Trauma and stressor related disorders

Trauma and stressor related disorders are mental health conditions that occur due to exposure to either a traumatic or stressful event. Specific disorders include Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD), alongside others such as: Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, and Adjustment Disorders. ASD and PTSD are similar except that ASD typically manifests immediately after the traumatic event and lasts approximately from 3 days to one month, whereas PTSD lasts for more than a month, either as continuing after ASD or as a separate occurrence up to 6 months after the trauma.

 

Posttraumatic stress disorder (PTSD) is a mental health condition consisting of recurring, intrusive, recollections of an overwhelming traumatic event. Recollections last more than one month and begin 6 months after the event.

Acute stress disorder (ASD) is a health condition characterized by a brief period of intrusive recollections occurring within 4 weeks of experiencing or witnessing a traumatic event. Symptoms begin within 4 weeks of the traumatic event and last for at least 3 days, but unlike PTSD does not last more than one month.

Reactive Attachment Disorder (RAD) is a stressor-related disorder, reactive attachment disorder is a serious, but rare emotional condition in which an infant or young child does not establish healthy attachment with the parents or caregivers. It can only be caused by social neglect during childhood.

Disinhibited Social Engagement Disorder (DSED) is an emotional disorder that begins in childhood and is classified as a Stressor-related condition similar to reactive attachment disorder, but presents externalizing behavior and disinhibition. It is caused by social neglect during childhood.

Adjustment disorders are stress-related mental disorders occurring due to an expectedly strong emotional or behavioral response to a stressful life event or life change, which occurred approximately three months prior. Adjustment disorders can be either acute with a span of less than six months or chronic, lasting longer than six months. However, for the adjustment disorder diagnosis to still be in effect even after the six months mark the stressful life change or event must be persistent. A proper diagnosis cannot be in effect for a period longer than six months after the event has terminated.

Causes

Posttraumatic Stress Disorder:

Traumatic events experienced directly:

Serious injuries

Events potentially causing death

Combat

Sexual assault

Natural or man-made disasters

Traumatic events experienced indirectly:

Witnessing others being seriously injured, threatened with death or killed

Learning of events that occurred to close family members or friends

Other possible contributing factors:

Inherited traits

The brain’s management of chemicals and hormone releases in response to stress

 

Acute Stress Disorder:

Traumatic events experienced directly:

Serious injuries

Events potentially causing death

Combat

Sexual assault

Natural or man-made disasters

Traumatic events experienced indirectly:

Witnessing others being seriously injured, threatened with death or killed

Learning of events that occurred to close family members or friends

Other possible contributing factors:

Inherited traits

The brain’s management of chemicals and hormone releases in response to stress

 

Reactive Attachment Disorder:

Basic emotional and physical needs are not met on a consistent basis

Lack of shared emotional exchange: eye contact, smiling, caressing

Studies are still being conducted on a better understanding of the potential risk factors involved:

Living in a children’s home or institution

Frequent change of foster homes or caregivers

Inexperienced parents

Prolonged separation from parents or caregivers due to hospitalization

Having a postpartum depressive mother

Parental time is scarce or unequally available due to being part of an unusually large family

However, most children who are neglected do not develop reactive attachment disorder

 

Disinhibited Social Engagement Disorder:

Similar causes to reactive attachment disorder:

Basic emotional and physical needs are not met on a consistent basis

Lack of shared emotional exchange: eye contact, smiling, caressing

Studies are still being conducted on a better understanding of the potential risk factors involved:

Living in a children’s home or institution

Frequent change of foster homes or caregivers

Inexperienced parents

Prolonged separation from parents or caregivers due to hospitalization

Having a postpartum depressive mother

Parental time is scarce or unequally available due to being part of an unusually large family

 

Adjustment disorders:

Causes of adjustment disorders are complex, a single factor having yet to be identified

Potential factors:

Genetics

Temperament

Changes in the brain’s natural chemistry

Stressful life events/changes (both positive and negative events having the power to elicit strong, emotional and stressful responses):

Being diagnosed with a serious illness

School or work related issues

Divorce or relationship breakup

Financial issues

Starting a family

Surviving a disaster

Retirement

Death of a loved one

Exposure to wars or violence

Other mental health problems

Difficult life circumstances

 

Symptoms and signs

Posttraumatic Stress Disorder:

