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Window of opportunity - the Golden Hours of Stress-related Disorders

Dr. Joseph Zohar talking
Dr. Zohar talking about PTSD
Dr. Zohar talking about PTSD

Prof Joseph Zohar, director of Psychiatry at the Sheba Medical Center, Israel, presented an important description of the “do’s and don’ts” in the hours immediately after a traumatic event, and how these approaches may impact the onset and course of posttraumatic stress disorder.

In DSM-5, posttraumatic stress disorder (PTSD) now fits under the category of Stress Related Disorders, one of three families of disorders that were previously housed under Anxiety Disorders. What is unique about PTSD compared to other anxiety disorders is that it has a clear point of onset - we know when it begins.

This gives us a unique window of opportunity - the so called “Golden hours” after a traumatic event in which there is opportunity to intervene to change the trajectory and long-term prognosis of PTSD.

“Golden hours” after a traumatic event in which there is opportunity to intervene to change the trajectory and long-term prognosis of PTSD

Erasing (traumatic) memory

Prof Zohar proposed that a reduction of fear memories associated with trauma is beneficial, and so it follows that amnesia of traumatic events may reduce the rate of PTSD. He highlighted the relevance of preventing the unstable, short-term memory of trauma from consolidating into a fixed, stable, long-term memory.

A study prospectively investigated the relationship between memory of a traumatic event and subsequent development of PTSD.1 Subjects with mild traumatic brain injury who were hospitalised for observation were assessed immediately after the trauma and followed-up for 6 months. All 120 participants underwent self-assessment of their memory of the traumatic event as well as psychiatric evaluation.

After 6 months, 14% of the participants had developed PTSD. Significantly fewer participants with no memory of the trauma 24 hours after the event displayed PTSD symptoms after 6 months compared to those who did have memory of the event (6% versus 23%).

This study showed that memory of a traumatic event may be a risk factor for development of PTSD.

Memory of a traumatic event may be a risk factor for development of PTSD

Repression - a stress-buffer?

A repressive coping style, in which there is cognitive and emotional effort to ignore or divert attention from a threat, may lower the rate of clinical PTSD, Prof Zohar explained.

A study examined the effect of repressive coping style in immediate and long-term adjustment to stress.2 It looked at the relationships between repressive coping style, acute stress disorder (ASD) and PTSD in 116 patients who had experienced myocardial infarction.

Patients were assessed within a week of their myocardial infarction and 7 months later. At the first time point, self-report questionnaires measured repressive coping style, perceived threat and ASD. The severity of the myocardial infarction was collected from hospital records. PTSD was evaluated at 7 months. The repressive coping style was compared with that of 72 matched controls.

They discovered that a repressive coping style acted as a stress-buffer and made a difference to outcomes - repressors reported less ASD and PTSD than non‑repressors.

Repressive coping style acted as a stress-buffer

Addressing Basic Needs

Traumatic events can be managed through a set of principles that Prof Zohar described as ABN (Addressing Basic Needs) via ERASE. ERASE gives support but without interfering with the potent, effective, spontaneous recovery process.

ERASE involves 5 key elements:

  1. Reduce Exposure to stress (such as finding secure places for people);
  2. Restore physiological needs (provide food and drink);
  3. Provide informAtion/orientAtion;
  4. Find a source of Support (family and friends)
  5. Emphasize the Expectation of returning to normal.

After a trauma, people are generally having a normal response to an abnormal situation. Prof Zohar emphasised that within the first few hours after a trauma it is crucial not to do any of the following 3 P’s:

  1. Don’t Pathologise;
  2. Don’t Psychologise (ie don’t facilitate an emotional reaction through therapy or debriefing);
  3. Don’t Pharmacologise.

ABN, Addressing Basic Needs
ASD, acute stress disorder
PTSD, posttraumatic stress disorder

  1. Gil S, Caspi Y, Ben-Ari IZ, Koren D, Klein E. Does memory of a traumatic event increase the risk for posttraumatic stress disorder in patients with traumatic brain injury? A prospective study. Am J Psychiatry. 2005 May;162(5):963-9.
  2. Ginzburg K, Solomon Z, Bleich A.Repressive coping style, acute stress disorder, and posttraumatic stress disorder after myocardial infarction. Psychosom Med. 2002 Sep-Oct;64(5):748-57.


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