Eduovisual
Behavioral Health
Acute stress disorder and adjustment disorders
— Acute stress disorder (ASD): trauma-spectrum syndrome occurring 3 days to 1 month after exposure to actual or threatened death, serious injury, or sexual violence (directly experienced, witnessed, learned of in close other, or repeated work-related exposure as in first responders)
— Adjustment disorder (AjD): emotional or behavioral symptoms in response to an identifiable non-life-threatening stressor, onset within 3 months, resolving within 6 months of the stressor (or its consequences) ending
— PTSD: trauma-spectrum symptoms persisting >1 month — temporal pivot from ASD
— Patient presenting to primary care, ED, or postpartum/oncology clinic with new insomnia, irritability, tearfulness, or somatic complaints after a discrete event (MVC, assault, job loss, divorce, diagnosis of cancer, miscarriage, deployment, immigration)
— Functional decline disproportionate to the stressor severity, or out-of-proportion distress
— New suicidal ideation in the wake of a life event — always screen
— Workplace, school, or family role impairment in the weeks following a trigger
Board pearl: The stressor magnitude is the diagnostic gate — life-threatening or sexual-violence trauma routes you to ASD/PTSD; ordinary (even severe) life stressors route you to adjustment disorder, regardless of how distressed the patient appears.
Step 3 management: First office visit should establish the timeline of the stressor, screen for SI/HI with PHQ-9 + C-SSRS, assess substance use, and document functional impairment — these drive billing, disability paperwork, and the choice between watchful waiting, brief therapy, or referral.
— Stressor characterization: what, when, ongoing vs. resolved, anticipated (e.g., terminal diagnosis with progressive decline = ongoing stressor)
— Symptom onset relative to stressor: AjD requires onset within 3 months; ASD within 1 month and lasting 3 days–1 month
— Functional impact: work attendance, parenting, ADLs, relationships
— Prior psychiatric history: preexisting MDD, PTSD, bipolar, personality disorder — recurrence vs. new diagnosis matters
— Substance use: new or escalated alcohol, cannabis, benzodiazepines, opioids — often the presenting complaint
— Suicide and homicide risk: ideation, plan, intent, access to firearms (lethal-means counseling)
— Social supports, housing, finances, legal stressors, IPV screen — particularly for AjD, where psychosocial intervention is first-line
— Sleep, appetite, concentration, energy — distinguishes from MDD
— Active SI with plan → emergency evaluation
— Psychotic features → not AjD/ASD; consider brief psychotic disorder or MDD with psychosis
— Symptoms >6 months after stressor resolves → reclassify (PTSD, MDD, persistent depressive disorder)
Key distinction: Dissociation (derealization, depersonalization, dissociative amnesia) is a hallmark of ASD and is not part of adjustment disorder criteria. If a stem highlights "felt like the world wasn't real," lean ASD.
Board pearl: Ask explicitly about bereavement — uncomplicated grief is a normal reaction and is not AjD; however, AjD can be diagnosed if grief reactions exceed cultural/religious expectations or cause marked impairment beyond expected.
— Vital signs may show resting tachycardia, mild hypertension from sympathetic arousal — should not be attributed to anxiety alone without workup if persistent
— Inspect for signs of self-harm (wrist/forearm cuts, healed scars), bruising patterns suggestive of IPV or assault
— Neurologic screen if MVC or assault: cranial nerves, gait, focal deficits — rule out occult TBI
— Thyroid exam (goiter, tremor) — hyperthyroidism mimics arousal symptoms
— Appearance/behavior: disheveled, psychomotor agitation or retardation, hypervigilant scanning of room
— Speech: may be soft, slowed, or pressured if anxious
— Mood/affect: anxious, sad, irritable, constricted; affect congruent with reported mood
— Thought process: generally linear; circumstantiality around the trauma
— Thought content: intrusive recollections, no delusions; assess SI/HI
— Perception: flashbacks (re-experiencing), depersonalization/derealization in ASD; true hallucinations argue against AjD/ASD
— Cognition: orientation intact; concentration often impaired; dissociative amnesia for parts of the traumatic event in ASD
— Insight/judgment: typically preserved — patients recognize their distress is linked to the stressor
— PHQ-9 for depressive symptom burden
— GAD-7 for anxiety
— PCL-5 if trauma is the stressor (PTSD checklist; useful baseline)
— AUDIT-C and drug screening
— Columbia Suicide Severity Rating Scale (C-SSRS)
Board pearl: Hypervigilance and exaggerated startle are arousal criteria for ASD/PTSD but are not required for adjustment disorder. A patient who startles at a slamming door 2 weeks post-assault is signaling ASD.
Step 3 management: Document a functional impairment statement ("unable to return to work as a delivery driver due to avoidance of driving") — this anchors short-term disability decisions and justifies therapy referral under insurance.
