Lecture 3 - Trauma and Stressor Related Disorders

Question 1

What are some potential challenges in the diagnostic process
in this initial stage?

Answer 1

• don’t have full story
• therapist is stranger, need to first set safe environment before all the details. Although some people do come out straight with all of the details.

Question 2

Definition of Mental Disorder

Answer 2

• clinically significant disturbance in behavior, emotion regulation, or cognitive function.
• These disturbances are thought to reflect dysfunction in biological, psychological, or developmental processes that are necessary for mental functioning.
• Mental Disorders are usually associated with significant distress or disability in key areas of functioning such as social, occupational, or other activities.

This difference in behaviour is not due to cultural differences, nor stemming from social deviance or societal conflict.

Question 3

Psychiatric Classification Systems

Answer 3

• Diagnostic and statistical manual of mental disorders (DSM).
• International classification of diseases (ICD)

Question 4

DSM

Answer 4

• Published by the American Psychiatric Association
• Used in the United States
• Currently on version 5, text revision DSM-5-TR

Question 5

ICD

Answer 5

• Published by the World Health Organization (WHO)
• Some similarities and differences to DSM
• Currently on version 11, ICD-11
• Used in many countries outside of the US

Question 6

DSM-5

Answer 6

• Describes 22 major categories containing more than 200 different mental disorders
• Medical Model
• Categorical and Dimensional
• Regarded as a work in progress
• Not a “cookbook” or checklist
• Atheoretical

Question 7

What’s included in each section of DSM-5

Answer 7

• Diagnostic Criteria
• Prevalence
• Development and Course
• Risk and Prognostic Factors
• Diagnostic Markers
• Suicide Risk
• Functional Consequences
• Differential Diagnosis
• Comorbidity

Question 8

How do we define trauma?

Answer 8

• Type
• Duration
• Severity
• Frequency

Question 9

Trauma and Stressor Related Disorders - DSM5

Answer 9

• Disorders in which exposure to a traumatic or stressful event is listed
  explicitly as a diagnostic criterion
• Close relationship between these diagnoses and disorders and the
  Anxiety Disorders, Obsessive Compulsive and Related Disorders, and
  Dissociative disorders
• Psychological Distress following exposure to a traumatic or stressful
  event is variable
• Some symptoms are well understood within an anxiety or fear-based
  context, but many individuals exposed to a traumatic or stressful event
  exhibit anhedonic (inability to feel pleasure) or dysphoric symptoms, externalising angry or aggressive symptoms, or dissociative symptoms.

Question 10

Difference between Trauma and related disorders vs anxiety disorders

Answer 10

• Some symptoms are well understood within an anxiety or fear-based
  context, but many individuals exposed to a traumatic or stressful event
  exhibit anhedonic (inability to feel pleasure) or dysphoric symptoms, externalising angry or aggressive symptoms, or dissociative symptoms.

Question 11

PTSD Variability in Presentation

Answer 11

• Fear-based re-experiencing, emotional and behavioral symptoms
  predominate
• In others, anhedonic (reduced motivation, pleasure) or dysphoric
  (unease, dissatisfaction) mood states and negative cognitions
  may be most distressing.
• In some other individuals, arousal and reactive externalizing
  symptoms are prominent
• In others, dissociative symptoms predominate
• Some individuals exhibit combinations of these symptom
  patterns.

Question 12

Related disorders (of trauma and stressor related disorders)

Answer 12

• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorder
• Other Specified Trauma and Stressor Related Disorder
• Unspecified Trauma and Stressor Related Disorder

Question 13

Reactive Attachment Disorder

Answer 13

• Persistent failure to initiate or respond to most social
  interactions
• Inhibited

Question 14

Disinhibited Social Engagement Disorder

Answer 14

Diffuse, non-selectively focused attachment behavior

Question 15

PTSD Criteria

Answer 15

The following criteria apply to adults, adolescents and children older than 6 years.

A. Exposure
B. Intrusion
C. Avoidance
D. Negative Mood and Cognitions
E. Alterations in arousal and reactivity
F. Duration-More than 1 month
G. Distress-Clinically significant distress or impairment in social, occupational, or other important
areas of functioning
H. Not due to Physiological Effects of a substance or another medical condition

Must specify whether it’s with dissociative symptoms (either depersonalisation or derealisation) and whether it’s with delayed expression.

