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PS8.1 | Stress Related Disorders Referral — SDL Guide (Part 2)

Management and Referral Criteria

Management of stress-related disorders at primary care level follows a tiered approach, escalating from immediate psychological support to specific psychological therapies to pharmacotherapy, with structured referral criteria guiding which patients require secondary psychiatric input. Competency PS8.1 explicitly requires not only diagnosis but also the ability to make appropriate referral — a skill that requires knowing both when to intervene at primary care and when to pass on.

Tier 1 — Psychological First Aid (PFA): For patients in the immediate post-trauma phase (first days to weeks), the WHO-endorsed Psychological First Aid framework is the appropriate first-line response. PFA involves five actions: (1) making contact and establishing a safe, non-judgmental relationship; (2) ensuring safety and immediate practical needs (shelter, food, physical safety); (3) listening with empathy and validating the patient's emotional response as normal; (4) providing accurate information about what to expect and where to get help; (5) connecting the patient with social support networks and community resources. PFA does not involve formal psychological debriefing (a single compulsory narrative retelling of the trauma — evidence shows this can be harmful), and it does not involve prolonged exploration of the trauma narrative in the acute phase.

Tier 2 — Monitoring and normalisation: For mild-to-moderate ASD and adjustment disorder without high-risk features, watchful waiting with a 2–4 week follow-up is appropriate. The majority of individuals with ASD do not progress to PTSD — studies suggest approximately 50% recover with minimal intervention within the first month. Similarly, most adjustment disorders resolve within 6 months of the stressor ending. Psychoeducation (explaining the expected natural course, the importance of maintaining daily routines, gentle resumption of activities) and social support facilitation are central.

Tier 3 — Specific psychological therapy:
Trauma-focused Cognitive-Behavioural Therapy (TF-CBT) is the first-line evidence-based treatment for ASD and PTSD. It includes: trauma narrative construction (gradual, structured recounting of the trauma to facilitate emotional processing and memory integration); cognitive restructuring (challenging maladaptive appraisals); and in-vivo exposure (graded return to avoided trauma reminders). A minimum of 8–12 sessions is needed for PTSD; shorter courses (4–6 sessions) may suffice for ASD.
Eye Movement Desensitisation and Reprocessing (EMDR) is an alternative evidence-based treatment for PTSD in which the patient processes traumatic memories while simultaneously performing bilateral eye movements — shown in RCTs to be as effective as TF-CBT.
For adjustment disorder, supportive psychotherapy, problem-solving therapy, and brief CBT targeting maladaptive appraisals of the stressor are appropriate.

Tier 4 — Pharmacotherapy:
Pharmacotherapy is not first-line for ASD (psychological first aid and watchful waiting are preferred). For PTSD, when psychological therapy is not available or the patient prefers pharmacotherapy, SSRIs are the first-line agents: sertraline (50–200 mg/day; FDA-approved for PTSD) and paroxetine (20–60 mg/day; FDA-approved for PTSD). Allow 8–12 weeks for SSRI response in PTSD (longer than for anxiety disorders). Venlafaxine (SNRI) is an acceptable second-line agent.
Benzodiazepines are NOT recommended for PTSD — evidence suggests they may impair fear extinction by reducing the cortisol response necessary for memory reconsolidation; they also carry dependence risk in a vulnerable population. For adjustment disorder, pharmacotherapy is generally not required unless a comorbid depressive or anxiety disorder is present.
For sleep disturbance, prazosin (an alpha-1 blocker) has RCT evidence for PTSD-related nightmares. Mirtazapine may be used where sedation and sleep promotion are needed.

Referral criteria from primary care to secondary psychiatric services:
- Suicidal ideation, active self-harm, or homicidal ideation
- Psychotic symptoms (command hallucinations directing self-harm, paranoid delusions)
- Severe functional impairment not responding to 4 weeks of primary care management
- Failure to respond to two adequate SSRI trials (8–12 weeks each)
- Comorbid severe substance use disorder requiring detoxification
- Complex PTSD (ICD-11) — prolonged, interpersonal trauma with self-organisation disturbances
- High-risk populations: children, military veterans, sexual assault survivors, torture survivors
- Medico-legal context (forensic documentation requirement, court proceedings)
- Diagnostic uncertainty

Under the Mental Healthcare Act 2017 (India), suicide attempt has been decriminalised — a patient presenting after a suicide attempt is a medical patient, not a criminal. The Act guarantees the right to mental healthcare and requires that primary care physicians facilitate access to specialist services. Document referral decisions and the rationale explicitly in clinical notes.

Self-Assessment: Diagnosing and Referring Stress-Related Disorders

Self-assessment in stress-related disorders requires not just recalling diagnostic criteria but applying the timeline-first differential framework to clinical vignettes — the same cognitive process you will use in your internship. Each scenario below tests a specific competency node from PS8.1: distinguishing ASD from PTSD from adjustment disorder, identifying the correct classification system, applying referral criteria, and avoiding the common error of prescribing benzodiazepines for PTSD.

For each scenario, work through: (a) Is the stressor traumatic? (b) What is the duration? (c) What are the key symptoms? (d) What is the diagnosis and classification? (e) What is the primary care management? (f) Does this patient require referral today?

Scenario A: A 45-year-old female survivor of a cyclone 10 weeks ago presents with recurrent nightmares about the flooding, hypervigilance, emotional numbing towards her children, and avoidance of any weather news. She was temporarily displaced and has returned home but cannot function. She has no suicidal ideation.

Answer: PTSD (DSM-5) — traumatic stressor (natural disaster with threat to life), duration >1 month (10 weeks), four DSM-5 criterion domains present (intrusion: nightmares; negative mood/cognition: emotional numbing; avoidance; hyperarousal: hypervigilance). Primary care management: sertraline 50 mg/day with titration; referral for TF-CBT if available; psychoeducation; social support facilitation. Referral to secondary services: not urgently required unless suicidality develops, but TF-CBT referral should be initiated. Monitor closely.

Scenario B: A 19-year-old student failed his NEET examination 3 weeks ago. He has been tearful, sleeping 12+ hours, has withdrawn from friends, and stopped eating properly. He feels 'worthless' but denies suicidal ideation. There is no history of depressive episodes; the symptoms began 2 weeks after the exam results.

Answer: Adjustment Disorder (ICD-11: onset within 1 month — approximately 2 weeks post-stressor, within criterion; DSM-5: within 3 months — also met). The stressor (exam failure) is identifiable but not traumatic (does not involve death/injury/sexual violence) — ASD/PTSD criteria are not applicable. The symptoms are disproportionate and causing significant impairment. Note: does not meet criteria for MDE (not 2 weeks of persistently depressed mood with daily features — duration and number of criteria may not yet be met, but watch closely). Management: psychoeducation, supportive counselling, problem-solving (steps to re-apply or alternative pathways), monitoring. Watchful waiting is appropriate given short duration; reassess at 2 weeks.

Scenario C: A 32-year-old police officer was the first responder at a fatal accident 7 weeks ago in which a child died. He has intrusive images of the scene, is drinking alcohol heavily 'to sleep,' and told his wife he has thought of using his service weapon. He has come to you with a shoulder sprain.

Answer: Likely PTSD (>1 month, traumatic stressor, intrusion + arousal symptoms) with comorbid alcohol misuse and active suicidal ideation with a plan and means access. This patient requires immediate referral to secondary psychiatric services today — do not defer. Remove access to service weapon (contact his superior — this is a clinical safety duty). Do not prescribe benzodiazepines. Conduct a thorough suicide risk assessment using structured tools. Document the referral and safety planning in the clinical notes. This is the highest-urgency scenario in this differential.