PTSD and Acute Stress Disorder

Definitions and Core Concepts

Acute Stress Disorder (ASD)

• Definition: A trauma- and stressor-related disorder that occurs within one month of exposure to a traumatic event (actual/threatened death, serious injury, or sexual violation).

• Onset and Duration: Symptoms begin immediately (or soon after) the trauma and last at least three days up to one month.

• Key Features: Prominent dissociative symptoms (e.g. numbness, detachment) may be present, alongside intrusive re-experiencing, avoidance, anxiety, and hyperarousal.

Post-Traumatic Stress Disorder (PTSD)

• Definition: A trauma-related condition that persists beyond one month of exposure to a traumatic event.

• Core Symptom Clusters (DSM-5):

  1. Intrusions (e.g. flashbacks, distressing memories, nightmares).

  2. Avoidance of trauma-related stimuli.

  3. Negative alterations in cognition and mood (e.g. guilt, shame, persistent negative beliefs).

  4. Alterations in arousal and reactivity (e.g. hypervigilance, startle response, irritability).

Epidemiology

• PTSD has a lifetime prevalence of approximately 5–10% in Australia (varies depending on the study).

• Rates are higher in specific populations (e.g. veterans, first responders, refugees).

• Women are more likely to develop PTSD than men after exposure to a traumatic event.

Risk Factors and Vulnerabilities

• Type of Trauma: Interpersonal traumas (e.g. assault, sexual violence, combat) tend to be more likely to result in PTSD compared to natural disasters.

• Previous Trauma: History of childhood abuse or multiple traumatic exposures increases susceptibility.

• Pre-existing Psychiatric History: Anxiety, depression, or substance misuse.

• Lack of Social Support: Poor support networks contribute to worse outcomes.

• Other Factors: Family history of mental health disorders, socioeconomic disadvantage.

Clinical Presentation

Both ASD and PTSD can present with:

• Distressing memories or flashbacks of the traumatic event(s).

• Persistent avoidance of reminders (people, places, conversations).

• Emotional numbness, detachment, or negative mood states.

• Hypervigilance and exaggerated startle reflex.

• Sleep disturbance (e.g. insomnia, nightmares).

• Irritability or angry outbursts.

• Poor concentration.

• Somatic symptoms (including autonomic hyperarousal, palpitations, headaches, gastrointestinal upset).

When to Suspect

A GP should consider ASD or PTSD in any patient presenting with:

• Recent traumatic life events.

• New-onset anxiety, panic attacks, or depressive features post-trauma.

• Changes in behaviour (social withdrawal, substance use) post-trauma.

• Unexplained somatic complaints.

Diagnosis

Diagnostic Criteria Highlights

• ASD: Symptoms last 3 days to 1 month post-trauma. Presence of at least 9 symptoms from any of these categories: intrusion, negative mood, dissociation, avoidance, arousal.

• PTSD: Symptoms present >1 month post-trauma. Must have symptoms from each of the four clusters (intrusion, avoidance, negative thoughts/mood, arousal) and clinically significant distress or impairment.

Screening Tools

• Primary Care PTSD Screen (PC-PTSD) or PC-PTSD-5: Simple 4–5 item questionnaire.

• PTSD Checklist (PCL-5): More comprehensive scale to gauge severity of PTSD symptoms.

• Kessler Psychological Distress Scale (K10): A measure for general psychological distress; can indicate comorbid issues.

Differential Diagnoses

• Adjustment Disorder: Emotional/behavioural symptoms in response to stressor(s), but typically milder and less enduring than PTSD, and not meeting full criteria.

• Major Depressive Disorder: Can overlap but lacks the hallmark re-experiencing and avoidance symptoms tied to a specific trauma.

• Anxiety Disorders (including Generalised Anxiety Disorder, Panic Disorder): May present with overlapping features but lack trauma-specific re-experiencing.

• Personality Disorders: Long-standing patterns of interpersonal difficulty and maladaptive coping can confound or coexist with PTSD.

• Traumatic Brain Injury: Particularly relevant in accidents or combat; can mimic or coexist with PTSD.

Management Approach

Guiding Principles

1. Trauma-informed Care: Recognise the trauma experience; minimise re-traumatisation by adopting a patient-centred and empathetic approach.

2. Stepped Care Model: Tailor interventions to symptom severity and functional impairment.

3. Early Identification: Prompt detection of ASD might allow early intervention, which can reduce the risk of developing chronic PTSD.

Non-Pharmacological (Psychological) Interventions

1. Psychoeducation and Support

   • Provide the patient with information about common responses to trauma, expected course, and available treatments.

   • Encourage social support and involvement of family/friends if appropriate.

2. Trauma-Focused Psychological Therapies (First-line treatments for PTSD)

   • Trauma-focused Cognitive Behavioural Therapy (tf-CBT): Helps patients reframe negative cognitions and progressively desensitise to trauma memories.

   • Eye Movement Desensitisation and Reprocessing (EMDR): Uses directed eye movements to facilitate processing of traumatic memories.

   • Prolonged Exposure Therapy: Systematic confrontation with trauma memories and cues to reduce avoidance.

3. Stress Management and Coping Skills

   • Relaxation training, mindfulness, grounding techniques.

   • Self-care strategies (e.g. regular exercise, structured routine).

4. Avoidance of Single-Session “Psychological Debriefing”

   • Formal single-session debriefing soon after trauma (critical incident stress debriefing) is not recommended, as it may exacerbate distress.

Pharmacological Interventions

Per current Australian Therapeutic Guidelines (eTG) and the RACGP:

1. First-Line Pharmacotherapy:

   • Selective Serotonin Reuptake Inhibitors (SSRIs)

   • Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs)

     
     

     Examples include sertraline, paroxetine, fluoxetine, venlafaxine.

2. Second-Line or Adjunctive Options:

   • Mirtazapine or other antidepressants if SSRIs/SNRIs not tolerated or ineffective.

   • Prazosin for trauma-related nightmares and sleep disturbances (though evidence is mixed, some practitioners find it helpful).

3. Avoiding Benzodiazepines

   • Generally contraindicated for long-term management due to dependence risk and potential to worsen recovery.

4. Monitoring and Duration

   • Continue medication for at least 12 months after symptom resolution to reduce relapse risk.

   • Regular reviews to monitor side effects, efficacy, and patient adherence.

Comorbidities

• Depression and Anxiety Disorders: Very common with PTSD/ASD.

• Substance Use Disorders: Patients may attempt self-medication to cope with distress.

• Chronic Pain: Especially if the trauma was associated with a physical injury (e.g. motor vehicle accidents).

• Personality Disorders: May complicate the clinical picture and require more intensive therapy.

Ensuring a comprehensive assessment for comorbid conditions is essential for an effective management plan.

Prognosis

• Many individuals with ASD will recover without developing PTSD, especially with early intervention and adequate support.

• PTSD can become chronic if unrecognised or poorly managed, leading to significant functional impairment.

• With evidence-based trauma-focused therapies and/or pharmacotherapy, a substantial proportion of patients experience symptom reduction and improved quality of life.