Question 16

Dissociative symptoms

Answer 16

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)

Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g. , the world around the individual is experienced as unreal, dreamlike, distant or distorted)

Question 17

Delayed expression

Answer 17

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)

Question 18

PTSD Criterion A

Answer 18

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).
   Note: Criterion A4 does not apply to exposure through electronic
   media, television, movies, or pictures, unless this exposure is work-
   related.

Question 19

Directly Experienced Traumatic Events.

Answer 19

Include but not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault, threated or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human made disasters, and severe motor vehicle accidents.
* A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking up during surgery, anaphylactic shock)

Question 20

Witnessed Events…

Answer 20

Include but not limited to, observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident or a medical catastrophe in one’s child

Question 21

Indirect exposure through Learning…

Answer 21

• Limited to experiences affecting close relatives or friends and experiences that are violent or accidental (e.g., death due to natural causes does not qualify).

Question 22

PTSD Criterion B

Answer 22

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).
3. Dissociative reactions (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)
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).

Question 23

PTSD Criterion C

Answer 23

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).

Question 24

PTSD Criterion D

Answer 24

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) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequence 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
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction or loving feelings)

Question 25

PTSD Criterion E

Answer 25

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 behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep)

Question 26

PTSD - development and course

Answer 26

• Symptoms typically begin within 3 months after the trauma
• A delay in months or years may occur before criteria for the
  diagnosis are met.
• Delayed Onset (DSM-IV) now termed Delayed Expression
• Frequently, an individual’s reaction to a trauma initially meets
  criteria for Acute Stress Disorders in the immediate aftermath
  of the trauma.
• Symptoms of PTSD and relative predominance of different
  symptoms may vary over time
• Duration varies:
• Complete recovery within 3 months occurring in approx. ½ of
  adults
• Others symptomatic longer than 1 year or for more than 50
  years.

Question 27

PTSD Risk and Prognostic factors

Answer 27

Risk factors may predispose individuals to trauma or to extreme emotional responses when exposed to traumatic events.

Prognostic factors:
Pretraumatic (temperamental, environmental).
- Peritraumatic (environmental)
- Post-traumatic (temperamental, environmental).

Question 28

Pretraumatic risk/prognostic factors

Answer 28

• Temperamental-childhood emotional problems by age 6, prior mental disorders, personality traits e.g. negative affectivity (neuroticism)
• Environmental-lower socioeconomic status, lower education, exposure to prior trauma, childhood adversity, lower intelligence, family psychiatric history. Social support protective.
• Genetic and Physiological-genetic risk is modestly heritable.

Question 29

Peritraumatic risk/prognostic factors

Answer 29

• Environmental-severity of the trauma, perceived life threat, personal injury, interpersonal violence. Vets-being a perpetrator, witnessing atrocities, or killing the “enemy.”
• Dissociation, fear, panic and other peritraumatic responses that occure during the trauma and persist afterward.

Question 30

Post-traumatic risk/prognostic factors

Answer 30

• Temperamental-negative appraisals, inappropriate coping strategies, development of acute stress disorder.
• Environmental-subsequent exposure to repeated upsetting reminders, subsequent adverse life events, financial or other trauma related losses. High levels of daily stressors. Social support is a protective factor,

Question 31

Functional Consequences of
PTSD and Trauma

Answer 31

Research demonstrates correlations to:
* High levels of medical utilization
* Impaired functioning in social, interpersonal, developmental,
educational, physical health, occupational domains
* Poor social and family relationships, absenteeism from work,
lower income, lower educational and occupational success
* High levels of comorbidity to a majority of mental disorders
* High Economic Costs

Question 32

Differential Diagnosis of PTSD

Answer 32

• Adjustment Disorders
• Acute Stress Disorder
• Anxiety Disorders and OCD
• Major Depressive Disorder
• Personality Disorders
• Dissociative Disorders
• Conversion Disorder
• Psychotic Disorders
• Traumatic Brain Injury

Question 33

PTSD Comorbidity

Answer 33

• Individuals with PTSD are more likely than those without PTSD
  to have symptoms that meet diagnostic criteria for at least
  one other mental disorder, such as depressive, bipolar,
  anxiety, or substance use disorders.
• PTSD is also associated with increased risk of major
  neurocognitive disorder.
• Women more likely to develop PTSD following a mild TBI.
• In children, PTSD most likely comorbid with oppositional
  defiant disorder and separation anxiety disorder.

