Trauma and Stressor Related Disorders PDF

TRAUMA- AND STRESSOR-RELATED DISORDERS TRAUMA- AND STRESSOR-RELATED DISORDERS  Exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.  The most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressiv...

TRAUMA- AND STRESSOR-RELATED DISORDERS TRAUMA- AND STRESSOR-RELATED DISORDERS  Exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.  The most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms.  Social neglect—that is, the absence of adequate caregiving during childhood— is a diagnostic requirement of both reactive attachment disorder and disinhibited social engagement disorder.  It has long been recognized that whereas grief, despair, and general dysphoria can be a part of the normal grieving process after the death of a loved one, the expression of such emotions is sometimes abnormally excessive in duration and/or intensity. TRAUMA- AND STRESSOR-RELATED DISORDERS  REACTIVE ATTACHMENT DISORDER  DISINHIBITED SOCIAL ENGAGEMENT DISORDER  POSTTRAUMATIC STRESS DISORDER (PTSD)  REACTIVE ATTACHMENT DISORDER  ACUTE STRESS DISORDER  ADJUSTMENT DISORDER  PROLONGED GRIEF DISORDER REACTIVE ATTACHMENT DISORDER A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: 1.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 adults. 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). REACTIVE ATTACHMENT DISORDER 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. 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. REACTIVE ATTACHMENT DISORDER  The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults.  A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments.  Diagnosis should be made with caution in children older than 5 years.  Often co-occurs with developmental delays, especially in delays in cognition and language. Includes stereotypies and other signs of neglect such as malnutrition. The Case of Emily Emily, 5 years old, was placed in foster care at 2 years old due to neglect and emotional abuse. She has had multiple placements before being adopted at age 4. Her adoptive parents noticed significant challenges in her behavior and emotional responses. Emily often sits alone during playtime at preschool, avoiding interactions with other children. When approached, she appears anxious and withdraws further. When she falls and scrapes her knee, Emily does not seek help from her caregivers or teachers. Instead, she silently cries and tries to comfort herself. When her adoptive parents try to console her after a nightmare, she pushes them away and remains tense, showing little reaction to their attempts to soothe her. s: Emily has trouble forming friendships and often reacts with anger or aggression when other children try to play with her. She struggles to share toys and frequently has outbursts when she feels threatened or cornered. 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. B. The behaviors in Criterion A are not limited to impulsivity (as inattention- deficit/hyperactivity disorder) but include socially disinhibited behavior. DISINHIBITED SOCIAL ENGAGEMENT 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 adults. 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 pathogenic care in Criterion C). DISINHIBITED SOCIAL ENGAGEMENT DISORDER E. The child has a developmental age of at least 9 months. Specify if: Persistent: The disorder has been present for more than 12 months. Specify current severity: Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels. DISINHIBITED SOCIAL ENGAGEMENT DISORDER  Culturally inappropriate, overly familiar behavior with relative strangers. This overly familiar behavior violates the social boundaries of the culture.  A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments.  Signs of the disorder often persist even after these other signs of neglect are no longer present.  Disinhibited Social Engagement Disorder VS ADHD (with social impulsivity) The Case of Lucy Jake lives with his biological parents, but they have a history of inconsistent caregiving. His parents often struggle with mental health issues and substance use, leading to neglectful behaviors in the home environment. Jake’s preschool teachers have raised concerns about his social behavior. His parents have noted similar patterns at home, leading them to seek help. Specific observations include:  Jake frequently approaches strangers in public places, such as grocery stores and parks, initiating conversations and physical interactions (like hugging) without hesitation. He often climbs into the laps of unfamiliar adults, expecting them to engage with him playfully.  His parents report that he has followed neighbors into their homes, believing them to be friends.  Jake shows little differentiation between his parents and unfamiliar adults, seeking comfort from anyone who offers it, regardless of their relationship to him.  DSED/RAD vs. OUTGOING CHILDREN/TYPICALLY DEVELOPING CHILDREN Attachment and Trust: Social Behavior: DSED/RAD: Children with these disorders often have DSED: Children may display disinhibited difficulty forming secure attachments. In DSED, they may engage in overly familiar behavior with strangers behavior, such as approaching strangers and due to a lack of understanding of social boundaries. In exhibiting a lack of caution. Their interactions RAD, they may withdraw from caregivers and have can seem overly intimate or inappropriate for trouble seeking comfort or establishing trust. the context. Typically Developing Children: Outgoing children usually have secure attachments to their caregivers. Outgoing Children: While they may be friendly They can be friendly and sociable while still and engage with others readily, they still understanding who they can trust and where to set recognize social cues and boundaries, displaying boundaries. appropriate caution with unfamiliar individuals. Understanding of Social Norms: DSED/RAD: Children may lack an understanding of appropriate social norms and boundaries, leading to behaviors that are puzzling to adults and peers alike. Typically Developing Children: Even if not shy, they generally understand and follow social norms, adjusting their behavior based on the context and the people they are interacting with. POSTTRAUMATIC STRESS DISORDER A. Exposure to actual or threatened death, serious injury, or sexual violence 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 traumatic event(s) occurred to a close family member or close 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 event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. POSTTRAUMATIC STRESS DISORDER 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: In children older than 6 years, 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 traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 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. POSTTRAUMATIC STRESS DISORDER 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). 