— CBC, CMP — anemia, hyponatremia, hepatic/renal dysfunction
— TSH (± free T4) — hyperthyroidism mimics arousal; hypothyroidism mimics adjustment-with-depressed-mood
— Glucose / HbA1c — hypoglycemia episodes mimic panic; new diabetes diagnosis is itself a stressor
— Vitamin B12, folate, vitamin D if mood symptoms predominate, especially in elderly
— Urine toxicology — cocaine, methamphetamine, cannabis, PCP can produce dissociation and hyperarousal
— Pregnancy test (β-hCG) in reproductive-age women — alters drug choice and is occasionally itself the stressor
— HIV, RPR if risk factors and neuropsychiatric symptoms present
— Baseline 12-lead ECG before starting SSRIs (especially citalopram, escitalopram) or any QT-prolonging psychotropic, particularly in elderly, cardiac history, or polypharmacy
— Rule out arrhythmia as a driver of palpitation/panic-like complaints
— Non-contrast head CT if recent head trauma, focal neuro findings, anticoagulation, or altered mental status — not routine
— MRI brain reserved for atypical presentations (first-episode psychosis-like features, focal deficits, age >50 with new psychiatric symptoms)
— No validated biomarker for ASD or AjD
— Cortisol, urinary catecholamines only if pheochromocytoma or Cushing suspected
Key distinction: A patient with paroxysmal hypertension, headache, diaphoresis, and tachycardia attributed to "panic from a stressor" deserves plasma metanephrines before psychiatric labeling — pheochromocytoma is the classic miss.
Board pearl: Always check TSH and a urine drug screen before committing to AjD or ASD on a Step 3 vignette — these two tests have the highest yield for unmasking a medical mimic and are frequently the "next best step."
Step 3 management: Document medical workup completion in the chart — this protects against the boards-favorite pitfall of premature psychiatric closure and supports later insurance authorization for psychotherapy.
— A: Exposure to actual/threatened death, serious injury, or sexual violence (direct, witnessed, close-other, or repeated occupational exposure)
— B: ≥9 symptoms across 5 clusters (intrusion, negative mood, dissociation, avoidance, arousal)
— C: Duration 3 days to 1 month post-trauma
— D: Clinically significant distress or impairment
— E: Not due to substance, medication, medical condition, or brief psychotic disorder
— A: Emotional/behavioral symptoms in response to identifiable stressor within 3 months of onset
— B: Symptoms are out of proportion to stressor severity (accounting for culture/context) OR cause significant impairment
— C: Does not meet criteria for another mental disorder and is not an exacerbation of a preexisting one
— D: Not normal bereavement
— E: Resolves within 6 months after stressor (or its consequences) ends; otherwise reclassify
— Acute (<6 months) vs persistent/chronic (≥6 months) — chronic AjD requires the stressor or its consequences to be ongoing
— ASD has no specifiers; if symptoms persist beyond 1 month, rediagnose as PTSD
— PCL-5 (PTSD Checklist for DSM-5): 20 items, 0–80; ≥31–33 suggests probable PTSD/ASD
— CAPS-5 (Clinician-Administered PTSD Scale): gold-standard structured interview, used in specialty settings
— Adjustment Disorder New Module (ADNM-20): validated AjD-specific scale increasingly used in research
— Impact of Event Scale-Revised (IES-R) for trauma symptom tracking
— Rule out MDD (need 5 of 9 SIGECAPS criteria for ≥2 weeks)
— Rule out GAD (≥6 months of excessive worry, not tied to discrete stressor)
— Rule out panic disorder (recurrent unexpected panic attacks)
— Rule out substance/medication-induced mood or anxiety disorder
Board pearl: The 3-day minimum for ASD prevents pathologizing the first 72 hours of normal acute stress reaction — a vignette at 48 hours post-event with intrusive thoughts is not ASD.
Key distinction: If a stressor is chronic (caring for a parent with dementia, ongoing job harassment), AjD can be "persistent" — duration alone doesn't disqualify it as long as the stressor (or its consequences) continues.
— First-line: psychotherapy, specifically brief problem-solving therapy, supportive therapy, or short-course CBT (6–12 sessions)
— Pharmacotherapy is adjunctive, not first-line — reserved for prominent insomnia, severe anxiety interfering with therapy engagement, or comorbid symptoms
— Reassess at 4–6 weeks; if symptoms persist or worsen, reconsider diagnosis (likely MDD or GAD)
— First-line: trauma-focused CBT (TF-CBT), typically 5 sessions starting ≥2 weeks post-trauma — strongest evidence for preventing progression to PTSD
— Avoid routine single-session psychological debriefing (e.g., Critical Incident Stress Debriefing) — may worsen outcomes
— Pharmacotherapy: short-term targeted symptom relief (sleep, severe arousal); SSRIs are not first-line in ASD but become first-line if symptoms persist >1 month (i.e., transition to PTSD treatment)
— Avoid benzodiazepines — associated with worse PTSD outcomes and dependence risk
— Female sex, prior trauma history, peritraumatic dissociation, low social support, ongoing threat, TBI, female assault survivors, refugees
— High PCL-5 score at 2 weeks post-event
— AjD has a notably elevated suicide risk, especially in adolescents and young adults, and in those with conduct subtype
— Use C-SSRS; safety plan with lethal-means counseling (firearm storage, medication lock boxes) at every visit with elevated risk
— Brief intervention: Safety Planning Intervention (Stanley-Brown) + follow-up call within 48 hours
— Outpatient for nearly all; partial hospitalization if functional collapse without imminent danger; inpatient only for active suicidality, psychosis, or inability to maintain safety
Step 3 management: For an ASD patient at 2 weeks post-MVC with insomnia and intrusive memories, the next best step is referral for trauma-focused CBT, not an SSRI prescription. Reserve pharmacotherapy for targeted symptoms or post-1-month persistence.
