Trauma- and stressor-related disorders

Trauma- and stressor-related disorders are a group of psychiatric disorders that arise following a stressful or traumatic event. They include acute stress disorder, posttraumatic stress disorder, and adjustment disorder. These three conditions often present similarly to other psychiatric disorders, such as depression and anxiety, although the presence of a trigger event is necessary to confirm a diagnosis. Because trauma- and stressor-related disorders share many common features, it is imperative to understand the nature of the triggering event, the temporal relationship between the triggering event and symptom occurrence, and the severity of symptoms. Treatment generally consists of both psychotherapy and pharmacotherapy.

References:^[1]

Overview

Definition

• The development of a strong psychological reaction to a traumatic event characterized by acute symptom onset and the persistence of symptoms for at least 3 days and up to 1 month

Epidemiology ^[1]

• Occurs in up to 50% of individuals experiencing interpersonal violence (e.g., assault, rape)
• Occurs in up to ∼ 13% of individuals involved in motor vehicle accidents

Risk factors ^[1]

• Preexisting mental disorder
• History of previous trauma
• Poor social support

Diagnostic criteria (DSM-5) ^[1]

• Exposure to death (actual or threatened), serious injury, or sexual violence that occurs in ≥ 1 of the following ways:
  • Direct experience of these events
  • Witnessing these events
  • Hearing about these events happening to close friends or family
  • Repeated exposure to distressing details of traumatic events occurring to others
• Presence of at least 9 of the following symptoms from any of the five categories below:
  • Intrusion
    • Recurrent distressing memories
    • Recurrent distressing dreams
    • Flashbacks
    • Severe psychological distress or physiological responses to internal or external cues related to the event
  • Negative mood: inability to feel positive emotions (e.g., happiness, satisfaction, or love)
  • Dissociation
    • Altered sense of reality
    • Loss of memory with regards to important details of the event
  • Avoidance
    • Avoidance of memories, thoughts, or feelings related to the event
    • Avoidance of external reminders (e.g., places, people, conversations, objects) related to the event
  • Arousal
    • Sleep disturbance
    • Irritable behavior
    • Hypervigilance
    • Poor concentration
    • Heightened startle reflex
• Duration: Symptoms last from 3 days to 1 month following the traumatic event.
• The affected individual has been experiencing significant distress or impaired social and/or occupational functioning since the traumatic event.
• Symptoms are not explained by substance use or another medical condition.

Treatment and prognosis ^[2]

• Assess all patients with acute first- and second-hand experiences of trauma for ASD and offer psychological care.
• Determine the setting of psychiatric treatment (inpatient or outpatient) based on the severity of symptoms, the risk of self-injurious behavior and suicide, and the severity of trauma experienced or exposed to.
• Provide education about the broad range of expected reactions to traumatic situations as well as about the natural course of the disorder and treatment options available
• First-line treatment: trauma-focused cognitive behavioral therapy ^[2]
• Pharmacotherapy: Benzodiazepines are not routinely recommended but may be useful in patients with severe anxiety, agitation, or sleep disturbances.
• Early intervention is important to avoid progression of ASD to PTSD. ^[3]

Overview

Definition

• A psychiatric disorder triggered by a personally experienced or witnessed traumatic event that persists for more than 1 month

Epidemiology ^[4]

• Lifetime prevalence: 6–9%
• Sex: ♀ > ♂ (4:1)

Etiology

• Triggers: exposure to traumatic events (either through direct experience or as a witness)
  • Sexual violence (most common) ^[5]
  • Physical violence
  • Accidents
  • Natural disasters
  • War: The duration of combat exposure, by either combatants or civilians, is directly proportional to the risk of developing PTSD. ^[6]
  • Diagnosis of a severe disease
  • Witnessing the death of another person
• Risk factors
  • Psychiatric comorbidities
  • Lower socioeconomic status
  • Younger age at the time of trauma
  • Lack of social support
  • Prior traumatic exposure and/or subsequent reminders, including childhood experiences
  • Initial severe reaction to the traumatic event
• Common comorbidities: depression, substance use disorders, somatic symptom disorder

Diagnostic criteria (consistent with DSM-5) ^[1]