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: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. 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). POSTTRAUMATIC STRESS DISORDER D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. 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). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). POSTTRAUMATIC STRESS DISORDER 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), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (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. POSTTRAUMATIC STRESS DISORDER 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). 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. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: POSTTRAUMATIC STRESS DISORDER 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). 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). The Case of Mia Mia, a 24-year-old college student, experienced a sexual assault while at a party. After the incident, she noticed profound changes in her emotional and mental health. Mia has intrusive thoughts about the assault and often has nightmares related to the event, waking up in a state of panic. She avoids parties, social gatherings, and places where alcohol is present. Mia also avoids discussing her feelings or the incident with friends and family. Mia feels isolated and struggles with feelings of shame and self-blame, believing she should have been able to prevent the assault. She has difficulty concentrating on her studies and experiences heightened anxiety, especially when encountering triggers related to the event. Mia cannot remember certain details of the assault, which causes her frustration and confusion. In crowded places like campus cafes, Mia feels as though the people around her are characters in a film. Their conversations sound muted and disconnected, and she often feels an overwhelming sense of being an outsider looking in. This sensation makes socializing feel exhausting and unappealing. During therapy sessions, Mia describes moments when she feels disconnected from her own body. While discussing her feelings about the sexual assault, she sometimes watches herself speak as if she is an observer. It’s as if she is floating above her body, unable to fully connect with her emotions or understand her reactions. POSTTRAUMATIC STRESS DISORDER Possible dominant symptoms  Fear-based reexperiencing, emotional, and behavioral symptoms  Anhedonic or dysphoric mood states and negative cognitions  Arousal and reactive-externalizing symptoms  Dissociative symptoms predominate. Traumatic Experience  Exposure to war as a combatant or civilian  Threatened physical assault in which the threat is perceived as imminent and realistic (e.g., physical attack, robbery, mugging, childhood physical abuse), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents. POSTTRAUMATIC STRESS DISORDER Traumatic Experience  Sexual trauma includes, but is not limited to, actual or threatened sexual violence or coercion (e.g., forced sexual penetration; alcohol/drug-facilitated nonconsensual sexual penetration; other unwanted sexual contact; and other unwanted sexual experiences not involving contact, such as being forced to watch pornography, exposure to the display of genitals by an exhibitionist, or being the victim of unwanted photography or videotaping of a sexual nature or the unwanted dissemination of these photographs or videos).  Life-threatening medical emergencies (e.g., an acute myocardial infarction, anaphylactic shock) or a particular event in treatment that evokes catastrophic feelings of terror, pain, helplessness, or imminent death (e.g., waking during surgery, debridement of severe burn wounds, emergency cardioversion). POSTTRAUMATIC STRESS DISORDER  The individual may experience dissociative states during which components of the event are relived and the individual behaves as if the event were occurring at that moment. These episodes, often referred to as “flashbacks,” are typically brief but can be associated with prolonged distress and heightened arousal.  Individuals with PTSD often report that the traumatic event has irrevocably altered their lives and their view of the world. They may also have persistent erroneous cognitions about the causes of the traumatic event that lead them to blame themselves or others (e.g., “It’s all my fault that my uncle abused me”)  Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before full criteria for the diagnosis are met. ACUTE STRESS DISORDER A. Exposure to actual or threatened death, serious injury, or sexual violence 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. 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 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: 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. 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. ACUTE STRESS DISORDER 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). 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 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). 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 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 the 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. The Case of Michael Michael is a 30-year-old man who recently experienced a traumatic event. He was involved in a serious workplace accident when a heavy piece of machinery fell, narrowly missing him but injuring a colleague. While Michael was physically unharmed, the psychological impact of the event was significant. Immediately after the accident, Michael felt an overwhelming sense of fear and shock. He helped his injured colleague until emergency services arrived, but the experience left him deeply shaken. Michael felt numb and detached, struggling to process the event. He found it hard to concentrate at work and had difficulty sleeping. Intrusive thoughts about the accident began to occur, replaying the incident in his mind. He experienced vivid nightmares about the event, waking up in a panic. Michael started to avoid reminders of the accident, including discussions about workplace safety. He felt anxious at the thought of returning to work and began isolating himself from friends and family. 