Board pearl: Benzodiazepines after acute trauma worsen long-term PTSD risk — this is a recurring Step 3 distractor.
— Trazodone 25–100 mg qhs — preferred; non-habit-forming, sedating via 5-HT2A and H1 antagonism; watch for orthostasis, priapism (rare)
— Prazosin 1–10 mg qhs — α1 antagonist; particularly useful for trauma-related nightmares; titrate slowly to avoid first-dose hypotension
— Mirtazapine 7.5–15 mg qhs if comorbid weight loss/poor appetite
— Avoid chronic z-drugs (zolpidem) and benzodiazepines; if used, limit to <2 weeks
— SSRIs (sertraline 25–50 mg start, escitalopram 5–10 mg) — onset 2–6 weeks; counsel on initial activation, GI symptoms, sexual dysfunction, and black-box warning for suicidality in <25 yo
— Buspirone 5–10 mg TID for anxiety without sedation, useful when benzodiazepine avoidance is critical
— Hydroxyzine 25–50 mg PRN for situational anxiety — non-addictive antihistamine; caution QT, anticholinergic effects in elderly
— No FDA-approved pharmacotherapy for ASD; sertraline and paroxetine are FDA-approved for PTSD and become appropriate if symptoms persist >1 month
— Propranolol for secondary prevention of PTSD is not recommended outside research — negative trials
— Hydrocortisone within hours of trauma has shown signal in ICU patients but is not standard
— SSRI/SNRI suicidality warning in patients <25
— Serotonin syndrome risk with tramadol, linezolid, triptans, MAOIs
— Citalopram >20 mg in patients >60 is contraindicated (QT prolongation)
— Discontinuation syndrome with paroxetine, venlafaxine — taper over weeks
— Avoid benzodiazepines in any patient with SUD history
— Address alcohol use disorder concurrently (naltrexone, acamprosate)
Board pearl: Prazosin for trauma-related nightmares is the classic Step 3 answer in a patient 6 weeks post-combat exposure who reports recurrent vivid nightmares despite sleep hygiene.
Step 3 management: Document informed consent for SSRI use, including the black-box suicidality warning, in patients under 25 — boards reward explicit charting.
— 5–12 sessions; components include psychoeducation, breathing retraining, in vivo and imaginal exposure, cognitive restructuring
— Best evidence for preventing PTSD progression; NNT ~4 for symptomatic ASD
— Begin ≥2 weeks post-trauma to allow natural recovery in some
— Effective for trauma symptoms; equivalent to TF-CBT in meta-analyses
— Useful when patients decline exposure protocols
— 4–8 sessions; identifies stressor, generates solutions, implements action plan
— Particularly effective for occupational, financial, relational stressors
— Useful for grief-related AjD, role transitions, interpersonal conflict
— Validating emotion, normalizing reaction, mobilizing social support
— Survivor groups for assault, bereavement, MVC; reduce isolation
— Avoid mandatory single-session debriefing post-disaster
— Connect to employee assistance program (EAP), legal aid, financial counseling, housing services
— Short-term disability paperwork when impairment prevents work; document objective findings
— Faith/community resources when culturally aligned
— Internet-delivered CBT (iCBT) — effective for AjD, expands access; appropriate when geography or stigma limits in-person care
— VA's PE Coach, CPT Coach apps support veterans
CCS pearl: When managing a CCS case of acute stress symptoms post-MVC, order psychotherapy referral, screen PHQ-9/PCL-5, prescribe prazosin for nightmares only if present, schedule follow-up in 2 weeks, and avoid alprazolam — selecting a benzodiazepine in this scenario costs points.
Board pearl: Single-session psychological debriefing immediately after trauma is contraindicated — paradoxically increases PTSD risk and is a classic wrong-answer trap.