Question 34

Acute Stress Disorder

Answer 34

• Individuals with Acute Stress Disorder shortly after a traumatic
  event are at increased risk for PTSD., only some of the time.
• Differential Dx: Acute Stress Disorder is distinguished from PTSD
  because symptom pattern in Acute Stress Disorder is restricted to
  a duration of 3 days to 1 month following exposure to the
  traumatic event.
• Presence of nine or more of the symptoms from any of the five
  categories of intrusion, negative mood, dissociation, avoidance,
  and arousal, beginning or worsening after the traumatic event
  occurred.
• Symptoms typically begin immediately after the trauma, but
  persistence for at least 3 days and up to a month is needed to
  meet criteria.

Question 35

Clinical presentation of acute stress disorder

Answer 35

• Presentation may vary
• Typically involves an anxiety response that includes re-
  experiencing or reactivity to the traumatic event.
• Dissociative or detached presentation may occur in some
  individuals, they also typically will display strong emotional or
  physiological reactivity in response to cues.
• In others a strong anger response, irritability or
  aggressiveness.
• Often engage in catastrophic or extremely negative thoughts
  about their role in the event, their response, or the likelihood
  of future harm.
• Common to experience panic attacks when triggered
• May display chaotic or impulsive behavior.

Question 36

Adjustment disorder

Answer 36

• Adjustment disorder is a psychological response to a common
  stressor (e.g., divorce, death of a loved one, loss of a job) that
  results in clinically significant behavioral or emotional symptoms.
• Symptoms begin within 3 months of the onset of the stressor and
  the person must experience more distress than would be expected
  given the circumstances or be unable to function as usual.
• Beyond 6 months, the diagnosis changes.
• In Adjustment Disorders, the stressor can be of any severity or type
  rather than that required by PTSD Criterion A.
• The diagnosis of an Adjustment Disorder is used when the response
  to a stressor that meets PTSD Criterion A does not meet all other
  PTSD criteria (or criteria for another mental disorder).
• An Adjustment Disorder is also diagnosed when the symptom
  pattern of PTSD occurs in response to a stressor that does not meet
  PTSD Criterion A (e.g., spouse leaving, being fired).

Question 37

Adjustment disorder specifiers

Answer 37

• Adjustment disorder with depressed mood (Sadness, crying, and feelings of hopelessness)
• Adjustment disorder with anxiety (Worrying, nervousness, and jitters (or in children, fear of separation from primary attachment figures).
• Adjustment disorder with mixed anxiety and depressed mood (A combination of anxiety and depression.)
• Adjustment disorder with disturbance of conduct (Violation of the rights of others or violation of social norms appropriate for one’s age; sample behaviors include vandalism, truancy, fighting, reckless driving, and defaulting on legal obligations (e.g., stopping alimony payments).)
• Adjustment disorder with mixed disturbance of emotion and conduct (Both emotional disturbance, such as depression or anxiety, and conduct disturbance (as described previously).)
• Adjustment disorder unspecified (A residual category that applies to people not classifiable in one of the other subtypes.)

Question 38

Other Specified Trauma and
Stressor Related Disorder

Answer 38

• Applies to presentations in which symptoms characteristic of
  a trauma and stressor related disorder that cause clinically
  significant distress or impairment in social, occupational, or
  other important areas of functioning predominate but do not
  meet the full criteria for any of the disorders in the category.
• Used in situations in which the clinician chooses to
  communicate the specific reason that the presentation does
  not meet the criteria for any specific trauma-and stressor
  related disorder.

Question 39

Unspecified Trauma and
Stressor Related Disorder

Answer 39

• Similar to Other Specified, but clinician chooses not to specify
  the reason that the criteria are not met
• Includes situations in which there is insufficient information to
  make a more specific diagnosis.

