2. Trauma and Stress Related Disorder
■ Overview
■ 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.
3. Acute Stress Disorder
■ INTRODUCTION
■ Acute stress disorder (ASD) is characterized by acute stress reactions that may
occur in the initial month after a person is exposed to a traumatic event
(threatened death, serious injury, or sexual violation). The disorder includes
symptoms of intrusion, dissociation, negative mood, avoidance, and arousal.
■ The intent of the ASD diagnosis is to facilitate identification and treatment of
severe acute stress responses. Treatment of ASD can have the additional
benefit of limiting subsequent posttraumatic stress disorder (PTSD), which is
diagnosed only after four weeks of symptoms following exposure to trauma.
4. Epidemiology
■ In both U.S. and non-U.S. populations, acute stress disorder tends to be
identified in less than 20% of cases following traumatic events that do not
involve interpersonal assault.
■ 13%-21% of motor vehicle accidents, 14% of mild traumatic brain injury, 19% of
assault, 10% of severe burns, and 6%-12% of industrial accidents.
■ Higher rates (i.e., 20%-50%) are reported following interpersonal traumatic
events, including assault, rape, and witnessing a mass shooting.
■ Women > men
5. DSM-5 Diagnostic Criteria
■ A. Exposure to actual or threatened death, serious injury, or sexual violation 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 event(s) occurred to a close family member or close friend. Note: 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: This does not apply to exposure through electronic media, television, movies, or pictures,
unless this exposure is work related.
■ B. Presence of nine (or more) of the following symptoms from any of the five categories of
intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the
traumatic event(s) occurred:
6. ■ Intrusion Symptoms
■ 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In
children, 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 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 or marked physiological reactions in response
to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
■ Negative Mood
■ 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).
7. Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s
perspective, being in a daze, time slowing).
7. 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).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated
with the traumatic event(s).
9. 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).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed
as verbal or physical aggression toward people or objects.
12. Hypervigilance.
8. 13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: 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.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol)
or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic
disorder.
9. Risk and Prognostic Factors
■ Temperamental.
■ Risk factors include prior mental disorder, high levels of negative affectivity
(neuroticism), greater perceived severity of the traumatic event, and an avoidant
coping style.
■ Catastrophic appraisals of the traumatic experience, often characterized by
exaggerated appraisals of future harm, guilt, or hopelessness, are strongly
predictive of acute stress disorder.
■ Environmental.
■ First and foremost, an individual must be exposed to a traumatic event to be at
risk for acute stress disorder. Risk factors for the disorder include a history of
prior trauma.
■ Genetic and physiological.
■ Females are at greater risk for developing acute stress disorder.
■ Elevated reactivity, as reflected by acoustic startle response, prior to trauma
exposure increases the risk for developing acute stress disorder
10. Development and Course
acute stress disorder may progress to posttraumatic stress disorder (PTSD) after 1 month, it
may also be a transient stress response that remits within 1 month of trauma exposure and
does not result in PTSD.
Approximately half of individuals who eventually develop PTSD initially present with acute
stress disorder. Symptom worsening during the initial month can occur, often as a result of
ongoing life stressors or further traumatic events.
■ The forms of re-experiencing can vary across development. Unlike adults or adolescents,
young children may report frightening dreams without content that clearly reflects aspects of
the trauma (e.g., awaking in fright in the aftermath of the trauma but being unable to relate
the content of the dream to the traumatic event).
■ Children age 6 years and younger are more likely than older children to express re-
experiencing symptoms through play that refers directly or symbolically to the trauma.
■ For example, a very young child who survived a fire may draw pictures of flames.
11. ■ Young children also do not necessarily manifest fearful reactions at the time of
the exposure or even during re-experiencing. Parents typically report a range of
emotional expressions, such as anger, shame, or withdrawal, and even
excessively bright positive affect, in young children who are traumatized.
■ Although children may avoid reminders of the trauma, they sometimes become
preoccupied with reminders (e.g., a young child bitten by a dog may talk about
dogs constantly yet avoid going outside because of fear of coming into contact
with a dog).
