Question 1

A 30-year-old man is brought to the emergency department by his wife 36 hours after witnessing a fatal shooting at a convenience store. He is trembling, tearful, and hypervigilant. He reports not sleeping, having vivid intrusive images of the shooting, and feeling as if "the world isn't real." His wife is alarmed and asks the psychiatry consultant whether her husband has acute stress disorder. What is the most appropriate response?

Accepted Answer

ASD cannot be diagnosed until 3 days (72 hours) post-trauma. This is a hard minimum. Symptoms in the first 72 hours are extremely common - up to 94% of trauma-exposed individuals experience acute distress - and are usually self-limiting. Premature diagnosis pathologizes normal recovery. PTSD cannot be diagnosed until symptoms have persisted for more than 1 month, making option C doubly incorrect (wrong diagnosis AND wrong timing). Benzodiazepines (option D) are not recommended for acute trauma because multiple studies show they may interfere with the natural fear extinction process and do not prevent PTSD. The evidence-based approach at 36 hours is psychological first aid and planned reassessment, not diagnosis, therapy, or medication.

Question 2

A hospital system implements mandatory psychological debriefing for all staff involved in critical incidents (patient deaths, workplace violence, code responses). All involved staff must participate in a single structured session within 48 hours where they recount their experience in detail and process their emotional responses. The rationale is that "talking about it prevents PTSD." A new psychiatrist reviewing the program also notices that staff who report significant distress are offered lorazepam prescriptions. What evidence-based recommendation should the psychiatrist make?

Accepted Answer

This question tests two high-yield evidence-based principles. First, mandatory psychological debriefing is one of the most well-established negative findings in trauma research - it does not prevent PTSD and can worsen outcomes by forcing premature trauma re-exposure. Second, benzodiazepines given acutely after trauma are not recommended because they may interfere with natural fear extinction. Option C recognizes the benzodiazepine problem but retains the debriefing, which also lacks evidence. Option D replaces one premature mandatory intervention with another - trauma-focused CBT is evidence-based for individuals who remain symptomatic at 2-4 weeks, but mandating it for all exposed individuals within 48 hours is the same fundamental error as mandatory debriefing: forcing intervention on a population where the majority will recover naturally.

Question 3

A 24-year-old woman presents 18 days after being sexually assaulted. She reports persistent intrusive memories and nightmares about the assault, emotional numbness, inability to feel happiness or love, a persistent sense that the world is unreal and dreamlike, inability to remember parts of the assault, avoidance of the campus area where it happened and of being alone with men, insomnia, hypervigilance, exaggerated startle, difficulty concentrating, and irritability. She counts 12 symptoms across all 5 ASD categories. Her therapist states: "She clearly has PTSD - and since she has prominent dissociative symptoms, she wouldn't have qualified for ASD under the old DSM-IV criteria without them, but now DSM-5 doesn't even require dissociation for ASD." How many errors are in the therapist's formulation?

Accepted Answer

This question tests three board-relevant concepts simultaneously. First, the temporal boundary: at 18 days, the diagnosis is ASD, not PTSD, regardless of symptom severity. PTSD requires >1 month of symptoms. Second, the DSM-IV to DSM-5 change: DSM-IV required dissociative symptoms for ASD; DSM-5 does not. The therapist correctly identifies this change but misapplies it - this patient HAS dissociative symptoms, so she would have qualified under either edition. The change matters for patients without dissociation. Third, prognosis: despite severe symptoms, ~50% of ASD cases recover without PTSD. Option C incorrectly states that dissociation is still required in DSM-5 - it is not. Option D is incorrect because ASD can and should be diagnosed when criteria are met during the 3-day to 1-month window; waiting until 1 month would delay appropriate intervention.

Acute Stress Disorder

Red Flags & Key Clinical Considerations

Premature Diagnosis Before 72 Hours

Suicidal Ideation in Acute Trauma

Psychological Debriefing Causes Harm

Benzodiazepines Contraindicated Acutely

Dissociation Masking Severity

ASD Does Not Equal Pre-PTSD

Related Medications

References & Further Reading