— Common stressors: bereavement, retirement, relocation to assisted living, new medical diagnoses, caregiver burden, elder abuse
— Differential broadens: delirium, major neurocognitive disorder with behavioral disturbance, hypothyroidism, B12 deficiency, depression with cognitive features ("pseudodementia"), medication side effects (β-blockers, steroids, benzodiazepines)
— Use Geriatric Depression Scale (GDS-15) alongside PHQ-9
— Screen for elder mistreatment with EASI or similar; mandatory reporting in most states
— Start low, go slow: sertraline 12.5–25 mg, escitalopram 5 mg
— Citalopram capped at 20 mg/day (QTc risk)
— Avoid benzodiazepines (Beers criteria — falls, delirium, cognitive decline)
— Avoid first-generation antihistamines (diphenhydramine, hydroxyzine high-dose) — anticholinergic burden
— Trazodone at low dose (25 mg) acceptable for sleep but watch orthostasis
— Mirtazapine 7.5 mg useful when weight loss and insomnia co-occur
— Monitor for SIADH/hyponatremia within 2–4 weeks of starting SSRI — check basic metabolic panel
— Sertraline, citalopram, escitalopram — minimal renal dose adjustment; preferred
— Venlafaxine, duloxetine — reduce dose if CrCl <30; duloxetine avoid if CrCl <30
— Paroxetine — reduce dose in severe renal impairment
— Gabapentin/pregabalin (if used adjunctively) — substantial renal adjustment required
— Most SSRIs are hepatically metabolized; reduce dose by ~50% in moderate cirrhosis
— Avoid duloxetine in any chronic liver disease and in heavy alcohol use
— Sertraline is generally preferred; monitor LFTs at baseline and 4–6 weeks
— SSRIs + NSAIDs/anticoagulants → GI bleeding risk; consider PPI co-prescription if combined
— Fluoxetine, paroxetine are potent CYP2D6 inhibitors — interact with tamoxifen, codeine, tramadol, metoprolol
Board pearl: In a 78-year-old woman with new depressive symptoms 6 weeks after her husband's death, before diagnosing AjD with depressed mood, check TSH, B12, and basic metabolic panel and review medications — pseudodementia and medication-induced mood symptoms are common.
— Stressors: pregnancy loss, NICU admission, traumatic delivery (a Criterion A event → can produce postpartum ASD/PTSD), unexpected diagnosis, IPV (increased in pregnancy)
— Screen with Edinburgh Postnatal Depression Scale (EPDS) at prenatal and postpartum visits per ACOG/USPSTF
— First-line: psychotherapy (CBT, IPT) — avoids fetal exposure
— If pharmacotherapy needed: sertraline is preferred SSRI in pregnancy and lactation (lowest milk transfer, extensive safety data)
— Avoid paroxetine in first trimester (cardiac malformation signal, FDA Category D historically)
— Avoid benzodiazepines in third trimester (neonatal sedation, withdrawal, floppy infant)
— Discuss persistent pulmonary hypertension of the newborn (PPHN) small absolute risk with late-pregnancy SSRI exposure; benefits typically outweigh
— AjD is among the most common psychiatric diagnoses in adolescents; often presents with conduct disturbance (truancy, fighting, substance experimentation)
— Stressors: parental divorce, school transitions, bullying, chronic illness diagnosis, LGBTQ+ identity stressors
— First-line: psychotherapy — CBT, family-based interventions, school-based counseling
— If SSRI needed: fluoxetine (FDA-approved age ≥8 for depression, ≥7 for OCD) or sertraline; black-box suicidality warning — weekly visits for 4 weeks, then biweekly
— Mandatory reporting of suspected child abuse precipitating the adjustment reaction
— Screen for non-suicidal self-injury (NSSI) and SI explicitly
— Combat trauma, military sexual trauma (MST), moral injury
— VA/DoD guidelines emphasize TF-CBT, PE, CPT, and EMDR as first-line
— Connect to VA mental health services; document service connection for benefits
— Higher suicide rates — lethal means counseling regarding firearms is essential
— Premigration trauma, ongoing acculturation stress, immigration status uncertainty
— Use cultural formulation interview; engage interpreters; consider somatic presentations (chest pain, headaches) as primary
Board pearl: Sertraline is the SSRI of choice in pregnancy and lactation for trauma- and adjustment-related disorders requiring pharmacotherapy.
Key distinction: In adolescents, AjD with conduct subtype often presents as new behavioral problems — don't reflexively label as oppositional defiant disorder without exploring the precipitating stressor.
