Trauma and Stressor-Related Disorders PDF

SCHOOL OF MEDICINE Trauma and stressor related disorders Open Sans Dr. Luis Pedro Ruiz Gómez L e a r n i n g objectives Describe the risk factors, psychopathology, clinical manifestations, and diagnosis of Trauma and Stressor Related Disorders (Reactive A...

SCHOOL OF MEDICINE Trauma and stressor related disorders Open Sans Dr. Luis Pedro Ruiz Gómez L e a r n i n g objectives Describe the risk factors, psychopathology, clinical manifestations, and diagnosis of Trauma and Stressor Related Disorders (Reactive Attachment Disorder, Post- traumatic stress disorder, Acute Stress Disorder, Adjustment Disorder, Prolonged Grief Disorder) Differentiate between Grief Response/Bereavement from Prolonged Grief Disorder Trauma and stressor-related disorders Traumatic events can have profound effects on memories, cognitions, emotions, and behaviors. Disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. Some individuals who have been exposed to a traumatic or stressful event exhibit anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms, rather than anxiety- or fear-based symptoms. Reactive attachment disorder This disorder is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. Reactive attachment disorder - Diagnostic Because of limited opportunities during early development, these children fail to show the behavioral manifestations of selective attachments. That is, when distressed, they show no consistent effort to obtain comfort, support, nurturance, or protection from caregivers. Children with reactive attachment disorder show diminished or absent expression of positive emotions during routine interactions with caregivers. Reactive attachment disorder - Development Conditions of social neglect are often present in the first months of life in children diagnosed with reactive attachment disorder, even before the disorder is diagnosed. The clinical features of the disorder manifest between the ages of 9 months and 5 years. That is, signs of absent-to-minimal attachment behaviors and associated emotionally aberrant behaviors are evident in children throughout this age range Reactive attachment disorder - Risk Serious social neglect is a diagnostic requirement for reactive attachment disorder and is also the only known risk factor for the disorder. However, most severely neglected children do not develop the disorder. Prognosis for children with the disorder appears to depend on the quality of the caregiving environment following serious neglect. Reactive attachment disorder - Differential diagnosis Autism spectrum disorder – Aberrant social behaviors are also key features of autism spectrum disorder. However, these children will only rarely have a history of social neglect. The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder. Intellectual developmental disorder – These children should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotion regulation difficulties evident in children with reactive attachment disorder. Post-traumatic stress disorder (PTSD) With DSM-5, PTSD is no longer considered an anxiety disorder and is listed under a new category of Stress and Trauma-Related Disorders Rates of PTSD vary depending on the nature of trauma. For example, rape results in high rates of PTSD in both men (65%) and women (46%), whereas automobile accidents have been associated with lower rates of PTSD (men, 25%; women, 13.8%). The Institute of Medicine estimated prevalence of PTSD to be between 13% and 20% among U.S. soldiers who served in Iraq and Afghanistan. Post-traumatic stress disorder (PTSD) The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. In some individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most prominent. In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in yet others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns. PTSD - Etiology 1. Fear conditioning/learning - Classical (Pavlovian) and operant (reinforcement) conditioning. 2. Information processing - Individuals are more likely to appraise a situation as threatening when they believe that they do not possess the personal capabilities to meet the demands of the situation. 3. Neurobiological systems - Genetic polymorphisms related to stress vulnerability, exaggerated fear conditioning, insufficient cortical inhibition of limbic activity, reduced capacity to extinguish fear-conditioned memories, and poor regulation of hypothalamic-pituitary-adrenal (HPA)-axis PTSD - Risk Psychosocial risk factors have typically been classified as pretraumatic, peritraumatic, and posttraumatic Pretraumatic - female gender, Hispanic race, younger age, lower education, lower intelligence, negative emotionality, past individual or family psychiatric history Peritraumatic - high degree of traumatic exposure, pronounced dissociation, and excessive peritraumatic physiological activation Posttraumatic - dysfunctional coping strategies (e.g., avoidance), low social support, and subsequent exposure to additional stressors and traumatic events PTSD - Resilience Not all individuals exposed to the same traumatic event will develop PTSD, some of them do well under stress and are able to recover from trauma. Neurobiological resilience factors – A sympathetic nervous system that responds robustly to stress but that returns to baseline rapidly; the capacity to contain the corticotropin-releasing factor (CRF) response to stress; a dopamine-mediated reward system that allows traumatized individuals to remain optimistic and hopeful during extreme or chronic stress; an amygdala that does not overreact to the environment; and ample cortical executive and inhibitory capacity. PTSD - Resilience Psychosocial resilience factors – Resilience to stress has been correlated with optimism, humor, social support, and an active rather than avoidant coping style. Research has also identified openness to change and extroversion as positive predictors of growth following traumatic experiences. Cognitive flexibility, marked by the ability to reframe problems and extract personal meaning from stressful situations, has been associated with reappraisal of events as less threatening and a greater sense of self-efficacy in the face of challenge. PTSD - Genetics Data from twin studies suggest that risk for PTSD is moderately heritable. Specific genes associated with PTSD have been linked to dopaminergic, serotonergic, noradrenergic, and HPA axis systems. Research in epigenetics has shown that a host of external and internal stimuli, such as social support, fear, and stress, can trigger biochemical reactions that can affect gene expression by either "turning on" or "turning off" genes.  PTSD – Diagnostic criteria A. Exposure to actual or threatened death, serious injury, or sexual violence B. Presence of one (or more) intrusion symptoms C. Persistent avoidance of stimuli associated with the traumatic event(s) D. Negative alterations in cognitions and mood associated with the traumatic event(s) E. Marked alterations in arousal and reactivity associated with the traumatic event(s) 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. PTSD – Diagnostic criteria A. Exposure to actual or threatened death, serious injury, or sexual violence 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.  