To meet the criteria for diagnosis patients must have experienced a traumatic event either directly or indirectly and must also exhibit symptoms from each of the following categories for a period of more than one month:

Intrusion symptoms (1 or more of the following):

Recurrent, intrusive, involuntary and disturbing memories

Recurring disturbing dreams about the event

Feeling and reacting as if the event were happening again – from flashbacks to completely losing awareness of the surrounding environment

Feeling intense psychological or physiologic distress when reminded of the event

Avoidance symptoms (1 or more of the following):

Avoiding thoughts, feelings or memories about the event

Avoiding activities, places, conversations, or people triggering memories of the event

Negative effects on mood and cognition (2 or more of the following):

Memory loss for significant parts of the event (dissociative amnesia)

Persistent and exaggerated negative beliefs or expectations about oneself, others or, the world

Persistent distorted thoughts about the event that lead to self-blame or to blaming of others

Persistent negative emotional state (fear, shame, anger, guilt)

Disinterest for participation in significant activities

Feelings of detachment/estrangement from others

Persistent inability to express positive emotions

Altered arousal and reflexivity (2 or more of the following):

Sleeping difficulties

Irritability or angry outbursts

Self-destructive behavior

Problems concentrating

Increased startle response

Hypervigilance

 

Acute Stress Disorder:

Diagnosis is based on criteria that include intrusion symptoms, negative mood, and dissociative, avoidance and arousal symptoms

Nine or more of the following criteria have to be met for a period of three days up to one month:

Recurrent, involuntary, and intrusive distressing memories of the event

Recurrent dreams about the event

Dissociative reactions such as flashbacks in which sufferers feel as if re-living the event

Intense psychological or physiologic distress when memories of the event are triggered

Persistent inability to experience positive emotions

Altered sense of reality

Inability to remember important parts of the event (dissociative amnesia)

Efforts to avoid distressing reminders, thoughts and feelings related to the event

Efforts to avoid external triggers

Sleep disturbances

Irritability

Angry outbursts

Hypervigilance

Difficulty concentrating

Exaggerated startle response

 

Reactive Attachment Disorder:

Reactive attachment disorder can begin in infancy

Due to the repeated neglect of the child’s needs, emotional responses, comfort and care do not come to be expected as signs of a stable attachment from the caregivers, nor can a stable attachment develop under these circumstances

Several of the following criteria must be met for a diagnosis to be given:

Consistent pattern of inhibited, emotionally withdrawn behaviour towards adult caregivers:

The child rarely or minimally seeks comfort when distressed

The child rarely or minimally responds to comfort when distressed

Persistent social and emotional disturbance:

Minimal social and emotional response to others

Limited positive emotions

Unexplained irritability, sadness, fearfulness evident even during nonthreatening interaction with the caregivers

Experience of a pattern of extreme or insufficient care:

Social neglect or deprivation in the form of repeated neglect of the child’s needs, in terms of affection, stimulation and comfort

Repeated change of primary caregivers – inability to form stable attachment

Growing up in unusual settings, limiting opportunities to form selective attachments

The criteria must also be excluded from autism spectrum disorder

The criteria must also be evident before the age of 5 and after a developmental stage of at least nine months (there is little research on signs and symptoms manifesting beyond early childhood, nor is it certain if the disorder does occur in children older than 5 years of age)

 

Disinhibited Social Engagement Disorder:

A pattern of behavior in which the child actively approaches and interacts with unfamiliar adults:

Reduced or no reticence in approaching and interacting with unfamiliar adults

Displaying social and physical behavior not consistent with age-appropriate or socially conditioned boundaries

No attention is being paid to informing primary caregivers of venturing in unfamiliar settings with unfamiliar adults

No hesitation in interacting with unfamiliar adults

Experience of a pattern of extreme or insufficient care:

Social neglect or deprivation in the form of repeated neglect of the child’s needs, in terms of affection, stimulation and comfort

Repeated change of primary caregivers – inability to form stable attachment

Growing up in unusual settings, limiting opportunities to form selective attachments

The criteria must be excluded from indicating impulsivity due to attention-deficit/hyperactivity disorder

The child has reached a developmental phase of at least 9 months of age

 

Adjustment disorders:

Emotional symptoms:

