Acute stress reaction, adjustment disorders, and post-traumatic stress disorder: epidemiology, etiology, clinical features, course, and treatment

01Definition and overview

Stress-related disorders are defined by their cause: an identifiable stressor without which the disorder would not have arisen. The stressor is necessary but never sufficient, as most people exposed to even severe trauma recover. ICD-11 calls the group disorders specifically associated with stress, and DSM-5 trauma- and stressor-related disorders.

A traumatic event is one of an extremely threatening or horrific nature: actual or threatened death, serious injury or sexual violence, experienced directly, witnessed, learnt of when it struck someone close violently or suddenly, or met repeatedly at work, as by police officers or paramedics. Divorce or losing a job are significant stressors, but not traumatic in this sense.

ICD-11 regards the acute stress reaction as a normal response to an abnormal event and codes it outside the mental disorders (QE84). ICD-10's enduring personality change after catastrophic experience (F62.0) gives way to complex PTSD in ICD-11. DSM-5 has no complex PTSD but a dissociative subtype of PTSD, with depersonalisation or derealisation.

02Etiology and pathophysiology

Who develops PTSD

The size of the trauma matters most, but what the person brings to it and what happens afterwards decide much of the outcome.

Twin studies suggest that genes account for roughly a third of the risk, with many variants each adding a little and overlapping with depression and anxiety.

Fear learning and the brain

PTSD can be seen as fear learning that is too strong and too general, and fear extinction that fails. The amygdala reacts more strongly to threat, while the medial prefrontal cortex, which normally damps it once danger has passed, is less active. The hippocampus, which places memories in their context of time and place, tends to be smaller, perhaps partly a vulnerability present before the trauma. So reminders of the event set off the alarm as if the danger were here again.

The stress hormones are altered in a characteristic way. Sympathetic drive and noradrenaline are raised, giving the startle, insomnia and nightmares, the rationale for trying the alpha-1 blocker prazosin. Cortisol is often normal or low rather than high, with an exaggerated negative feedback of the HPA axis, unlike in depression. These findings are group averages and are of no use in diagnosis.

Why it persists

Ehlers and Clark's cognitive model explains why symptoms continue long after the danger is over, and it underlies cognitive therapy for PTSD.

1. 1

   A poorly stored memory

   The worst moments are laid down as vivid sensory fragments, poorly linked to their context and to what came after, so a sound or smell can trigger them and they feel as if happening now.
2. 2

   Threatening meanings

   The person reads the event and its aftermath as signs of present danger or personal failure: nowhere is safe, it was my fault, I am going mad, I will never be the same.
3. 3

   A sense of current threat

   Together these keep fear, hyperarousal and intrusions going, as if the trauma were not over.
4. 4

   Coping that backfires

   Avoiding reminders, pushing the memories away, ruminating, staying on guard and drinking all bring short relief but stop the memory being updated and the meanings being tested.

In adjustment disorders and grief the reaction is understandable; the disorder lies in its intensity, duration and cost, and personal vulnerability and support matter more than the stressor itself.

03Clinical features

Acute stress reaction

It begins within an hour of an exceptional stress, first as a daze, with narrowed attention, disbelief and unreality. Changeable anxiety, anger, despair, overactivity or withdrawal follow, with sweating and palpitations, sometimes partial amnesia, and in severe forms dissociative stupor. It fades within hours once the person is safe, and usually within a few days even if the stress continues.

Adjustment disorder

It follows a significant life change such as divorce, illness, disability, migration or unemployment. The person is preoccupied with the stressor, worrying and ruminating, and fails to adapt, with poor sleep and concentration and a loss of function. Low mood, anxiety, irritability or, in adolescents, conduct problems colour it, but a depressive or anxiety disorder takes precedence when its criteria are met. It is common in the general hospital, where the stressor is often the illness itself.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) has three core clusters in ICD-11, and DSM-5 adds a fourth:

Re-experiencing is the hallmark. A flashback is relived, not recalled: the person sees, hears or smells the event again and may act as if back there, which can be mistaken for psychosis. Many present with something else, such as insomnia, irritability, drinking, depression or physical symptoms. In young children the trauma returns in repetitive play, frightening dreams and regression. The PCL-5, a 20-item self-report checklist, measures DSM-5 symptoms and their change with treatment.

Complex PTSD

ICD-11 complex PTSD needs all the features of PTSD plus disturbances in self-organisation, which are severe and pervasive:

• problems regulating emotion, with high reactivity, outbursts, reckless or self-destructive behaviour, or numbing and dissociation under stress;
• a persistent belief that one is diminished, defeated or worthless, with deep shame, guilt or failure;
• difficulty sustaining relationships and feeling close to others.

It typically follows prolonged or repeated trauma from which escape is difficult or impossible: torture, slavery, genocide, long domestic violence, or repeated sexual or physical abuse in childhood. The International Trauma Questionnaire measures both ICD-11 diagnoses.