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. 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. ADJUSTMENT DISORDER D. The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify whether: With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant. With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. With disturbance of conduct: Disturbance of conduct is predominant. With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. ADJUSTMENT DISORDER Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder. Specify if: Acute: This specifier can be used to indicate persistence of symptoms for less than 6 months. Persistent (chronic): This specifier can be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier therefore applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences. The Case of Sarah Sarah, 30 years old, recently moved to a new city for a job opportunity, leaving behind her friends and family. Sarah has been experiencing significant emotional distress since her move three months ago. She feels overwhelmed by the changes in her life and is struggling to adapt to her new environment. Sarah reports feeling anxious and depressed most days. She often cries and feels a sense of hopelessness about her situation. Sarah has stopped attending social events and gatherings that she previously enjoyed. She feels disconnected from her new coworkers and misses her friends back home. At work, she finds it challenging to focus on tasks and complete her projects on time, leading to increased stress. Acute Stress Disorder vs. Adjustment Disorder vs. PTSD ACUTE STRESS ADJUSTMENT PTSD DISORDER DISORDER Stressor Severe Mild/moderate Severe (Traumatic (life stressors) (Traumatic event) event) Time between Few days to Up to 3 months Sometimes stress and maximum of 4 years symptoms weeks Duration of Maximum of one 6 months after >1 month symptoms month the end of stressor PROLONGED GRIEF DISORDER A. The death, at least 12 months ago, of a person who was close to the bereaved individual (for children and adolescents, at least 6 months ago). B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree. In addition, the symptom(s) has occurred nearly every day for at least the last month: 1. Intense yearning/longing for the deceased person. 2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death). C. Since the death, at least three of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month: PROLONGED GRIEF DISORDER 1. Identity disruption (e.g., feeling as though part of oneself has died) since the death. 2. Marked sense of disbelief about the death. 3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders). 4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death. 5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future). 6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death. 7. Feeling that life is meaningless as a result of the death. 8. Intense loneliness as a result of the death. PROLONGED GRIEF DISORDER D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual’s culture and context. F. The symptoms are not better explained by another mental disorder, such as major depressive disorder or posttraumatic stress disorder, and are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. PROLONGED GRIEF DISORDER  Prolonged Grief Disorder VS Normal Grief - severe grief reactions that persist at least 12 months (6 months in children or adolescents) - interference with the individual’s capacity to function, and exceed cultural, social, or religious norms that prolonged grief disorder is diagnosed.  Prolonged Grief Disorder VS PTSD - intrusive memories in prolonged grief disorder focus on thoughts about many aspects of the relationship with the deceased, including positive aspects of the relationship and distress over the separation. - the avoidance in prolonged grief disorder is of reminders that the loved one is no longer present - yearning for the deceased Explanations BIOLOGICAL AND GENETIC FACTORS abnormal activity of the hormone cortisol and the neurotransmitter/hormone norepinephrine PERSONALITY people who cope with a trauma by trying to avoid thinking about it are more likely than others to develop PTSD. In the aftermath of Hurricane Hugo in 1989, children who had been highly anxious before the storm were more likely than other children to develop severe stress reactions (Hardin et al., 2002). people who generally view life’s negative events as beyond their control tend to develop more severe stress symptoms after sexual or other kinds of traumatic events than people who feel that they have more control over their lives (Catanesi et al., 2013; Bremner, 2002) people who generally find it difficult to derive anything positive from unpleasant situations adjust more poorly after traumatic events than people who are generally resilient and who typically find value in negative events Algoe & Fredrickson, 2011; Kunst, 2011 CHILDHOOD EXPERIENCES People whose childhoods have been marked by poverty appear more likely to develop these disorders in the face of later trauma. So do people who went through an assault, abuse, or a catastrophe at an early age; who were younger than 10 when their parents separated or divorced; or whose family members suffered from psychological disorders (Ogle et al., 2014; Yehuda et al., 2010; Koopman et al., 2004). CHILDHOOD EXPERIENCES  People whose social and family support systems are weak are also more likely to develop acute or posttraumatic stress disorder after a traumatic event (DiGangi et al., 2013; Uchino & Birmingham, 2011). Rape victims who feel loved, cared for, valued, and accepted by their friends and relatives recover more successfully (Street et al., 2011). Treatment EYE MOVEMENT DESENSITIZATION AND PROCESSING An exposure treatment in which clients move their eyes in a rhythmic manner from side to side while flooding their minds with images of objects and situations they ordinarily avoid. RAP GROUPS The initial term for group therapy sessions among veterans, in which members meet to talk about and explore problems in an atmosphere of mutual support. PSYCHOLOGICAL DEBRIEFING A form of crisis intervention in which victims are helped to talk about their feelings and reactions to traumatic incidents. Also called critical incident stress debriefing. DRUG THERAPY  Antianxiety drugs help control the tension that many veterans experience (benzodiazepines) Antidepressant medications may reduce the occurrence of nightmares, panic attacks, flashbacks, and feelings of depression (SSRI’s e.g. sertraline, paroxetine)