# Seminar 06: Trauma and Stressor-Related Disorders ## Year 3: Psychiatry Clerkship --- ## Learning Objectives By the end of this seminar, students will be able to: 1. Diagnose PTSD using DSM-5 criteria 2. Differentiate acute stress disorder from PTSD 3. Recognize adjustment disorders 4. Apply trauma-informed care principles 5. Describe evidence-based treatments for PTSD 6. Identify complex trauma and dissociative responses --- ## Seminar Outline ### I. Overview of Trauma-Related Disorders The trauma and stressor-related disorders comprise a category of conditions in which exposure to a traumatic or stressful event is explicitly required as a diagnostic criterion. This category, newly established in DSM-5 separate from anxiety disorders, includes posttraumatic stress disorder, acute stress disorder, adjustment disorders, reactive attachment disorder, and disinhibited social engagement disorder. The reorganization reflects recognition that while these conditions share the common thread of requiring an identifiable precipitant, their clinical presentations vary considerably and may emphasize anxiety, depression, dissociation, or behavioral disturbances depending on the specific disorder and individual patient. Defining what constitutes a traumatic event for the purpose of PTSD and acute stress disorder diagnosis requires understanding Criterion A. Qualifying traumatic events involve exposure to actual or threatened death, serious injury, or sexual violence in one of four ways: directly experiencing the traumatic event; witnessing in person the event as it occurred to others; learning that the traumatic event occurred to a close family member or close friend, with the event being violent or accidental; or experiencing repeated or extreme exposure to aversive details of traumatic events in the course of professional duties such as first responders collecting human remains. Importantly, media exposure does not qualify unless work-related. Epidemiological data reveal that trauma exposure is common while PTSD is not, indicating substantial individual variation in response to traumatic events. Fifty to seventy percent of the general population will experience at least one traumatic event during their lifetime, yet lifetime PTSD prevalence is approximately six to nine percent. Women are approximately twice as likely as men to develop PTSD following trauma exposure. High-risk traumas include combat exposure, sexual assault, childhood abuse, and torture, which carry higher conditional probability of PTSD development. The majority of trauma-exposed individuals demonstrate resilience and do not develop PTSD, though they may experience transient distress. Risk and protective factors influence the probability of developing PTSD following trauma exposure. Risk factors include prior trauma exposure, pre-existing mental illness, peritraumatic dissociation during or immediately after the event, perceived life threat during the trauma, lack of social support following the trauma, and greater trauma severity. Protective factors include strong social support networks, higher educational attainment, active coping styles, and psychological resilience. Understanding these factors helps identify individuals who may benefit from enhanced monitoring or early intervention following trauma exposure. Early intervention for high-risk individuals may prevent PTSD development. Panel A: A classification diagram showing the trauma and stressor-related disorders with their key distinguishing features. Panel B: A breakdown of Criterion A trauma types with examples of qualifying events for each category. Panel C: A funnel diagram showing trauma exposure prevalence narrowing to PTSD prevalence, illustrating resilience as the common outcome. Panel D: A balance scale showing risk factors versus protective factors for PTSD development. --- ### II. PTSD Diagnostic Criteria The DSM-5 diagnostic criteria for PTSD require exposure to a traumatic event meeting Criterion A followed by symptoms in four distinct clusters. Criterion B requires at least one intrusion symptom. Criterion C requires at least one avoidance symptom. Criterion D requires at least two negative alterations in cognitions and mood. Criterion E requires at least two alterations in arousal and reactivity. Symptoms must persist for more than one month, representing the duration criterion that distinguishes PTSD from acute stress disorder. The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Intrusion symptoms in Cluster B involve unwanted re-experiencing of the traumatic event in various forms. Intrusive memories are recurrent, involuntary, and distressing memories of the traumatic event. Traumatic nightmares involve distressing dreams with content or affect related to the event. Flashbacks are dissociative reactions in which the individual feels or acts as if the traumatic event were recurring, ranging from brief sensory intrusions to complete loss of awareness of present surroundings. Psychological distress and physiological reactions occur upon exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. These intrusion symptoms are often