• Clinical science

Trauma- and stressor-related disorders

Abstract

Trauma- and stressor-related disorders are a family of psychiatric disorders (acute stress disorder, post-traumatic stress disorder, and adjustment disorder) that arise following a stressful or traumatic event. These three conditions often present similarly to other psychiatric disorders such as depression and anxiety although the presence of a trigger event is necessary for 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 severity of symptoms. Treatment generally consists of both psychotherapy and pharmacotherapy. The specific types of therapy and medications vary among the conditions.

Overview

Differential diagnoses of Trauma- and stressor-related disorders
Acute stress disorder
  • Major complaint: anxiety in response to a traumatic event
  • Intrusive symptoms, low mood, poor cognition, avoidance, and altered reactivity
  • Impaired functioning
  • Restricted to a duration of 3 days to 1 month following exposure
PTSD
  • Major complaint: anxiety in response to a traumatic event
  • Intrusive symptoms, low mood, poor cognition, avoidance, and altered reactivity
  • Impaired functioning
  • Lasts > 1 month
Adjustment disorder
  • Major complaint: anxiety in response to an identifiable intrinsic or extrinsic stressor
  • Distress that is not proportional to the scale of the stressor
  • Impaired functioning
  • Onset within 3 months and lasts no longer than 6 months
Bereavement
  • Major complaint: feeling of loss after losing a loved one
  • Normal self-esteem
  • Daily functioning maintained
Generalized anxiety disorders
  • Major complaint: anxiety in response to unspecific events or themes (e.g., health, relationships)
  • Impaired memory), sleep disturbances, muscle tension, and/or fatigue
  • Impaired functioning
  • Lasts > 6 months
Major depressive disorder
  • Major complaint: depressed mood or anhedonia
  • Impaired memory, sleep disturbances, feelings of guilt, weight changes, or suicidal ideation
  • Impaired functioning
  • Lasts at least 2 weeks

Acute stress disorder

  • Definition: characteristic symptoms that last between 3 days to 1 month following ≥ 1 traumatic event(s)
  • Epidemiology
    • Presents in up to ∼ 50% of individuals suffering interpersonal traumatic events
    • Occurs in up to ∼ 13% of individuals in motor vehicle accidents
  • Risk factors
    • Preexisting mental disorder
    • Poor social support
    • Witnessing a traumatic event (e.g., rape, assault)
    • Significant physical injury from a traumatic event
Diagnostic criteria (according to DSM-5)
A Exposure to death (actual or threatened), injury, or sexual abuse; includes ≥ 1 of the following
  • Personal experience of these events
  • Witnessing these events
  • Hearing about these events happening to close friends or family
  • Repeating exposure to details of traumatic events occurring to others
B ≥ 9 of the following 14 symptoms
  • Intrusion
    • 1) Repeated distressing memories
    • 2) Repeated distressing dreams
    • 3) Flashbacks
    • 4) Severe psychological distress or physiological responses to internal or external cues related to the event
  • Negative mood
    • 5) Unable to feel positive emotions
  • Dissociation
    • 6) Altered sense of reality
    • 7) Memory loss of important events related to the event
  • Avoidance
    • 8) Avoiding memories, thoughts, or feelings related to the event
    • 9) Avoiding external reminders related to the event
  • Arousal
    • 10) Sleep disturbances
    • 11) Irritable behavior
    • 12) Hypervigilance
    • 13) Poor concentration
    • 14) Easily startled
C Duration: symptoms last between 3 days to 1 month following trauma
D Significant distress or impaired functioning (social, occupational)
E Not explained by substance abuse or another medical condition

Benzodiazepines should be used with caution because of the risk of drug addiction!

References:[1][2]

Post-traumatic stress disorder (PTSD)

  • Definition: characteristic symptoms that last > 1 month following ≥ 1 traumatic event(s)
  • Epidemiology
    • Lifetime prevalence: ∼ 9%
    • Duration of combat exposure directly proportional to risk of developing PTSD
  • Etiology
    • Triggers: experiencing or witnessing
      • Sexual abuse (most common)
      • Physical abuse
      • Accidents
      • Natural disasters
      • Acts of war
      • Diagnosis of a severe disease
    • Risk factors
      • Psychiatric comorbidities
      • Lower socioeconomic status
      • Younger age at time of trauma
      • Lack of social support
      • Traumatic childhood experiences
    • Common comorbidities: depression, suicidality, addictive disorders, somatic symptom disorder
Diagnostic criteria (according to DSM-5)
A Experienced or observed actual or threatened death, serious injury, or sexual violence; and ≥ 1 of the following:
  • Personal experience of these events
  • Witnessing these events
  • Hearing about these events happening to close friends or family
  • Repeating exposure to details of traumatic events occurring to others
B ≥ 1 intrusive symptoms that begin after the traumatic events occurred:
  • Intrusive thoughts: recollection and reliving of psychotraumatic events
  • Recurrent distressing dreams
  • Flashbacks: re-experience of the traumatic event that lasts for seconds to days
  • Intense and persistent distress due to internal or external cues related to the traumatic event
  • Physiological reactions due to internal or external cues related to the traumatic event
C Avoidance of triggering stimuli following the event; includes ≥ 1 of the following:
  • Avoiding memories, thoughts, or feelings associated with the event
  • Avoiding external reminders related to the event
D Negatively affected mood and cognition which begin or worsen after the event; includes ≥ 2 of the following:
  • Memory loss of an important aspect related to the event
  • Severe negative beliefs or expectations about oneself or the world
  • Distorted memories of the cause and/or consequences related to the event
  • Constant negative emotions (e.g., fear, guilt)
  • Reduced or absent interest in important life activities
  • Detachment from others
  • Inability to experience positive feelings and emotions
E Altered reactivity beginning or worsening after the event; includes ≥ 2 of the following:
  • Irritability
  • Self-destructive behavior
  • Hypervigilance
  • Easily startled
  • Poor concentration
  • Sleep disturbances
F

Symptoms (B-E) last > 1 month

G Significant distress or impaired functioning (social, occupational)
H Not explained by substance abuse or another medical condition

Benzodiazepines should be used with caution because of the risk of drug addiction!

References:[3][4][5][6][2]

Adjustment disorder

  • Definition: a maladaptive emotional or behavioral response to a stressor that lasts ≤ 6 months following termination of the stressor
  • Epidemiology
    • Presents in ∼ 5–20% of individuals undergoing outpatient mental health care
    • Up to one-third of patients with a cancer diagnosis develop this disorder
  • Etiology: a combination of intrinsic and extrinsic stressors
  • Diagnostic criteria (according to DSM-5)
    • Emotions or behaviors in response to a stressor within 3 months of onset
    • Clinically significant responses, including ≥ 1 of the following:
      • Inappropriate subjective distress (not in relation to the nature of the event; also, if cultural or social norms are considered)
      • Impaired functioning (social, occupational, or other important areas)
    • Not explained by another mental disorder
    • Not due to normal bereavement
    • Symptoms last ≤ 6 months following termination of the stressor
  • Differential diagnosis: normal stress reaction
  • Treatment

References:[7][8][2]