Week 5 - Acute Stress and PTSD

Trauma and Stressor-related Disorders (TSR’s)

Definition of Stress is difficult to have a consensus on, is it physical or mental state or combination?

Working Definition: psychological condition experienced when our coping resources or abilities are insufficient to respond to an actual (or perceived) physical or emotional challenge

In general, Stress may not be an inherent “event”, but there may be some events that are exceptions, such as “life stressors” that are exceptions, which most people would rate as such

Helpful to consider that the properties (or considerations) of an event that might determine if it is a “stressor”, and why some events can still produce this response even though they are widely recognised “stressors”.

Life stressors for college students

High stress (90+ stress rating)

• SASH (sexual assault, sexual harassment

• Death or serious illness of close friend/family

• Relationships or sexual health concerns, including unplanned pregnancy

• Major assessments (exam blocks, assignments)

Low stress (stress rating >60)

• Falling asleep in class

• Taking subject you enjoy, but find hard

• Travelling to work/campus

• Starting the semester

Health effects of high stress:

• Susceptibility to illnesses (e.g. respiratory illness)

• Immune system functions (e.g. stress-related immunosuppression)

• Increased risk of coronary heart disease

• Links to premature ageing (shortened telomeres)

Selected evidence-based strategies for certain stress exposures

• Monitoring/maximising physical health

• Developing strategies for emotional management (CBT, practicing emotional disclosure, relaxation/meditation)

Social strategies (e..g. addressing social disadvantages/inequities/social support & isolation)

TSR disorders:

• Reactive attachment disorder

• Disinhibited social engagement disorder

• Acute stress disorder

• Posttraumatic stress disorder

• Adjustment disorder

• Prolonged grief disorder

The diagnostic criteria for PTSD were substantially modified with the publication of the DSM-5, despite the revision process being described as “very conservative” by the work group

Prolonged Grief Disorder:

• Diagnosis added by DSM-5TR to Trauma and Related Stressor Disorders

• Not a mood disorder, but “bereavement” as referred to in DSM-4

• Differentiated from a non-clinical condition by severity/intensity and duration of deatures

• Ongoing discussion and evidence (as well as codification) about how long grief “should” last roughly 12 months according to the DSM, and 6 months according to the ICD

• Take home from this: Grieving is a highly individualised process, Determining when grief become PGD can be difficult and requires consideration of social and cultural norms

PGD is controversial, according to Cacciatore and Francis (2022) the inclusion of PGD “solves no existing problems” but instead creates on. If diagnosis is needed, they recommend “Adjustment Disorder” instead.

Main issues they have:

• Threshold is too low, many people will be diagnosed/medicated as a result

• Imposes expiration date on grief, when no uniform agreement exists

• Approach is blind to potentially critical contextual factors (relationship between parties) and/or the death itself (expected VS catastrophic) including personal factors such as available supports and cultural expectations

• No field testing for diagnostic criteria, so no empirical evidence for it

Adjustment Disorder:

• Possible diagnosis when severe (not not traumatic stressor, i.e. Divorce) or multiple combined smaller stressors can overwhelm coping resources and lead to clinically significant but not extreme behavioural or emotional symptoms.

• Less severe than ASD or PTSD

• Onset of symptoms linked to the stressor (occurs within certain time period after event) and symptoms have terminology similar to “due to” or “because” attached to said event

• Typically abates once stressor is removed

• If symptoms persist longer than 6 months, a different psychopathology may be considered

• Dysfunction caused as result of stressor seems excessive for circumstances (other people usually cope better)

History of PTSD

• Maladaptive reactions to trauma have long been of interest to military (shell shock, combat neurosis)

• Vietnam was prompted much interest in PTSD, highlighting a “delayed” reaction to combat

• Remains significant issue for veterans

• Changed from “military disorder” to being understood as something that can affect anyone, from non combat-related events

Traumatic Stress: An event that involves actual or threatened:

• death

• serious injury

• sexual violence to self

• witnessing others experience trauma

• learning that a loved one has been traumatised

• repeatedly being exposed to details of trauma

In DSM-4 it was an anxiety disorder, in DMS-5 revised to be a Trauma and Stress-Related Disorder, as well as raised the threshold

A study in 2013 found this significantly reduced the prevalence of PTSD diagnoses on two of six estimates. However, women were still more likely to attract a PTSD diagnoses than men, and authors concluded that the new criteria did not lower but might have successfully raised the threshold

After experiencing traumatic stress exposure, the defining symptoms for both acute and post-traumatic stress disorder include:

1. Intrusive re-experiencing

• Repeated, distressing memories (1), dreams (2), Intrusive flashbacks (Dissociative reactions) (3), Psychological (4) or Physiological (5) distress from event related cues

1. Avoidance

• Avoids or tries to avoid internal reminders (thoughts, feelings)

• Avoids external reminders (people, places, activities)

1. Increased arousal or reactivity

• Hyper-vigilance

• Irritability

• Exaggerated startle response

• Sleep disturbances

1. Negative mood or thoughts

• Anhedonia (Inability to experience pleasure or enjoyment from activities that were once pleasurable)

• Negative emotions (anger, guilt, fear)

• Self blame

• Negative world view

1. Dissociation

• Depersonalisation (loss of sense of self disconnection or detachment from ones body and mental processes, Feeling as if one is in a dream

• Derealisation (experiencing distortion or detachment from reality, outside world seems to not be stable or palpable or real

In ASD, dissociative features are listed separately (as a symptom cluster) whereas in PTSD they are subsumed within other clusters and can be added as specifiers

