Clinical Medicine I: Trauma and Stressor Disorders

bereavement

situation in which loved one has died

grief

natural response to the loss of a loved one, associated with physical, emotional, and cognitive symptoms, evolved over time eventually the person is able to adapt and integrate the loss and reengage with life (process of mourning)

What is mourning influenced by?

cultural/religious/social rituals, behaviors, and practices

acute grief/uncomplicated bereavement

-time-limited, unique/individualized process

-involves social, religious, cultural norms

-severity depends on suddenness and circumstances of death, relationship to the deceased

Clinical manifestations of acute grief

intense focused thoughts/memories of deceased accompanied by sadness and yearning (hallmark), emotional pain (sorrow, remorse, frustration, anger, guilt, anxiety), somatic physical distress, loss of interest and feeling disconnected (social withdrawal)

timing of acute grief

begin within first 2 months of loss, starts to resolve/re-engage by 6-12 months

Grief treatment

reassurance, self-care, emotional support through family and friends, support groups, regular check-ins with validation of grief experience and monitoring for signs of function impairment, persistent inability to adapt, or suicidal ideation

prolonged grief disorder

pervasive, intense, and functionally impairing symptoms after the loss

What does incidence of prolonged grief disorder depend on?

severity and relationship of death

Risk factors for prolonged grief disorder

sudden/violent death, older age, females at greater risk, low socioeconomic status, low educational level, affected by racism/inequity/disparities, psychiatric history, military personnel, bereaved multiple times or prior traumatic loss, inadequate social support

According to DSM-5, to diagnose prolonged grief disorder the grief response exceeds ___-___ months

6-12

Treatment for prolonged grief disorder

self-care, psychotherapy (grief-focused is 1st line), support groups, medications if underlying co-morbidities

Trauma

exposure to actual or threatened death, serious injury, or sexual violence

What are ways in which a person can experience trauma?

directly experiencing the event, witnessing it in person as it occurs to others, learning it happened to a close family member or friend, repeated indirect exposure to details of traumatic events (1st responders, military)

Stressors for children/teens (adjustment disorder)

family problems/fighting within family, problems in school, sexuality or identity issues

Stressors for adults (adjustment disorder)

death of a loved one, divorce/relationship problems, person or loved one getting a serious illness, moving to a new home or city, change in financial situation/money problems, problems at work

Adjustment disorder clinical manifestations

depressed mood, anxiety, aggression/vandalism, unable to do usual tasks, trouble concentrating or thinking clearly, sleep disturbances/ bad dreams/ insomnia, acting recklessly (drinking, drugs, affairs), suicidal thoughts

Timing of adjustment disorder

Within 3 months of identifiable stressor, lasts less than 6 months

Diagnosis of adjustment disorder is categorized by major _______ symptom

associated

Treatment for adjustment disorder

psychotherapy (CBT)/ counseling is 1st line, self-care, screen for suicidal ideation and substance abuse

Reactive attachment disorderr

severe neglect, repeated caregiver changes, or institutional rearing during early childhood

reactive attachment disorder etiology

pathogenic caregiving environment

Clinical manifestations of reactive attachment disorder

significant social and emotional impairment, pervasive absence of attachment behaviors (fail to see or accept comfort), marked withdrawal or hypervigilance in social situations, limited positive affect unexplained irritability, sadness, or fearfulness during nonthreatening interactions

timing of reactive attachment disorder

symptoms must be evident before age 5 years

What does reactive attachment disorder have increased risks for?

comorbid psychiatric and psychosocial problems in adolescents, mood disorders, behavioral problems, suicidal ideation, and substance abuse

treatment for reactive attachment disorder

provide stable and nurturing environment, early ID And intervention are critical

acute stress disorder

exposure to actual or threatened death, serious injury, or sexual violence

Clinical manifestations of acute stress disorder

intrusive thoughts/memories, hyperarousal/hypervigilance, avoidance of trauma reminders, depressed mood, dissociation

Timing of acute stress disorder

occurring within 3 days to 1 month following trauma, greater than 1 month is PTSD

Acute stress disorder treatment

trauma focused CBT is first line, ensure safety (SI), self care, meds if comorbid condition

Post-traumatic stress disorder risk factors

adverse childhood experiences (ACEs), less education, lower socioeconomic status, personal/family psychiatric history, females more at risk, poor social support, intentional trauma more risk than unintentional trauma, physical injury as part of trauma event

Clinical manifestations of PTSD

traumatic event, flashbacks (hallmark), hyperarousal/hypervigilance, avoidance of environments or situations that remind them of trauma, depressive symptoms

Timing for PTSD

symptoms greater than 1 month

PTSD diagnosis criteria

patient older than age 6, disturbance causes clinically significant distress or impairment in social or occupational functioning, disturbance not attributable to substance abuse or other medical/psychological condition

Subtypes and complex PTSD

recurrent severe trauma, dissociative identity disorder

Treatment goals of PTSD

-maintain safety while reducing distressing symptoms, avoidant behaviors, and anxiety

-improve adaptive and psychosocial functioning to lessen risk of relapse

Treatment for PTSD

trauma focused psychotherapy is 1st line (CBT, exposure-based therapy, eye movement desensitization and reprocessing- EMDR), self care, SSRI if comorbidities, alpha 1 blocker (prazosin) given before bed

Prognosis of PTSD

the sooner the therapy the better but not beneficial to begin immediately after trauma, 1/3 recovered after 1 year, 1/3 still symptomatic at 10 years