Trauma & Stressor Related Disorders

• Traumatic event


  An event or incident that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g. serious threat to one's life and of physical integrity, serious threat or harm to one's children, spouse, or close relative
• Trauma or psycho-trauma


  The result of an extraordinary human experience, caused by a catastrophic phenomenon which makes it almost impossible for human beings to cope
• Traumatic events


  • Serious threat to one's life or physical integrity
  • Serious threat or harm to one's children, spouse or other close relatives and friends
  • Sudden destruction of one's home or community
  • Seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence
  • History of childhood abuse physical, sexual, verbal, emotional, neglect and abandonment
  • Victims/survivors or witnesses of tragic vehicular accidents
  • Survivors of natural and man-made disasters and other overwhelming events: flash flood, devastating typhoons, volcanic eruption, horrifying earthquake, etc.
  • Tragic death or sudden loss of loved ones (or being close to death)
  • Chronic/terminal illness
  • Exposure to domestic violence or community violence
  • Exposure to murders, assault, rapes, accidents, child abuse, man's inhumanity to man
  • Gang violence and drug-related problems
  • Traumatic surgery and fatal illness
  • Torture, shooting, hold-up
  • Disappearance or sudden/unexpected separation of/from a loved one or family
• Reactions to critical incidents (after the incident)


  • Cognitive
  • Physical
  • Emotional
  • Behavioral
• Serious trauma signs - Cognitive signs


  • Disorientation: Inability to tell name, date or relate what has happened over the past 24 hours
  • Much concern over little things has become exclusive pre-occupation with one idea
  • Denial of severity of the problem has become wholesale denial that a problem exists
  • Brief visual or auditory flashbacks have become hallucinations which are out of control
  • Self-doubt has become feeling of unreality, disconnectedness, fear of "losing my mind"
  • Difficulty in planning practical things has become inability to carry out basic life functions
  • Confusion has become bizarre, irrational beliefs, and those form the basis for action

  
• Serious trauma signs - Emotional signs


  • Crying has become uncontrolled hysteria
  • Anger and self-blame become fear or threats of harm to self or others
  • Blunted emotional response or numbing has become complete withdrawal with no emotional response
  • Appropriate expression of despair or depression has become self destructive
• Serious trauma signs - Behavioral signs


  • Restlessness or excitement has become unfocused agitation
  • Excessive talking or nervous laughter has become uncontrolled
  • Frequent retelling of the incident has become continual or unrealistic
  • Pacing, hand wringing or clenched fists have become ritualistic or uncontrolled
  • Withdrawal has become immobility or rigidity
  • Disheveled appearance over time becomes inability to care for self
  • Irritability has become destructive

  
• Many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristic are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms
• Because of these variable expressions of clinical distress following exposure to catastrophic or aversive events, the aforementioned disorders have been grouped under a separate category: trauma- and stressor-related disorders
• Trauma- and stressor-related disorders


  • Reactive attachment disorder
  • Disinhibited social engagement disorder
  • Posttraumatic stress disorder (PTSD)
  • Acute stress disorder
  • Adjustment disorders
• Posttraumatic Stress Disorder (PTSD)


  The essential feature is the development of characteristic symptoms following exposure to one or more traumatic events. The clinical presentation of PTSD varies, with different symptom patterns predominating in different individuals.
• PTSD


  • Can occur at any age, beginning after the first year of life
  • Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years, before criteria for the diagnosis are met
  • The symptoms and the relative predominance of different symptoms may vary over time
  • Complete recovery within 3 months occurring in approximately one-half of adults, while some individuals remain symptomatic for longer than 12 months and sometimes for more than 50 years
  • Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events
  • For older individuals, declining health, worsening cognitive functioning, and social isolation may exacerbate PTSD symptoms
• Reactive Attachment Disorder


  The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. When distressed, they show no consistent effort to obtain support, nurturance or protection from caregivers. The disorder is associated with diminished or absent expression of positive emotions during routine interaction with caregivers, and compromised emotion regulation capacity.
• Reactive Attachment Disorder


  • The child must have a developmental age of at least 9 months
  • The disorder has been found in young children exposed to severe neglect before being placed in foster care or raised in institutions
• Disinhibited Social Engagement Disorder


  The essential feature is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. It may co-occur with developmental delays, especially cognitive and language delays and other signs of severe neglect.
• Disinhibited Social Engagement Disorder


  • A diagnosis should not be made before the child is developmentally able to form selective attachments
  • Manifestations differ from early childhood through adolescence, with verbal and social intrusiveness, inauthentic expressions of emotion, and more "superficial" peer relationships and more peer conflicts in adolescence
• Adjustment disorders