• Experience of a traumatic event involving death (actual or threatened), serious injury, or sexual violence in one or more of the following ways:
  • Direct experience of the event(s)
  • Witnessing the event(s)
  • Learning about the event(s) happening to close friends or family
  • Repeated exposure to details of the traumatic event(s) occurring to others
• One or more the following intrusion symptoms that begin after the traumatic event(s):
  • Recurrent intrusive memories of the traumatic event(s)
  • Recurrent, distressing dreams related to the traumatic event(s)
  • Dissociative reactions (e.g., flashbacks): individuals act and/or feel as if they were reexperiencing the traumatic event(s)
  • Intense and persistent distress when exposed to internal or external cues related to the traumatic event(s)
  • Physiological reactions triggered by external or internal cues associated with the traumatic event(s)
• Avoidance of stimuli related to the traumatic event(s) as expressed in one or both of the following ways:
  • Avoidance of memories, thoughts, or feelings associated with the event(s)
  • Avoidance of external reminders (e.g., places, people, conversations, objects) related to the event(s)
• Negatively affected mood and cognition associated with the traumatic event(s) that begins or worsens after the event(s) in at least two of the following ways:
  • Inability to remember important details of the event(s)
  • Exaggerated negative thoughts or expectations about oneself or the world
  • Distorted cognitions regarding the cause and/or consequences of the event(s)
  • Persistent negative emotions (e.g., fear, horror, distress, guilt)
  • Reduced or absent interest in important activities
  • Detachment from others
  • Inability to experience positive emotions (e.g., happiness, satisfaction, or love)
• Altered reactivity or arousal associated with the traumatic event(s) beginning or worsening after the event(s) in at least two of the following ways:
  • Irritability or angry outbursts
  • Hypervigilance
  • Excessive startle response
  • Sleep disturbance; (e.g., nightmares, difficulty initiating or maintaining sleep)
  • Poor concentration
  • Self-destructive behavior
• Duration: Symptoms last > 1 month following the traumatic event(s).
• The affected individual has been experiencing significant distress or impaired social and/or occupational functioning.
• Symptoms are not explained by substance use or another medical condition.
• Diagnostic criteria for children > 6 years of age are the same as for adults.

To remember the features of PTSD, think of “TRAUMMA”: Traumatic event, Reexperience, Avoidance, Unable to function, More than a Month of duration, Arousal is increased

Subtypes and variants

• PTSD with delayed expression: individuals who only meet the diagnostic criteria for PTSD at least 6 months after the inciting event.
• PTSD with dissociative symptoms: individuals who meet the diagnostic criteria for PTSD and concomitantly experience symptoms of either derealization or depersonalization.

Treatment and prognosis ^[7]

• First-line: psychotherapy with or without adjunctive pharmacotherapy ^[7]
  • Trauma-focused cognitive-behavioral therapy
    • Exposure therapy (e.g., showing war veterans images of war, returning to the scene of an accident)
    • Cognitive processing therapy
  • Eye movement desensitization and reprocessing: The patient recalls traumatic images while following the therapist's fingers with their eyes from left to right. ^[8]
• Pharmacotherapy
  • SSRIs, SNRIs (e.g., venlafaxine)
  • Prazosin: for nightmares
  • Benzodiazepines should generally be avoided due to the risk of misuse and lack of evidence supporting the benefits.
• Approx. 60% of patients receiving treatment achieve full recovery within an average timespan of 36 months. ^[9][10]

Pharmacotherapy alone is used in patients with PTSD who opt against or do not have access to psychotherapy.

Special patient groups

Diagnostic criteria for PTSD in children < 6 years of age (DSM-5) ^[1]

• Experience of a traumatic event involving (actual or threatened) death, serious injury, or sexual violence that occurs in one or more of the following ways:
  • Direct experience of the traumatic event(s)
  • Witnessing the traumatic event(s) in person, especially if it occurred to a primary caregiver
  • Learning about the traumatic event(s) happening to a parent or caregiver
• One or more of the following intrusion symptoms that begin after the traumatic event(s):
  • Intrusive thoughts and memories of the traumatic event; these may not appear distressing and may be expressed as play reenactment.
  • Recurrent, distressing dreams
  • Dissociative reactions (e.g., flashbacks)
    • Individuals act and/or feel as if they were reexperiencing the traumatic event(s)
    • Reenactment of traumatic events may occur in play.
  • Intense and persistent distress when exposed to internal or external cues related to the traumatic event(s)
  • Physiological reactions triggered by external or internal cues associated with the traumatic event(s)
• One or more of the following symptoms of either avoidance of triggering stimuli or negatively affected mood and cognition following the event(s):
  • Avoidance of triggering stimuli
    • Avoidance of persons, interpersonal situations, or conversations associated with the event(s)
    • Avoidance of external reminders (e.g., places, activities, objects) related to the event(s)
  • Negatively affected mood and cognition
    • Socially withdrawn behavior
    • Increased frequency of negative emotions (e.g., fear, sadness, guilt, confusion)
    • Reduced or absent interest in important life activities, including constriction of play
    • Markedly reduced expression of positive emotions (e.g., happiness, satisfaction, or love)
• Altered reactivity or arousal beginning or worsening after the event in ≥ 2 of the following ways:
  • Irritability or angry outbursts
  • Hypervigilance
  • Heightened startle reflex
  • Poor concentration
  • Sleep disturbance (e.g., nightmares, difficulty initiating or maintaining sleep)
• Duration: Symptoms last > 1 month following the traumatic event(s).
• The affected individual has been experiencing significant distress or impaired social interactions with parents, siblings, colleagues, or caregivers since the traumatic event(s).
• Symptoms are not explained by the effects of a substance (e.g., medication) or another medical condition.

Children with PTSD may experience developmental regression.

