د.وليد عزيز العميديTrauma- and Stressor-Related Disorders
The stress : Refers to experiencing events that are perceived as endangering one’s physical or
psychological wellbeing. These events are usually referred to as stressors .People’s reactions to
these stressors are termed stress responses.
Characteristics of stressful events:
Some events are major changes affecting large no. of people , others are major changes in
the life of an individual, some are daily hassles.
Some are acute ,some are chronic.
Events that are perceived as stressful usually fall into one or more of the following categories:
1. Traumatic events.
2. Uncontrollable events.
3. Unpredictable events.
4. Major changes in life circumstances.
5. Internal conflicts.
Responses to stressful events :
Emotional response , with somatic complaints : the responses are of 2 kinds : anxiety
response with autonomic arousal leading to apprehension , irritability , tachycardia
and dry mouth .they are usually associated with events that pose a threat .
While depressive response with pessimistic thoughts and reduced physical activity associated
with events that involve separation or loss.
Coping strategy : serve to reduce the impact of stressful event , thus attenuating the
emotional and somatic response .
Coping strategies are of 2 kinds :
- Problem solving strategies: seeking help from another person , obtaining informations or
advice , making implementing plans to deal with problems and confrontation .
- Emotion reducing strategies : ventilation of emotion , evaluation of the problem , positive
reappraisal of the problem and avoidance of the problem.
Defense mechanisms : are unconscious responses to external stressors as well as to
anxiety arising from internal conflict .
The most frequent mechanisms are repression , denial , displacement , projection and
regression .
How stress affects health?
Emotional stress plays an important role in more than half of all medical problems.
Chronic stress can lead to physical disorders such as: ulcers, high blood pressure, and
heart disease.
It impairs immune system.
Psycho-physiological (psychosomatic) disorders: are physical disorders in which
emotions are believed to play a central role. Examples : asthma, hypertension, ulcers,
colitis, and rheumatoid arthritis.
Classification according to DSM-V :
There are six conditions that fall under category of Trauma- and Stressor-Related Disorders: .
Reactive Attachment Disorder. This disorder appears in infancy or early childhood and is
characterized by a severe impairment in the ability to relate because of grossly pathological
caregiving.
Disinhibited Social Engagement Disorder. This is a condition in which the child or adolescent
has a deep-seated fear of interacting with strangers, especially adults, usually as a result of a
traumatic upbringing.
Posttraumatic Stress Disorder (PTSD). PTSD occurs after a traumatic event in which the
individual believes that he or she is in physical danger or that his or her life is in jeopardy. PTSD
can also occur after witnessing a violent or life-threatening event happening to someone else.
The symptoms of PTSD usually occur soon after the traumatic event, although, in some cases,
the symptoms develop months or even years after the trauma. PTSD is diagnosed when a person
reacts to the traumatic event with fear and re-experiences symptoms over time or has symptoms
of avoidance and hyperarousal. The symptoms persist for at least 1 month and cause clinically
significant impairment in functioning or distress.
Acute Stress Disorder. Acute stress disorder occurs after the same type of stressors that
precipitate PTSD; however, acute stress disorder is not diagnosed if the symptoms last beyond 1
month.
Adjustment Disorders. Adjustment disorders are maladaptive reactions to clearly defined life
stress. They are divided into subtypes depending on symptoms—with anxiety, with depressed
mood, with mixed anxiety and depressed mood, disturbance of conduct, and mixed disturbance of
emotions and conduct.
Persistent Complex Bereavement Disorder. Chronic and persistent grief that is characterized
by bitterness, anger, or ambivalent feelings toward the dead accompanied by intense and
prolonged withdrawal characterizes persistent complex bereavement disorder (also known as
complicated grief or complicated bereavement). This must be distinguished from normal grief or
bereavement.
Acute reaction to stress: immediate and brief response to sudden intense stressors in a person
who does not have another psychiatric disorder at the time .
ICD- 10 definition of acute stress reaction that the response should start within an hour of
exposure to the stressor and begins to diminish after not more than 48 hr.
DSM-V definition : the condition should lasts for at least 3 days and for no more than 1
month after trauma exposure.
The core symptoms of acute stress reaction are depression or anxiety , avoidance is the most
frequent coping strategy , while the most frequent defense mechanism is denial .
The principle components of psychological first aid:
- comfort and consolation.
- Protection from further threat and distress.
- immediate physical care.
- helping reunion with loved ones.
- sharing the experience.
- facilitating the sense of being in control.
Post-traumatic stress disorder (PTSD) : this term denotes an intense , prolonged , and
sometime delayed reaction to an intensely stressful event.
Epidemiology:
Estimates of the PTSD in the general population are mainly from USA.
The lifetime prevalence ranges from about 10 to 12 percent among women and 5 to 6
percent among men.
Although PTSD can appear at any age, it is most prevalent in young adults, because they
tend be more exposed to precipitating situations.
Children can also have the disorder.
The lifetime prevalence is significantly higher in women, and a higher proportion of
women go on to develop the disorder.
Historically, men's trauma was usually combat experience, and women's trauma was most
commonly assault or rape.
