8. Trauma- and Stressor-Related Disorders

Question 1

Name DSM-5 diagnostic criteria: Post-Traumatic Stress Disorder (9)

Answer 1

1. exposure to actual or threatened death, serious injury, or sexual violence in ≥1 of the following ways:
   
   • directly experiencing the traumatic event(s)
   • witnessing, in person, the event(s) as it occurred to others
   • 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
   • experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (i.e. first responders collecting human remains, police officers repeatedly exposed to details of child abuse)
2. presence of ≥1 of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
   
   • recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
   • recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)
   • dissociative reactions (i.e. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
   • intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
   • marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
3. 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:
   
   • avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
   • 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)
4. negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
   
   • inability to remember an important aspect of the traumatic event(s)
   • persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
   • persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
   • persistent negative emotional state (i.e. fear, horror, anger, guilt, or shame)
   • markedly diminished interest or participation in significant activities
   • feelings of detachment or estrangement from others
   • persistent inability to experience positive emotions
5. marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by ≥2 of the following:
   
   • irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
   • reckless or self-destructive behaviour
   • hypervigilance
   • exaggerated startle response
   • problems with concentration
   • sleep disturbance (i.e. difficulty falling or staying asleep or restless sleep)
6. duration of the disturbance (criteria B, C, D, and E) is more than 1 mo
7. the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
8. the disturbance is not attributable to the physiological effects of a substance or another medical condition

• specifiers:
  
  • with dissociative symptoms (not attributable to physiologic effects of a substance or a medical condition)
  • depersonalization: persistent or recurrent experiences of feeling detached from, or as if one were an outside observer of one’s mental processes or body
  • derealization: persistent or recurrent experiences of unreality of surroundings
  • with delayed expression: the full diagnostic criteria are not met until 6 mo after the event

Question 2

Name: Criteria for Post-Traumatic Stress Disorder (Acronym) (7)

Answer 2

TRAUMA

• 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

Question 4

Describe epidemiology: PTSD (4)

Answer 4

• lifetime prevalence in Canada is 9%
• 75% have another comorbid psychiatric disorder
• high rates of chronic pain, sleep problems, sexual dysfunction, cognitive dysfunction
• twice as high among women versus men

Question 5

Describe: Acute Stress Disorder (3)

Answer 5

• May be a precursor to PTSD
• Similar symptoms to PTSD
• Symptoms persist 3 d after a trauma until 1 mo after the exposure

Question 6

Describe treatment: PTSD (3)

Answer 6

• trauma therapy, CBT
  
  • ensure safety and stabilize: emotional regulation techniques (i.e. breathing, relaxation)
  • once coping mechanisms established, can explore/mourn trauma, challenge dysfunctional beliefs, etc.
  • reconnect and integrate: exposure therapy, etc.
• biological
  
  • first line: fluoxetine, paroxetine, sertraline, venlafaxine XR
  • prazosin (for treating disturbing dreams and nightmares)
  • benzodiazepines (for acute anxiety)
  • adjunctive atypical antipsychotics (risperidone, olanzapine)
• eye movement desensitization and reprocessing (EMDR): an experimental method of reprocessing memories of distressing events by recounting them while using a form of dual attention stimulation such as eye movements, bilateral sound, or bilateral tactile stimulation (its use is controversial because of limited evidence)

Question 7

Name complications: PTSD (5)

Answer 7

• substance abuse
• relationship difficulties
• depression
• impaired social and occupational functioning disorders
• personality disorders

Question 8

Define: Adjustment Disorder (1)

Answer 8

• a diagnosis encompassing patients who have difficulty coping with a stressful life event or situation and develop acute, often transient, emotional or behavioural symptoms that resemble less severe versions of other psychiatric conditions

Question 9

Name DSM-5 criteria: Adjustment Disorder (5)

Answer 9

1. the development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 mo of the onset of the stressor(s)
2. these symptoms or behaviours are clinically significant as evidenced by either of the following:
   
   • marked distress that is in excess of what would be expected from exposure to the stressor
   • significant impairment in social or occupational functioning
3. the stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder
4. the symptoms do not represent normal bereavement
5. once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 mo

• specifiers: with depressed mood, with anxiety, with mixed anxiety/depression, with conduct disturbance, with mixed disturbance of conduct/emotions, unspecified

Question 10

Name types of stressors: Adjustment Disorder (5)

Answer 10

• single (i.e. termination of romantic relationship)
• multiple (i.e. marked business difficulties and marital problems)
• recurrent (i.e. seasonal business crises)
• continuous (i.e. living in a crime-ridden neighbourhood)
• developmental events (i.e. going to school, leaving parental home, getting married, becoming a parent, failing to attain occupational goals, retirement)

Question 11

Describe epidemiology: Adjustment Disorder (1)

Answer 11

• F:M 2:1, prevalence 2-8% of the population

Question 12

Describe tx: Adjustment Disorder (2)

Answer 12

• brief psychotherapy: individual or group (particularly useful for patients dealing with unique and specific medical issues; i.e. colostomy or renal dialysis groups), crisis intervention
• biological
  
  • benzodiazepines may be used for those with significant anxiety symptoms (short-term, low-dose, regular schedule)