13. Treatment
Psychotherapy
■ 1st-line treatment is trauma-focused CBT. Trauma-focused CBT may reduce risk of
PTSD progression.
■ Pharmacotherapy:
■ No FDA-approved medication therapy for acute stress disorder
■ Short-term benzodiazepine (e.g., Alprazolam, lorazepam< 4 weeks) is suggested if
patient suffers from intense anxiety or agitation. Sleep disturbances may benefit from
medication treatment with short course of hypnotics (e.g., eszopiclone).
14. Post Traumatic stress Disorder
■ Posttraumatic stress disorder (PTSD) is characterized by the development of
multiple symptoms after exposure to one or more traumatic events: intrusive
symptoms (e.g., nightmares, flashbacks), avoidance, negative alterations in
thoughts and mood, and increased arousal.
■ The symptoms last for at least a month and may occur immediately after the
trauma or with delayed expression.
15. Epidemiology
■ Lifetime prevalence in Canada is 9%; onset in mid-late 20s
■ 75% have another comorbid psychiatric disorder; increased risk of suicide 2-3x
■ high rates of chronic pain, sleep problems, sexual dysfunction, cognitive
dysfunction
■ prevalence F:M = 2:1
■ most common forms of trauma: unexpected death of someone close, sexual
assault, serious illness or injury to someone close, physical assault by partner or
caregiver.
16. Etiology
■ Triggers: exposure to traumatic events (either through direct experience or as a
witness)
– Sexual violence (most common)
– 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
– Diagnosis of a severe disease
– Witnessing the death of another person
17. DSM-5 DIAGNOSTIC CRITERIA FOR POST-
TRAUMATIC STRESS DISORDER
■ A. 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)
■ B. 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)
■ 2. recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s)
18. •3. dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were
recurring
•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)
•C. 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)
• D. 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)
• 2. persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
• 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
19. •7. persistent inability to experience positive emotions
• E. 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 behaviour and angry outbursts (with little or no provocation) typically expressed as
verbal or physical aggression toward people or objects
• 2. reckless or self-destructive behaviour
• 3. hypervigilance
• 4. exaggerated startle response
• 5. problems with concentration
• 6. sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep)
• F. duration of the disturbance (criteria B, C, D, and E) is more than 1 month
• G. the disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning
H. the disturbance is not attributable to the physiological effects of a substance or another medical
condition
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic
stress disorder, and in addition, in response to the stressor, the individual experiences
persistent or recurrent symptoms of either of the following:
1. 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).
20. 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the
individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a
substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex
partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event
(although the onset and expression of some symptoms may be immediate).
21.
22. Posttraumatic Stress Disorder for
Children 6 Years and Younger
■ A. 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 care-giving figure.
■ B. 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.
23. •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).
•C. 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.
24. •F. The disturbance causes clinically significant distress or impairment in relationships with
parents, siblings, peers, or other caregivers or with school behavior.
•G. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication or alcohol) or another medical condition.
•Specify whether:
•With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic
stress disorder, and the individual experiences persistent or recurrent symptoms of either of
the following:
•1. 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).
•2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the
world around the individual is experienced as unreal, dreamlike, distant, or distorted).
•Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts) or another medical condition (e.g.,
complex partial seizures).
•Specify if:
•With delayed expression: If the full diagnostic criteria are not met until at least 6 months after
the event (although the onset and expression of some symptoms may be immediate).
25. Course/Prognosis
■ PTSD usually begins within 3 months after the trauma.
■ Symptoms may manifest after a delayed expression.
■ Fifty percent of patients with PTSD have complete recovery within 3 months.