The disorder is most likely to occur in those who are single, divorced, widowed, socially
withdrawn, or of low socioeconomic level.
The most important risk factors, however, for this disorder are the severity, duration, and
proximity of a person's exposure to the actual trauma.
A familial pattern seems to exist for this disorder, and first-degree biological relatives of
persons with a history of depression have an increased risk for developing PTSD
following a traumatic event.
Comorbidity :
Comorbidity rates are high among patients with PTSD, with about two thirds having at least
two other disorders.
Common comorbid conditions include depressive disorders, substance-related disorders,
other anxiety disorders, and bipolar disorders.
Comorbid disorders make persons more vulnerable to developing PTSD.
ETIOLOGY
Stressor
: stressor is the prime causative factor in the development of PTSD. Not everyone
experiences the disorder after a traumatic event, however. The stressor alone does not suffice to
cause the disorder. Clinicians must also consider individual’s preexisting biological and
psychosocial factors and events that happened before and after the trauma.
Predisposing Vulnerability Factors in Posttraumatic Stress Disorder
- Presence of childhood trauma.
- Borderline , antisocial , dependent and paranoid personality disorder or trait.
- Poor social support.
- Being female.
- Genetic vulnerability.
- Recent stressful life changes.
- Recent excessive alcohol intake.
Biological Factors
:
- Noradrenergic System. Soldiers with PTSD-like symptoms exhibit nervousness,
increased blood pressure and heart rate, palpitations, sweating, flushing, and tremors—
symptoms associated with adrenergic drugs.
- Opioid System. Abnormality in the opioid system is suggested by low plasma β-
endorphin concentrations in PTSD. Combat veterans with PTSD demonstrate a naloxone
-reversible analgesic response to combat-related stimuli, raising the possibility of opioid
system hyperregulation similar to that in the HPA axis
- Corticotropin-Releasing Factor and the HPA Axis: Studies have demonstrated low
plasma and urinary free cortisol concentrations in PTSD. Suppression of cortisol by
challenge with low-dose dexamethasone (Decadron) is enhanced in PTSD. This indicates
hyperregulation of the HPA axis in PTSD.
- Brain imaging : smaller volume of hippocampus , overactivity of amygdala to traumatic
psychological stimuli .
DIAGNOSIS
The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria
for PTSD specify that the symptoms of intrusion, avoidance, alternations of mood and
cognition, and hyperarousal must have lasted more than 1 month. The DSM-5 diagnosis of PTSD
allows the physician to specify if the symptoms occur in preschool-aged children or with
dissociative (depersonalization/derealization) symptoms. For patients whose symptoms have
been present less than 1 month, the appropriate diagnosis may be acute stress disorder.
The essential features of PTSD are :
- Hyperarousal : persistent anxiety , irritability , insomnia and poor concentration.
- Intrusions : intense intrusive imagery , flashbacks and recurrent distressing dream.
- Avoidance : difficulty in recalling stressful events at will , avoidance of reminders of the
events , detachment , numbness and diminished interest in activities.
- Onset and course : symptoms of PTSD may begin very soon after the stressful event or
after an interval usually of days , but occasionally of months , though not more than 6
months . In DSM-V PTSD cannot diagnosed until at least a month of symptomatology
has elapsed , until then the condition is regarded an acute stress disorder .
Treatment
Counselling : provide emotional support , encourage recall of traumatic events to integrate
them into patient`s experience .
CBT :
- Information about the normal response to severe stress and importance of confronting
situations and memories related to traumatic events.
- Self monitoring of the symptoms.
- Exposure to situations that are being avoided.
- Recall of images of traumatic events , to integrate these with the rest of patient`s
experience
- Cognitive restructuring .
- Anger management.
Medications : Selective serotonin reuptake inhibitors (SSRIs), such as sertraline and
paroxetine , are considered first-line treatments for PTSD, owing to their efficacy,
tolerability, and safety ratings. Anxiolytic drugs should be avoided because prolonged
use may lead to dependence .
Adjustment disorder : the term refers to psychological reactions arising in relation to
adapting to new circumstances . such circumstances include divorce and separation , a
major change of work and abode , such as transition from school to university or
migration and the birth of handicapped child. By definition, the symptoms must begin
within 3 months of the stressor. A variety of subtypes of adjustment disorder are
identified in the fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5). These include adjustment disorder with depressed mood, mixed
anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and
conduct, features of acute stress disorder or posttraumatic stress disorder (PTSD),
bereavement, and unspecified type.
Clinical features : Although by definition adjustment disorders follow a stressor, the symptoms
do not necessarily begin immediately. Up to 3 months may elapse between a stressor and the
development of symptoms the symptoms of an adjustment disorder include anxiety , worry , poor
concentration , depression and irritability , together with physical symptoms caused by
autonomic arousal such as palpitations and tremor. The onset is more gradual than that of an
acute reaction to stress and the course is more prolonged . usually the social functioning is
impaired.
Treatment : treatment is designed to help the patient resolve the stressful problems and to
aid the natural processes of adjustment , this is done by reducing denial and avoidance of
stressful events , encouraging problem solving and discouraging maladaptive coping
responses.