— ASD → PTSD in approximately 50% of cases without treatment; TF-CBT reduces this substantially
— AjD → MDD or persistent depressive disorder if stressor unresolved or maladaptive coping persists
— AjD can evolve into GAD when worry generalizes beyond original stressor
— AjD is associated with disproportionately high suicide attempt rates, particularly among adolescents and young adults — comparable to or exceeding MDD in some cohorts due to acuity and impulsivity
— ASD with dissociation predicts higher self-harm risk
— Screen at every visit with C-SSRS; reassess after any change in stressor or treatment
— Self-medication with alcohol, cannabis, benzodiazepines, opioids — particularly common in ASD
— Screen with AUDIT-C, DAST-10 at baseline and follow-up
— Work absenteeism, presenteeism, job loss, academic failure
— Relationship dissolution, parenting impairment
— Disability claims — document objectively to support legitimate claims and avoid secondary gain confounds
— Worsened glycemic control, hypertension, asthma exacerbations from chronic stress
— New or exacerbated chronic pain, IBS, tension/migraine headaches
— Takotsubo cardiomyopathy ("broken heart syndrome") after acute emotional trauma — postmenopausal women classic
— Benzodiazepine dependence if prescribed liberally
— SSRI discontinuation syndrome (dizziness, electric-shock sensations, flu-like symptoms) — taper paroxetine and venlafaxine over weeks
— Serotonin syndrome from drug combinations
— Sleep medication misuse — z-drug parasomnias, complex sleep behaviors
— Persistent insomnia is an independent predictor of PTSD progression and depression — treat early with CBT-I
Board pearl: A patient with apparent AjD whose symptoms persist or worsen at 6 months after stressor resolution has, by definition, another diagnosis (MDD, PTSD, GAD) — re-evaluate rather than continue AjD coding.
Step 3 management: At every follow-up, reassess the four pivots: symptom trajectory, suicidality, substance use, and functional status — these drive escalation decisions.
— Active suicidal ideation with plan, intent, or means — especially with access to firearms
— Homicidal ideation toward identifiable target — duty to warn (Tarasoff) in most US jurisdictions
— Psychotic symptoms (suggests another diagnosis)
— Severe self-neglect (not eating, not drinking, not taking essential medications)
— Catatonia, severe dissociation precluding safety
— Imminent danger to self or others without safer disposition
— Failure of intensive outpatient management
— Inability to maintain safety with available support
— Involuntary hold criteria (state-specific, typically 72-hour) — danger to self, danger to others, or grave disability
— Significant functional impairment without imminent danger
— Need for daily therapeutic structure
— Step-down from inpatient
— Diagnostic uncertainty (AjD vs MDD vs PTSD vs bipolar)
— Inadequate response to first-line treatment at 6–8 weeks
— Need for second-line or combination pharmacotherapy
— Comorbid substance use disorder requiring specialized care
— High-risk medication use (lithium, MAOIs, clozapine — unlikely here but applicable if comorbidity)
— Persistent ASD symptoms approaching 1-month mark
— Complex trauma history (childhood abuse, repeated trauma)
— Military sexual trauma — consider VA specialty programs
— PCP + care manager + consulting psychiatrist; proven to improve depression and anxiety outcomes in primary care; appropriate framework for AjD management
— Measurement-based care with PHQ-9/GAD-7 at every visit
CCS pearl: In a CCS case where a patient with adjustment disorder develops new suicidal ideation with a plan to overdose on stockpiled medications, your sequence is: assess safety → remove access to means (collect medications) → 1:1 observation → psychiatric consultation → inpatient admission — do not discharge with outpatient follow-up.
Board pearl: Tarasoff duty to warn/protect applies when there is a specific, identifiable victim — informing intended victim and/or police, not just the patient, may be required.
— Same Criterion A traumatic event as ASD; symptom duration >1 month
— Symptom clusters: intrusion, avoidance, negative alterations in cognitions/mood, alterations in arousal/reactivity
— ASD that persists past 1 month is reclassified as PTSD — same patient, different label
— Symptoms within first 3 days after trauma — by DSM-5-TR, ASD requires ≥3 days
— Self-limited in majority; provide psychoeducation, support, watchful waiting
— Stressor magnitude — life-threatening/sexual violence routes to ASD; non-Criterion A stressors route to AjD
— Dissociative symptoms favor ASD
— Death of a close other ≥12 months ago (≥6 months in children)
— Persistent intense yearning, preoccupation, identity disruption, emotional numbness
— Distinct from AjD — bereavement-specific and duration-defined
— Used when symptoms cause distress but don't meet full criteria for any specific disorder
— E.g., ataque de nervios in culture-bound contexts
— Pediatric trauma-spectrum diagnoses related to insufficient caregiving in early childhood
— Not typical Step 3 adult vignettes but appear in pediatric/CPS contexts
— Psychotic symptoms (delusions, hallucinations, disorganized speech) lasting ≥1 day but <1 month after a markedly stressful event
— Full return to premorbid functioning expected
— Psychosis distinguishes from ASD/AjD
Key distinction: Stressor severity is the gateway — Criterion A (death/serious injury/sexual violence) sorts patients into ASD/PTSD; everything else with significant impairment sorts into AjD.
Board pearl: A patient at 5 weeks post-trauma with full intrusion, avoidance, and arousal symptoms is PTSD, not ASD — the 1-month mark is the inflection point even if the clinical picture looks identical.
