PS8.1 | Stress Related Disorders Referral — Summary & Reflection

KEY TAKEAWAYS

Key takeaways — Stress Related Disorders Referral:

1. Timeline-first differential: Traumatic stressor + 3 days–1 month = ASD (DSM-5); same stressor + >1 month = PTSD (DSM-5/ICD-11); any identifiable stressor + onset ≤1 month (ICD-11)/≤3 months (DSM-5) + resolves ≤6 months post-stressor = Adjustment Disorder.

1. ASD is DSM-5; ICD-11 uses 'Acute Stress Reaction' as a normal non-disorder category — always attribute your diagnosis to its classification system.

1. Adjustment disorder does NOT require a traumatic stressor — any significant identifiable stressor suffices. Its exclusion criterion is that the symptoms are not better explained by another mental disorder.

1. Psychological first aid is the immediate intervention — not formal debriefing (may be harmful), not benzodiazepines.

1. TF-CBT is first-line specific therapy for ASD and PTSD; EMDR is an evidence-based alternative for PTSD.

1. SSRIs (sertraline, paroxetine — FDA-approved) are first-line pharmacotherapy for PTSD; benzodiazepines are NOT recommended.

1. Referral criteria: suicidality with plan/means, psychotic symptoms, comorbid severe substance use, failure of two SSRI trials, Complex PTSD, high-risk populations, medico-legal requirements.

1. Adjustment disorder carries suicidal risk — always include a suicide risk assessment even when the stressor appears minor.

REFLECT

Return to the bus driver in our opening scenario — 3 weeks post-trauma, nightmares, flashbacks, emotional numbing, avoidance of bus stands, and a wife who says he has 'changed completely.'

1. Three weeks post-trauma places him within the ASD window (DSM-5). If he comes back to you 5 weeks later with the same symptoms, how does your diagnosis change? And does your management plan change?
2. He lives in a rural district where TF-CBT is not available. What modified version of psychological support could you provide using your knowledge of CBT principles in a 20-minute consultation?
3. His employer is pressuring him to return to driving. Under the Mental Healthcare Act 2017, what are your obligations to this patient, and how would you document a fitness-to-drive assessment?
4. You have a patient who completed suicide last year after 'just' an adjustment disorder following a job loss. How does that clinical experience change how you now approach adjustment disorder presentations in your practice?