the most recognizable PTSD features. Avoidance symptoms in Cluster C involve persistent effortful avoidance of trauma-related stimuli. Internal avoidance involves efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event. External avoidance involves efforts to avoid external reminders including people, places, conversations, activities, objects, or situations that arouse distressing memories, thoughts, or feelings about the trauma. The avoidance criterion requires only one symptom but is considered a core feature of PTSD. Avoidance behavior may progressively restrict the patient's activities and functioning, contributing to significant impairment. Negative alterations in cognitions and mood, Criterion D, represent features of PTSD that overlap with depression but are specifically trauma-related. Dissociative amnesia involves inability to remember an important aspect of the traumatic event. Persistent and exaggerated negative beliefs about oneself, others, or the world may develop. Persistent distorted cognitions about the cause or consequences of the trauma lead to blaming oneself or others inappropriately. Persistent negative emotional states including fear, horror, anger, guilt, or shame characterize post-trauma affective experience. Markedly diminished interest in significant activities and feelings of detachment or estrangement from others reflect social and hedonic withdrawal. Persistent inability to experience positive emotions reflects emotional numbing or anhedonia. Panel A: A comprehensive checklist of DSM-5 PTSD criteria organized by clusters B through E with symptom counts required. Panel B: An illustration of intrusion symptoms showing intrusive memories, nightmares, flashbacks, and triggered distress. Panel C: A diagram showing internal and external avoidance patterns with examples of each. Panel D: A depiction of Criterion D symptoms showing negative cognitions, emotions, and social detachment. --- ### III. PTSD Clinical Features and Specifiers Arousal and reactivity symptoms in Cluster E describe persistent alterations in the individual's baseline arousal and reactivity following trauma. Irritable behavior and angry outbursts with little or no provocation may be expressed as verbal or physical aggression. Reckless or self-destructive behavior may include substance use, dangerous driving, or self-harm. Hypervigilance involves constant scanning of the environment for threat, being on guard at all times. Exaggerated startle response involves heightened reactivity to unexpected stimuli. Concentration problems reflect difficulty focusing attention. Sleep disturbance includes difficulty falling or staying asleep. At least two arousal symptoms are required, and these symptoms often significantly impair daily functioning. DSM-5 includes two important specifiers for PTSD that guide treatment planning. The dissociative subtype specifier applies when the individual experiences persistent or recurrent symptoms of depersonalization, feeling detached from one's own mind or body as though one were an outside observer, or derealization, experiencing surroundings as unreal, dreamlike, distant, or distorted. Approximately ten to fifteen percent of PTSD patients meet criteria for this subtype, which is associated with more severe trauma, particularly early life trauma, and may require modified treatment approaches emphasizing stabilization. The delayed expression specifier applies when full diagnostic criteria are not met until at least six months after the event, though some symptoms typically begin immediately. The dissociative subtype warrants additional clinical attention given its prevalence and treatment implications. Patients with the dissociative subtype have typically experienced more severe trauma, often including chronic childhood trauma or repeated interpersonal violence. These patients may show blunted emotional and physiological responses to trauma reminders rather than the hyperreactivity more typical of PTSD. Standard trauma-focused treatments may need modification, with greater emphasis on stabilization and grounding skills before trauma processing. Some evidence suggests that the dissociative subtype may respond differently to certain treatments. Comorbidity in PTSD is the rule rather than the exception, with most patients meeting criteria for at least one additional disorder. Major depressive disorder co-occurs in approximately fifty percent of PTSD cases, and shared symptoms including anhedonia, sleep disturbance, and concentration problems can make differential diagnosis challenging. Substance use disorders affect forty to fifty percent of PTSD patients, representing both an attempt to self-medicate symptoms and an independent risk factor. Other anxiety disorders occur in thirty to forty percent. Chronic pain frequently co-occurs, creating a bidirectional relationship in which each condition worsens the other. Medical conditions including cardiovascular disease occur at elevated rates, possibly related to chronic stress physiology. Panel A: An illustration of Cluster E arousal symptoms showing hypervigilance, startle, irritability, and