Same symptoms, different name depending on the clock. Learn the qualifying trauma, the four clusters, the 1-month line, and why prazosin owns the nightmares.
The Setup
The Clock Is the Diagnosis
The same symptoms get a different name depending on how long it has been since the trauma. First make sure the trauma qualifies, then read the calendar.
A 28-year-old soldier survived a roadside bombing. Three weeks later he has nightmares and flashbacks of the blast, avoids anything that reminds him of it, feels numb and detached, and startles violently at loud noises. His sleep is wrecked and he is irritable. The symptoms began within days of the event.
At this point in time, which is the correct diagnosis?
For trauma disorders, the clock is the diagnosis. The same cluster of symptoms gets a different name depending on how long it has lasted since the trauma. Three days to 1 month is acute stress disorder. Beyond 1 month is post-traumatic stress disorder (PTSD). The symptoms can look identical on a given day; the duration is what you are tested on.
First, the trauma has to qualify. PTSD requires exposure to actual or threatened death, serious injury, or sexual violence. That exposure can be direct, witnessed in person, learned about happening to a close loved one, or repeated exposure to grim details (as with first responders). An ordinary stressful life event, like a divorce or losing a job, does not qualify, and that points you toward adjustment disorder instead.
Map the timeline once.
A note on onset. PTSD symptoms usually begin within months, but the diagnosis allows for delayed expression, where full criteria are not met until at least 6 months after the trauma. The trauma can be old; the disorder can be new.
At the Bedside
The Four Clusters
PTSD is built from intrusion, avoidance, negative mood, and arousal. Acute stress disorder is the same picture under a month; adjustment disorder follows an ordinary stressor.
PTSD is built from four symptom clusters. A patient needs symptoms from all four, lasting more than a month, with real impairment. Tap each cluster.
Intrusion
Tap to reveal
The trauma forces its way back in: intrusive memories, recurrent nightmares, and flashbacks where the event feels like it is happening again, plus intense distress at reminders.
Avoidance
Tap to reveal
The patient steers clear of anything tied to the trauma: thoughts, feelings, people, places, or conversations that bring it back. This is the hallmark cluster that separates PTSD from ordinary stress.
Negative cognition and mood
Tap to reveal
Persistent negative beliefs about oneself or the world, an inability to recall key parts of the event, detachment from others, loss of interest, and a numbed inability to feel positive emotions.
Arousal and reactivity
Tap to reveal
A body stuck on high alert: hypervigilance, an exaggerated startle, irritability or angry outbursts, reckless behavior, trouble concentrating, and disturbed sleep.
Acute stress disorder
Tap to reveal
Same symptom pool as PTSD, but the duration is 3 days to 1 month after the trauma. If it persists past a month, the diagnosis becomes PTSD.
Adjustment disorder
Tap to reveal
Emotional or behavioral symptoms within 3 months of an ordinary (non-life-threatening) stressor, out of proportion to it, that do not meet criteria for another disorder and resolve within 6 months after the stressor ends.
From the AttendingWhen a stem lists nightmares, avoidance, numbness, and a jumpy startle after a life-threatening event, do not stop at the symptoms. Find the date. Less than a month is acute stress disorder; more than a month is PTSD. The cluster tells you it is trauma; the calendar tells you which trauma diagnosis.
Confirming It
Sorting the Spectrum
The forks come down to the trauma type and the duration. Get those two right and the diagnosis falls out.
Three forks sort the trauma spectrum. Work each before revealing it.
A woman has full trauma symptoms 3 weeks after a sexual assault. Which diagnosis fits the timeline?
Acute stress disorder. The trauma qualifies and the symptoms are present, but it has been under a month (3 days to 1 month window). If they persist past 1 month, the label changes to PTSD. Qualifying trauma plus duration under 1 month equals acute stress disorder.
A man laid off from his job becomes tearful and anxious for 2 months, but a job loss is not a life-threatening trauma and he does not have flashbacks or hyperarousal. Which fits?
Adjustment disorder. The stressor is an ordinary life event, not actual or threatened death or sexual violence, and the symptoms are an excessive reaction without the full PTSD cluster. It should resolve within 6 months of the stressor ending. Ordinary stressor plus out-of-proportion distress equals adjustment disorder.
A combat veteran has nightmares, avoidance, numbing, and hypervigilance that have lasted 5 months. What is the first-line treatment?
Trauma-focused psychotherapy (such as prolonged exposure, cognitive processing therapy, or EMDR) is first-line for PTSD overall. SSRIs like sertraline or paroxetine are the first-line medications when pharmacotherapy is used. PTSD: trauma-focused psychotherapy first; SSRI is the first-line drug.
Line up the trauma- and stressor-related disorders.
Disorder
Trauma or stressor
Timing
Key feature
Acute stress disorder
Life-threatening trauma
3 days to 1 month
Same symptoms as PTSD, shorter window
PTSD
Life-threatening trauma
More than 1 month
Four clusters: intrusion, avoidance, negative mood, arousal
Adjustment disorder
Ordinary life stressor
Within 3 months; resolves by 6 months
Excess reaction, no full PTSD cluster
Reactive attachment disorder
Early neglect
Before age 5
Emotionally withdrawn child who does not seek comfort
Disinhibited social engagement
Early neglect
Before age 5
Overly familiar, wanders off with strangers
The Plan
Therapy First, Then the Right Drug
Trauma-focused psychotherapy leads. SSRIs are the first-line medication, prazosin owns the nightmares, and chronic benzodiazepines are the trap.
Psychotherapy leads; medication supports. The single most effective treatment for PTSD is trauma-focused psychotherapy: prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing (EMDR). When medication is added, the first-line agents are SSRIs (sertraline and paroxetine are specifically approved) or the SNRI venlafaxine.
One drug owns a niche: nightmares. For trauma-related nightmares and sleep disruption, prazosin, an alpha-1 blocker, is the targeted choice. It blunts the adrenergic surge that drives the nightmares.
Trauma-focused CBT; treat to prevent progression to PTSD
Adjustment disorder
Psychotherapy; brief, supportive, problem-focused
From the AttendingWhen the stem emphasizes that nightmares are the dominant problem, the answer they want is usually prazosin. It is the cleanest single association in this topic, so flag the word nightmares and let it point you.
Board TrapDo not treat PTSD with chronic benzodiazepines. They do not treat the core disorder, they blunt the emotional processing that therapy depends on, they worsen outcomes, and they are dangerous in a population with high rates of substance use. If a PTSD answer choice is a standing benzodiazepine, it is almost always wrong.
Prove It
Board Walkthrough
Original clinical vignettes, 5 dealt per round, answer choices shuffled, never repeating within a round. Tap a wrong answer first to see why it almost works, then read the glowing clues.
Medically reviewed by Fatima Ali, DO and Kaitlyn Cocuzzo, MD · Last reviewed June 2026
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