Trauma and Stressor-Related Disorders PDF

Trauma- and Stressor- Related Disorders Prepared by: Mr. Gerald M. Llanes, RPm, LPT What is Stress? Stress is the body's reaction to any change that requires an adjustment or response. The body reacts to these changes with physical, mental, and emotional responses. Stress is a normal pa...

Trauma- and Stressor- Related Disorders Prepared by: Mr. Gerald M. Llanes, RPm, LPT What is Stress? Stress is the body's reaction to any change that requires an adjustment or response. The body reacts to these changes with physical, mental, and emotional responses. Stress is a normal part of life. You can experience stress from your environment, your body, and your thoughts. Even positive life changes such as a promotion, a mortgage, or the birth of a child produce stress. What is Stressor? It is any event, experience, or environmental stimulus that causes stress in an individual. These events or experiences are perceived as threats or challenges to the individual and can be either physical or psychological. What is Stressor? Types of Stress Types of Stress 1. Acute stress Acute stress is the most common type of stress. It’s your body's immediate reaction to a new challenge, event, or demand, and it triggers your fight-or-flight response. As the pressures of a near-miss automobile accident, an argument with a family member, or a costly mistake at work sink in, your body turns on this biological response. Types of Stress 2. Episodic acute stress When acute stress happens frequently, it’s called episodic acute stress. People who always seem to be having a crisis tend to have episodic acute stress. They are often short-tempered, irritable, and anxious. People who are “worry warts” or pessimistic or who tend to see the negative side of everything also tend to have episodic acute stress. Negative health effects are persistent in people with episodic acute stress. It may be hard for people with this type of stress to change their lifestyle, as they accept stress as a part of life. Types of Stress 3. Chronic stress This is the most harmful type of stress and grinds away over a long period. Ongoing poverty, a dysfunctional family, or an unhappy marriage can cause chronic stress. It occurs when a person never sees an escape from the cause of stress and stops seeking solutions. Sometimes, it can be caused by a traumatic experience early in life. Stress Response System Kinds of Trauma- and Stressor-Related Disorders Acute Stress Disorder ( ASD) Acute Stress Disorder ( ASD) Diagnostic Criteria A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Acute Stress Disorder ( ASD) 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related Acute Stress Disorder ( ASD) B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred Acute Stress Disorder ( ASD) Intrusion Symptoms 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content. Acute Stress Disorder ( ASD) 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Acute Stress Disorder ( ASD) Negative Mood 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Dissociative Symptoms 6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). 7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Acute Stress Disorder ( ASD) Avoidance Symptoms 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 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). Acute Stress Disorder ( ASD) Arousal Symptoms 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 ( ASD) 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 (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder Acute Stress Disorder ( ASD) ASD is a relatively new psychological diagnosis. The American Psychiatric Association first introduced it to the fourth edition of the Diagnostic and Statistical Manual of Mental Health Disorders in 1994. Although it shares many of the same symptoms as PTSD, ASD is a distinct diagnosis. A person with ASD experiences psychological distress immediately following a traumatic event. Unlike PTSD, ASD is a temporary condition, and symptoms typically persist for at least 2 to 4 weeks after the traumatic event. If a person experiences symptoms for longer than a month, a doctor will usually assess them for PTSD. Acute Stress Disorder ( ASD) Causes A person must be exposed to a traumatic event to be at risk for acute stress disorder. It is not clear why only a small proportion of people exposed to develop a stress disorder. Individuals may be at greater risk for developing stress disorder if they have previously been diagnosed with a mental disorder, perceive the traumatic event to be very severe, have an avoidant coping style when experiencing distress, or have a history of previous trauma. Women are more likely to develop acute stress disorder than men. Posttraum atic Stress Disorder (PTSD) Posttraumatic