concentration difficulty. Panel B: A comparison of standard PTSD versus dissociative subtype presentations with characteristic features. Panel C: A flowchart showing the delayed expression specifier with typical timeline. Panel D: A comorbidity diagram showing conditions frequently co-occurring with PTSD and their prevalence rates. --- ### IV. Acute Stress Disorder Acute stress disorder shares symptom overlap with PTSD but is distinguished primarily by duration and occurs in the immediate aftermath of trauma. The disorder requires exposure to a traumatic event meeting Criterion A, the same as for PTSD. Symptoms must begin within three days of the traumatic event and may last up to one month, after which PTSD would be diagnosed if symptoms persist. At least nine symptoms must be present from any of five categories encompassing intrusion, negative mood, dissociation, avoidance, and arousal domains. The flexibility in allowing symptoms from any category reflects the variable presentations in the acute post-trauma period. The symptom categories for acute stress disorder parallel those of PTSD but with different grouping and threshold requirements. Intrusion symptoms include intrusive memories, distressing dreams, flashbacks, and intense or prolonged distress at exposure to reminders. Negative mood involves persistent inability to experience positive emotions. Dissociative symptoms include altered sense of reality of surroundings or oneself and inability to remember important aspects of the trauma. Avoidance symptoms mirror PTSD avoidance of memories and external reminders. Arousal symptoms include sleep disturbance, irritability, hypervigilance, concentration problems, and exaggerated startle response. The nine-symptom threshold can be met through various combinations. The relationship between acute stress disorder and PTSD has important implications for early intervention. Acute stress disorder is a significant predictor of subsequent PTSD development, though not all individuals with acute stress disorder progress to PTSD and not all PTSD patients had prior acute stress disorder. Approximately fifty percent of those with acute stress disorder subsequently meet PTSD criteria. Early intervention during the acute stress disorder phase may prevent progression to chronic PTSD. However, natural recovery occurs in many individuals without intervention, making selective early intervention targeting those at highest risk most appropriate. Treatment of acute stress disorder and acute post-trauma presentations emphasizes supportive care and targeted intervention for those at elevated risk. Brief trauma-focused cognitive behavioral therapy delivered in the weeks following trauma has demonstrated efficacy in preventing PTSD development among those with acute stress disorder. Psychological first aid provides immediate support emphasizing safety, calm, connectedness, self-efficacy, and hope without requiring trauma processing. Single-session psychological debriefing, once common, has been shown to be ineffective and potentially harmful and should be avoided. Monitoring high-risk individuals through the acute period allows identification of those developing persistent symptoms who may benefit from treatment. Panel A: A comparison of acute stress disorder versus PTSD criteria showing shared features and distinguishing duration requirements. Panel B: A symptom category breakdown for acute stress disorder showing the five domains and nine-symptom threshold. Panel C: A flowchart illustrating trajectories from trauma through acute stress disorder with branches to recovery versus PTSD. Panel D: An early intervention model showing psychological first aid and brief CBT for at-risk individuals. --- ### V. Adjustment Disorders Adjustment disorders describe emotional or behavioral symptoms that develop in response to an identifiable stressor but do not meet criteria for another specific mental disorder. Unlike PTSD and acute stress disorder, adjustment disorders do not require exposure to an extreme traumatic event and may follow any stressor of any severity. Symptoms must begin within three months of the onset of the stressor. The response must involve marked distress that is out of proportion to the severity of the stressor, taking into account contextual factors, or significant impairment in social, occupational, or other important areas of functioning. Once the stressor or its consequences have terminated, symptoms must resolve within six months. Adjustment disorder subtypes specify the predominant symptom pattern. With depressed mood indicates low mood, tearfulness, or feelings of hopelessness as predominant symptoms. With anxiety indicates nervousness, worry, jitteriness, or separation anxiety as predominant features. With mixed anxiety and depressed mood involves a combination of depression and anxiety without either predominating. With disturbance of conduct indicates behavioral problems such as violation of rights of others or age-appropriate societal norms. With mixed disturbance of emotions and conduct involves both emotional symptoms and behavioral problems. Unspecified applies