— ≥5 of 9 SIGECAPS symptoms for ≥2 weeks, including depressed mood or anhedonia
— Can be precipitated by a stressor — if full MDD criteria met, diagnose MDD, not AjD
— Anhedonia, neurovegetative symptoms, psychomotor changes favor MDD
— Excessive worry about multiple domains for ≥6 months
— Not tied to a discrete identifiable stressor
— Chronicity differentiates from AjD
— Recurrent unexpected panic attacks with ≥1 month of anticipatory worry or behavioral change
— Discrete attacks vs sustained AjD distress
— Each has specific triggers/themes distinct from a recent life stressor
— Always screen for prior manic/hypomanic episodes before starting an SSRI — antidepressant monotherapy can induce mania
— Use MDQ or CIDI-3.0 screening
— Stimulants, cannabis withdrawal, alcohol withdrawal, corticosteroids, interferon, isotretinoin, β-blockers, varenicline, levetiracetam
— Temporal relationship to substance/medication use confirms
— Hyperthyroidism — tachycardia, tremor, weight loss, anxiety
— Pheochromocytoma — paroxysmal HTN, headache, diaphoresis, palpitations
— Cushing syndrome — mood lability, depression, anxiety
— Hypoglycemia — palpitations, diaphoresis, anxiety
— Cardiac arrhythmia — palpitations mimic panic
— Pulmonary embolism — acute dyspnea/anxiety in postoperative or postpartum patient
— Anti-NMDA receptor encephalitis — young woman with psychiatric symptoms + seizures + autonomic instability
— Delirium — fluctuating attention, especially in elderly or hospitalized
— Borderline personality disorder — chronic affective instability, identity disturbance, fear of abandonment; stressor may unmask pattern but baseline pathology predates
Board pearl: Always rule out bipolar disorder before prescribing an SSRI for anxious or depressive symptoms in AjD — antidepressant-induced mania is a recurring Step 3 stem and triggers a different treatment pathway (mood stabilizer or second-generation antipsychotic).
Key distinction: Symptom duration and the presence/absence of a discrete identifiable stressor are the two diagnostic axes that resolve most differential confusion.
— If SSRI initiated for AjD-with-depressed-mood or persistent symptoms: 30-day supply with refill, follow-up scheduled before prescription runs out
— If prazosin for trauma nightmares: titration schedule written explicitly, BP check at 1–2 weeks
— Avoid discharge benzodiazepine prescriptions in trauma/stressor presentations; if absolutely needed, ≤7-day supply, no refills
— Naloxone co-prescription if any opioid prescription or known opioid use disorder
— Document Stanley-Brown Safety Plan in the chart
— Counsel on firearm storage (offsite storage, lock boxes, trigger locks) — single highest-leverage suicide prevention intervention
— Medication lockup; limit acetaminophen and TCA supplies in high-risk patients
— Sleep hygiene and CBT-I principles — bedtime regularity, limit caffeine after noon, no screens 1 hour before bed
— Exercise: ≥150 min/week moderate aerobic — antidepressant-equivalent effect in mild cases
— Limit alcohol to <1 drink/day women, <2 drinks/day men (or abstinence if substance use concerns)
— Cannabis counseling — frequent use associated with worse anxiety and PTSD outcomes
— Social re-engagement, return-to-work planning, gradual exposure to avoided contexts
— For ASD: complete the 5-session TF-CBT course; reassess at 1 month with PCL-5
— For AjD: schedule check at 4–6 weeks to confirm trajectory; if persistent past stressor resolution by >6 months, reformulate diagnosis
— Stress impairs immune response; ensure routine immunizations are current
— Resume cancer screening, BP, lipid, HbA1c monitoring deferred during acute distress
— FMLA paperwork, short-term disability forms — provide objective findings, functional limitations, and expected duration
— Avoid documentation that inadvertently harms patient (e.g., overly broad "permanent disability")
Step 3 management: Every discharge from an acute stress evaluation should include: (1) safety plan documented, (2) lethal-means counseling, (3) follow-up appointment within 1–2 weeks, (4) clear return precautions, (5) crisis line (988) provided in writing.
Board pearl: 988 Suicide and Crisis Lifeline is the US national number — give it in writing to every patient at any elevated risk.
