Trauma/Stressor-Related, Dissociative, and Somatic Symptom Disorders

the 5 trauma and stressor-related disorders (not including dissociative disorders) on EPPP

reactive attachment disorder

disinhibited social engagement disorder

PTSD

acute stress disorder

prolonged grief disorder

the 2 dissociative disorders on EPPP

dissociative amnesia

depersonalization/derealization disorder

4 somatic disorders on EPPP

somatic symptom disorder

illness anxiety disorder

functional neurological symptom disorder (conversion disorder)

factitious disorder

reactive attachment disorder criteria

a) persistent pattern of inhibited and emotionally withdrawn behavior toward adult caregivers as demonstrated by a lack of seeking or responding to comfort when distressed; and,

b) persistent social and emotional disturbances that include at least 2 of the following:

• limited positive affect

• unexplained irritability

• sadness

• fearfulness when interacting with adult caregivers

there also must be a history of extreme insufficient care that is believed to be responsible for the person’s symptoms

onset before age 5

must have developmental age of at least 9 monthsd

disinhibited social engagement disorder criteria

a persistent pattern of behavior that’s characterized by inappropriate interactions with unfamiliar adults as demonstrated by at least 2 of the four symptoms:

• reduced and absent reticence in approaching or interacting with strangers

• overly familiar behavior with strangers

• diminished or absent checking with adult caregivers after being separated from them

• willingness to accompany a stranger with little or no hesitation

also requires that the personal has a history of extreme insufficient care that’s believed to be responsible for his/her symptoms

must have developmental age of at least 9 months

PTSD criteria

1+ month of symptoms due to exposure to actual or threatened death, serious injury, or sexual violence

must have symptoms of:

• intrusion

• avoidance

• negative changes in mood/cognition

• alterations in arousal and reactivity

PTSD risk factors

prior exposure to trauma

prior psychiatric disorder

negative affectivity

female gender

low education level

exposure to racial/ethnic discrimination

brain abnormalities linked to PTSD (not including neurotransmitters)

hyperactive amygdala and anterior cingulate cortex

hypoactive ventromedial prefrontal cortex

reduced volume of hippocampus

increased/decreased activity of hippocampus (findings defer based on study)

the cause of exaggerated fear response in PTSD

ventromedial prefrontal cortex reduces inhibitory top-down control of the amygdala

neurotransmitter abnormalities in PTSD

increased levels/activity of dopamine, norepinephrine, and glutamate

decreased levels/activity of serotonin and GABA

1st and 2nd line treatments of PTSD

1st line

• CPT

• PE

• Trauma focused CBT

2nd line

• cognitive therapy (CT)

• EMDR

• narrative exposure therapy (NET)

• medication (fluoxetine [SSRI], paroxetine [SSRI], sertraline [SSRI], venlafaxine [SNRI])

medications and PTSD

no medication is considered 1st line treatment, but the SSRIs fluoxetine, paroxetine, and sertraline; and the SNRI venlafaxine as 2nd line treatments

recommended treatments for comorbid PTSD and SUD (adults)

treatment used to focus on SUD first, but now Guideline recommends 3 integrated (concurrent) interventions:

1. treatment of PTSD and SUD using prolonged exposure (COPE)

• prolonged imaginal and in vivo exposure to trauma-associated stimuli for PTSD

• relapse prevention for SUD

2. prolonged exposure for PTSD and treatment as usual for SUD

3. trauma-focused cognitive behavioral therapy and treatment as usual for SUD

single-session psychological debriefing (“critical incident stress debriefing”) may worsen symptoms

treatment for children and adolescents with PTSD

TF-CBT

• family therapy

• parenting skills training

• conjoint parent-child therapy

not only reduces PTSD symptoms but also depression, anxiety, and grief

acute stress disorder criteria

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

9+ symptoms from any 5 categories (intrusion, negative mood, dissociative symptoms, avoidance, arousal)

symptoms present for 3 days to 1 month

prolonged grief disorder criteria

death of a person close to them at least 12+ months/1 year ago for adults, or 6+ months for kids/adolescents

grief response must include:

• an intense yearning for them; AND/OR

• preoccupation with thoughts about them

must have 3+ symptoms

• disbelief about the death

• avoidance of reminders

• emotional numbness

• intense loneliness

dissociative amnesia (including the specifier)

inability to recall important personal information that can’t be attributed to forgetfulness and causes distress or impaired functioning.

often related to victimization or exposure to traumatic event.

specifier is used to indicate if it includes dissociative fugue (purposeful travel or purposeless wandering)

the 4 types are on another card

4 types of dissociative amnesia

localized = inability to recall all events that occurred during a circumscribed period of time

generalized = complete loss of memory for entire life

systematized = loss of memory for a specific category of information

continuous = inability to remember new events

depersonalization/derealization disorder

persistent or recurrent episodes of depersonalization (sense of unreality, detachment, or being an outside observer) or derealization (sense of unreality/detachment from surroundings). with intact reality testing and significant distress or impaired functioning

somatic symptom disorder (including specifiers)

1+ somatic symptoms that are distressing or cause significant disruption in daily life and are accompanied by excessive thoughts, emotions, or behaviors related to the symptom(s) or associated health concerns as indicated by at least 1 of the following:

• disproportionate or persistent thoughts about the seriousness of symptoms

• persistently high level of anxiety about health or symptoms

• excessive time and energy spent on health concerns or symptoms

specifiers:

• mild, moderate, or severe

• involve predominant pain

• persistent (severe and caused marked impairment for 6+ months)

illness anxiety disorder

preoccupation with having a serious illness with no or mild somatic symptoms, excessive anxiety about health, and either excessive health-related behaviors or avoidance of health care

symptoms must be present 6+ months, but the nature of symptoms may vary over time

functional neurological symptom disorder (conversion disorder)

1+ symptoms involving a disturbance in voluntary motor or sensory functioning (e.g., paralysis, blindness).

symptoms must be incompatible with any known neurological or medical condition and cause significant distress or impaired functioning

specifiers include symptom type, course (acute or persistent), and presence or absence of a psychological stressor.

can sometimes involve psychogenic non-epileptic seizures (PNES) that resemble true epileptic seizures in terms of behavioral symptoms but are not accompanied by the typical brain activity. EEG + live video can be used to identify PNES by comparing brain activity to behaviors.