when the presentation does not fit the other subtypes. Common stressors precipitating adjustment disorders span multiple life domains. Relationship stressors include divorce, separation, relationship conflicts, and ending of romantic relationships. Work-related stressors include job loss, workplace conflicts, and job changes. Financial stressors include debt, loss of income, and economic hardship. Health-related stressors include diagnosis of serious medical illness in oneself or a loved one. Life transitions include moving to a new location, retirement, becoming a parent, and children leaving home. The stressor need not be catastrophic; the diagnosis applies when the response is disproportionate or causes significant impairment regardless of stressor severity. Treatment of adjustment disorders is generally supportive and time-limited, reflecting the expected resolution with stressor termination. Supportive therapy focusing on emotional processing and validation represents the mainstay of treatment. Brief problem-focused psychotherapy helps patients develop coping strategies and address modifiable aspects of the stressor. Addressing the stressor directly, when possible, may resolve symptoms more rapidly than symptom-focused treatment. Medications are generally not first-line treatment but may be considered for severe symptoms or when other disorders are emerging. The prognosis is generally good with most cases resolving within months, particularly when the stressor is removed or resolved. Panel A: A checklist of DSM-5 adjustment disorder criteria showing stressor, timing, symptoms, and duration requirements. Panel B: A diagram of adjustment disorder subtypes with characteristic symptom patterns for each. Panel C: A categorization of common precipitating stressors organized by life domain. Panel D: A treatment algorithm showing supportive therapy as first-line with brief psychotherapy and consideration of medication for severe cases. --- ### VI. Trauma-Informed Care Principles Trauma-informed care represents a framework for service delivery that recognizes the widespread impact of trauma and integrates knowledge about trauma into policies, procedures, and practices. The approach shifts the fundamental question from "What is wrong with you?" to "What happened to you?" recognizing that many presentations and behaviors represent adaptations to trauma rather than pathology. Trauma-informed care does not require providing trauma-specific treatment but rather creating an environment that avoids retraumatization and supports recovery. The approach applies across healthcare settings, not only mental health services. The core principles of trauma-informed care guide organizational and clinical practices. Safety involves ensuring physical and emotional safety for patients throughout their care. Trustworthiness requires maintaining clear boundaries and consistency in interactions. Choice emphasizes providing patients with control and options wherever possible within the care setting. Collaboration involves working together with patients rather than doing to them. Empowerment focuses on building on patient strengths and supporting skill development. Cultural, historical, and gender issues require recognition of how these factors influence trauma experience and recovery. Screening for trauma history should be incorporated into routine clinical care given the high prevalence of trauma exposure and its impact on health. Universal screening approaches ensure that all patients are asked about trauma history, reducing the chance that trauma-related issues go unaddressed. Screening should be conducted sensitively using validated tools such as the PC-PTSD-5 for PTSD screening or the PCL-5 for more detailed symptom assessment. Normalization helps patients feel comfortable disclosing by framing questions in terms of common experiences. Patient choice about whether and how much to disclose should be respected, with patients informed that they do not have to share details. Avoiding retraumatization requires attention to practices throughout care delivery. Informed consent before procedures ensures patients know what to expect. Explaining what will happen during examinations or treatments reduces unexpected triggering. Providing options and choices where possible gives patients a sense of control. Allowing patients to stop procedures if distressed respects autonomy. Creating safe, private environments for sensitive discussions prevents exposure to additional distress. Training all staff, not only clinical providers, in trauma-informed approaches ensures consistent trauma-sensitive interactions throughout the care experience. Panel A: A conceptual diagram contrasting traditional care approaches with trauma-informed care approaches. Panel B: A hexagonal model showing the six core principles of trauma-informed care with applications for each. Panel C: A screening implementation guide showing tools, timing, and response to positive screens. Panel D: A checklist of practices for avoiding retraumatization throughout the care experience. --- ### VII. Pharmacotherapy for PTSD First-line pharmacotherapy for PTSD consists of selective serotonin reuptake inhibitors, with sertraline and paroxetine holding FDA approval for this indication. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, has strong evidence supporting efficacy though lacks FDA approval specifically for PTSD. These medications are dosed similarly to treatment of depression and typically require eight to twelve weeks for full effect. Duration of treatment should extend at least twelve months and often longer given the chronic nature of PTSD in most patients. Combination with trauma-focused psychotherapy generally produces better outcomes than either treatment alone. Additional medications address specific PTSD symptoms or augment first-line treatment. Prazosin, an alpha-1 adrenergic receptor antagonist, has demonstrated efficacy specifically for PTSD-related nightmares and sleep disturbance, with starting doses of one milligram at bedtime titrated up based on response and blood pressure. Mirtazapine may help with sleep and appetite problems. Trazodone is commonly used for sleep but has limited evidence specifically for PTSD. Propranolol given shortly after trauma may prevent PTSD development in some studies, though evidence remains mixed. Atypical antipsychotics such as risperidone or quetiapine may augment SSRI treatment in resistant cases. Certain medications should be avoided or used cautiously in PTSD treatment. Benzodiazepines, despite their anxiolytic effects, may interfere with the natural recovery process and fear extinction learning, carry risk of dependence particularly problematic in the context of high substance use comorbidity, and have not demonstrated efficacy for PTSD in controlled trials. Current guidelines recommend against benzodiazepine use in PTSD. Typical antipsychotics lack efficacy evidence. Alcohol, commonly used for self-medication, worsens PTSD symptoms and outcomes. Patient education about the negative effects of these substances supports recovery. Augmentation strategies for partial medication response include adding prazosin for persistent nightmares, adding an atypical antipsychotic for persistent symptoms, and ensuring that trauma-focused psychotherapy is incorporated. Combination of medication with evidence-based psychotherapy consistently outperforms either alone and represents the optimal treatment approach for most patients. Treatment duration should be guided by symptom response, with consideration of gradual medication taper after extended periods of remission, typically one to two years minimum. Relapse is common following medication discontinuation. Panel A: A comparison of first-line PTSD medications showing FDA approval status, dosing, and key considerations. Panel B: A detailed profile of prazosin for PTSD nightmares showing mechanism, dosing protocol, and monitoring. Panel C: A list of medications to avoid in PTSD with rationale for each. Panel D: An augmentation algorithm for partial SSRI response showing medication and psychotherapy options. --- ### VIII. Psychotherapy for PTSD Evidence-based psychotherapies for PTSD have strong empirical support and are recommended as first-line treatments alone or in combination with medication. Prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing all have robust evidence and are strongly recommended in treatment guidelines. These therapies are typically delivered over eight to sixteen sessions, though exact duration varies by protocol and patient needs. All three approaches have demonstrated efficacy across trauma types and populations. Selection among these treatments may be guided by patient preference, therapist availability and training, and specific clinical features. Prolonged exposure is based on emotional processing theory and involves systematic confrontation with trauma memories and avoided situations. Components include psychoeducation about PTSD and treatment rationale, breathing retraining as a coping skill, in vivo exposure to trauma-related situations that are objectively safe but avoided due to trauma reminders, and imaginal exposure involving repeated recounting of the trauma memory in detail during sessions. Processing discussions help patients examine thoughts and meanings associated with the trauma. Through repeated exposure, the trauma memory becomes less distressing and avoidance decreases. Cognitive processing therapy focuses on identifying and modifying trauma-related thoughts and beliefs that maintain PTSD symptoms. Treatment addresses "stuck points," which are problematic beliefs about why the trauma occurred or its meaning, often involving themes of self-blame or distorted responsibility. Cognitive restructuring techniques help patients evaluate evidence for and against these beliefs and develop more balanced perspectives. Written accounts of the trauma may or may not be included depending on the protocol version. CPT addresses five themes particularly affected by trauma: safety, trust, power and control, esteem, and intimacy. Eye movement desensitization and reprocessing employs bilateral stimulation, typically eye movements following the therapist's fingers, while