Feelings of sadness

Feelings of hopelessness

Lack of enjoyment

Crying bouts

Nervousness

Anxiety

Feelings of fright or uneasiness

Worry

Desperation

Sleeping difficulties

Difficulty concentrating

Feeling overwhelmed

Suicidal ideation

Behavioral symptoms:

Frequent fighting

Reckless behaviour (i.e. driving under the influence, vandalizing property)

Avoidant tendencies (i.e. family or friends)

Performing poorly in school or at work

Ignoring responsibilities

Physical symptoms:

Twitching or trembling

Heart palpitations

Unaccounted physical complaints

Advice

Posttraumatic Stress Disorder

Psychotherapy:

Cognitive therapy for improving cognitive patterns

Exposure therapy for learning to cope with the fear occurring when re-entering the site of the trauma

Eye movement desensitization and reprocessing – it combines exposure therapy with a series of guided eye movements that help process traumatic memories and help improving reaction patterns to the memories

Medications:

Antidepressants

Anti-anxiety medications

Prazosin for insomnia or recurrent nightmares

Acute Stress Disorder

Psychiatric evaluation

Cognitive behavioral therapy

Exposure-based therapies

Hypnotherapy

Medications:

Anti-anxiety medication

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) to improve negative mood symptoms

Reactive Attachment Disorder

Children with reactive attachment disorder are thought of as having the capability of forming attachment, but that past experiences and the environment have hindered its development

Treatments are then based on this belief and usually translate to offering the child a safe and stable environment and ensuring positive and consistent interaction with primary caregivers

Early intervention seems to improve outcome

Potential treatment strategies (there is no standard treatment) include:

Encouraging development by being nurturing, caring, and responsive to the child’s needs on a regular basis

Ensuring a stable presence of the caregivers to foster stable attachment

Providing a positive, stimulating, and interactive environment for the child

Addressing medical, safety and housing needs

Individual and family counselling

Education of caretakers of the condition

Parenting skills classes

Disinhibited Social Engagement Disorder

Treatments are similar to those recommended for reactive attachment disorder:

Offering the child a safe and stable environment and ensuring positive and consistent interaction with primary caregivers

Early intervention seems to improve outcome

Potential treatment strategies (there is no standard treatment) include:

Encouraging development by being nurturing, caring, and responsive to the child’s needs on a regular basis

Ensuring a stable presence of the caregivers to foster stable attachment

Providing a positive, stimulating, and interactive environment for the child

Addressing medical, safety and housing needs

Individual and family counselling

Adjustment disorders

In many cases adjustment disorder treatment is effective, most patients needing only brief therapy

Psychotherapy:

Individual therapy

Group therapy

Family therapy

It helps with providing emotional support

It helps with understanding the condition, its cause and how to manage its symptoms

It helps with learning and reinforcing healthy coping skills

Medications:

Medications are usually offered in more severe cases where depression, anxiety and suicidal thoughts pose an immediate threat

Antidepressants

Anti-anxiety medication

Education of caretakers of the condition

Parenting skills classes

MISCONCEPTIONS
  • Posttraumatic Stress Disorder

    PTSD sufferers are mentally weak

    Everybody has some form of PTSD – the condition is strictly linked to one particular traumatic event

    PTSD symptoms manifest right after the traumatic event

    PTSD sufferers are always violent or unstable

    PTSD is limited to a specific age group – children can very well suffer from PTSD as well

    PTSD sufferers are unable to function in the world

    Recovery is impossible – recovery depends on the individual make-up of each patient

    Acute Stress Disorder

    Anyone who has experienced trauma will develop ASD

    Anyone suffering from ASD will act violently

    Only war veterans experience ASD

    Everyone with ASD has the same symptoms

    Only weak people develop ASD

    Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

    Children are acting out, specifically to draw attention to themselves

    Children are intentionally disobedient

    Forcing the child to respond to social cues as expected is a form of ‘treatment’

    Parents/primary caregivers cannot remedy their behavior

    Adjustment disorders

    Experiencing an adjustment disorder is a sign of weakness

    The condition is not that common

    Issues stem from an unhappy childhood

    People with adjustment disorder should just stay away from their stress inducing triggers

Statistics

Posttraumatic Stress Disorder

According to the U.S. Department of Veteran Affairs:

70% of adults in the U.S. have experienced some type of traumatic event at least once in their lives. This equates to approximately 223.4 million people

An estimated one out of every nine women develops PTSD, making them about twice as likely as men

