapy, or as an adjunct in severe cases. Refer through IAPT services with a trauma pathway, or directly to specialist trauma services if available locally.

Should I encourage the patient to report the assault to the police?

No. The decision to report is entirely the patient's. Your role is to inform: 'If you ever want to explore reporting, I can help you understand the process and connect you with support services.' Pushing for a report can feel like another violation of autonomy and may damage the therapeutic relationship. Signpost to Rape Crisis and the Sexual Assault Referral Centre (SARC), which can preserve forensic evidence and provide support regardless of whether a formal report is made. Document the disclosure in the medical record with appropriate sensitivity.