the patient focuses on trauma memories and associated thoughts and feelings. The proposed mechanism involves facilitation of adaptive information processing and memory reconsolidation, though the specific contribution of eye movements remains debated. EMDR follows an eight-phase protocol including history taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation. The trauma memory becomes less distressing as processing occurs. EMDR does not involve detailed verbal recounting of the trauma or homework exposures, which some patients prefer. Panel A: A comparison of the three first-line PTSD psychotherapies showing components, session number, and distinguishing features. Panel B: A diagram of prolonged exposure components showing psychoeducation, breathing, in vivo exposure, and imaginal exposure. Panel C: An illustration of cognitive processing therapy showing stuck points, cognitive restructuring, and the five trauma-affected themes. Panel D: A visual representation of the EMDR eight-phase protocol with bilateral stimulation. --- ### IX. Complex Trauma and Dissociation Complex PTSD describes a clinical syndrome that may develop following prolonged, repeated trauma, particularly when the trauma occurs in the context of captivity or lack of escape and involves interpersonal violence. While not included as a separate diagnosis in DSM-5, complex PTSD is recognized in ICD-11 and is widely acknowledged clinically. In addition to core PTSD symptoms, complex PTSD includes disturbances in self-organization comprising affect dysregulation with difficulty modulating emotional responses, negative self-concept involving persistent beliefs about being diminished, defeated, or worthless, and disturbances in relationships manifested as difficulty feeling close to others or persistent interpersonal problems. The contexts that produce complex trauma typically involve prolonged exposure to traumatic circumstances from which escape is not possible. Childhood abuse, particularly when chronic and occurring within caregiving relationships, represents a prototypical complex trauma. Domestic violence, human trafficking, prisoner of war experiences, and torture similarly involve repeated trauma within conditions of captivity. The relational context of these traumas, often occurring within attachment relationships or at the hands of trusted figures, particularly damages the capacity for trust and relationships. The developmental timing of childhood trauma affects personality development and emotion regulation capacities. Dissociative symptoms frequently accompany complex trauma presentations and include a spectrum of experiences. Depersonalization involves feeling detached from one's mind or body, as if an outside observer of oneself. Derealization involves experiencing the world as unreal, dreamlike, or distant. Dissociative amnesia involves gaps in memory for personal information or events, beyond ordinary forgetting. Identity confusion involves uncertainty about one's sense of identity. At the most severe end, dissociative identity disorder involves the presence of two or more distinct personality states with associated gaps in recall. These dissociative disorders are strongly linked to severe early trauma. Treatment of complex PTSD and significant dissociation typically requires modification of standard trauma-focused approaches. Phase-based treatment is generally recommended, beginning with a stabilization phase that establishes safety, develops coping skills, addresses basic life functioning, and builds the therapeutic relationship before proceeding to trauma processing. Grounding techniques help patients manage dissociation by reconnecting with the present moment and physical surroundings. Affect regulation skills build capacity to tolerate and modulate emotional states. Only after stabilization should trauma processing proceed, and it may need to be conducted more gradually than in standard protocols. Treatment duration is typically longer than for uncomplicated PTSD. Panel A: A comparison of DSM-5 PTSD versus ICD-11 complex PTSD showing the additional disturbances in self-organization. Panel B: A diagram showing contexts producing complex trauma including childhood abuse, domestic violence, and captivity. Panel C: A spectrum of dissociative symptoms from depersonalization through amnesia to identity alteration. Panel D: A phase-based treatment model showing stabilization, trauma processing, and integration phases. --- ### X. Special Populations and Prevention PTSD in children presents differently than in adults, with developmental considerations affecting both symptom expression and treatment approaches. Children may reenact trauma through repetitive play rather than experiencing intrusive memories in adult form. Nightmares may have frightening content without clearly recognizable trauma-related themes. Regression to earlier developmental stages, such as loss of acquired skills or return of separation anxiety, may occur. Treatment for children emphasizes trauma-focused cognitive behavioral therapy, specifically TF-CBT, which has strong evidence and incorporates psychoeducation, coping