TRAUMA- AND STRESSOR-RELATED DISORDER

STRESSORS

Before we dive into clinical presentations for the three most common
trauma and stress-related disorders, let’s discuss common events that
precipitate a stress-related diagnosis. A stress disorder occurs when an
individual has difficulty coping with or adjusting to a recent stressor.
Stressors can be any event—either witnessed firsthand, experienced
personally, or experienced by a close family member—that increases
physical or psychological demands on an individual. These events are
significant enough that they pose a threat, whether real or imagined, to
the individual. While many people experience similar stressors
throughout their lives, only a small percentage of individuals experience
significant maladjustment to the event that psychological intervention is
warranted.

Among the most commonly studied triggers for trauma-related disorders

are combat and physical/sexual assault. Symptoms of combat-related
trauma date back to World War I when soldiers would return home with
“shell shock” (Figley, 1978). Unfortunately, it wasn’t until after the
Vietnam War that significant progress was made in both identifying and
treating war-related psychological difficulties (Roy-Byrne et al., 2004).
With the more recent wars in Iraq and Afghanistan, attention was again
brought to Posttraumatic Stress Disorder (PTSD) symptoms due to the
large number of service members returning from deployments and
reporting significant trauma symptoms.

Physical assault, and more specifically sexual assault, is another

commonly studied traumatic event. Rape, or forced sexual intercourse or
other sexual act committed without an individual’s consent, occurs in one
out of every five women and one in every 71 men (Black et al., 2011).
Unfortunately, this statistic likely underestimates the actual number of
cases that occur due to the reluctance of many individuals to report their
sexual assault. Of the reported cases, it is estimated that nearly 81% of
female and 35% of male rape victims report both acute stress disorder
and posttraumatic stress disorder symptoms (Black et al., 2011).

Now that we’ve discussed a little about some of the most commonly
studied traumatic events, let’s take a look at the presentation for
posttraumatic stress disorder, acute stress disorder, and adjustment
disorder.

Clinical Presentation and DSM Criteria

Posttraumatic Stress Disorder

Posttraumatic stress disorder, or more commonly known as PTSD, is

identified by the development of physiological, psychological, and
emotional symptoms following exposure to a traumatic event. Individuals
must have been exposed to a situation where actual or threatened death
occurred. Examples of these situations include but are not limited to:
witnessing a traumatic event as it occurred to someone else; learning
about a traumatic event that occurred to a family member or close friend;
or being exposed to repeated events where one experiences an aversive
event (e.g., victims of child abuse/neglect, ER physicians in trauma
centers, etc.). It is important to understand that while the presentation
of these symptoms varies among individuals, to meet the criteria for a
diagnosis of PTSD, individuals need to report symptoms among the four
different categories of symptoms.

The first category involves recurrent experiences of the traumatic event,

which can occur via flashbacks, distinct memories (which may be
voluntary or involuntary), or even distressing dreams. These recurrent
experiences must be specific to the traumatic event or the moments
immediately following to meet the criteria for PTSD. Regardless of the
method, the recurrent experiences can last several seconds or extend for
several days. They are often initiated by physical sensations similar to
those experienced during the traumatic events or environmental triggers
such as a specific location. Because of these triggers, individuals with
PTSD are known to avoid stimuli (i.e., activities, objects, people, etc.)
associated with the traumatic event.

The second category involves avoidance of stimuli related to the

traumatic event. Individuals with PTSD may be observed trying to avoid
the distressing thoughts and/or feelings related to the memories of the
traumatic event. One way individuals will avoid these memories is by
avoiding physical stimuli such as locations, individuals, activities, or even
specific situations that trigger the memory of the traumatic event.

The third category experienced by individuals with PTSD

is negative alterations in cognition or mood. This is often reported as
difficulty remembering an important aspect of the traumatic event. It
should be noted that this amnesia is not due to a head injury, loss of
consciousness, or substances, but rather, due to the traumatic nature of
the event. The impaired memory may also lead individuals to have false
beliefs about the causes of the traumatic event, often blaming themselves
or others. An overall persistent negative state, including a generalized
negative belief about oneself or others is also reported by those with
PTSD. Similar to those with depression, individuals with PTSD may
report a reduced interest in participating in previously enjoyable
activities, as well as the desire to engage with others socially.
The fourth and final category is alterations in arousal and reactivity.
Because of the negative mood and increased irritability, individuals with
PTSD may be quick-tempered and act out aggressively, both verbally and
physically. While these aggressive responses may be provoked, they are
also sometimes unprovoked. It is believed these behaviors occur due to
the heightened sensitivity to potential threats, especially if the threat is
similar to their traumatic event. More specifically, individuals with PTSD
have a heightened startle response and easily jump or respond to
unexpected noises just as a telephone ringing or a car backfiring. Given
this heightened arousal state, it should not be surprising that individuals
with PTSD also experience significant sleep disturbances, with difficulty
falling asleep, as well as staying asleep due to nightmares.

