PTSD & Trauma-Related Disorders
A high-yield STEP 2 CK lesson on PTSD and trauma-related disorders, anchored on the DSM-5 duration rules (acute stress disorder 3 days–1 month vs. PTSD >1 month vs. adjustment disorder, onset ≤3 months) with the 4 symptom clusters, epidemiology, first-line therapy/meds (trauma-focused CBT/EMDR; sertraline and paroxetine — the only FDA-approved agents — plus venlafaxine/fluoxetine; prazosin for nightmares), drugs to avoid (benzodiazepines, routine debriefing), and classic next-best-step traps.
The trauma-and-stressor spine: it's all about DURATION
DSM-5 moved PTSD out of the anxiety disorders into a new class: Trauma- and Stressor-Related Disorders (PTSD, acute stress disorder, adjustment disorder, plus the childhood attachment disorders — reactive attachment & disinhibited social engagement). The unifying theme: an identifiable stressor precedes the symptoms.
For boards the whole discriminator is Criterion A trauma + symptom clusters + DURATION — and duration is the single highest-yield split:
- Acute stress disorder (ASD): 3 days–1 month
- PTSD: >1 month
- Adjustment disorder: onset within 3 months of a stressor (which need NOT be life-threatening)
Criterion A = exposure to actual/threatened death, serious injury, or sexual violence by: directly experiencing it; witnessing it in person; learning a close relative/friend was affected (if a death, it must have been violent or accidental); or repeated exposure to aversive details (first responders, police reviewing abuse cases). Classic trap: learning of events only through media/TV/movies does NOT qualify unless work-related.
PTSD needs >1 month duration plus symptoms across all 4 clusters (Criteria B–E):
- Intrusion (≥1): flashbacks, nightmares, intrusive memories, intense distress or physiologic reactivity to cues
- Avoidance (≥1): avoids internal reminders (thoughts/feelings) OR external reminders (people/places)
- Negative cognition/mood (≥2): dissociative amnesia for the event, persistent negative beliefs, distorted blame of self/others, anhedonia, detachment/emotional numbing
- Arousal & reactivity (≥2): hypervigilance, exaggerated startle, irritability/anger, reckless/self-destructive behavior, poor concentration, sleep disturbance
- Specifiers: with dissociative symptoms (depersonalization/derealization); with delayed expression (full criteria not met until ≥6 months post-trauma)
- Epidemiology: lifetime prevalence ~7–8%; women ≈2× men; highest risk after sexual assault, combat, interpersonal violence; heavy comorbidity with MDD, substance use, and elevated suicide risk
ASD vs PTSD vs Adjustment disorder
| Feature | Acute Stress Disorder | PTSD | Adjustment Disorder |
|---|---|---|---|
| Trigger | Criterion A trauma | Criterion A trauma | Any identifiable stressor (non-life-threatening OK: divorce, job loss) |
| Onset | Within 1 month | Any time after trauma | Within 3 months of stressor |
| Duration | 3 days – 1 month | >1 month | Resolves ≤6 months after stressor/consequences end |
| Symptom rule | ≥9 of 14 symptoms across 5 categories | Clusters B–E all met | Distress out of proportion / functional impairment |
| First-line Tx | Trauma-focused CBT | Trauma-focused CBT + SSRI/SNRI | Psychotherapy (supportive) |
Vignette: A 34-year-old combat veteran, 4 months after deployment, has nightmares of an IED blast, flashbacks triggered by fireworks, avoids crowds and war news, feels emotionally numb and detached from his family, sleeps poorly, and has an exaggerated startle response. No substance use.
- Diagnosis: PTSD — duration >1 month with all 4 clusters (intrusion, avoidance, negative mood/cognition, arousal).
- Next best step: Trauma-focused psychotherapy (prolonged exposure, cognitive processing therapy, or EMDR), ± an SSRI (sertraline or paroxetine) or SNRI (venlafaxine).
Timing twists:
- Same picture for only 2 weeks → Acute Stress Disorder (still trauma-focused CBT).
- Symptoms first meeting full criteria only 8 months after the trauma → PTSD with delayed expression.
- Distress after a non-life-threatening stressor (e.g., being fired) that doesn't meet PTSD criteria → adjustment disorder.
"TRAUMA" cues most — not all — of the criteria:
- T – Traumatic event (Criterion A: death/serious injury/sexual violence)
- R – Re-experiencing (intrusion: flashbacks, nightmares)
- A – Avoidance of reminders
- U – Unable to function / marked distress (impairment)
- M – Month or more (>1 month = PTSD; 3 days–1 month = ASD)
- A – Arousal increased (hypervigilance, exaggerated startle, irritability)
Caveat (don't get burned): TRAUMA does NOT cue the 4th symptom cluster — negative cognitions/mood (distorted self-blame, persistent negative beliefs, dissociative amnesia, emotional numbing). Remember it separately or you'll under-diagnose.
The M is the money letter — it's how the exam forces PTSD (>1 month) vs. acute stress disorder.
- First-line overall: trauma-focused psychotherapy — prolonged exposure, cognitive processing therapy, or EMDR
- First-line pharmacotherapy: SSRIs — sertraline and paroxetine are the only FDA-approved agents for PTSD; fluoxetine and the SNRI venlafaxine are also guideline-recommended (off-label). Onset takes weeks; continue ≥6–12 months
- Prazosin (central α1-adrenergic antagonist): classic buzzword for trauma-related nightmares / sleep disturbance — used as an adjunct (RCT evidence is mixed, but still the tested answer)
- AVOID benzodiazepines — ineffective for core PTSD, risk dependence, and may worsen outcomes (a favorite "which drug to avoid" answer)
- Do NOT routinely use single-session debriefing (Critical Incident Stress Debriefing) right after trauma — no benefit and may increase PTSD risk
- Adjunctive atypical antipsychotics (e.g., risperidone) have limited/mixed evidence — reserve for refractory augmentation or comorbid psychosis, not monotherapy
- "Hours after a mass-casualty event, what best prevents PTSD?" → Psychological first aid / supportive watchful waiting — NOT a mandatory single-session debriefing (may worsen outcomes).
- Veteran already on sertraline with persistent distressing nightmares → add prazosin (targets trauma-related nightmares).
- PTSD patient asks for a benzodiazepine for anxiety/sleep → decline; optimize the SSRI + trauma-focused therapy instead.
- Full symptom picture but only present for 3 weeks post-assault → diagnose acute stress disorder, start trauma-focused CBT; re-diagnose as PTSD if it crosses 1 month.
- ED nurse deeply distressed after a stressor, symptoms out of proportion but not meeting PTSD/ASD criteria, within 3 months → adjustment disorder → psychotherapy.
Practice Psychiatry now
Board-style questions, spaced-repetition flashcards, and a Socratic AI tutor — free to start.