23. Trauma, Acute Stress and PTSD

The timeline (get the windows right)

• Acute stress reaction — transient, within hours–days, self‑limiting.
• Acute stress disorder — characteristic symptoms 3 days–1 month post‑trauma.
• PTSD — symptoms >1 month with impairment.
• Complex PTSD (ICD‑11) — PTSD + disturbances in self‑organisation (affect dysregulation, negative self‑concept, relationship difficulties), typically after prolonged/repeated trauma.

The four symptom clusters (DSM‑5)

Re‑experiencing (intrusions, nightmares, flashbacks), avoidance, negative alterations in cognition/mood, hyperarousal (startle, hypervigilance, sleep/concentration disturbance, irritability). Exposure to actual/threatened death, serious injury, or sexual violence is the gateway criterion.

Discriminators

• PTSD vs normal trauma response: persistence beyond a month + functional impairment; most acute reactions remit.
• Flashback vs psychosis: a flashback is a re‑experiencing phenomenon with trauma content and (usually) retained reality testing between episodes, not a primary psychotic process.
• Complex vs classic PTSD: the self‑organisation disturbances.

Management logic

Trauma‑focused psychotherapy is first‑line — TF‑CBT or EMDR. Pharmacotherapy (SSRI/SNRI) is adjunctive; prazosin for trauma nightmares. Benzodiazepines are contraindicated (worsen outcomes, dependence). Avoid single‑session psychological debriefing (ineffective/harmful).

Pitfalls

• Diagnosing PTSD within the first month (it's ASD or an acute reaction).
• Benzodiazepines as a "quick fix."

Pearls

• 🎯 Trauma = exposure; PTSD = a persistent >1‑month syndrome.
• 🩺 First‑line is trauma‑focused psychotherapy, not medication.

Next → From episodic disorders to enduring patterns — personality (Concept 24).