Lecture 7 - Trauma and Stressor-Related Disorders

Question 1

PTSD isn’t about _____, it’s about _____

Answer 1

what’s wrong w/ you, what happened to you

Question 2

DSM-5 definition of trauma and stressor related disorder

Answer 2

disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion

• relationship w/ Anxiety Disorders, Obsessive Compulsive and Related Disorders, and Dissociative Disorders

psychological distress following exposure to a traumatic or stressful event is variable
- anxiety or fear based
- anhedonic and dysphoric symptoms
- externalizing angry and aggressive symptoms
- dissociative symptoms

Question 3

DSM-IV viewing of PTSD

Answer 3

was viewed as a pathological response to an extreme form of stress

• initially viewed as a normal response to an abnormal stressor (emphasis was on the nature of the stressor itself and not on the emotional response)
• range of experiences was broadened
• required an emotional reaction, “intense fear, helplessness or horror”
• broadening led to increase in report 89.6% of community samples reporting exposure to a traumatic event w/ the required emotional response (in most cases, sudden and unexpected death of a loved one)

in DSM-5, criteria tightened

Question 4

PTSD criteria

Answer 4

A. Exposure
B. Intrusion (presence of 1 or more)
C. Avoidance
D. Negative Mood and Cognitions (2 or more)
E. Alterations in arousal and reactivity (2 or more)
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

specify whether:
- w/ dissociative symptoms either depersonalization or derealization

specify if:
- w/ 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)

Question 5

PTSD Criterion A: Exposure

Answer 5

exposure to actual or threatened death, serious injury, or sexual violence in one (or more 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 of 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) (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

note: the criteria apply to adults, adolescents, and children older than 6 years

Question 6

PTSD Criterion B: Intrusion

Answer 6

presence of one (or more) of the following intrusion symptoms associated w/ 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 (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, w/ the most extreme expression being a complete loss of awareness of present surroundings)
• 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)

Question 7

PTSD Criterion C: Avoidance

Answer 7

persistent avoidance of stimuli associated w/ the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one of both of the following:

• avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely associated w/ the traumatic event(s)

Question 8

PTSD Criterion D: Negative Cognitions and Mood

Answer 8

negative alterations in cognitions and mood associated w/ the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following

• 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)
• 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”)
• persistent, distorted cognitions about the case or consequence of the traumatic event(s) that lead the individual to blame himself/herself or others
• persistent negative emotional state (e.g. 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 (e.g. inability to experience happiness, satisfaction or loving feelings)

Question 9

PTSD Criterion E: Arousal and Reactivity

Answer 9

marked alterations in arousal and reactivity associated w/ the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

• irritable behavior and angry outbursts (w/ little or no provocation) typically expressed as verbal or physical aggression toward people or objects
• reckless or self-destructive behavior
• hypervigilance
• exaggerated startle response
• problems w/ concentration
• sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep)

Question 10

functional consequences of PTSD

Answer 10

• high levels of social, occupational, and physical disability
• economic costs
• medical utilization
• impaired functioning in social, interpersonal, developmental, educational, physical health, occupational domains
• poor social and family relationships, absenteeism from work, lower income, lower education and occupational success

Question 11

Acute Stress Disorder

Answer 11

individuals w/ Acute Stress Disorder shortly after a traumatic event are at increased risk for PTSD

differential Dx w/ PTSD

• 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 9 or more symptoms from any of the 5 categories of intrusion, negative mood, dissociation, avoidance, and arousal and beginning or worsening after the traumatic event

Question 12

clinical presentation of Acute Stress Disorder

Answer 12

• presentation may vary
• typically involves an anxiety response that includes re-experiencing or reactivity to the traumatic event
• dissociate 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 13

Adjustment Disorder

Answer 13

a psychological response to a common stressor (e.g. divorce, loss of a job) that results in clinically significant behavioral or emotional symptoms

• symptoms begin within 3 months of the onset of the stressor
• must experience more distress than would be expected given the circumstances or be unable to function as usual
• beyond 6 months, the diagnosis may change
• the stressor/event can be of any severity or type rather than that required by PTSD Criterion A

Question 14

Adjustment Disorder is diagnosed when …

Answer 14

… the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria (or criteria for another mental disorder)

Question 15

specifiers of Adjustment Disorders

Answer 15

• w/ depressed mood
• w/ anxiety
• w/ mixed anxiety and depressed mood
• w/ disturbance of conduct
• w/ mixed disturbance of emotion and conduct
• unspecified

Question 16

Adjustment Disorder w/ depressed mood

Answer 16

sadness, crying, and feelings of hopelessness

Question 17

Adjustment Disorder w/ anxiety

Answer 17

worrying, nervousness, and jitters (or in children, fear of separation from primary attachment figures)

Question 18

Adjustment Disorder w/ mixed anxiety and depressed mood

Answer 18

a combination of anxiety and depression

Question 19

Adjustment Disorder w/ disturbance of conduct

Answer 19

violation of the rights of others or violation of social norms appropriate for ones age; sample behaviors include vandalism, truancy, fighting, reckless driving, and defaulting on legal obligations (e.g. stopping alimony payments)

Question 20

Adjustment Disorder w/ mixed disturbance of emotion and conduct

Answer 20

both emotional disturbance, such as depression or anxiety, and conduct disturbance (as described previously)

Question 21

Adjustment Disorder unspecified

Answer 21

a residual category that applies to people not classifiable in one of the other subtypes

Question 22

Other Specified Trauma and Stressor Related Disorder

Answer 22

• 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 23

Unspecified Trauma and Stressor Related Disorder

Answer 23

• 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 24

Complex Trauma

Answer 24

• repetitive, prolonged, or cumulative
• most often interpersonal, involving direct harm, exploitation, and maltreatment including neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults
• 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 w/ disability/disempowerment/dependency/age/infirmity, and so on

DSM-5 does not have a diagnosis for Complex Trauma

Question 25

ICD-11 definition PTSD

Answer 25

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:

• re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares; are typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations
• avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the vent or events
• persistent perceptions or heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises

symptoms persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning

Question 26

ICD-11 of Complex PTSD

Answer 26

• 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, is characterized by severe and persistent 1) problems in affect regulation; 2) beliefs about oneself as diminished, defeated or worthless, accompanied by feeling 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

Question 27

the major conceptual understanding of PTSD derives from the …

Answer 27

… behavioral or learning perspective

• contemporary conceptualizations focus on the Neuroscience of Trauma (stress response, emotional brain, fear memory)

Question 28

perspective of PTSD from classical conditioning

Answer 28

• traumatic experiences are unconditioned stimuli that become paired w/ neutral (conditioned) stimuli such as the sights, sounds, and even smells associated w/ the trauma
• anxiety becomes a conditioned response that is elicited by exposure to trauma-related stimuli

Question 29

perspective of PTSD from operant conditioning

Answer 29

• avoidance behaviors negatively reinforced by relief from anxiety
• extinction when person encounters cues to the trauma in absence of unconditioned stimuli