■ TRAUMA Mnemonic PTSD
Traumatic event
Re-experience the event
Avoidance of stimuli associated with the trauma
Unable to function
More than a Month
Arousal increased
+ negative alterations in cognition and mood
26. Risk factors
Pre-traumatic
• Temperamental:
(prior mental or
emotional disorder)
• Environmental: (low
socio-economic
status)
• Genetic and
physiological:
(female and
younger age)
Peri-traumatic
• Environmental:
• Greater Magnitude
of trauma
• Perceived life threat
• Personal injury
• Being a perpetrator
Post traumatic
• Temperamental:
• Bad coping
strategies.
• ASD
• Environmental:
recurrent exposure
• Poor social support
• Subsequent
adverse life events.
28. Treatment
• Trauma therapy, CBT
■ stage 1 - safety and stabilization: emotional regulation techniques (i.e. breathing,
relaxation) to help build coping skills, medications for PTSD, manage substance use
■ stage 2 - remembrance and mourning: exposure to traumatic memories and work through
distorted thoughts, relational patterns, and grief
■ stage 3 - reconnection and integration: exposure therapy, etc. create a new future, new
relationships, strengthen identity
• early intervention via psychological support (not de-briefing)
• psychotherapy: CBT, DBT, supportive, eye movement desensitization and reprocessing
(EMDR) • biological
■ First line: SSRIs : fluoxetine, paroxetine, sertraline and SNRIs : venlafaxine XR (50-80%
response with residual symptoms is common)
■ prazosin (for treating disturbing dreams and nightmares)
■ benzodiazepines (for acute anxiety; use with extreme caution)
■ adjunctive atypical antipsychotics (risperidone, olanzapine)
■ beta-blocker may prevent PTSD
29. Adjustment Disorder
■ Introduction
■ Adjustment disorder is a psychological and physical response (feeling sad,
stressed, or hopeless, and certain physical symptoms) to an identifiable stressor
(death of a loved one, divorce, life changes, illness, family problems, school
problems, or sexual issues).
■ A diagnosis encompassing patients who have difficulty coping with a stressful
life event or situation and develop acute, often transient, emotional or behavioral
symptoms that resemble less severe versions of other psychiatric conditions.
30. Epidemiology
■ Lifetime prevalence: approximately 2%–8% of the general population
■ Women are twice as likely to be diagnosed as men.
■ One of the most common psychiatric diagnosis for patients
■ hospitalized for any other medical/surgical reason
■ Etiology
■ Precipitated by 1 or multiple stressors
■ Severity of stressor does not predict prognosis.
■ Personality of the patient as well as societal norms contribute to the pathologic
reactions to the stressors.
31. DSM-5 DIAGNOSTIC CRITERIA
FOR ADJUSTMENT DISORDER
■ 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.
32. ■ 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.
■ Specify whether:
■ With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
■ With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
■ With mixed anxiety and depressed mood: A combination of depression and anxiety is
predominant.
■ With disturbance of conduct: Disturbance of conduct is predominant.
■ With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g.,
depression, anxiety) and a disturbance of conduct are predominant.
■ Unspecified: For maladaptive reactions that are not classifiable as one of the specific
subtypes of adjustment disorder.
34. Treatment
■ 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
35. 3days- 1 month
Acute stress Disorder
1 month >>
Post traumatic stress Disorder
Day 1- 6months post stressor
Adjustment Disorder
duration
36. References
•Toronto Notes
•First Aid for the Psychiatry Clerkship
•Diagnostic and Statistical Manual of Mental Disorders, 5TH Edition
•Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral
sciences/clinical psychiatry (11th ed.). Chapter 11, Trauma and stressor-related disorders, pages 446-450.
Philadelphia, PA: Lippincott Williams and Wilkins.
•Zelviene P, Kazlauskas E. (2018). Adjustment disorder: current perspectives. Neuropsychiatr Dis Treat.
14:375-381.
•O’Donnell ML, Agathos JA, Metcalf O, Gibson K, Lau W. (2019). Adjustment Disorder: Current Developments
and Future Directions. Int J Environ Res Public Health. 16(14):2537.
•Frank J, Bienenfeld D. Adjustment Disorders . Adjustment Disorders . New York, NY: WebMD. Updated:
October 31, 2016. Accessed: July 4, 2017.