Summarised Diagnostic criteria’s for PTSD and ASD

PTSD:

• 1/5 intrusion symptoms

• 1/2 avoidance symptoms

• 2/7 negative mood/thought symptoms

• 2/6 arousal or reactivity symptoms

Symptoms lasting more than 1 month

Cause distress

Not due to substance or medical condition

ASD:

9 symptoms from any of following clusters:

• Intrusion

• Avoidance

• Negative thoughts/feelings

• Arousal or Reactivity

Symptoms lasting 3 days to 1 months

Causing Distress

Not due to substance of medical condition

ASD conceptually precedes PTSD

• 80% of people with ASD have PTSD 6 months later, but not everyone

• PTSD can develop in absence of ASD. 4-13% of people will have no ASD but PTSD in later months/years

Prototypical trajectories:

• Chronic (bad initial response that lingers at high level chronically)

• Delayed (slight increased response but increased dramatically over time)

• Recovery (Bad initial response but returns slowly to baseline)

• Resilience (remains baseline response compared to others)

Assessment challenges

Malingering: deliberate faking of illness or symptoms for a specific (non-medical) benefit. Significant issue for diagnoses due to patient having potential material gain such a financial compensation

Study by QUT examined Malingered PTSD in relation to effect of Direct vs Indirect trauma exposure on symptom profiles and detectability

Interim summary:

• Stressful life events can be impactful on physical and mental health, the event properties are an important consideration for how the exposure might impact individuals (stressor considerations)

• TSR group may offer a diagnosis that could apply when stress event signifies the ability to cope has been overwhelmed, with some events cross into category of an event associated with ASD or PTSD

• Concluded that ASD and PTSD are conceptually linked, however possible permutations lead to heterogenous presentations, and longitudinal studies have shown that people follow one of four previously shown trajectories, with resilience being most common

Acute and Post-traumatic stress disorders:

• More people experience trauma than not

• Global PTSD estimates vary around 6-8%

• More common in women

• Minorities have higher rates of PTSD

PTSD risk involves two elements

• Risk of exposure to trauma

• Risk of developing PTSD after exposure

Individual-level Risk factors: sex, social support, prior health

Individual-level Protective factors: cognitive ability (possibly supports meaning-making post trauma

Specifically:

• Nature of the trauma relating to event seriousness/intensity, exposure frequency, how “directly” it is experienced

• Lack of social support

• Incarceration, post-trauma refugee experiences

• Personality vulnerability (anxiety, neuroticism)

• Adverse developmental experience - poor parental mental health, adverse childhood experience/abuse

• Genetic contributions (but also environment) demonstrated frequently through twin and epigenetic studies

• Other biological e.g. stress hormone dysregulation (mixed findings show that neural architecture affects PTSD vs non-PTSD groups, particularly looking at hippocampus structure. Research design and non-specificity needs to be considered here however)

DNA Methylation and PTSD

• Study by QUT shows how DNA methylation of NR3C1 and FKBP5 is associated with posttraumatic stress disorder, growth and resilience

Hippocampal research and hypothesis:

• Reduced hippocampal volume is associated with overgeneralisation of negative context in individuals with PTSD

• Things to consider are is sample population studied on/off medication? How well matched is control group (apart from being PTSD free)

Comorbidity and course

• High for depression, anxiety and substance use disorders

• Anger, usually prominent and risk for completed suicide

• Risk that parental PTSD/trauma can become intergenerational

• Symptoms typically diminish over time, in 2/3rds of people greatest improvement occurs after first 12 months, especially with treatment (also treatment of ASD can reduce likelihood of being diagnosed with PTSD later)

Intergenerational Trauma:

On simplest level, acknowledges that exposure to extremely adverse events impacts parents to the degree that their offspring finds themselves grappling with their parents post-traumatic states

Mechanisms involved are not yet resolved, but include epigenetic theories, transmission due to socioeconomic family/developmental disadvantages

Risks of this change based on demographic, due to certain demographics going through differing sociopolitical conditions and states of living in the past

Prevention:

Social-level: to prevent traumatic events from occurring. Ranges from governmental policy decisions such as gun-reform, climate action, fire/flood resilience programs, family and DV reforms that can reduce risk of traumatic exposure

Strategies for high-risk groups:

• Stress inoculation training: prepares people to withstand exposure and maintain resilience through cognitive training. Can be done before, after and during traumatic events

• psychoeducation about understanding typical vs deviant responses and preparing to handle potential symptoms/fluctuations

We must consider that prevention approaches are widely affected by their ability to cover potentials. Traumatic events, sometimes by their nature, can be unpredictable and catch us under-prepared

Treatment:

• Immediate treatment includes support and access to 24/7 crisis hotlines

• Avoidance and management of potential stressors

• Later treatment can be group programs, assessment and monitoring of comorbidities, Medication, and psychotherapy

Psychotherapeutic approaches:

• Psychological debriefing - CISD - structured group based process for emergency personnel to cope with trauma from responding to critical incidents. Can at times be harmful if done too early. Forces individuals to relive trauma before natural coping mechanisms have a chance to function, potentially increasing the risk of PTSD

• Exposure therapy

• Interpersonal psychotherapy - Developing self-concept, personal control over situation, emotional processing (learning to engage, organise and accept) and personal meaning of trauma

Most effective psychotherapy frameworks supported by literature to treat PTSD

• Prolonged exposure

• Cognitive processing or Cognitive Therapy

• Trauma focused CBT

Emotion processing is common to these approaches, they involve revisiting the event in a supported environment and redeveloping responses we have to them. Changing the cognitive appraisal (meaning) we derive