Acute and posttraumatic stress disorders

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 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.

• Acute stress disorder
  • Occurs in up to 50% of individuals experiencing interpersonal violence (e.g., assault, rape) ^[1]
  • Occurs in up to ∼21% of individuals involved in motor vehicle accidents ^[1]
• PTSD
  • Lifetime prevalence: 6–9% ^[1][2]
  • Sex: ♀ > ♂ ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Triggers: exposure to traumatic events (either personally experienced or witnessed) ^[3]
  • Sexual violence (most common trigger) ^[3]
  • Physical violence
  • Accidents
  • Natural disasters
  • War ^[4]
  • Diagnosis of a severe disease
  • Witnessing the death of another person
• Risk factors ^[1]
  • Psychiatric comorbidities
  • Lower socioeconomic status
  • Child or adolescent at the time of trauma
  • Lack of social support
  • Female sex
  • Prior traumatic exposure (including childhood experiences) 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. ^[1]

• 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
• In young children: developmental regression

The clinical features of acute stress disorder and PTSD are the same. The duration of symptoms differentiates these disorders. ^[1]

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

• 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) ^[1]
• 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 ^[1]

Approach ^[5]

• 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 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. ^[6]

DSM-5 criteria for stress-related disorders ^[1]

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

• Acute stress reaction
• Other trauma- and stressor-related disorders, e.g., adjustment disorder
• Anxiety disorders, e.g., generalized anxiety disorder, panic 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 ^[5]

• 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. ^[7]

Psychotherapy ^[5]

• 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). ^[8][9]

Pharmacological treatment ^[5]

• Acute stress disorder
  • There are no approved pharmacological treatments for acute stress disorder.
  • SSRIs may be considered. ^[10]
• 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) ^[5]
  • 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. ^[5]

Approx. 50% of adults with PTSD who receive treatment have complete recovery within 3 months. ^[1]

Diagnostic criteria for PTSD in children ≤ 6 years of age (DSM-5) ^[1]

• Experience of a traumatic event involving (actual or threatened) death, serious injury, or sexual violence that occurs in one or more of the following ways:
  • Direct experience of the traumatic event(s)
  • Witnessing the traumatic event(s) in person, especially if it occurred to a primary caregiver
  • Learning about the traumatic event(s) happening to a parent or caregiver
• One or more of the following intrusion symptoms that begin after the traumatic event(s):
  • Intrusive thoughts and memories of the traumatic event; these may not appear distressing and may be expressed throug play.
  • Recurrent, distressing dreams
  • Dissociative reactions (e.g., flashbacks)
    • Individuals act and/or feel as if they were reexperiencing the traumatic event(s)
    • Reenactment of traumatic events may occur in play.
  • Intense and persistent distress when exposed to internal or external cues related to the traumatic event(s)
  • Physiological reactions triggered by external or internal cues associated with the traumatic event(s)
• One or more of the following symptoms of either avoidance of triggering stimuli or negatively affected mood and cognition following the event(s):
  • Avoidance of triggering stimuli
    • Avoidance of persons, interpersonal situations, or conversations associated with the event(s)
    • Avoidance of external reminders (e.g., places, activities, objects) related to the event(s)
  • Negatively affected mood and cognition
    • Socially withdrawn behavior
    • Increased frequency of negative emotions (e.g., fear, sadness, guilt, confusion)
    • Reduced or absent interest in important life activities, including constriction of play
    • Markedly reduced expression of positive emotions (e.g., happiness, satisfaction, love)
• Altered reactivity or arousal beginning or worsening after the event in ≥ 2 of the following ways:
  • Irritability or angry outbursts
  • Hypervigilance
  • Heightened startle reflex
  • Poor concentration
  • Sleep disturbance (e.g., nightmares, difficulty initiating or maintaining sleep)
• Duration: Symptoms last > 1 month following the traumatic event(s).
• The affected individual experiences significant distress or impaired social interactions with parents, siblings, colleagues, or caregivers since the traumatic event(s).
• Symptoms are not explained by the effects of a substance (e.g., medication) or another medical condition.

Children with PTSD may experience developmental regression.