other trauma and stressor related disorder by Dr Haileleul Mekonnen

1. Other trauma and stressor
related disorder
Prepared by :Haileleul Mekonnen, PGY 1
Moderator : Dr Benyam Worku (Associate professor of psychiatry
,trauma psychiatrist)

2. Outline
• Introduction
• Acute stress disorder
• Adjustment Disorder

3. Introduction
• Reactive Attachment Disorder
• Disinhibited Engagement disorder
• Prolonged Grief Disorder
• UNSPECIFIED TRAUMA- OR STRESSOR-RELATED DISORDER
• Acute stress disorder
• Adjustment Disorder

4. UNSPECIFIED TRAUMA- OR STRESSOR-RELATED DISORDER
• the category of “unspecified trauma- or stressor-related disorder” is used
for patients who develop emotional or behavioral symptoms in response to
an identifiable stressor but do not meet the full criteria of any other
specified trauma- or stressor related disorder (e.g., acute stress disorder,
PTSD, or adjustment disorder).
• The symptoms cannot meet the criteria for another mental, medical
disorder and is not an exacerbation of a preexisting mental disorder.
• The symptoms also cannot be attributed to the direct physiological effects
of a substance.

5. Acute stress disorder
• 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.

6. EPIDEMIOLOGY
• the prevalence of acute stress disorder (ASD) following trauma
exposure has been estimated at between 5 and 20 percent,
depending on the nature and severity of trauma and the
instrument used to identify the disorder.

7. Risk factors
• History of a pre trauma psychiatric disorder
• History of traumatic exposures prior to recent exposure
• Female gender
• Trauma severity
• Neuroticism
• Avoidant coping

8. Pathogenesis
Dissociative symptoms
• When ASD was initially introduced, dissociative symptoms in
response to trauma are a pivotal factor in maladaptive
responses to trauma
• dissociating trauma memories and their associated affect from
normal awareness impedes processing of these reactions and
thereby leads to subsequent PTSD

9. Cognitive processing
• extremely negative and unrealistic appraisals about the
traumatic event,
• greater levels of symptomatic response, and
• stronger beliefs about the likelihood of future harm will increase
the extent to which PTSD develops

10. Panic/elevated arousal
• Fear conditioning models posit that the fear elicited during a
traumatic event results in conditioning in which subsequent
reminders of the trauma elicit anxiety in response to trauma
reminders
• According to this model, most trauma survivors successfully
engage in extinction learning in the days and weeks after
trauma as they learn that the reminders are not signaling further
threat.

11. DSM-5-TR
• “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.

12. • 4. Experiencing repeated or extreme exposure to aversive details
of the traumatic event(s) (eg, 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.

13. • 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:
• •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 (eg, 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).

14. • Negative mood
• -5. Persistent inability to experience positive emotions (eg, inability
to experience happiness, satisfaction, or loving feelings).
• •Dissociative symptoms
• -6. An altered sense of the reality of one's surroundings or oneself
(eg, 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).

15. • 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 (eg, 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
• -13. Problems with concentration
• -14. Exaggerated startle response

16. • C. Duration of the disturbance (symptoms in Criterion B) is three days
to one month after trauma exposure.
• Note: Symptoms typically begin immediately after the trauma, but
persistence for at least three 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 (eg, medication or alcohol) or another medical condition
(eg, mild traumatic brain injury) and is not better explained by brief
psychotic disorder.”

17. COURSE OF ILLNESS
• The acute stress disorder (ASD) diagnosis has been proposed as
a means to identify among patients experiencing an acute stress
reaction to trauma those at higher risk for subsequent
posttraumatic stress disorder (PTSD) who thus may benefit from
early intervention.
• Approximately half of individuals who eventually develop PTSD
initially present with acute stress disorder
• acute stress symptoms can remit, remain constant, or worsen
over time, largely as a result of ongoing life stressors or further
traumatic events

18. Differential diagnosis
• panic disorder
• adjustment disorder.

19. Management
• trauma-focused cognitive-behavioral therapy (CBT)
• Patient education
• cognitive restructuring
• Exposure
• has been found to reduce the likelihood of subsequent PTSD in
people with acute stress disorder

20. PHARMACOTHERAPY
• SSRIs
• Benzodiazepines
• Propranolol , reduced conditioning of the trauma memories and
prevent the development of PTSD

