Last updated: October 20, 2022
Summary
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.
Overview
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References:[1]
Acute stress disorder
Overview
Definition
- The development of a strong psychological reaction to a traumatic event characterized by acute symptom onset and the persistence of symptoms for at least 3 days and up to 1 month
Epidemiology [1]
Risk factors [1]
Diagnostic criteria [DSM-5] [1]
- Exposure to death [actual or threatened], serious injury, or sexual violence that occurs in ≥ 1 of the following ways:
- Presence of at least 9 of the following symptoms from any of the
five categories below:
-
Intrusion
- Recurrent distressing memories
- Recurrent distressing dreams
- Flashbacks
- Severe psychological distress or physiological responses to internal or external cues related to the event
- Negative mood: inability to feel positive emotions [e.g., happiness, satisfaction, or love]
- Dissociation
- Altered sense of reality
- Loss of memory with regards to important details of the event
- Avoidance
- Avoidance of memories, thoughts, or feelings related to the event
- Avoidance of external reminders [e.g., places, people, conversations, objects] related to the event
-
Arousal
- Sleep disturbance
- Irritable behavior
- Hypervigilance
- Poor concentration
- Heightened startle reflex
-
Intrusion
- Duration: Symptoms last from 3 days to 1 month following the traumatic event.
- The affected individual has been experiencing significant distress or impaired social and/or occupational functioning since the traumatic event.
- Symptoms are not explained by substance use or another medical condition.
Treatment and prognosis [2]
- Assess all patients with acute first- and second-hand experiences of trauma for ASD and offer psychological care.
- Determine the setting of psychiatric treatment [inpatient or outpatient] based on the severity of symptoms, the risk of self-injurious behavior and suicide, and the severity of trauma experienced or exposed to.
- Provide education about the broad range of expected reactions to traumatic situations as well as about the natural course of the disorder and treatment options available
- First-line treatment: trauma-focused cognitive behavioral therapy [2]
- Pharmacotherapy: Benzodiazepines are not routinely recommended but may be useful in patients with severe anxiety, agitation, or sleep disturbances.
- Early intervention is important to avoid progression of ASD to PTSD. [3]
Posttraumatic stress disorder [PTSD]
Overview
Definition
- A psychiatric disorder triggered by a personally experienced or witnessed traumatic event that persists for more than 1 month
Epidemiology [4]
Etiology
- Triggers: exposure to traumatic events [either
through direct experience or as a witness]
- Sexual violence [most common] [5]
- 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. [6]
- Diagnosis of a severe disease
- Witnessing the death of another person
-
Risk factors
- Psychiatric comorbidities
- Lower socioeconomic status
- Younger age at the time of trauma
- Lack of social support
- Prior traumatic exposure and/or subsequent reminders, including childhood experiences
- Initial severe reaction to the traumatic event
- Common comorbidities: depression, substance use disorders, somatic symptom disorder
Diagnostic criteria [DSM-5] [1]
- Experience of a traumatic event involving
death [actual or threatened], serious injury, or
sexual violence in one or more of the following ways:
- Direct experience of the event[s]
- Witnessing the event[s]
- Learning about the event[s] happening to close friends or family
- Repeated exposure to details of the traumatic event[s] occurring to others
- One or more the following
intrusion symptoms that begin after the traumatic event[s]:
- Recurrent intrusive memories of the traumatic event[s]
- Recurrent, distressing dreams related to the traumatic event[s]
- Dissociative reactions [e.g., flashbacks]: individuals act and/or feel as if they were reexperiencing the traumatic event[s]
- Intense and persistent distress when exposed to internal or external cues related to the traumatic event[s]
- Physiological reactions triggered by external or internal cues associated with the traumatic event[s]
- Avoidance of stimuli related to the traumatic event[s] as expressed in one or both of the following ways:
- Negatively affected mood and
cognition associated with the traumatic event[s] that begins or worsens after the event[s] in at least two of the following ways:
- Inability to remember important details of the event[s]
- Exaggerated negative thoughts or expectations about oneself or the world
- Distorted cognitions regarding the cause and/or consequences of the event[s]
- Persistent negative emotions [e.g., fear, horror, distress, guilt]
- Reduced or absent interest in important activities
- Detachment from others
- Inability to experience positive emotions [e.g., happiness, satisfaction, or love]
- Altered reactivity or arousal associated with the traumatic event[s] beginning or worsening after the event[s] in at least two of the following ways:
- Irritability or angry outbursts
- Hypervigilance
- Excessive startle response
- Sleep disturbance; [e.g., nightmares, difficulty initiating or maintaining sleep]
- Poor concentration
- Self-destructive behavior
- Duration: Symptoms last > 1 month following the traumatic event[s].
- The affected individual has been experiencing significant distress or impaired social and/or occupational functioning.
- Symptoms are not explained by substance use or another medical condition.
- Diagnostic criteria for children > 6 years of age are the same as for adults.
