Acute and posttraumatic stress disorders

To see contributor disclosures related to this article, click on this reference: ^[1]

Physicians can earn CME/MOC credit by using this article to address a clinical question and completing a brief evaluation about how they applied the information in their practice.

AMBOSS designates this internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see “Tips and links” at the bottom of this article.

Acute stress disorder and posttraumatic stress disorder (PTSD) are psychiatric conditions that arise following exposure to traumatic events, such as natural disasters, war, accidents, or personal assaults. Acute stress disorder occurs in up to 50% of individuals exposed to a traumatic event, and PTSD affects 6–9% of the US population at some point in their lives. Both conditions are characterized by intrusive memories, avoidance behaviors, mood disturbances, and increased arousal. Acute stress disorder symptoms last from three days to one month after trauma, while PTSD is distinguished by the persistence of symptoms beyond one month. Diagnosis is confirmed using the DSM-5-TR criteria for stress-related disorders. Trauma-focused psychotherapy is the first-line treatment; SSRIs or venlafaxine may also be used. Early intervention following trauma exposure is crucial in preventing the progression of acute stress disorder to PTSD. In children, features of PTSD may include developmental regression and trauma-related play. For children > 6 years of age, adult diagnostic criteria are used; separate diagnostic criteria are used for children ≤ 6 years of age. First-line treatment involves developmentally appropriate trauma-focused psychotherapy. Pharmacotherapy can be considered for refractory symptoms.

• Acute stress disorder
  • Occurs in up to 50% of individuals experiencing interpersonal violence (e.g., assault, rape)^[2]
  • Less prevalent following traumatic events not related to interpersonal violence, e.g., motor vehicle accidents ^[2]
• PTSD
  • Lifetime prevalence: 6–9% ^[2][3]
  • Sex: ♀ > ♂ ^[2]

Epidemiological data refers to the US, unless otherwise specified.

• Triggers: exposure to traumatic events (either personally experienced or witnessed) ^[4]
  • Sexual violence (most common trigger) ^[4]
  • Physical violence
  • Accidents
  • Natural disasters
  • War ^[5]
  • Diagnosis of a severe disease
  • Witnessing the death of another person
• Risk factors ^[2]
  • Psychiatric comorbidities
  • Lower socioeconomic status
  • Lack of social support
  • Female sex
  • Adverse childhood experiences, including prior traumatic exposure and/or subsequent reminders
  • High perceived severity of the traumatic event
• Common comorbidities
  • Major depressive disorder
  • Substance use disorders
  • Somatic symptom disorder

Individuals with acute stress disorder and PTSD experience similar symptoms, which begin after a traumatic event. ^[2]

• Intrusive memories and/or dreams associated with the trauma
• Avoidance of reminders of the traumatic event
• Mood and cognitive disturbances (e.g., dissociative amnesia, guilt, shame, isolation)
• Increased arousal (e.g., hypervigilance, violent outbursts)
• Sleep disturbances
• Difficulty concentrating
• Distress or impairment in social, occupational, or other important areas of functioning

Acute stress disorder and PTSD have the same clinical features and are distinguished by symptom duration.^[2]

To remember the features of PTSD, think of “TRAUMMA”: Traumatic event → Reexperience, Avoidance, Unable to function, More than a Month in duration, Arousal is increased

Approach ^[6]

• Screen patients who have experienced a traumatic event using the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).
• Perform a detailed history, focusing on traumatic events and personal and family psychiatric history.
• Consider diagnostic studies (e.g., urine drug screen) if alternative causes are suspected.
• Confirm diagnosis using the DSM-5-TR criteria for stress-related disorders.
• Assess for psychiatric and medical comorbidities, e.g., major depressive disorder, anxiety disorders, substance use disorder.
• Evaluate suicide risk.

Screen military veterans for PTSD annually for the first 5 years after separation from active duty. ^[7]

DSM-5-TR criteria for stress-related disorders ^[2]

The following criteria apply to individuals aged > 6 years. See “Special patient groups” for diagnostic criteria for PTSD in children ≤ 6 years of age.

Specifiers for PTSD ^[2]

• PTSD with delayed expression: a subtype of PTSD in which individuals first meet the full diagnostic criteria ≥ 6 months after the associated traumatic event(s)
• PTSD with dissociative symptoms: a subtype of PTSD in which individuals meet the diagnostic criteria for PTSD and concomitantly experience symptoms of either derealization or depersonalization

• Acute stress reaction
• Other trauma- and stressor-related disorders, e.g., adjustment disorder
• Anxiety disorders, e.g., generalized anxiety disorder, panic disorder
• Attention deficit hyperactivity disorder
• Mood disorders, e.g., major depressive disorder, bipolar disorder
• Obsessive-compulsive disorder
• Dissociative disorders
• Psychotic disorders, e.g., schizophrenia
• Personality disorders
• Substance-related and addictive disorders
• Somatic symptom disorder
• Traumatic brain injury

The differential diagnoses listed here are not exhaustive.