— Initial visit → 1–2 weeks for safety reassessment, especially if SSRI started or high-risk
— Weeks 2–4: assess SSRI response, side effects, suicidality (peak risk early in treatment)
— Weeks 4–6: reassess diagnostic accuracy; if no improvement, reconsider AjD vs MDD/GAD/PTSD
— Weeks 8–12: evaluate for full remission; AjD typically resolves within 6 months of stressor end
— Maintain measurement-based care with PHQ-9, GAD-7, PCL-5 at each visit
— 2–4 weeks post-initiation: check sodium (SIADH/hyponatremia risk, especially elderly)
— Assess suicidality at each visit, particularly in patients <25 (black-box warning)
— Bleeding risk if on antiplatelet/anticoagulant or NSAIDs — consider PPI
— Sexual side effects — proactively ask; consider bupropion augmentation or switch
— Weight, BP, glucose if on mirtazapine or atypical antipsychotic adjunct
— ECG if QT-prolonging combinations or doses
— Orthostatic BP at 1–2 weeks; titrate by 1 mg increments
— Symptom diary for nightmare frequency
— Track session attendance, homework completion (in CBT), exposure hierarchy progress
— Communicate with therapist (with consent) — collaborative care improves outcomes
— Graded return-to-work plan — half-days, modified duties, then full duty
— Occupational therapy referral if cognitive or functional deficits persist
— School re-entry plans for adolescents with 504 plans or IEPs as needed
— 6-month checkpoint: AjD should be resolved or close to it; if not, re-diagnose
— 12-month checkpoint: assess for recurrence with new stressors; build coping toolkit
— After 6–12 months of stability in mild AjD; longer (1–2 years or indefinite) for PTSD that emerged from ASD
— Taper over 4 weeks minimum; paroxetine and venlafaxine require longer tapers
Board pearl: The highest suicidality risk on SSRIs is in the first 1–4 weeks of treatment in patients <25 — schedule a weekly check-in for the first month and document each contact.
Step 3 management: Use measurement-based care — repeat PHQ-9 every 2–4 weeks; a <50% reduction by 6–8 weeks signals need for dose adjustment, switch, or augmentation.
— Maintain confidentiality except when mandatory reporting applies: child abuse, elder abuse, dependent-adult abuse, certain communicable diseases, gunshot/stab wounds (state-dependent)
— Duty to warn/protect (Tarasoff) when an identifiable third party is at risk — notify intended victim and/or law enforcement; document reasoning
— 42 CFR Part 2 governs heightened protection of substance use treatment records — separate consent required for disclosure
— Discuss black-box warning for SSRI/SNRI suicidality in patients <25 and document
— Discuss SSRI bleeding risk if anticoagulated
— Risks/benefits/alternatives/no treatment framework documented
— Pregnancy: shared decision-making on SSRI in pregnancy and lactation, weighing maternal mental illness risks against medication risks
— Patients with AjD/ASD generally retain capacity for medical decisions
— Acute dissociation, severe suicidality, or psychotic features may transiently impair capacity — formal capacity assessment with documentation if refusing essential care
— State-specific criteria — typically danger to self, danger to others, or grave disability
— Follow least restrictive alternative principle
— Right to refuse medications retained in most states absent emergency or court order
— Suspected child abuse as precipitating stressor — report to child protective services
— Intimate partner violence — not mandatorily reportable in most states for competent adults; offer resources, safety planning
— Elder/dependent adult abuse — mandatory in most states
— Highest-risk window for suicide is the 30 days post-ED or post-discharge from inpatient psychiatry
— Ensure warm handoff to outpatient provider, follow-up within 7 days, crisis resources provided
— Caring contacts (postcards, calls) reduce post-discharge suicide attempts
— Provide accurate, minimum-necessary information for FMLA, ADA accommodations
— Avoid documenting unverifiable claims; do not falsify for secondary gain
— Use trauma-informed care principles; avoid pathologizing normal responses
— Be alert to disparities in trauma exposure (refugees, low-income, racial/ethnic minorities, LGBTQ+) and tailor care accordingly
Step 3 management: The post-ED discharge phone call within 24–48 hours for any patient with stressor-related crisis presentation is a Step 3 favorite — it concretely reduces re-presentation and suicide attempts and reflects systems-level safety thinking.
Board pearl: Always document the Tarasoff analysis when homicidal ideation is voiced — even if no warning is issued, the reasoning must be in the chart.
— <3 days post-trauma: normal acute stress reaction
— 3 days–1 month post-trauma: acute stress disorder
— >1 month post-trauma: PTSD
— AjD onset: within 3 months of stressor
— AjD resolution: within 6 months of stressor end
— Criterion A trauma (death/serious injury/sexual violence) → ASD/PTSD pathway
— Any other significant stressor → AjD pathway
— ASD: trauma-focused CBT, starting ≥2 weeks post-trauma
— AjD: brief problem-solving or supportive psychotherapy
— Pharmacotherapy is adjunctive in both
— Trauma nightmares → prazosin
— Persistent PTSD symptoms → sertraline or paroxetine (FDA-approved)
— Benzodiazepines post-trauma — worsen PTSD outcomes
— Single-session psychological debriefing — increases PTSD risk
— Paroxetine in pregnancy first trimester
— Citalopram >20 mg in elderly (QTc)
— Pregnancy/lactation: sertraline
— Elderly: sertraline or escitalopram at low dose
— Trauma nightmares: prazosin
— Insomnia in trauma: trazodone or prazosin (never long-term benzodiazepines)
— Takotsubo cardiomyopathy ↔ acute emotional stressor in postmenopausal women
— Brief psychotic disorder with marked stressor ↔ <1-month psychotic episode post-stressor
— AjD with conduct disturbance ↔ adolescent behavior changes post-divorce/move
— Postpartum PTSD ↔ traumatic delivery, NICU admission
— MST and combat trauma ↔ veterans with trauma symptoms
— Female sex, prior trauma, peritraumatic dissociation, low social support, ongoing threat, TBI
— AjD has surprisingly high suicide attempt rates, especially in adolescents — never dismiss as "minor"
— 988 Suicide and Crisis Lifeline is the standard US number
Board pearl: Two reflex-level rules: never prescribe a benzodiazepine after acute trauma, and never order single-session debriefing — both are recurring Step 3 traps and represent the most common wrong answers.
