These disorders follow exposure to a traumatic or stressful event, which is an explicit diagnostic requirement. Most people exposed to trauma recover naturally; a minority develop persistent disorders. Risk rises with trauma severity and duration, interpersonal violence, childhood adversity, prior mental illness, low social support, and ongoing stressors after the event.

Mechanisms — fear conditioning with failure of fear extinction; an overactive amygdala, reduced prefrontal (medial) regulation, and hippocampal changes that impair placing the memory in context; sympathetic (noradrenergic) hyperactivity; altered HPA axis function. Avoidance prevents new learning that reminders are now safe.

DSM-5-TR disorders

PTSD symptom clusters (adults)

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 years and younger have separate criteria; trauma often appears as repetitive play reenacting the event, frightening dreams without clear content, regression (bedwetting, loss of speech), and clinginess.

Complex PTSD is an ICD-11 diagnosis (not DSM-5-TR): PTSD plus persistent problems in affect regulation, negative self-concept, and relationships, usually after prolonged or repeated trauma such as childhood abuse or captivity.

• Trauma history — asked with sensitivity and choice about how much to share; detail is not needed to begin care
• Safety first: suicidal ideation, self-harm, risk of harm to others, and current danger (e.g., ongoing domestic violence)
• Sleep, nightmares, startle, irritability, concentration, emotional numbing, guilt (including survivor guilt), relationship and work problems
• Substance use (common self-medication), depression, chronic pain, somatic complaints
• Children: reenactment play, regression, school problems, separation fears

Early after trauma

• Psychological first aid: safety, calming, connection, practical help, information about normal stress reactions, and linkage to support
• Single-session psychological debriefing that requires everyone to recount the event is not recommended — it does not prevent PTSD and can increase distress
• Acute stress disorder: brief trauma-focused CBT; monitor for progression to PTSD

PTSD — first-line treatment is trauma-focused psychotherapy, preferred over medication

• Prolonged exposure (PE): repeated, controlled imaginal and in-vivo exposure to trauma memories and reminders so that fear decreases (extinction)
• Cognitive processing therapy (CPT): identifies and restructures trauma-related "stuck points" (self-blame, danger, trust)
• Eye movement desensitization and reprocessing (EMDR)
• Written exposure therapy is a briefer suggested option
• Trauma-focused CBT for children and adolescents, with caregiver involvement

Medications

MDMA-assisted therapy is investigational and was not approved by the FDA in 2024.

Adjustment disorder — brief supportive psychotherapy, problem-solving, stress management; identify the stressor and strengthen coping skills. Prolonged grief disorder — grief-focused psychotherapy (e.g., prolonged grief therapy). RAD and DSED — stable, responsive caregiving (placement, caregiver training).

Listed in priority order.

1. Safety
   • Screen for suicide, self-harm, and violence; establish a safety plan
   • Assess for ongoing abuse and follow mandatory reporting laws for child and elder abuse
2. Establish safety and trust before trauma work — calm, predictable environment; consistent staff; explain every procedure and ask permission before touch; offer choices
3. Trauma-informed care — principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; attention to cultural, historical, and gender issues. Ask "What happened to you?" rather than "What's wrong with you?"; avoid re-traumatizing practices (restraint, seclusion, unnecessary exposure)
4. Manage hyperarousal and flashbacks
   • During a flashback: speak calmly, state your name and where the client is, use grounding (name 5 things you see, feel the chair, hold a cold object), and orient to the present
   • Teach and practice relaxation, slow breathing, and mindfulness; reduce caffeine; sleep hygiene
   • Do not force the client to recount trauma details; exposure is done by trained therapists within a plan
5. Children — observe play and drawings, allow expression through play, maintain routines, support caregivers
6. Adjustment disorder — identify the stressor, build problem-solving and coping skills, mobilize social support
7. Staff care — after critical events, offer peer support, psychological first aid, and access to counseling; watch for secondary traumatic stress and burnout in nurses

Common nursing diagnoses: post-trauma syndrome; anxiety; ineffective coping; risk for suicide; disturbed sleep pattern; complicated grieving.

• PTSD reactions (nightmares, startle, avoidance) are common after trauma and treatable — trauma-focused therapy has the strongest evidence
• Avoidance brings short-term relief but keeps symptoms going
• Antidepressants take several weeks; do not stop suddenly
• Prazosin: take at bedtime; get up slowly; report dizziness or fainting
• Avoid alcohol and cannabis to cope; they worsen sleep, mood, and PTSD over time
• Keep regular sleep and exercise routines; practice grounding and breathing daily
• Families: expect irritability and withdrawal as symptoms, not rejection; support treatment

• PTSD = trauma exposure + intrusion, avoidance, negative cognition/mood, arousal for more than 1 month
• ASD = 3 days to 1 month after trauma, often with dissociation
• Adjustment disorder = within 3 months of a stressor; resolves within 6 months after it ends
• Prolonged grief disorder = DSM-5-TR addition; ≥ 12 months after a death in adults
• Flashbacks and nightmares = intrusion (re-experiencing); avoiding places = avoidance — not arousal
• Arousal cluster: hypervigilance, startle, poor concentration, sleep disturbance
• First step in care: safety and a trusting relationship
• First-line: PE, CPT, EMDR; drugs: sertraline, paroxetine, venlafaxine
• Prazosin for nightmares; watch first-dose hypotension
• Avoid benzodiazepines in PTSD
• Early after trauma: psychological first aid, not mandatory debriefing
• Young children show trauma through repetitive reenactment play and regression