Aisha Rahman

Assaulted during an attempted robbery at the pharmacy where she works, alone, on an evening shift. She was threatened with a knife, struck, and locked in the dispensary for roughly twenty minutes before a colleague arrived. No serious physical injury. She returned to work after six weeks and has been signed off twice since.

PCL-5 at assessment: 58. Intrusions daily, including a specific recurring image of the door handle turning. Nightmares four to five nights a week. She has not been into the dispensary alone since; a colleague accompanies her, which is now an established arrangement that nobody discusses. She takes a different route to work to avoid the street. She has stopped watching television dramas.

Hypervigilance is marked — she sits facing doors, checks locks repeatedly at home, and describes scanning every customer. Sleep is poor. She is irritable with her husband and eight-year-old daughter and describes this as the thing she most wants fixed: "I am not the mother I was."

She has told the full story once, to the police. She has not told her husband the details, and she has not told anybody about the twenty minutes locked in, which she refers to as "waiting". She becomes quiet and still when the topic approaches.

Appraisals

• "I should have seen it coming — I let him in."
• "If I let myself think about it properly I will fall apart and not come back."
• "Nowhere is safe; I just used to be naive."
• "My daughter can tell there is something wrong with me."

The Ehlers and Clark model fits well: a sense of current threat produced by disjointed, poorly elaborated trauma memory and by negative appraisals of the event, of herself, and of her own reactions — maintained by avoidance, safety behaviours, rumination and thought suppression.

The sequencing question

Trauma-focused CBT, prolonged exposure, cognitive processing therapy and EMDR all have strong first-line evidence for PTSD, and direct comparisons show broad equivalence. The clinically consequential question is not which of them but when: whether to begin trauma-focused work now, or to stabilise first. The stabilisation-first orthodoxy has been substantially challenged — evidence suggests most patients tolerate trauma-focused work earlier than clinicians assume, and that delaying it prolongs suffering.