Stress Disorder (PTSD) Characterized by the re-experiencing of an extremely traumatic event, avoidance of stimuli associated with the event, numbing of responsiveness, and persistent increase of arousal it usually begins 3 months to a year after the event and may last a few months or years. Posttraumatic Stress Disorder (PTSD) Not every traumatized person develops ongoing (chronic) or even short-term (acute) or PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Posttraumatic Stress Disorder (PTSD) Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms To be diagnosed with PTSD, an adult must have all of the following for at least 1 month: At least one re-experiencing symptom At least one avoidance symptom At least two arousal and reactivity symptoms At least two cognition and mood symptoms Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Re-experiencing symptoms include: Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating Bad dreams Frightening thoughts Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Avoidance symptoms include: Staying away from places, events, or objects that are reminders of the traumatic experience Avoiding thoughts or feelings related to the traumatic event In PTSD , the avoidance also manifest itself as a general numbing of responsiveness – emotions are dampened or even nonexistent. This symptoms may be referred to as “emotional amnesia” a term that manifests captures its essence. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Emotional numbing can cause sufferers to withdraw from others, particularly from close relationships. Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Arousal and Reactivity symptoms include: Being easily startled Feeling tense or “on edge” Having difficulty sleeping Having angry outbursts Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Exaggerated Startle Responds It is an excessive fear reaction to unexpected stimuli, such as loud noises. Your heart may race, you may sweat, you may breathe faster, your muscles may tense (to the point you might even jump), and you may feel scared. Posttraumatic Stress Disorder (PTSD) Sign and Symptoms Cognition and Mood symptoms include: Trouble remembering key features of the traumatic event. Negative thoughts about oneself or the world Distorted feelings like guilt or blame Loss of interest in enjoyable activities Cognition and mood symptoms can begin or worsen after the traumatic event but are not due to injury or substance use. Posttraumatic Stress Disorder (PTSD) Traumatic Event 1-3 months 9 months 3 years Usual onset of Many recover without Generally, 33% remain treatment within symptomatic for 3 years or symptoms months/years of event longer with a greater risk of (45-80% natural secondary problems remission at 9 months)  What Brain Areas are Implicated in PTSD? 1. The Amygdala Amygdala is the stress evaluator and decides when to react Detect threats in the environment and activate the “fight or flight” response Activate the sympathetic nervous system to help you deal with the threat Help you store new emotional or threat- related memories What Brain Areas are Implicated in PTSD? Signs and symptoms of PTSD associated with Amygdala; Anxiety Hypervigilance Avoidance of Stimuli associated with the trauma Exaggerated tendency to be easily startled Excessive amygdala activity  What Brain Areas are Implicated in PTSD? 2. The Prefrontal Cortex (PFC) The Prefrontal Cortex is located in the frontal lobe just behind your forehead. The PFC is designed to: Regulate attention and awareness Make decisions about the best response to a situation  What Brain Areas are Implicated in PTSD? 2. The Prefrontal Cortex (PFC) Initiate conscious, voluntary behavior Determine the meaning and emotional significance of events Regulate emotions Inhibit or correct dysfunctional reactions  What Brain Areas are Implicated in PTSD? 3. Hippocampus is essential for memory formation when traumatic events occur the hippocampus: Create and store memory Retrieves the memory Calm the amygdala alarm circuit What Brain Areas are Implicated in PTSD? Signs and symptoms of PTSD associated with Prefrontal Cortex and Hippocampus; Confusion Disorientation Disturbing thoughts , nightmares and or flashback Difficulty of sleep Reduce the size of the hippocampus What Brain Areas are Implicated in PTSD? Treatments and Therapies 1. Psychotherapy Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but it can last longer. Research shows that support from family and friends can be an important part of recovery. Treatments and Therapies 2. Exposure therapy This helps people face and control their fear. It gradually exposes them to the trauma they experienced in a safe way. It uses imagining, writing, or visiting the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings. Treatments and Therapies 3. Cognitive Restructuring This helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about something that is not their fault. The therapist helps people with PTSD look at what happened in a realistic way. What Brain Areas are Implicated in PTSD? 4. Psychodynamic Therapy the goal of the treatment is to work through and resolve an unconscious conflict that the traumatic event is thought to have provoked. 