integ: abpsych (trauma and stressor-related disorders

Trauma-and-Stressor Related Disorders

• a group of disorders marked by psychological distress following exposure to traumatic or highly stressful events

• They all differ in the severity and duration of symptoms

Trauma-and-Stressor Related Disorders

• Direct or indirect exposure to trauma or stress

• Emotional dysregulation

• Intrusive symptoms (e.g., flashbacks, thoughts)

• Avoidance behaviors

• Impaired functioning in social, occupational, or developmental areas

Acute Trauma

Caused by a single, highly stressful or dangerous event

Triggers intense and immediate emotional reaction

Ex. natural disasters, accidents, sudden loss

Chronic Trauma

Results from repeated exposure to stressful events

Can lead to long-term emotional and psychological effects

Ex. domestic violence, abuse, war

Complex Trauma

Involves multiple or prolonged traumatic experiences, often interpersonal

Deeply impacts sense of self, relationships, and emotional regulation

Ex. abuse, neglect

Secondary Trauma

Occurs from indirect exposure to trauma

Can lead to emotional distress similar to that of the trauma survivor

Ex. therapists, first responders

Developmental Trauma

Early exposure to abuse, neglect, or dysfunctional family dynamics

Disrupts normal development and causes emotional/behavioral issues

Attachment Disorders

•  disturbed and developmentally inappropriate behaviors in children

• Emerges before five years of age

• Child is unable or unwilling to form normal attachment relationships with caregiving adults

Reactive Attachment Disorder

• emotionally withdrawn inhibited type

• Child will rarely respond to or seek out a caregiver for protection, support, and nurturance

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A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: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 laci< 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).

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.

Reactive Attachment Disorder— persistent

Disinhibited social engagement disorder — persistent

The disorder has been present for more than 12 months.

reactive attachment disorder — severe

Disinhibited social engagement disorder — severe

when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Reactive attachment disorder

• the absence of expected comfort seeking and response to comforting behaviors.

• diminished or absent expression of positive emotions during routine interactions with caregivers.

• they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained.

9

A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments. For this reason, the child must have a developmental age of at least how many months.

9 months and 5 years

The clinical features of the reactive attachment disorder manifest in a similar fashion between the ages of

cognitive delays, language delays, and stereotypies

severe malnutrition

often co-occur with reactive attachment disorder

Disinhibited Social Engagement Disorder

• inappropriate social behavior with strangers; indiscriminately social disinhibited type

• Occurs in a minority of children

Disinhiblted 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 in attention-deficit/hyper-activity disorder)

Disinhiblted 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).

E. The child has a developmental age of at least 9 months.

Disinhiblted Social Engagement Disorder

culturally inappropriate, overly familiar behavior with relative strangers that violates the social boundaries of the culture.

Disinhiblted Social Engagement Disorder

Imagine a 5-year-old child at a park:

• They walk up to a complete stranger and start talking like they’ve known them forever

• They might hug or hold hands with the stranger without hesitation

• They could even leave with the stranger without checking back with their caregiver

A child in school:

• Calls the teacher or visitors “mom” or “dad”

• Shares very personal information quickly

• Climbs onto a visitor’s lap or seeks comfort from unfamiliar adults instead of their caregiver

reactive attachment disorder

A 4-year-old child falls and gets hurt:

• Instead of running to a parent or crying for help, they stay quiet or withdraw

• When the caregiver tries to comfort them, they may pull away or not react

Disinhibited social engagement disorder

cognitive delays, language delays, and stereotypies

adhd

Posttraumatic Stress Disorder

• indiscriminately social disinhibited type

• following exposure to one or more traumatic events.

Posttraumatic Stress Disorder

The following criteria apply to adults, adolescents, and children older than 6 years:

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

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.

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).

Posttraumatic Stress Disorder

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

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).

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).

Posttraumatic Stress Disorder

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.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

1 month

Duration of the disturbance for PTSD is more than how long

PTSD With dissociative symptoms

The individual’s symptoms meet the criteria for post-traumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: Depersonalization and Dereaiization

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).

Dereaiization

Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).

PTSD With delayed expression

If the full diagnostic criteria of PTSD are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

In children 6 years and younger, 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, especially primary caregivers.

Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.

Posttraumatic Stress Disorder for Children 6 Years and Younger

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child 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.) Such trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to reminders of the traumatic event(s).