The annual cost to society of anxiety disorders is estimated to be significantly over $42.3 billion

People with PTSD have among the highest rates of healthcare service use

Almost 50% of all outpatient mental health patients have PTSD

17% of combat troops are women; 71% of female military personnel develop PTSD due to sexual assault within the ranks

 

Acute Stress Disorder

According to the U.S. Department of Veteran Affairs:

Studies of motor vehicle accident have found rates of ASD ranging from 13% to 21%

Studies of typhoon survivors have found a rate of ASD of 7%

Studies of survivors of industrial accidents have found a rate of 6%

In cases of violent assault a rate of 19% was found

In cases of victims of robbery and assault have found that 25% meet the criteria for an ASD diagnosis, while 33% of victims of a mass shooting met the criteria

A study performed in 2000 found several strong predictors of ASD severity in cases of motor vehicle accident survivors: depression score, history of psychiatric treatment, history of PTSD, and prior motor vehicle accidents

 

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

Although RAD is fairly common among institutionalized children, it is a rare condition worldwide, with a prevalence rate of 1% of children under the age of 5

In the U.S. it is estimated that half of the children adopted from orphanages and 40% of children in foster care are diagnosed with RAD

In a 2015 published study aimed to investigate the factor structure of RAD and DSED based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) results indicated a higher prevalence rate for DSED-related symptoms for the sample study of 122 children between the ages of 6 to 12 years of age**

 

Adjustment disorders

According to the Outcome of Depression International Network adjustment disorder had a prevalence of less than 1% of population

Adjustment disorders are commonly seen in primary care settings in which the 1-year prevalence varies from 11% to 18% of those with any clinical psychiatric disorder

A cross-sectional survey of 3815 patients from 77 healthcare centers found the prevalence rate of adjustment disorders to be of 2.94%

A study of patients admitted through psychiatric emergency showed that 7.1% of the adults and 34.4% of adolescents had adjustment disorders at the time of admission

Among patients admitted to a public psychiatric inpatient unit during a 6-month period adjustment disorder was the third most common (9% of patients) after psychotic illnesses (62% of patients) and mood disorders (24% of patients)

Did you know?

Posttraumatic Stress Disorder

PTSD was once considered a psychological condition of combat veterans who were ‘shocked’ by their experience on the battlefields

Soldiers with symptoms of PTSD were often rejected by their military peers and were feared by society at large

These soldiers were deemed as ‘weak’ and remove from the battlefield or discharged from the military service altogether

Much of the general public and mental health specialists in the past were unsure if PTSD was an actual disorder

Famous people who suffered from PTSD: Jacqueline Kennedy Onassis, Alanis Morissette, Barbara Streisand, Mick Jagger, Monica Seles, Whoopi Goldberg

 

Acute Stress Disorder

ASD is highly predictive of PTSD

The Acute Stress Disorder Interview is the only structured interview approved for valid diagnosis

The Acute Stress Disorder Scale is a self-assessment measure of ASD symptoms

 

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

According to an article published in the Columbia Social Work Review, Volume III*:

Full recovery from RAD usually occurs when deprivation of a primary caregiver does not last beyond the age of six months

Otherwise, the child is believed to be at risk for developing social and cognitive deficits that may result in developing other long-term mental health disorders, such as: oppositional defiant disorder, conduct disorder, and adult antisocial personality disorder

Attachment disorders have also been recently identified in 6-12 year-old foster children assessed with the Developmental and Well-Being Assessment diagnostic interview

 

Adjustment disorders

There are six subtypes of adjustment disorder classified according to predominant symptoms:

Adjustment disorder with depressed mood:

Symptoms of depression

Low self-esteem

Lack of motivation

Adjustment disorder with anxiety:

Anxiety-related symptomatology

Excessive worrying

Feeling overwhelmed

Predominantly negative outlook on events

Adjustment disorder with mixed anxiety and depressed mood:

Symptomatology reflects a combination of depression and anxiety

Adjustment disorder with disturbance of conduct:

Antisocial behavior

Substance abuse

Angry outbursts

Adjustment disorder with mixed disturbance of emotions and conduct:

Symptomatology reflects a mixture of emotional responses with disturbances of conduct

Unspecified adjustment disorder:

Problematic thinking pattern and behavior not classifiable by other adjustment disorder types