21. Adjustment disorder
• Adjustment disorders are characterized by an emotional response to a
stressful
event.
• It is one of the few diagnostic entities in which an external stressful event
is
linked to the development of symptoms.
• Typically, the stressor involves financial issues, a medical illness, or
relationship problem.
• The symptom complex that develops may involve anxious or depressive
affect or may present with a disturbance of conduct.
• By definition, the symptoms must begin within 3 months of the stressor

22. EPIDEMIOLOGY
• The prevalence of the disorder is estimated to be from 2 to 8 percent of the
general population .
• Women are diagnosed with the disorder twice as often as men
• The disorders can occur at any age but are most frequently diagnosed in
adolescents
• Among adults, common precipitating stresses are marital
problems, divorce, moving to a new environment, and financial
problems

23. • Among adolescents of either sex, common precipitating stresses are
school problems, parental rejection and divorce, and substance abuse
• Adjustment disorders are one of the most common psychiatric diagnoses
for disorders of patients hospitalized for medical and surgical problems.

24. ETIOLOGY
• an adjustment disorder is precipitated by one or more stressors.
• The severity of the stressor or stressors does not always predict the
severity of the disorder; the stressor severity is a complex function of
degree, quantity, duration, reversibility, environment, and personal context.
• Stressors may be recurrent, such as seasonal business difficulties, or
continuous, such as chronic illness or poverty
• Specific developmental stages, such as beginning school, leaving home,
getting married, becoming a parent, failing to achieve occupational goals,
having the last child leave home, and retiring, are often associated with
adjustment disorders.

25. Psychodynamic Factors
• The nature of the stressor, the conscious and unconscious meanings of the stressor, and
the patient’s preexisting vulnerability.
• A concurrent personality disorder or organic impairment may make a person vulnerable to
adjustment disorders.
• Vulnerability is also associated with the loss of a parent during infancy or being reared in
a dysfunctional family. Actual or perceived support from key relationships can affect
behavioral and emotional responses to stressors.
• the same stress can produce a range of responses in various persons. Throughout early
development, each child develops a unique set of defense mechanisms to deal with
stressful events. Because of greater amounts of trauma or greater constitutional
vulnerability, some children have less mature defensive constellations than other children

26. CONT.
• the good-enough mother, a person who adapts to the
infant’s needs and provides sufficient support to enable the growing child to
tolerate the
frustrations in life
• Psychodynamic clinicians must consider the relation between a stressor and the
human developmental life cycle.
• When adolescents leave home for college, for example, they are at high
developmental risk for reacting with a temporary symptomatic picture
• Similarly, if the young person who leaves home is the last child in the family, the
parents may be particularly vulnerable to a reaction of adjustment disorder.

27. Diagnosis

28. DIFFERENTIAL DIAGNOSIS
• uncomplicated bereavement
• Major depressive disorder
• brief psychotic disorder
• generalized anxiety disorder
• Somatic symptom disorder
• substance-related disorder
• conduct disorder
• PTSD
• These diagnoses should be given precedence in all cases that meet their
criteria
• Because no absolute criteria help to distinguish an adjustment disorder

29. COURSE AND PROGNOSIS
• With appropriate treatment, the overall prognosis of an adjustment
disorder is generally favorable.
• Most patients return to their previous level of functioning within 3 months.
• Some persons (particularly adolescents) who receive a diagnosis of an
adjustment
disorder later have mood disorders or substance-related disorders.
Adolescents usually require a longer time to recover than adults.
• Risk of suicide is high, Comorbid diagnoses of substance abuse and
personality disorder contributed to the suicide risk profile.

30. TREATMENT
• Psychotherapy remains the treatment of choice for adjustment disorders. Group
therapy
can be particularly useful for patients who have had similar stresses—for
example, a
group of retired persons or patients having renal dialysis
Crisis Intervention
• short-term treatments aimed at helping persons with adjustment disorders
resolve their situations quickly by supportive techniques, suggestion,
reassurance, environmental modification, and even hospitalization, if necessary.
Pharmacotherapy
• No studies have assessed the efficacy of pharmacological interventions in
individuals
with adjustment disorder, but it may be reasonable to use medication to treat
specific
symptoms for a brief time.

31. Reference
• Kaplan and Sadock’s synopsis text book of psychiatry 11th edition
• DSM 5th edition text revision
• UpToDate 2023

32. Thank you