Posttraumatic Stress Disorder for Children 6 Years and Younger

One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).

4. Markedly diminished interest or participation in significant activities, including constriction of play.

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

Posttraumatic Stress Disorder for Children 6 Years and Younger

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 (including extreme temper tantrums).

2. Hypervigilance.

3. Exaggerated startle response.

4. Problems with concentration.

5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

flashbacks

These episodes, often referred to as what are typically brief but can be associated with prolonged distress and heightened arousal.

Auditory pseudo-hallucinations,

having the sensory experience of hearing one's thoughts spoken in one or more different voices

first 3 months

PTSD Symptoms usually begin within the what months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met.

3

12

50

Duration of the PTSD symptoms also varies, with complete recovery within how many months occurring in approximately one-half of adults, while some individuals remain symptomatic for longer than how many months and sometimes for more than how many years.

play

Before age 6 years (see criteria for preschool subtype), young children are more likely to express reexperiencing symptoms through what that refers directly or symbolically to the trauma.

females

PTSD is more prevalent among and experience longer duration

rape, and other forms of interpersonal violence.

PTSD in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as

Biomarkers

people who react more emotionally to strong physiological symptoms are at higher risk

hippocampus

in PTSD, If there is damage to the what, we might expect persistent and chronic arousal

alarm reaction

The what that is a panic attack is similar in both panic disorder and PTSD but that in panic disorder the alarm is false

• Depressive Disorders (esp MDD)

• Anxiety Disorders

• Substance Use Disorders

• Dissociative Disorders

• Borderline Personality Disorder 

• Traumatic Brain Injury 

• Somatic Symptom and Related Disorders

• Obsessive-Compulsive Disorder

Common Comorbidities of PTSD

Prozac

Paxil

common SSRI treatment of PTSD

Catharsis

reliving emotional trauma

Imaginal Exposure

content of the trauma and emotions associated with it are worked through systematically

Acute Stress Disorder

• PTSD symptoms lasting from 3 days to 1 month following exposure to the traumatic event/s

• Occurs within the first month after the trauma

• Alterations in awareness can include depersonalization or derealization

Acute Stress Disorder

• PTSD like symptoms

• 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.

temperamental risks

• Prior mental disorder

• High levels of negative affectivity (neuroticism)

• Greater perceived severity of the traumatic event

• Avoidant coping style

• Catastrophic appraisals of the traumatic experience are strongly predictive of acute stress disorder

acoustic startle response

Elevated reactivity, as reflected by what, prior to trauma exposure increases the risk for developing acute stress disorder

• Post-Traumatic Stress Disorder

• Depressive Disorders

• Other Anxiety Disorders

• Substance Use Disorders

• Dissociative Disorders

• Sleep-Wake Disorders

Common Comorbidities of acute stress disorder

Adjustment Disorder

• anxious or depressive reactions to life stress that are generally milder than one would see in acute stress disorder or PTSD

• Life stress may provoke some conduct problems, especially in adolescence

• Individual is unable to cope with the demands of the situation and some intervention is typically required

Adjustment Disorders

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.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

adjustment disorders With depressed mood

Low mood, tearfulness, or feelings of hopelessness are predominant.

adjustment disorders With anxiety

Nervousness, worry, jitteriness, or separation anxiety

is predominant.

adjustment disorders With mixed anxiety and depressed mood:

A combination of depression and anxiety is predominant.

adjustment disorders with disturbance of conduct:

Disturbance of conduct is predominant.

adjustment disorders With mixed disturbance of emotions and conduct:

Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.

adjustment disorders Unspecified

For maladaptive reactions that are not classifiable as one

of the specific subtypes of adjustment disorder

Adjustment disorders

may be diagnosed following the death of a loved one when theintensity, quality, or persistence of grief reactions exceeds what normally might be ex-

pected, when cultural, religious, or age-appropriate norms are taken into account.

3

6

adjustment disorders begins within how many months of onset of a stressor and lasts no longer than how many months after the stressor or its consequences have ceased.

chronic

if the symptoms in adjustment disorder persist for more than 6 months after the removal of the stress or its consequences

• Depressive Disorders

• Other Anxiety Disorders

• Substance Use Disorders

• Sleep Disturbances

• Somatic Symptoms

Common Comorbidities of adjusment disorder