PTSD – Diagnostic criteria B. Presence of one (or more) intrusion symptoms 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 traumatic 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 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). PTSD – Diagnostic criteria C. Persistent avoidance of stimuli associated with the traumatic event(s) 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).  PTSD – Diagnostic criteria D. Negative alterations in cognitions and mood associated with the traumatic event 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. 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. PTSD – Diagnostic criteria E. Marked alterations in arousal and reactivity associated with the traumatic event(s) 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 (e.g., difficulty falling or staying asleep or restless sleep). PTSD – Diagnostic criteria The diagnosis of PTSD requires that the duration of the symptoms in Criteria B, C, D, and E be more than 1 month (Criterion F). For a current diagnosis of PTSD, Criteria B, C, D, and E must all be met for more than 1 month, for at least the past month. For a lifetime diagnosis of PTSD, there must be a period lasting more than 1 month during which Criteria B, C, D, and E have all been met for the same 1-month period. This differentiates it from Acute stress disorder, in which symptoms must last for less than 1 month after the traumatic experience.  PTSD – Associated features Auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices, as well as paranoid ideation, can be present. 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 involves the violent death of someone with whom the individual had a close relationship, symptoms of both prolonged grief disorder and PTSD may be present.  PTSD – Differential diagnosis Adjustment disorders - the stressor can be of any severity or type rather than a stressor involving exposure to actual or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. Acute stress disorder - is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month following exposure to the traumatic event. Major depressive disorder – this disorder may or may not be preceded by a traumatic event and should be diagnosed if full criteria have been met.  Acute stress disorder The essential feature of acute stress disorder is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events (Criterion A), which are the same type as described in PTSD Criterion A Presentations may include intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms. The full symptom picture must last for at least 3 days after the traumatic event but should not last longer than 1 month. Symptoms that occur immediately after the event but resolve in less than 3 days would not meet criteria for acute stress disorder.  Acute stress disorder – Differential diagnosis Adjustment disorders - The diagnosis of an adjustment disorder is used when the response to a Criterion A event does not meet the criteria for acute stress disorder (or another specific mental disorder) and when the symptom pattern of acute stress disorder occurs in response to a stressor that does not meet Criterion A for exposure to actual or threatened death, serious injury, or sexual violence PTSD - Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder must resolve within 1 month of the traumatic event. If the symptoms persist for more than 1 month and meet criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD. Adjustment disorders The disturbance in adjustment disorders begins within 3 months of onset of a stressor. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature of adjustment disorders. The stressor may be a single event, or there may be multiple stressors. Stressors may be recurrent or continuous Adjustment disorders – functional consequences The subjective distress or impairment in functioning associated with adjustment disorders is frequently manifested as decreased performance at work or school and temporary changes in social relationships. An adjustment disorder may complicate the course of illness in individuals who have another medical condition  Adjustment disorders – Differential diagnosis Major depressive disorder - If an individual has symptoms that meet criteria for a major depressive disorder in response to a stressor, the diagnosis of an adjustment disorder is not applicable. PTSD - In adjustment disorders, the stressor can be of any severity rather than of the severity and type required by Criterion A of acute stress disorder and posttraumatic stress disorder (PTSD). Bereavement - may sometimes be diagnosed as an adjustment disorder if the bereavement is judged to be out of proportion or significantly impairs self-care and interpersonal relations - more than 12 months after the death, the diagnosis may be prolonged grief disorder if full criteria are met. Prolonged grief disorder Maladaptive grief reaction that can be diagnosed only after at least 12 months have elapsed since the death of someone with whom the bereaved had a close relationship. The condition involves the development of a persistent grief response characterized by intense yearning or longing for the deceased person (often with intense sorrow and frequent crying) or preoccupation with thoughts or memories of the deceased. Prolonged grief disorder At least three additional symptoms have been present most days to a clinically significant degree and have occurred nearly every day for at least the past month: Identity disruption Marked sense of disbelief about the death Avoidance of reminders Intense emotional pain Difficulty reintegrating into personal relationships and activities Emotional numbness Feeling that life is meaningless Intense loneliness Prolonged grief disorder Individuals with symptoms of prolonged grief disorder often experience maladaptive cognitions about the self, guilt about the death, and diminished future life expectancy and life goals. The course of prolonged grief disorder may be complicated by comorbid posttraumatic stress disorder, which is more common in situations of bereavement following the violent death of a loved one (e.g., murder, suicide) when grief for the bereaved may be accompanied by personal life threat and/or witnessing of violent and potentially gruesome death. Prolonged grief disorder – Differential diagnosis Normal grief - distinguished from normal grief by the presence of severe grief reactions that persist at least 12 months. It is only when severe levels of grief response persist for the specified duration following the death, interfere with the individual’s capacity to function that prolonged grief disorder is diagnosed. Depressive disorders - In prolonged grief disorder the distress is focused on feelings of loss and separation from a loved one rather than reflecting generalized low mood. Major depressive disorder may also be preceded by the death of a loved one, with or without comorbid prolonged grief disorder. Prolonged grief disorder – Differential diagnosis PTSD - Whereas intrusions in PTSD revolve around the traumatic event (which may have caused the death of a loved one), 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. References Johnson D.C., & Krystal J.H., & Southwick S.M. (2019). Posttraumatic stress disorder and acute stress disorder. Ebert M.H., & Leckman J.F., & Petrakis I.L.(Eds.), Current Diagnosis & Treatment: Psychiatry, 3e. McGraw-Hill Education. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787