References:^[11]

Overview

Definition

• A maladaptive emotional (e.g., anxiety) or behavioral (e.g., outburst) response to a stressor, lasting ≤ 6 months following resolution of the stressor

Epidemiology

• Occurs in ∼ 5–20% of individuals undergoing outpatient mental health treatment
• Up to one-third of patients with a cancer diagnosis develop this disorder. ^[12]

Etiology

• A combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)

Diagnostic criteria (DSM-5) ^[1]

• Emotions or behaviors in response to a stressor that occur within 3 months of onset
• Clinically significant responses that include ≥ 1 of the following:
  • A level of distress that is disproportionate to the expected response to the stressor
  • Impaired functioning in social, occupational, and/or other important areas
• Symptoms are not explained by another mental disorder.
• Symptoms are not explained by a normal response to grief.
• Symptoms last ≤ 6 months following resolution of the stressor.

Differential diagnosis

• Normal stress reaction
• Major depressive disorder: Although some symptoms can be shared between the two conditions, the criteria for MDD are not met. (See Diagnostic criteria for major depressive disorder.)
• Generalized anxiety disorder : If symptoms of adjustment disorder last > 6 months the diagnosis is changed to GAD.

Treatment and prognosis ^[12]

• Psychotherapy
  • First-line treatment: cognitive-behavioral therapy or psychodynamic psychotherapy
  • May be provided as individual, family, or group support therapy
  • Interpersonal psychotherapy
• Pharmacotherapy
  • SSRIs: depressed mood
  • Benzodiazepines: anxiety or panic attacks
  • Benzodiazepines or other sedative-hypnotic agents (e.g., zolpidem): insomnia

Although psychotherapy alone is usually sufficient in patients with adjustment disorder who have no other disabling symptoms, pharmacotherapy may be used when psychotherapy has little or no effect.

References:^[1][12][13]

• Description
  • A psychiatric disorder characterized by inhibited, emotionally withdrawn interactions with caregivers and associated with social neglect during early childhood
  • An inability to relate interpersonally with peers and adults leads to impaired social development throughout early childhood (e.g. cognitive and/or language delays, academic difficulties, and pervasive anger/resentment)
• Diagnostic criteria (DSM-V) ^[1]
  • Emotionally withdrawn and inhibited behavior towards caregivers as manifested by the child rarely seeking or responding to comfort when upset.
  • A consistent emotional disturbance and social inhibition characterized by two or more of the following:
    • Limited response to the social and emotional cues of others
    • Blunted affect
    • Caregivers note irritable, fearful, or emotional behavior, even in the absence of a threatening situation.
  • A history of neglect in early childhood (< 2 years of age) as indicated by at least one of the following:
    • Persistent social neglect (inadequate comfort, stimulation, and affection provided by caregivers)
    • Repeated changes in primary caregivers (e.g., foster carers) that impede the development of selective social attachments
    • Childrearing settings with a high child-to-caregiver ratio
  • The inhibited behavior begins after the onset of insufficient or inconsistent care.
  • Not due to other psychiatric disorders (e.g., autistic spectrum disorder)
  • Onset: symptoms manifest before the age of 5 years
  • Developmental age of 9 months or more
  • Specifiers
    • Persistent: duration of disorder > 12 months
    • Severe: presence of all symptoms at high levels of severity
• Treatment ^[14]
  • Ensuring the presence of an emotionally available attachment figure
    • If the caregiver is emotionally available and not overwhelmed: Encourage sensitive responsiveness and offer coaching the caregiver as a co-therapist in the child's treatment.
    • If the caregiver is emotionally unavailable and/or too overwhelmed: child–parent psychotherapy and/or attachment and biobehavioral catch-up
  • Pharmacotherapy: not recommended and should only be considered with a high degree of caution for related psychiatric comorbidities such as ADHD, mood disorders, and anxiety disorders.
• Complications: developmental delays associated with neglect (for more information, see “Child neglect”)

• Description
  • A psychiatric disorder characterized by uninhibited interactions with unfamiliar adults and associated with social neglect during early childhood
  • Affected adolescents are less likely to experience stable peer relationships (e.g., more frequent conflicts)
• Diagnostic criteria (DSM-V) ^[1]
  • Consistent pattern of disinhibited behavior characterized by at least two of the following:
    • Lack of restraint in approaching and engaging with unfamiliar adults
    • Excessively familiar behavior towards strangers that is inconsistent with age-appropriate or culturally accepted norms
    • Venturing away without checking back with adult caregiver, even in unfamiliar settings
    • Little or no hesitation to accompany unfamilar adults away from caregiver
  • Disinhibited behavior is not marked exclusively by impulsivity (as seen in ADHD) but must have a social component.
  • A history of neglect in early childhood (< 2 years of age) ^[14]
    • Persistent social neglect (inadequate comfort, stimulation, and affection provided by caregivers)
    • Repeated changes in primary caregivers (e.g., foster carers) impede the development of selective social attachments.
    • Childrearing settings with a high child-to-caregiver ratio
  • The disinhibited behavior begins after the onset of insufficient or inconsistent care
  • Developmental age of at least 9 months
• Treatment ^[14]
  • Psychotherapy: parent-child interaction therapy, family therapy
  • Coaching techniques for primary caregivers
• Complications: developmental delays associated with neglect (for more information, see “Child neglect”)