Day # 100: Intro to Trauma and Stressor Related Disorders

If you are following along in the suggested curriculum you have now finished the first six themes (psychotic disorders, depressive disorders, bipolar disorder, anxiety disorders, emergency psychiatry, and OCD and related disorders). Nice work!

We will now begin the seventh theme in the Bullet Psych curriculum which is trauma and stressor related disorders. This includes adjustment disorder, persistent complex bereavement disorder, acute stress disorder, and posttraumatic stress disorder (PTSD). Reactive attachment disorder and disinhibited social engagement disorder will be included later in the child and adolescent theme. Today we will discuss a brief overview of these disorders.

Today's Content Level: Beginner; Intermediate (Review)

GENERAL CLINICAL FEATURES

• Common to all of these disorders is exposure to a traumatic or stressful event.

• The psychological response following exposure to traumatic/stressful events can be variable and may include a normal stress response, anxiety/fear based symptoms, depressive/anhedonic symptoms, irritability/anger, or dissociative symptoms.

• These variable responses to distress are one of the reasons that trauma and stressor related disorders deserve a separate category instead of just being lumped in with depressive or anxiety disorders.

• Like every DSM-5 diagnosis, symptoms must cause significant distress or impairment and not be caused by another substance or medical condition.

• Today will just be a brief refresher of the criteria for each disorder, so you are able to distinguish them during the remaining articles of this theme. We will go into further detail of the criteria and clinical features in later posts.

DIAGNOSTIC CRITERIA

Adjustment Disorder

• Development of emotional or behavioral symptoms.

• Symptoms develop within 3 months of an identifiable stressful life event.

• Symptoms resolve within 6 months after the stressor has terminated. If symptoms persist this is sometimes called "chronic adjustment disorder".

• Must experience either:

  • 1) distress that is > normally expected after such an event or

  • 2) significant impairment of daily functioning (social, occupational, etc.).

• Symptoms do not represent normal bereavement and is not merely an exacerbation of a preexisting mental disorder.

• Specifiers to further clarify nature of response:

  • Depressed mood

  • Anxiety

  • Mixed anxiety and depressed mood

  • Disturbance of conduct (such as aggression)

  • Mixed disturbance of emotions and conduct

  • Unspecified

Acute Stress Disorder and Posttraumatic Stress Disorder (PTSD)

• Exposure to actual or threatened death, serious injury, or sexual violence. Exposure may occur through direct experience or witnessing the trauma. More details and nuances on this in a later post.

• Acute stress disorder and posttraumatic stress disorder have very similar diagnostic criteria with the exception of timeline:

  • PTSD: Trauma occurred at any time in the past. Symptoms last > 1 month.

  • Acute stress disorder: Trauma occurred < 1 month ago. Symptoms last > 3 days and < 1 month.

• Intrusive symptoms: recurrent and intrusive re-experiencing of the event. Can occur via memories, nightmares, or "flashbacks" (dissociative reactions). May include intense psychological distress or physiological reactions to cues relating to the trauma. (1 or more intrusive symptoms for PTSD diagnosis)

• Avoidance behaviors: active and persistent avoidance of reminders of the trauma which can include internal (memories/thoughts/feelings) and external (people/places/conversations/activities/situations) reminders. (1 or more intrusive symptoms for PTSD diagnosis)

• Mood/Cognitive alterations: negative alterations of mood or cognitions can include amnesia, negative beliefs about self/others/world, distorted sense of self-blame, persistent negative emotions (guilt, fear, anger, etc.), anhedonia, feelings of detachment or isolation, and inability to experience positive emotions. (2 or more intrusive symptoms for PTSD diagnosis)

• Arousal/Reactivity alterations: increased arousal/reactivity manifested in a number of possible ways such as irritability/anger, reckless behavior, hypervigilance, exaggerated startle response, difficulty concentrating, or insomnia. (2 or more intrusive symptoms for PTSD diagnosis)

• Specifiers in PTSD:

  • With dissociative symptoms (depersonalization or derealization)

  • With delayed expression (if full diagnostic criteria are not met until >6 months after event)

• Keep in mind that the presentation differs in children 6 years and younger. More on that in a later post.

Persistent Complex Bereavement Disorder

• Normal bereavement, sometimes called simple grief, is a normal reaction to the loss of a loved one. In an upcoming lesson we will compare and contrast features of normal bereavement with complicated/complex bereavement.

• Persistent complex bereavement disorder is actually not yet included in the stressor related disorder section in DSM-5. Currently it is included in the "conditions for further study" section and the following is the *proposed* criteria. I personally think it is helpful to include this disorder here in order to compare/contrast with adjustment disorder.

• Experiences the death of a loved one or someone they had a close relationship with.

• Symptoms occur more days than not for >12 months after the death (>6 months if patient is a child).

• Symptoms may include persistent yearning/longing/preoccupation for the deceased, intense emotional pain/sorrow, or a preoccupation with the circumstances of the death. (at least one of the above)

• Symptoms of reactive distress: difficulty accepting the death, avoidance of reminders, emotional numbness, bitterness/anger, self-blame, or difficulty with positive reminiscing about the deceased.

• Symptoms of social/identity disruption: difficulty trusting others, feeling alone/detached, feeling that life is now meaningless, diminished sense of identity, difficulty maintaining interests/hobbies, or desire to die in order to be with the deceased.

• At least six combined symptoms of reactive distress and social/identity disruption.

• Specify if associated with traumatic bereavement. Includes bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death.

CONCLUSION

Congrats on finishing day 1 of the trauma and stressor related disorders theme. I hope it will be a helpful reference, so that you can easily compare the stressor related disorders. Next post we will discuss adjustment disorder in more detail.

Resources for today's post include DSM-5 and First Aid for Psychiatry.

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