To remember the features of PTSD, think of “TRAUMMA”: Traumatic event, Reexpereince, Avoidance, Unable to function, More than a Month of duration, Arousal is increased
Treatment and prognosis [7]
- First-line:
psychotherapy with or without adjunctive pharmacotherapy
[7]
- Trauma-focused cognitive-behavioral therapy
- Eye movement desensitization and reprocessing: The patient recalls traumatic images while following the therapist's fingers with their eyes from left to right. [8]
- Pharmacotherapy
- SSRIs, SNRIs [e.g., venlafaxine]
- Prazosin: for nightmares
- Benzodiazepines should generally be avoided due to the risk of misuse and lack of evidence supporting the benefits.
- Approx. 60% of patients receiving treatment achieve full recovery within an average timespan of 36 months. [9][10]
Pharmacotherapy alone is used in patients with PTSD who opt against or do not have access to psychotherapy.
Diagnostic criteria for PTSD in children < 6 years of age [DSM-5] [1]
Children with PTSD may experience developmental regression.
References:[11]
Adjustment disorder
Overview
Definition
- A maladaptive emotional [e.g., anxiety] or behavioral [e.g., outburst] response to a stressor, lasting ≤ 6 months following resolution of the stressor
Epidemiology
Etiology
- A combination of intrinsic and extrinsic stressors [e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness]
Diagnostic criteria [DSM-5] [1]
- Emotions or behaviors in response to a stressor that occur within 3 months of onset
-
Clinically significant responses that include ≥ 1 of the following:
- A level of distress that is disproportionate to the expected response to the stressor
- Impaired functioning in social, occupational, and/or other important areas
- Symptoms are not explained by another mental disorder.
- Symptoms are not explained by a normal response to grief.
- Symptoms last ≤ 6 months following resolution of the stressor.
Differential diagnosis
- Normal stress reaction
- Major depressive disorder: Although some symptoms can be shared between the two conditions, the criteria for MDD are not met. [See Diagnostic criteria for major depressive disorder.]
- Generalized anxiety disorder : If symptoms of adjustment disorder last > 6 months the diagnosis is changed to GAD.
Treatment and prognosis [12]
- Psychotherapy
- First-line treatment: cognitive-behavioral therapy or psychodynamic psychotherapy
- May be provided as individual, family, or group support therapy
- Interpersonal psychotherapy
- Pharmacotherapy
Although psychotherapy alone is usually sufficient in patients with adjustment disorder who have no other disabling symptoms, pharmacotherapy may be used when psychotherapy has little or no effect.
References:[1][12][13]
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
- Ursano et al.. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.. The American journal of psychiatry. 2004; 161 [11 Suppl]: p.3-31.
- Bisson JI, Wright LA, Jones KA, et al. Preventing the onset of post traumatic stress disorder.. Clin Psychol Rev. 2021; 86 : p.102004. doi: 10.1016/j.cpr.2021.102004 . | Open in Read by QxMD
- Vieweg WVR, Julius DA, Fernandez A, Beatty-Brooks M, Hettema JM, Pandurangi AK. Posttraumatic Stress Disorder: Clinical Features, Pathophysiology, and Treatment. Am J Med. 2006; 119 [5]: p.383-390. doi: 10.1016/j.amjmed.2005.09.027 . | Open in Read by QxMD
- Kessler et al.. How well can post-traumatic stress disorder be predicted from pre-trauma risk factors? An exploratory study in the WHO World Mental Health Surveys.. World psychiatry : official journal of the World Psychiatric Association [WPA]. 2014; 13 [3]: p.265-74. doi: 10.1002/wps.20150 . | Open in Read by QxMD
- Combat Exposure Scale. //www.ptsd.va.gov/professional/assessment/te-measures/ces.asp. . Accessed: October 12, 2022.
- VA/DOD. VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Clinician Summary.. Focus [Am Psychiatric Publ]. 2018; 16 [4]: p.430-448. doi: 10.1176/appi.focus.16408 . | Open in Read by QxMD
- Yehuda R, Hoge CW, McFarlane AC, et al. Post-traumatic stress disorder.. Nature reviews. Disease primers. 2015; 1 : p.15057. doi: 10.1038/nrdp.2015.57 . | Open in Read by QxMD
- Grinage BD. Diagnosis and management of post-traumatic stress disorder.. Am Fam Physician. 2003; 68 [12]: p.2401-8.
- National Academies Press [US]. Treatment for posttraumatic stress disorder in military and veteran populations: final assessment.. Mil Med. 2014; 179 [12]: p.1401-3. doi: 10.7205/MILMED-D-14-00418 . | Open in Read by QxMD
- Sareen J, Stein MB, Hermann R. Posttraumatic Stress Disorder in Adults: Epidemiology, Pathophysiology, Clinical Manifestations, Course, Assessment, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. //www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis.Last updated: April 25, 2017. Accessed: July 5, 2017.
- Frank J, Bienenfeld D. Adjustment Disorders . Adjustment Disorders . New York, NY: WebMD. //emedicine.medscape.com/article/2192631. Updated: November 1, 2016. Accessed: July 5, 2017.
- Ganti L, Kaufman MS, Blitzstein SM. First Aid for the Psychiatry Clerkship. McGraw Hill Professional ; 2016
- Trauma- and Stressor-Related Disorders. //dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm07. . Accessed: July 12, 2017.