  In adjustment disorders, the stressor can be of any severity
• Disinhibited Social Engagement Disorder

  • Differences in manifestations from early childhood through adolescence
  • At youngest ages, children show reticence when interacting with strangers
  • Young children fail to show reticence to approach, engage with, and even accompany adults
  • In preschool, verbal and social intrusiveness appear most prominent, accompanied by attention-seeking behavior
  • Verbal and physical overfamiliarity continue through middle childhood, accompanied by inauthentic expressions of emotion
  • In adolescence, the indiscriminate behavior extends to peers, with more "superficial" peer relationships and more peer conflicts
  • Adult manifestations are unknown
• Adjustment disorders


  • The stressor can be of any severity or type rather than that required by PTSD Criterion A
  • Diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A
• Stressors for adjustment disorders


  • Termination of a romantic relationship
  • Marked business difficulties/crises
  • Marital problem
• Adjustment to developmental events


  • Going to school
  • Getting married
  • Becoming a parent
  • Retirement
  • Failing to attain occupational goals
• Acute stress disorder


  Distinguished from PTSD because the symptom pattern is restricted to a duration of 3 days to 1 month following exposure to the traumatic event
• Anxiety disorders and obsessive-compulsive disorder

  • In OCD, there are recurrent intrusive thoughts that meet the definition of an obsession, not related to an experienced traumatic event, compulsions are usually present, and other symptoms of PTSD or acute stress disorder are typically absent
  • The symptoms of separation anxiety disorder are clearly related to separation from home or family, rather than to a traumatic event

  
• Major depressive disorder


  May or may not be preceded by a traumatic event and should be diagnosed if other PTSD symptoms are absent
• Psychotic disorders


  Flashback in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, brief psychotic disorder, and other psychotic disorders, depressive and bipolar disorders with psychotic features, delirium, substance/medication-induced disorders, and psychotic disorders due to another medical condition

  
• Traumatic brain injury


  • When a brain injury occurs in the context of a traumatic event, symptoms of PTSD may appear
  • Traumatic brain injury (TBI)-related neurocognitive symptoms are not mutually exclusive and may occur concurrently with PTSD
  • Symptoms previously termed postconcussive can occur in brain-injured and non-brain-injured populations, including individuals with PTSD
  • Differential diagnosis between PTSD and neurocognitive disorder symptoms attributable to TBI may be possible based on the presence of symptoms distinctive to each presentation
  • Reexperiencing and avoidance are characteristics of PTSD and not the effects of TBI, while persistent disorientation and confusion are more specific to TBI (neurocognitive effects) than to PTSD

  
• Individuals with PTSD are 80% more likely than those without PTSD to have symptoms that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipolar, anxiety, or substance use disorders)
• Comorbid substance use disorder and conduct disorder are more common among males than among females
• Among U.S. military personnel and combat veterans who have been deployed to recent wars in Afghanistan and Iraq, co-occurrence of PTSD and mild TBI is 48%
• Although most young children with PTSD also have at least one other diagnosis, the patterns of comorbidity are different than in adults, with oppositional defiant disorder and separation anxiety disorder predominating
• There is considerable comorbidity between PTSD and major neurocognitive disorder and some overlapping symptoms between these disorders
• Simple steps in trauma counseling


  1. Address immediate needs/ crisis/ medical needs

  2. Assure victims/ survivors that they are SAFE

  3. Debriefing: relieving/ retelling of story/ encourage narrative expressions

  4. Stabilize Somatic/ Psychological Symptoms

  5. Counseling (Education about the impact of trauma/ PTSD, Education about adaptive and maladaptive coping responses, Validate the nature of reactions and symptoms, Recognize and process the greatest damage which is inner self, Address the presenting and diagnosed problems)

  6. Normalization/ Recovery (Restore functioning: reinvest new/ meaningful relationships (socializing), Restore activities/ exercise, Teach Coping Strategies)
• Psychotrauma management


  • Evidence-based approaches (Action video game modifies visual selective attention, Mindfulness practice leads to increase in regional brain gray matter density, Loving-kindness meditation for PTSD, Omega-3 fatty acids for secondary prevention of PTSD, Clearance of fear memory from the hippocampus through Neurogenesis by omega-3 fatty acids, The effects of playing the computer game "Tetris' on instructions for traumatic images, Spirituality as a critical ingredient of meditation)
• 1. A-I-N


  Process, purpose, patience, prayer
• 1. I-N


  Acknowledge the hurt, Integrate or blend into a functioning whole, New "u" (outcome of the liberating & empowering p-a-i-n)