Trauma- and stressor-related disorders

Trauma- and stressor-related disorders are a group of psychiatric disorders that arise following a stressful or traumatic event. They include acute stress disorder, post-traumatic 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.

References:^[1]

• Definition: : distressing symptoms related to the traumatic event that last between 3 days to 1 month following the exposure
• Epidemiology
  • Occurs in ∼ 50% of individuals experiencing interpersonal traumatic events (e.g., assault, rape)
  • Occurs in up to ∼ 13% of individuals involved in motor vehicle accidents
• Risk factors
  • Pre-existing mental disorder
  • Poor social support
• Diagnostic criteria (according to DSM-5)
  • Exposure to death (actual or threatened), injury, or sexual abuse that occurs in ≥ 1 of the following:
    • Direct experience of these events
    • Witnessing these events
    • Hearing about these events happening to close friends or family
    • Repeated exposure to unpleasant details of traumatic events occurring to others
  • At least 9 of the following 14 symptoms are present:
    • Intrusion
      • 1) Recurrent distressing memories
      • 2) Recurrent distressing dreams
      • 3) Flashbacks
      • 4) Severe psychological distress or physiological responses to internal or external cues related to the event
    • Negative mood
      • 5) Inability to feel positive emotions (e.g., happiness, satisfaction, or love)
    • Dissociation
      • 6) Altered sense of reality
      • 7) Loss of memory with regards to important details of the event
    • Avoidance
      • 8) Avoidance of memories, thoughts, or feelings related to the event
      • 9) Avoidance of external reminders (e.g., places, people, conversations, objects) related to the event
    • Arousal
      • 10) Sleep disturbance
      • 11) Irritable behavior
      • 12) Hypervigilance
      • 13) Poor concentration
      • 14) Heightened startle reflex
  • 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 misuse or another medical condition.
• Treatment
  • Cognitive-behavioral therapy is the first-line treatment.
  • Pharmacotherapy is usually not indicated.
  • Benzodiazepines can be administered to reduce agitation or sleep disturbances.

Benzodiazepines should be used with caution because of the risk of comorbid substance-use disorders, especially among patients with active or previous alcohol or substance use disorder.

References:^[1][2]

• Definition: distressing symptoms related to a specific traumatic event and lasting > 1 month following the event
• Epidemiology ^[3]
  • Lifetime prevalence: 6–9%
  • Sex: ♀ > ♂ (4:1)
• Etiology
  • Triggers: exposure to traumatic events (either through direct experience or as a witness)
    • Sexual abuse (most common)
    • Physical abuse
    • Accidents
    • Natural disasters
    • War: The duration of combat exposure, by either combatants or civilians, is directly proportional to the risk of developing PTSD.
    • Diagnosis of a severe disease
    • Witnessing the death of another person
  • Risk factors
    • Psychiatric comorbidities
    • Lower socioeconomic status
    • Younger age at 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 (according to DSM-5) ^[1]
  • Experience of a traumatic event involving death (actual or threatened), serious injury, or sexual violence that occurs in ≥ 1 of the following ways:
    • Direct experience of these events
    • Witnessing these events
    • Hearing about these events happening to close friends or family
    • Repeated exposure to unpleasant details of traumatic events occurring to others
  • ≥ 1 of the following intrusion symptoms that begin after the traumatic event:
    • Intrusive thoughts: recollection of psychotraumatic events
    • Recurrent, distressing dreams
    • Flashbacks: Reexperiencing the traumatic event. Flashbacks can last from 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
  • Avoidance of triggering stimuli following the event in ≥ 1 of the following ways:
    • Avoidance of memories, thoughts, or feelings associated with the event
    • Avoidance of external reminders (e.g., places, people, conversations, objects) related to the event
  • Negatively affected mood and cognition that begins or worsens after the event in ≥ 2 of the following ways:
    • Inability to remember important details of the event
    • Severe negative thoughts or expectations about oneself or the world
    • Distorted memories of the cause and/or consequences of the event
    • Constant negative emotions (e.g., fear, horror, distress, guilt)
    • Reduced or absent interest in important life activities
    • Detachment from others
    • Inability to feel positive emotions (e.g., happiness, satisfaction, or love)
  • Altered reactivity or arousal beginning or worsening after the event in ≥ 2 of the following ways:
    • Irritability or angry outbursts
    • Self-destructive behavior
    • Hypervigilance
    • Heightened startle reflex
    • Poor concentration
    • Sleep disturbance ; (e.g., nightmares, difficulty initiating or maintaining sleep)
  • Duration: Symptoms last > 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 misuse or another medical condition.
• Treatment
  • Psychotherapy: first-line treatment; with or without adjunctive pharmacotherapy ^[4]
    • Trauma-focused cognitive-behavioral therapy
      • Exposure therapy (e.g., showing war veterans images of war, returning to the scene of an accident)
      • Cognitive processing therapy
    • Eye movement desensitization and reprocessing: Under the guidance of a therapist, the patient recalls traumatic images while following the therapist's fingers with their eyes from left to right.
  • Pharmacotherapy ^[5]
    • SSRIs, SNRIs (e.g., venlafaxine)
    • Prazosin: for nightmares
    • Consider atypical antipsychotics to augment SSRIs and SNRIs.
    • Benzodiazepines should generally be avoided due to the risk of drug misuse and lack of evidence supporting the benefits.
• Prognosis: Approx. 60% of patients receiving treatment have reported a full recovery within an average of 36 months ^[6][7]

Pharmacotherapy alone is used in patients with PTSD who refuse psychotherapy or who do not have access to cognitive-behavioral therapy.

To remember the features of PTSD, think of “TRAUMMA”: Traumatic event, Reexposure, Avoidance, Unable to function, More than a Month of duration, Arousal is increased

References:^[8]

• 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
  • Occurs in ∼ 5–20% of individuals undergoing outpatient mental health treatment
  • Up to one-third of patients with a cancer diagnosis develop this disorder. ^[9]
• Etiology: a combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)
• Diagnostic criteria (according to 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 ^[9]
  • Psychotherapy
    • First-line treatment: cognitive-behavioral therapy or psychodynamic psychotherapy
    • May be provided as individual, family, or group support therapy
    • Interpersonal psychotherapy
  • Pharmacotherapy
    • SSRIs: depressed mood
    • Benzodiazepines: anxiety or panic attacks
    • Benzodiazepines or other sedative-hypnotic agents (e.g., zolpidem): insomnia

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][9][10]