skills, trauma narrative development, and parent involvement. The child's developmental level guides treatment adaptations. PTSD in military personnel and veterans requires attention to specific trauma exposures and cultural factors. Combat exposure produces high rates of PTSD, with estimates of ten to twenty percent among deployed service members. Military sexual trauma affects both women and men and requires sensitive inquiry. Traumatic brain injury frequently co-occurs with combat-related PTSD, creating diagnostic complexity and treatment challenges. Stigma about mental health treatment may serve as a barrier to care in military populations. VA healthcare systems provide specialized PTSD treatment programs. Evidence-based treatments are effective in veteran populations, though engagement and retention in treatment may be challenging. Cultural considerations influence trauma response, symptom expression, and treatment acceptability. Cultural idioms of distress may result in different symptom presentations than those emphasized in DSM criteria developed in Western contexts. Stigma associated with mental health problems varies across cultures and may affect help-seeking. The meaning attributed to traumatic events is culturally influenced and shapes the psychological impact. Treatment should be culturally adapted to enhance acceptability and effectiveness. Refugee populations present particular challenges given exposure to multiple traumas, losses, ongoing stressors related to displacement and resettlement, and potential language barriers. Prevention of PTSD following trauma exposure represents an important public health goal. Psychological first aid provides immediate support without pushing for detailed trauma processing. Strong social support following trauma exposure serves as a protective factor that can be enhanced through psychoeducation for support systems. Screening high-risk populations, such as trauma-exposed individuals with risk factors or acute stress disorder, allows targeted early intervention. Brief trauma-focused CBT delivered to those with acute stress disorder can prevent progression to chronic PTSD. Single-session psychological debriefing should be avoided as evidence indicates it is ineffective and potentially harmful. Panel A: A developmental guide to PTSD presentation in children showing age-appropriate manifestations. Panel B: A framework for addressing PTSD in military and veteran populations including common co-occurring conditions and barriers. Panel C: A cultural adaptation model for trauma treatment addressing idioms of distress, meaning, and treatment preferences. Panel D: A prevention framework showing immediate, early, and ongoing intervention strategies for trauma-exposed populations. --- ## Summary - PTSD requires trauma exposure (Criterion A) plus symptoms in four clusters: intrusion, avoidance, negative cognitions and mood, and arousal, lasting more than one month - Acute stress disorder has similar symptoms but duration of three days to one month; may predict PTSD but not all cases progress - Adjustment disorders involve maladaptive response to any identifiable stressor; subtypes based on depressed mood, anxiety, conduct, or mixed presentations - First-line PTSD medications are SSRIs, with sertraline and paroxetine FDA-approved; venlafaxine also effective - Prazosin, an alpha-1 blocker, is specifically helpful for PTSD-related nightmares - Benzodiazepines should be avoided in PTSD as they may interfere with recovery and lack efficacy evidence - First-line psychotherapies include prolonged exposure, cognitive processing therapy, and EMDR; all are trauma-focused and effective - Trauma-informed care emphasizes safety, trustworthiness, choice, collaboration, and empowerment - Complex PTSD follows prolonged trauma and includes affect dysregulation, negative self-concept, and relationship difficulties - Dissociative subtype of PTSD, present in ten to fifteen percent, involves depersonalization or derealization and may require modified treatment --- ## Key Terms | Term | Definition | |------|------------| | Criterion A | Traumatic event exposure involving actual or threatened death, serious injury, or sexual violence | | Flashback | Dissociative reaction in which the person feels or acts as if the traumatic event is recurring | | Hypervigilance | Persistent state of increased alertness and scanning for threat | | Dissociation | Disruption in the integration of consciousness, memory, identity, or perception | | Prolonged exposure | Evidence-based PTSD treatment using imaginal and in vivo exposure to trauma memories and reminders | | Cognitive processing therapy | Evidence-based PTSD treatment focusing on modifying trauma-related thoughts and beliefs | | EMDR | Eye movement desensitization and reprocessing; evidence-based PTSD treatment using bilateral stimulation | | Trauma-informed care | Framework recognizing trauma impact and integrating trauma knowledge into all aspects of service delivery | --- *This content is subject to the [MIT License](https://opensource.org/licenses/MIT). © 2024–2026 Hibbert School of Medicine.*