Posttraumatic stress disorder

PTSD appears across many case types; you must confirm a qualifying trauma, map symptoms to the four clusters, check the duration, and choose a trauma-focused treatment while screening for safety and substance use.

Criteria at exam depth. Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing it, witnessing it in person, learning it happened to a close family member or friend (violent or accidental if a death), or repeated or extreme exposure to aversive details (for example, first responders); media exposure counts only when work-related. Symptoms span four clusters:

• Intrusion (at least 1): memories, nightmares, flashbacks, distress or physiological reactions to cues.
• Avoidance (at least 1): of memories or of external reminders.
• Negative alterations in cognition and mood (at least 2): amnesia for key parts, distorted blame, persistent negative beliefs or emotions, diminished interest, detachment, inability to feel positive emotions.
• Arousal and reactivity (at least 2): irritability or aggression, reckless behavior, hypervigilance, exaggerated startle, poor concentration, sleep disturbance.

Duration is more than 1 month, with distress or impairment, not due to a substance or medical condition. Specifiers: with dissociative symptoms (depersonalization or derealization) and with delayed expression (full criteria not met until at least 6 months after the event). Children 6 and younger have separate, developmentally adapted criteria.

Hinge differentials.

• Acute stress disorder: same exposure, but symptoms last 3 days to 1 month.
• Adjustment disorder: follows any stressor (not necessarily traumatic), or follows trauma without meeting full PTSD criteria.
• Major depressive disorder: no intrusion or trauma-linked avoidance; both may coexist.
• GAD: worry is diffuse, not tied to a trauma context.
• ADHD: concentration problems predate the trauma and are pervasive rather than tied to trauma cues.
• Primary sleep disorder: nightmares with trauma content point to PTSD.

On the NCMHCE. Screen suicide risk, substance use, and current safety (for example, ongoing intimate partner violence) before trauma processing. Use a structured measure such as the PCL-5 to track symptoms. First-line psychotherapies are trauma-focused: Cognitive Processing Therapy, Prolonged Exposure, EMDR, and TF-CBT for children and adolescents. Build stabilization and coping skills when needed, but do not let avoidance persist indefinitely. Single-session psychological debriefing is not recommended. Refer to a prescriber when indicated; SSRIs and SNRIs are the usual classes. Attend to cultural expressions of distress, military culture, and the client's sense of control.

Clinical Pearl: Qualifying trauma + 1 intrusion + 1 avoidance + 2 negative cognition/mood + 2 arousal, lasting more than a month = PTSD. Under a month is acute stress disorder; "delayed expression" means full criteria first met 6 or more months later.