5. Pharmacotherapy SSRI’S-sertraline and paroxetine are considered first-line treatments for PTSD TCA’S-Imipramine and amitriptyline - Dosages same as those used to treat depressive disorders, the trial should last at least 8 weeks, continue the pharmacotherapy for at least 1 year if respond well. MAOI’S -phenelzine, trazodone are effective in reducing re-experiencing symptoms and insomnia Adjustment Disorder Adjustment Disorder Adjustment disorders are stress-related conditions. You experience more stress than would normally be expected in response to a stressful or unexpected event, and the stress causes significant problems in your relationships, at work or at school. Most of the time, people adjust to such changes within a few months. But if you have an adjustment disorder, you continue to have emotional or behavioral reactions that can contribute to feeling anxious or depressed. Adjustment Disorder Symptoms The mental and physical symptoms associated with adjustment disorder usually occur during or immediately after you experience a stressful event. While the disorder lasts no longer than six months, your symptoms may continue if the stressor isn’t removed. Some people have just one symptom. Others may experience many symptoms. Adjustment Disorder The mental symptoms of adjustment disorders can include: rebellious or impulsive actions Anxiousness feelings of sadness, hopelessness, or being trapped Crying withdrawn attitude lack of concentration loss of self-esteem suicidal thoughts Adjustment Disorder There is one type of adjustment disorder that is associated with physical symptoms as well as psychological ones. These physical symptoms can include: Insomnia Muscle twitches or trembling Fatigue Body pain or soreness Indigestion TYPES OF ADJUSTMENT DISORDER 1. Adjustment disorder with depressed mood people diagnosed with this type of adjustment disorder tend to experience feelings of sadness and hopelessness. It’s also associated with crying. You may also find that you no longer enjoy activities that you did formerly. 2. Adjustment disorder with anxiety Symptoms associated with adjustment disorder with anxiety include feeling overwhelmed, anxious, and worried. People with this disorder may also have problems with concentration and memory. For children, this diagnosis is usually associated with separation anxiety from parents and loved ones. TYPES OF ADJUSTMENT DISORDER 3. Adjustment disorder with mixed anxiety and depressed mood People with this kind of adjustment disorder experience both depression and anxiety. 4. Adjustment disorder with disturbance of conduct Symptoms of this type of adjustment disorder mainly involve behavioral issues like driving recklessly or starting fights. Teens with this disorder may steal or vandalize property. They might also start missing school. TYPES OF ADJUSTMENT DISORDER 5. Adjustment disorder with mixed disturbance of emotions and conduct Symptoms linked to this type of adjustment disorder include depression, anxiety, and behavioral problems. 6. Adjustment disorder unspecified Those diagnosed with adjustment disorder unspecified have symptoms that aren’t associated with the other types of adjustment disorder. These often include physical symptoms or problems with friends, family, work, or school. How is adjustment disorder diagnosed? In order to be diagnosed with an adjustment disorder, a person must meet the following criteria: experiencing psychological or behavioral symptoms within three months of an identifiable stressor or stressors occurring in your life having more stress than would be ordinary in response to a specific stressor, or stress that causes issues with relationships, in school or at work, or experiencing both of these criteria the improvement of symptoms within six months after the stressor or stressors are removed symptoms that aren’t the result of another diagnosis Adjustment Disorder: Treatment Adjustment disorder is primarily treated with psychotherapy, although in some cases medication may also be prescribed to alleviate symptoms. Adjustment Disorder: Treatment Psychotherapeutic: Talk therapy is extremely effective in treating adjustment disorder. A therapist might encourage the patient to express emotions in a supportive environment and in a constructive fashion, or suggest that a typical reaction to stress has gotten out of hand but is within