Trauma and Stressor-Related Disorders PDF

veronica clarisse mendoza, rpm, chra Trauma- and Stressor-related This set o f disorder s include : attachme nt disord inadequa ers in chi te or abu ldhood fo adjustme...

veronica clarisse mendoza, rpm, chra Trauma- and Stressor-related This set o f disorder s include : attachme nt disord inadequa ers in chi te or abu ldhood fo adjustme sive child llowing nt disord -rearing p anxiety a ers chara ractices nd depre cterized b event ssion foll y p ersistent owing a s reactions tressful l to trauma ife disorder s uch as pos and acut ttraumat e stress d ic stress isorder Reactive Attachment Disorder A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregiv­ers, manifested by both of the following: 1. The child rarely or minimally seeks comfort when distressed. 2. The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: 1. Minimal social and emotional responsiveness to others. 2. Limited positive affect. 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers. Reactive Attachment Disorder C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adult 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C). E. The criteria are not met for autism spectrum disorder. F. The disturbance is evident before age 5 years. G. The child has a developmental age of at least 9 months.  Specifiers Specify if: Persistent: The disorder has been present for more than 12 months. Specify current severity: Reactive attachment disorder is specified as severe when a child exhibits all symp­toms of the disorder, with each symptom manifesting at relatively high levels.  Unknown but seen rarely in clinical settings Prevalence Found in children exposed to severe neglect before being placed in foster care/institutions Occurs in 10% of severely neglected children Conditions of sotial neglect are often present in Development the first months of life in children diag­nosed with reactive attachment disorder, even before the and Course disorder is diagnosed Without remediation and recovery through normative caregiving environments, it appears that signs of the disorder may persist, at least for several years. Risk and Prognostic Factor Environmental Serious social neglect is required However, majority of severely neglected children do not develop this disorder Prognosis depend on the quality of the caregiving environment following serious neglect Disinhibited Social Engagement Disorder A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. 2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. *Other criteria and specifier is similar with RAD Other features May co-occur with developmental delays, especially cognitive and lan­guage delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor care. However, signs of the disorder often persist even after these other signs of neglect are no longer present. May be seen in children with a history of neglect who lack attachments or whose attach­ments to their caregivers range from disturbed to secure.  Unknown but seen rarely in clinical settings Prevalence Appears to be rare even in children exposed to severe neglect before being placed in foster care/institutions Occurs in 20% of high risk population There is no evidence that neglect beginning after Development age 2 years is associated with manifestations of the disorder and Course Accompanied by attention-seeking behaviors in pre­schoolers The disorder has not been described in adults. Described from the second year of life through adolescence. Risk and Prognostic Factors Environmental Serious social neglect is required However, majority of severely neglected Course Modifier children do not develop this disorder Caregiving quality seems to The disorder has not been identified in children moderate the course However, even after who experience social neglect only after age 2 placement in normative years caregiving environments, Prognosis depend on the quality of the some children show caregiving environment following serious persistent signs of the neglect disorder, at least through In many cases, the disorder persists, even in ado­lescence. children whose caregiving environment becomes markedly improved. Postraumatic Stress Disorder (older than 6) A. Actual exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following: 1. Direct experience 2. Witnessing in person 3. Learning that it happened to a close family or friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic events Note: Does not apply to exposure through electronic media, TV, movies, or pictures unless this exposure is work related Postraumatic Stress Disorder (older than 6) B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams about the traumatic event 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Postraumatic Stress Disorder (older than 6) C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s) as evidence by 2 (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others Postraumatic Stress Disorder (older than 6) 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), as evidenced by 2 (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance Postraumatic Stress Disorder (older than 6) F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning. F. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition Postraumatic Stress Disorder (6 and below) A. Actual exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following: 1. Direct experience 2. Witnessing in person especially if it occured to primary caregivers Note: Does not apply to exposure through electronic media, TV, movies, or pictures 3. Learning that it happened to a parent or caregiving figure Postraumatic Stress Disorder (6 and below) B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distress­ ing and may be expressed as play reenactment. 2. Recurrent distressing dreams about the traumatic event Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to reminders of the traumatic event(s). Postraumatic Stress Disorder (6 and below) C. One (or more) of the following symptoms associated with the traumatic event(s) beginning or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). Negative Alterations in Cognitions 1. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 2. Markedly diminished interest or participation in significant activities, including con­ striction of play. 3. Socially withdrawn behavior. 4. Persistent reduction in expression of positive emotions. Postraumatic Stress Disorder (6 and below) E. Duration of the disturbance is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning. G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition  Specifiers Specify whether: With dissociative symptoms: if the individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization 2. Derealization Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). Other features Developmental regression may occur Audi­tory pseudo-hallucinations and paranoid ideation is possible Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or maintaining stable interpersonal relationships, or dissociative symptoms. When the trau­matic event produces violent death, symptoms of both problematic bereavement and PTSD may be present.  