Key distinction: The first decision tree node is Criterion A trauma — yes or no — getting this right routes you to the correct disorder and treatment in ~90% of vignettes.
— "A 28-year-old man, 3 weeks after surviving a building collapse, reports nightmares, avoidance, hypervigilance, and feeling 'unreal.'" → ASD (within 1 month)
— Same vignette at 6 weeks → PTSD
— Same vignette at 48 hours → normal acute stress reaction, supportive care only
— Patient with low mood after job loss, sleep disturbance, tearfulness, but no anhedonia, no neurovegetative cluster → AjD with depressed mood
— Patient with 5+ SIGECAPS symptoms for ≥2 weeks → MDD, treat as MDD regardless of stressor
— ASD patient post-MVC; options include alprazolam, sertraline, prazosin, lorazepam, TF-CBT referral
— Correct: TF-CBT referral (and prazosin only if specifically targeting nightmares)
— Trap: alprazolam — worsens long-term PTSD
— Disaster mass-casualty scenario asking about the optimal next step for survivors
— Correct: psychoeducation, watchful waiting, screen for ASD at 2 weeks
— Trap: mandatory critical incident stress debriefing — increases PTSD risk
— Postpartum woman 5 weeks after traumatic delivery with intrusion, avoidance, arousal — breastfeeding
— Pharmacotherapy of choice: sertraline
— Trap: paroxetine, benzodiazepine
— Teen with declining grades and fighting after parents' divorce
— Correct: family-based therapy and individual CBT
— Trap: starting an SSRI as first-line
— Veteran 6 weeks post-deployment with recurrent combat nightmares despite sleep hygiene
— Correct: prazosin, titrate from 1 mg qhs
— Trap: zolpidem, alprazolam
— Patient labeled as having "anxiety from work stress" but with paroxysmal HTN, headache, diaphoresis
— Correct next step: plasma metanephrines (pheochromocytoma)
— Trap: starting SSRI
— Patient with AjD voices specific homicidal ideation toward an identified ex-partner
— Correct: warn intended victim and/or police, document
Board pearl: When in doubt on a stressor vignette, the safest answer set is usually (1) psychotherapy referral, (2) screen for SI, (3) follow-up within 1–2 weeks, (4) avoid benzodiazepine — this composite covers most stems.
Acute stress disorder and adjustment disorders are stressor-defined diagnoses in which the magnitude of the precipitating event (Criterion A trauma vs ordinary life stressor) and the symptom timeline (3 days–1 month for ASD, within 3 months and resolving within 6 months for AjD) determine the label, while psychotherapy is first-line treatment for both and pharmacotherapy is adjunctive, with benzodiazepines and single-session debriefing specifically avoided.
— Stressor type: life-threatening or sexual violence → ASD/PTSD; everything else → AjD
— Timeline: <3 days = normal reaction; 3 days–1 month = ASD; >1 month = PTSD; AjD within 3 months of stressor, resolves within 6 months of stressor end
— First-line: psychotherapy (TF-CBT for ASD; brief problem-solving or supportive therapy for AjD)
— Targeted pharmacotherapy: prazosin for trauma nightmares; sertraline/escitalopram for persistent depressive/anxious symptoms; trazodone for insomnia
— Avoid: benzodiazepines post-trauma, single-session debriefing, paroxetine in first-trimester pregnancy, citalopram >20 mg in elderly
— C-SSRS screening at every visit; AjD carries underrecognized suicide risk
— Lethal-means counseling, especially firearm storage
— 988 Suicide and Crisis Lifeline in writing; follow-up within 1–2 weeks of any acute stressor visit
— Tarasoff duty-to-warn when an identifiable victim is at risk
— Measurement-based care (PHQ-9, GAD-7, PCL-5) at each visit
— Collaborative care model in primary care for AjD/mild ASD
— Warm handoff and post-ED follow-up call within 24–48 hours after any crisis presentation
— Document functional impairment for FMLA/disability with objective findings
— Reassess at 6 months; if AjD persists past stressor resolution, reformulate the diagnosis to MDD, GAD, or PTSD
Board pearl: Two reflex rules — no benzodiazepines after trauma, no mandatory single-session debriefing — solve a large fraction of Step 3 stems in this domain on their own.