his power to control. Another goal of the therapy is to teach him healthier ways of dealing with future stressful situations. Since adjustment disorders often affect the whole family, some sessions might include the parents or other caregivers. Group therapy can also be helpful. A few sessions are usually sufficient for treatment, though occasionally it might take months. Adjustment Disorder: Treatment Even neuroleptic medication to help with anxiety and behavior problems. Antidepressants may also be prescribed to treat depressive or suicidal thoughts. In most cases pharmacological treatment is short-lived. Reactive Attachment Disorder (RAD) Reactive Attachment Disorder Reactive attachment disorder (RAD) is a condition where a child doesn’t form healthy emotional bonds with their caretakers (parental figures), often because of emotional neglect or abuse at an early age. Children with RAD have trouble managing their emotions. Reactive attachment disorder is most common among children who experience physical or emotional neglect or abuse. Reactive Attachment Disorder Children may be more likely to develop RAD if they: Have many different parent figures, like multiple foster care situations. Were taken away from their primary caretakers after bonding with them emotionally. Experienced several traumatic losses early in life. Have parental figures who didn’t try to become emotionally close to them. Spent time in an institution, like an orphanage, where they didn’t have a loving parent figure. Reactive Attachment Disorder Symptoms of reactive attachment disorder? Symptoms of reactive attachment disorder are unique to each child. Common symptoms among toddlers and young children with RAD include: Not showing positive emotions, like comfort, love or joy when interacting with others. Avoiding eye contact and physical touch. Expressing fear or anger by throwing tantrums or frequently showing unhappiness or sadness. Disinhibited Social Engagement Disorder Disinhibited Social Engagement Disorder Disinhibited social engagement disorder (DSED) is a relatively rare mental health condition that typically stems from early childhood neglect or inconsistent caregivers. A child with DSED will appear fearless around new adults, seek attention or comfort from strangers, and often wander off with unfamiliar people. Therapeutic interventions can help, but having consistent, caring adults in the child’s life is the best way to reduce DSED symptoms. Disinhibited Social Engagement Disorder Symptoms of DSED To be diagnosed with DSED, two of four specific symptoms must be present. Reduced or absent restraint when approaching or interacting with unknown or unfamiliar adults An overly comfortable and familiar exchange with the unknown adults, either through verbal or behavioral interactions Limited interest in checking in with caregiver to gain assurance or allowance for behaviors and actions A willingness to go to new situations or leave current settings with strangers Disinhibited Social Engagement Disorder Causes of DSED It must stem from the insufficient care they received earlier in life. Social neglect or deprivation: The adults were not able to meet the child’s needs related to comfort, attention, or affection Repetitive changes in caregivers: The people primarily responsible for childcare were frequently shifting or being inconsistent, like in the case of ever-changing foster care placements Being raised in environments with limited access to relationships: Places where the number of children far outweighed the number of adults, so the child could not form a strong attachment (e.g., institutions and residential centers with high child-to-staff ratios) Disinhibited Social Engagement Disorder Here are three examples of the ways DSED could manifest: Example 1 A child with DSED may be walking through a park, notice a stranger’s shoes, and comment that they like the shoes. Alone, this comment is not significant, but then the child could try to enter into a long conversation with the adult and ask them a long list of personal or inappropriate questions, despite no prompting or encouragement. Disinhibited Social Engagement Disorder Example 2 Another child with DSED could meet a new adult at a party or school function and quickly encroach on the adult’s personal space. After no time knowing each other, the child could ask for hugs, kisses, or sit on the adult’s lap. They could even start cuddling with the adult in an attempt to receive the desired level of comfort that they have been unable to achieve in the past Example 3 A third variation of a child with DSED is one that will quickly leave the security of their guardian to be with strangers or struggles to make healthy peer relationships and will spend time with anyone, regardless of their age, danger, or safety.