Approach ^[6]

• Provide education about the broad range of expected reactions to traumatic situations, the natural course of the disorder, and treatment options.
• Refer all patients for individual trauma-focused psychotherapy.
• For patients with PTSD:
  • Consider SSRI or SNRI therapy.
  • Track symptom severity using, e.g., the PTSD Checklist for DSM-5.
• For patients with suicidal ideation or at risk of self-harm, refer to psychiatry and consider hospitalization.

Early trauma-focused psychotherapy prevents progression to PTSD in patients with acute stress disorder. ^[8]

Psychotherapy ^[6]

• Trauma-focused psychotherapy is the first-line treatment for all patients with acute stress disorder or PTSD.
• Recommended modalities
  • Prolonged exposure therapy
  • Cognitive processing therapy
  • Eye movement desensitization and reprocessing (EMDR): The patient recalls traumatic images, sensations, and emotions while undergoing bilateral hemispheric stimulation (e.g., moving eyes from left to right). ^[9][10]

Pharmacological treatment ^[6]

• Acute stress disorder
  • There are no approved pharmacological treatments for acute stress disorder.
  • SSRIs may be considered. ^[11]
• PTSD
  • SSRIs or SNRIs
    • Consider for patients who are incomplete responders to, decline to engage in, or are unable to access trauma-focused psychotherapy.
    • Agents include: sertraline , paroxetine , venlafaxine (off-label) ^[6]
  • Prazosin: may be considered for PTSD-associated nightmares

Benzodiazepines and cannabis should be avoided due to the risk of misuse and lack of evidence supporting therapeutic benefit. ^[6]

Approx. 50% of adults with PTSD who receive treatment have complete recovery within 3 months. ^[2]

Etiology

In addition to risk factors for PTSD in adults, risk factors for PTSD in children include the following:

• Development of emotional problems (e.g., anxiety) by 6 years of age ^[2]
• Trauma inflicted by a caregiver or involving harm to a caregiver ^[2]
• Parental psychiatric conditions, including PTSD ^[12][13]
• Acute post-trauma panic symptoms (e.g., panic attacks) ^[12]
• Caregiver distress in reaction to the traumatic event ^[14][15]

Clinical features

Clinical features of PTSD are similar in adults and children, with the following additions.

• Young children ^[2][12][15]
  • Developmental regression (e.g., language regression, incontinence)
  • Trauma-themed play (e.g., trauma reenactments, intervention fantasies)
  • New or worsened separation anxiety
  • New phobias unrelated to the traumatic event (e.g., fear of the dark)
  • Aggressive or oppositional behavior
• Adolescents ^[2]
  • Social disconnection from peers
  • Impulsive behaviors
  • Suicidal ideation

Symptoms of PTSD in children (e.g., inattention, struggling with focus and learning) can be mistaken for symptoms of ADHD. ^[2][12]

Diagnostics

Approach

• Screen children with trauma exposure or symptoms of PTSD using a developmentally appropriate tool. ^[12][13]
• Diagnose PTSD using appropriate age-based criteria.
  • Children ≤ 6 years of age: DSM-5-TR criteria for PTSD in children ≤ 6 years of age
  • Children > 6 years of age: DSM-5-TR criteria for stress-related disorders
• Evaluate for comorbidities, e.g.: ^{[12] [2][15]}
  • ADHD
  • Depression in children
  • Oppositional defiant disorder
  • Separation anxiety disorder
• Perform a suicide risk assessment. ^[2][12]
• Diagnostic uncertainty: Refer to pediatric psychiatry. ^[16]

Interview children and caregivers individually when appropriate; children may minimize symptoms in front of caregivers. ^[13]

DSM-5-TR criteria for PTSD in children ≤ 6 years of age ^[2]

Management

Management involves a multidisciplinary team (e.g., pediatrician, psychotherapist). ^[16]

Approach ^[12]

• Involve caregivers and consider school accommodations in treatment plans.
• Refer for trauma-focused psychotherapy.
• Treat comorbid psychiatric conditions, e.g.:
  • Treatment of depression in children
  • Treatment of separation anxiety disorder
• For patients with symptoms refractory to psychotherapy, consider adjunctive pharmacotherapy. ^[16]
• Medication-refractory symptoms : Refer to pediatric psychiatry. ^[16]

Engaging caregivers in the treatment process improves outcomes. ^[12]

Trauma-focused psychotherapy

• Preferred: trauma-focused CBT ^[12][13]
• Alternative options include: ^[13]
  • EMDR
  • Psychodynamic trauma-focused psychotherapy
  • Multidisciplinary programs that combine therapies

Modify psychotherapy according to the child's developmental capacity. ^[12][14]

Pharmacotherapy ^[16]

• All medication use for PTSD in children is off-label. ^[16]
• Tailor medication to specific symptom management, e.g.:
  • Hyperarousal symptoms (e.g., impulsivity, anxiety, tachycardia) ^[12][16]
    • Alpha-2 adrenergic agonists (e.g., clonidine, guanfacine)
    • Beta blockers (e.g., propranolol)
  • Sleep disturbances: prazosin ^[16]
• There is a lack of consensus on the use of SSRIs to treat PTSD in children. ^{[12][16][17][18]}