Question 40

DSM-5-TR: Culture Related
Diagnostic Issues

Answer 40

• Different demographic, cultural and occupational groups have
  different levels of exposure to traumatic events
• The relative risk of developing PTSD following a similar level of
  exposure may vary across cultural, ethnic, and racialized groups.
• Variation in the type of traumatic exposure, impact on disorder
  severity of the meaning attributed to the traumatic event, the
  ongoing sociocultural context, exposure to racial and ethnic
  discrimination may influence risk and severity of PTSD across
  groups.
• Some communities are exposed to pervasive and ongoing
  traumatic environments, rather than isolated Criterion A events; in
  these communities, the predictive power of individual traumatic
  events for the development of PTSD may diminish.

Question 41

Differences in culture related responses and PTSD

Answer 41

• In cultures where social image (e.g. maintaining a family’s “face”) is emphasized, public defamation or shaming may magnify the impact of Criterion A events.
• Some cultures may attribute PTSD syndromes to negative supernatural experiences.
• The clinical expression of the symptoms or symptom clusters of PTSD can vary culturally.
• In many non-Western groups, avoidance is less commonly observed, whereas somatic symptoms (dizziness, shortness of breath, heat-sensations) are more common

Question 42

DSM-5-TR: Sex and Gender-
Related Diagnostic Issues

Answer 42

• PTSD is more prevalent among women than among men across the life span.
• Lifetime prevalence of PTSD ranges from 8-11% for women and 4.1%-5.4% for men based on two large U.S. population-based studies using DSM-5 criteria.
• Some of the increased risk for PTSD in women appears to be attributable to a greater likelihood of exposure to childhood sexual abuse, sexual assault, and other forms of interpersonal violence which carry the highest ris of development of PTSD.
• Women in the general population experience PTSD for longer duration than do men.
• Other factors likely contributing to the higher prevalence in women include gender differences in the emotional and cognitive processing of trauma, as well as effects of reproductive hormones.
• When responses of men and women to specific stressors are compared, gender differences in risk for PTSD persist.
• PTSD symptom profiles and factor structures are similar between men and women..

Question 43

Complex trauma

Answer 43

• DSM-5 does not have a diagnosis for Complex Trauma defined
  as…
• (1) repetitive, prolonged, or cumulative
• (2 ) most often interpersonal, involving direct harm,
  exploitation, and maltreatment
  including neglect/abandonment/antipathy by primary
  caregivers or other ostensibly responsible adults, and
• (3) often occur at developmentally vulnerable times in the
  victim’s life, especially in early childhood or adolescence, but
  can also occur later in life and in conditions of vulnerability
  associated with disability/ disempowerment/dependency/age
  /infirmity, and so on.

Question 44

ICD Complex PTSD

Answer 44

• PTSD is now restricted to three symptoms: re-experiencing
  the trauma, avoiding reminders of the trauma, and
  experiencing a heightened sense of threat and arousal.
• By comparison, the new Complex PTSD diagnosis is broader. It
  is comprised of all three symptoms of PTSD, but also includes:
• Difficulty regulating emotion
• Feelings of shame, guilt, or failure
• Conflictual interpersonal relationships.
• “The intent is to distinguish patients whose responses are
  focused mainly on the trauma itself from those whose
  difficulties ripple more widely through their lives.”

Question 45

ICD PTSD

Answer 45

• Post-traumatic stress disorder (PTSD) is a disorder that may develop following exposure to an extremely threatening or horrific event or series of events.
• It is characterized by all of the following:
• 1) re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares. These are typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations
• 2) avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event or events; and
• 3) persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.
• The symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Question 46

ICD complex PTSD definition

Answer 46

• May develop following exposure to an event or series of events
  of an extremely threatening or horrific nature, most commonly
  prolonged or repetitive events from which escape is difficult or
  impossible (e.g., torture, slavery, genocide campaigns, prolonged
  domestic violence, repeated childhood sexual or physical abuse).
• All diagnostic requirements for PTSD are met.
• In addition, Complex PTSD is characterized by severe and
  persistent 1) problems in affect regulation; 2) beliefs about
  oneself as diminished, defeated or worthless, accompanied by
  feelings of shame, guilt or failure related to the traumatic event;
  and 3) difficulties in sustaining relationships and in feeling close
  to others.
• These symptoms cause significant impairment in personal, family,
  social, educational, occupational or other important areas of
  functioning.