US: Lifetime risk at age 75 years is 8.7% (DSM IV Prevalence Criteria) US Adults: 3.5% Europe, Asia, Africa, Latin America: 0.5% - 1.0% Higher in veterans and workers with more exposure Females: more prevalent and experience longer (attributed to rape and other forms of interpersonal violence) Symptoms usually begin within the first 3 months Development after the trauma, although there may be a delay of months, or even years, before criteria for the and Course diagnosis are met. Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events. Risk and Prognostic Factors Pretraumatic factors Temperamental Childhood emotional problems by age 6 and prior mental disorders Environmental Lower socioeconomic status, lower education, exposure to prior trauma, childhood adversity, cultural characteristics, lower intelligence, minority racial/ethnic status Familial psychiatric history Social support prior to event exposure is protective Genetic and physiological Female gender and younger age at the time of exposure for adults Certain genotypes may either be protective or increase risk of PTSD after exposure to traumatic events. Risk and Prognostic Factors Peritraumatic factors Postraumatic factors Environmental Temperamental Severity of the trauma , Negative appraisals, inappropriate coping perceived life threat, personal strategies, and development of acute stress injury, interpersonal violence, disorder and for military personnel, being a perpetrator, Environmental witnessing atrocities, or killing Subsequent exposure to repeated upsetting the enemy reminders Dissociation that occurs Subsequent adverse life event and financial or during the trauma and other trauma-related losses persists afterward is a risk Social support is a protective factor factor. Acute Stress Disorder A. Actual exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following: 1. Direct experience 2. Witnessing in person 3. Learning that it happened to a close family or friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic events Note: Does not apply to exposure through electronic media, TV, movies, or pictures unless this exposure is work related Acute Stress Disorder B. Presence of 9 (or more) of the following beginning or worsening after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s) 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. 4. Intense or prolonged psychological distress or marked physiological reactions in re­ sponse to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Persistent inability to experience positive emotions 6. An altered sense of the reality of one’s surroundings or oneself 7. Inability to remember an important aspect of the traumatic event(s) 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) Acute Stress Disorder B. Presence of 9 (or more) of the following beginning or worsening after the traumatic event(s) occurred: 9. Efforts to avoid external reminders (people, places, conversations, activities, ob­jects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response. Acute Stress Disorder C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. D. The disturbance causes clinically significant distress or impairment in social, occupa­tional, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition Other features May feel excessively guilty about not having prevented the traumatic event May also interpret their symptoms in a catastrophic manner It is common r to experience panic attacks in the initial month after trauma exposure May display chaotic or impulsive behavior In children, may be significant separation anxiety, possibly manifested by excessive needs for attention from caregivers Postconcussive symptoms are frequently seen  Less than 20% - not involving interpersonal assault Prevalence 12% - 21% - motor vehicle accidents 14% - mild traumatic brain injury 19% - assault 10% - severe burns 6% - 12% industrial accidents Higher rates related to interpersonal traumatic events (assault, rape, mass shooting) Cannot be diagnosed until 3 days after the event May progress to PTSD but may also remit within 1 month Symptom worsening during the initial month can occur, often as a result of ongoing life stressors or Development further traumatic events Young children also do not necessarily manifest fearful reactions at the time of the exposure or even and Course during reexperiencing. Risk and Prognostic Factors Temperamental Prior mental disorder, high levels of negative affectivity, greater perceived. severity of the traumatic event, and an avoidant coping style. Catastrophic appraisals of the traumatic experience, often characterized by exaggerated appraisals of future harm, guilt, or hopelessness, are strongly predictive of acute stress disorder. Environmental History of prior trauma Genetic and physiological Female are at a greater risk Elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure increases the risk for developing acute stress disorder. Adjustment Disorder A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. 2. Significant impairment in social, occupational, or other important areas of functioning. Adjustment Disorder C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. D. The symptoms do not represent normal bereavement. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specifiers Specify whether: 1. With depressed mood 2. With anxiety 3. With mixed anxiety and depressed mood 4. With disturbance of conduct 5. With mixed disturbane of emotions and conducts 6. Unspecified Other features The stressor may be a single event or there may be multiple stressors Stressor may be recurrent or continuous Stressors may affect a single individual, an entire family, or a community Adjustment disorders may be diagnosed following the death of a loved one when the intensity, quality, or persistence of grief reactions that exceeds appropriate norms Persistent Complex Bereavement Disorder - a more specific set of bereavement-related symptoms Associated with increased risk of suicide attempts and completed suicide,  5% - 20% - Outpatient mentall health Prevalence treatment 50% - Hospital psychiatric consultation Begins within 3 months of onset of a stressor anf Development lasts no longer than 6 months after the stressor have ceased and Course if stressor is an acute event, the onset is usually immediate and the duration is relatively brief. If the stressor or its consequence persist, the disorder may also continue and become the persistent form Risk and Prognostic Factor Environmental Individuals from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for adjustment disorders. Any question/clarification?