Trauma and Stressor-Related Disorders

Trauma and Stressor-Related Disorders

• Trauma and stressor-related disorders have profound effects on memories, cognitions, emotions, and behaviors.
• Exposure to a traumatic or stressful event is a diagnostic criterion for these disorders.
• Some individuals exposed to trauma may exhibit anhedonic, dysphoric, externalizing (angry and aggressive), or dissociative symptoms, rather than anxiety or fear-based symptoms.

Reactive Attachment Disorder

• Characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors.
• Children rarely or minimally turn to attachment figures for comfort, support, protection, and nurturance.
• A crucial feature is the absence or gross underdevelopment of attachment between the child and caregiving adults.
• Limited opportunities during early development lead to a failure of these children to display behavioral manifestations of selective attachments and a lack of consistent effort to obtain comfort, support, nurturance, or protection from caregivers.
• Children exhibit diminished or absent expression of positive emotions during routines.
• Conditions of social neglect are commonly present from the first months of life in those diagnosed.
• Clinical features appear between 9 months and 5 years old.
• Serious social neglect is the sole known risk factor for this disorder, though most severely neglected children do not develop it.
• Prognosis depends on the caregiving environment after neglect.

Differential Diagnosis of Reactive Attachment Disorder

• Autism Spectrum Disorder: Aberrant social behaviors are present in both, but children with ASD rarely have a social neglect history. Restricted interests and repetitive behaviors are not features of RAD.
• Intellectual Developmental Disorder: Children with IDD show social and emotional skills comparable to their cognitive abilities and don't show the profound reduction in positive affect and emotion regulation difficulties found in RAD.

Post-Traumatic Stress Disorder (PTSD)

• No longer considered an anxiety disorder.
• PTSD is now listed under the Stress and Trauma-Related Disorders category.
• Prevalence varies depending on trauma type. Rape results in higher rates than automobile accidents in both men and women.
• The prevalence among U.S. soldiers in Iraq and Afghanistan is estimated to be 13-20%.
• Characteristic symptoms develop after exposure to one or more traumatic events.
• Symptoms can include fear-based reexperiencing, emotional, behavioral symptoms, anhedonic or dysphoric mood states, and negative cognitions.
• Additional symptoms can include arousal and reactive-externalizing behaviors or dissociative symptoms.

PTSD - Etiology

• Fear conditioning/learning: Classical (Pavlovian) and operant conditioning play a role
• Information processing: Individuals are more likely to appraise situations as threatening if they feel unable to meet demands.
• Neurobiological systems: Genetic polymorphisms related to stress vulnerability, difficulty extinguishing fear-conditioned memories, and poor regulation of the HPA axis are involved.

PTSD - Risk Factors

• Pretraumatic factors include female gender, Hispanic race, younger age, lower education, lower intelligence, negative emotionality, and past psychiatric history.
• Peritraumatic factors include high traumatic exposure, pronounced dissociation, and excessive peritraumatic physiological activation.
• Posttraumatic factors include dysfunctional coping strategies (avoidance), low social support, and subsequent exposure to additional stressors and traumatic events.

PTSD - Resilience

• Not all individuals exposed to trauma develop PTSD.
• Neurobiological resilience factors include a robust sympathetic nervous system that returns rapidly to baseline, ability to contain CRF, well-functioning dopamine-mediated reward system, appropriate amygdala functioning, and strong cortical executive and inhibitory capacity.
• Psychosocial factors such as optimism, humor, social support, an active coping style, openness to change, and extroversion are also correlated with resilience.
• Cognitive flexibility, or the ability to reframe problems and find meaning in stressful situations, is associated with a greater sense of self-efficacy and less perceived threat.

PTSD - Genetics

• PTSD risk is moderately heritable.
• Specific genes related to dopaminergic, serotonergic, noradrenergic, and HPA axis systems have been linked to PTSD.
• Epigenetic research shows that external and internal stimuli (e.g., social support, fear, stress) can trigger biochemical reactions that impact gene expression ("turning genes on" or "off").

PTSD - Diagnostic Criteria

• Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence (can include direct experience; witnessing; learning about it related to a family member or close friend).
• Criterion B: Presence of one or more intrusion symptoms (e.g., distressing memories, recurring dreams, flashbacks).
• Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s) (avoid distressing memories, thoughts, or feelings; avoid external reminders).
• Criterion D: Negative alterations in cognitions and mood (e.g., inability to remember an aspect; persistent negative beliefs or expectations; blaming oneself or others).
• Criterion E: Marked alterations in arousal and reactivity (e.g., irritability; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; sleep disturbance).
• Criterion F: Duration of disturbance (B, C, D, and E) is more than 1 month. This distinction is crucial, as it separates PTSD from acute stress disorder.

Acute Stress Disorder

• Characterized by characteristic symptoms lasting from 3 to 1 month following traumatic events.
• Intrusion, negative mood, dissociative, avoidance, and arousal symptoms can be present.
• The full symptom picture must last for at least 3 days but no more than 1 month to be diagnosed as ASD.
• If symptoms last longer than 1 month, the diagnosis changes to PTSD.

Adjustment Disorders

• Disturbance begins within 3 months of a stressor onset.
• Disturbance must resolve within 6 months of the stressor's termination or its consequences.
• Subjective distress or impairment in functioning is present, often manifested as decreased work/school performance and social relationship difficulties.
• Adjustment disorder can complicate other medical conditions.

Differential Diagnosis of Adjustment Disorders

• Major Depressive Disorder: If an individual demonstrates symptoms indicative of major depression, an adjustment disorder diagnosis is not applied.
• PTSD: In adjustment disorders, the stressor can be any severity, unlike PTSD, which requires specific severity thresholds of trauma;
• Bereavement: Prolonged grief disorder may be considered in cases of severe and prolonged grief reactions that last more than 12 months.

Prolonged Grief Disorder

• Maladaptive grief reaction diagnosed at least 12 months after the death of a close relationship.
• Characterized by persistent grief, intense yearning or longing for the deceased, frequent crying, and preoccupation with thoughts or memories of the deceased.
• Symptoms must be present for at least one month and at a clinically relevant level for the diagnosis (e.g., difficulty functioning).
• Must be distinguished from normal grief reactions, which resolve within a shorter timeframe and don't typically impair functioning as much.

Differential Diagnosis for Prolonged Grief Disorder

• Normal grief: Distinguishing factor is that prolonged grief involves significantly more intense, persistent reactions and impairment in functioning.
• Depressive Disorders: Prolonged grief is focused on loss and separation from a loved one, not reflecting on generalized low mood associated with depressive disorders.
• PTSD: Intrusions in PTSD are typically focused on the traumatic event, while in prolonged grief, the intrusive thoughts may revolve around the positive aspects of the relationship.