Prolonged grief disorder

Normal grief brings shock, sadness, anger, guilt, yearning and poor sleep; briefly seeing or hearing the dead person is common and not psychosis. It usually eases within a year. In prolonged grief disorder, longing for or preoccupation with the deceased persists with intense emotional pain (guilt, anger, difficulty accepting the death, feeling part of oneself lost, numbness), beyond what the person's culture expects and with impaired functioning. Sudden or violent deaths, the death of a child and a dependent relationship raise the risk.

04Diagnosis and management

Assessment

Patients rarely volunteer trauma, so ask. Assessment covers what happened and when, the current symptoms and how they affect daily life, and the present situation.

• Safety now: is the threat continuing, as with domestic abuse or trafficking? Therapy needs a reasonably safe life first, and children at home may need safeguarding.
• Risk: suicidal thoughts, self-harm and aggression, which are all more common after trauma.
• Comorbidity: Depression, other anxiety disorders, alcohol and drug misuse, and physical injury, including head injury.
• Pace: a full account is not needed at the first meeting, and pressing for it can overwhelm. Use a professional interpreter, not a relative.

The differential diagnosis:

In the first weeks

Most distress after trauma fades, so the aim is to support recovery and catch those who do not recover.

1. 1

   Safety and practical help

   Shelter, medical care, reliable information, contact with family and friends, and practical help: what is often called psychological first aid.
2. 2

   No debriefing

   Do not hold single-session psychological debriefing, in which people are asked to relive the event in detail soon after it. It does not prevent PTSD, and in trials some did worse.
3. 3

   Active monitoring

   For mild or subthreshold symptoms within a month, watchful waiting with an arranged follow-up within a month.
4. 4

   Early treatment

   For acute stress disorder or clinically important symptoms within a month, individual trauma-focused CBT; for children after a large shared trauma, group trauma-focused CBT can be considered.
5. 5

   No preventive drugs

   Do not give drugs, benzodiazepines included, to prevent PTSD. None has been shown to work, and benzodiazepines may hinder recovery.

Adjustment disorder and grief

Adjustment disorder is treated with supportive psychotherapy and problem solving, helping the person cope with what cannot be changed and giving practical help with what can. Antidepressants are not routine, but a depressive episode that develops is treated. Normal grief needs only support and bereavement services. In prolonged grief disorder, grief-focused therapies based on CBT work better than supportive counselling; antidepressants help a coexisting depression but little for the grief itself.

Treating PTSD

Trauma-focused psychological treatment is first line at all ages.

When depression coexists, PTSD is usually treated first, as the depression often lifts too, unless it is severe enough to block therapy or bring risk. Substance misuse does not exclude anyone from treatment. In complex PTSD, therapy takes longer, with time to build trust and stability first.

Benzodiazepines do not treat the core symptoms, may worsen the outcome and bring dependence, all the more with the alcohol misuse common in PTSD.

05Epidemiology

meet at least one traumatic event in their lifetime

7 in 10adultsmeet at least one traumatic event in their lifetime

lifetime prevalence of PTSD across the WHO World Mental Health Surveys

4per centlifetime prevalence of PTSD across the WHO World Mental Health Surveys

develop PTSD, among the highest risks of any trauma

1 in 5after rapedevelop PTSD, among the highest risks of any trauma

develop prolonged grief disorder after a natural death

1 in 10bereaved adultsdevelop prolonged grief disorder after a natural death

In the WHO World Mental Health Surveys, lifetime PTSD was about 4 per cent overall and about 6 per cent among those exposed to trauma, varying widely between countries. Women are affected about twice as often as men, partly through the traumas they meet, such as sexual violence. Rape, other sexual assault, physical abuse by a partner and kidnapping carry the highest risks, between about 1 in 10 and 1 in 5, while accidents, disasters and even combat carry much lower ones, though PTSD after combat lasts longest. In populations affected by war and displacement, around a third have PTSD, and torture is the strongest single predictor. Complex PTSD affects roughly 1 to 8 per cent of the population, and up to half of patients in mental health services.

Acute stress disorder follows in roughly 13 to 33 per cent of trauma survivors, depending on the event. Adjustment disorders may affect up to a fifth of general hospital patients. Prolonged grief disorder affects about 1 in 10 bereaved adults, and many more after suicide, homicide or disaster.

06Prognosis

• An acute stress reaction resolves within days. Acute stress disorder raises the risk of PTSD, but many who later develop PTSD never had it, so it is a poor screen on its own.
• Adjustment disorder usually resolves within six months as the stressor fades or the person adapts. At five years about 70 per cent of adults have recovered, but only about 40 per cent of adolescents, many of whom go on to other disorders. The risk of suicide and self-harm is real, especially in the young.
• PTSD improves in half to two-thirds during the first year, but about a third have symptoms for years, fluctuating with anniversaries and new stresses. Severe early symptoms, repeated or interpersonal trauma, poor support and continuing stress predict a worse course, and in a minority PTSD appears only after months or years. It brings depression, substance misuse and a raised risk of suicide, yet trauma-focused treatment helps most people even years later.
• Prolonged grief disorder tends to persist without treatment, with a higher risk of depression, suicidal thoughts and physical illness; targeted grief therapy helps.