Although somewhat obvious, these symptoms likely cause significant

distress in social, occupational, and other (i.e., romantic, personal) areas
of functioning. Duration of symptoms is also important, as PTSD cannot
be diagnosed unless symptoms have been present for at least one
month. If they have not been present for a month, the individual may
meet criteria for Acute Stress Disorder (see below).

Acute Stress Disorder

Acute stress disorder is very similar to PTSD except for the fact that
symptoms must be present from 3 days to 1 month following exposure
to one or more traumatic events. If the symptoms are present after one
month, the individual would then meet the criteria for PTSD.
Additionally, if symptoms present immediately following the traumatic
event but resolve by day 3, an individual would not meet the criteria for
acute stress disorder.

Symptoms of acute stress disorder follow that of PTSD with a few

exceptions. PTSD requires symptoms within each of the four categories
discussed above; however, acute stress disorder requires that the
individual experience nine symptoms across five different categories
(intrusion symptoms, negative mood, dissociative symptoms, avoidance
symptoms, and arousal symptoms). For example, an individual may
experience several arousal and reactivity symptoms such as sleep issues,
concentration issues, and hypervigilance, but does not experience issues
regarding negative mood. Regardless of the category of the symptoms, so
long as nine symptoms are present and the symptoms cause significant
distress or impairment in social, occupational, and other functioning, an
individual will meet the criteria for acute stress disorder.

Adjustment Disorder

Adjustment disorder is the least intense of the three stress-related

disorders discussed in this module. An adjustment disorder occurs
following an identifiable stressor that happened within the past 3
months. This stressor can be a single event (loss of job, death of a family
member) or a series of multiple stressors (cancer treatment,
divorce/child custody issues).

Unlike PTSD and acute stress disorder, adjustment disorder does not
have a set of specific symptoms an individual must meet for diagnosis,
rather, whatever symptoms the individual is experiencing must be
related to the stressor and must be significant enough to impair social,
occupational, or other important areas of functioning. Bereavement can
be diagnosed as an adjustment disorder in extreme cases where an
individual’s grief exceeds the intensity or persistence that is expected.

It should be noted that there are modifiers associated with adjustment

disorder. Due to the variety of behavioral and emotional symptoms that
can be present with an adjustment disorder, clinicians are expected to
classify a patient’s adjustment disorder as one of the following: with
depressed mood, with anxiety, with mixed anxiety and depressed mood,
with disturbance of conduct, with mixed disturbance of emotions and
conduct, or unspecified if the behaviors do not meet criteria for one of
the aforementioned categories. Based on the individual’s presenting
symptoms, the clinician will determine which category best classifies the
patient’s condition. These modifiers are also important when choosing
treatment options for patients.

PTSD

The prevalence rate for PTSD in the US is 8.7% (APA, 2013). It should
not come as a surprise that the rates of PTSD are higher among veterans
and others who work in fields with high traumatic experiences (i.e.,
firefighters, police, EMTs, emergency room providers). In fact, PTSD
rates for combat veterans are estimated to be as high as 30% (NcNally,
2012). Between one-third and one-half of all PTSD cases consist of rape
survivors, military combat and captivity, and ethically or politically
motivated genocide (APA, 2013).

Concerning gender, PTSD is more prevalent among females than males,

likely due to their higher occurrence of exposure to traumatic
experiences such as rape, domestic abuse, and other forms of
interpersonal violence (APA, 2013). Gender differences are not found in
populations where both males and females are exposed to significant
stressors suggesting that both genders are equally predisposed to
developing PTSD. Prevalence rates vary slightly across cultural groups,
which may reflect differences in exposure to traumatic events. (Hinton &
Lewis-Fernandez, 2011). More specifically, prevalence rates of PTSD are
highest for African Americans, followed by Latino/Hispanic Americans
and European Americans, and lowest for Asian Americans (Hinton &
Lewis-Fernandez, 2011).
Acute Stress Disorder

The prevalence rate for acute stress disorder varies across the country
and by traumatic event. Accurate prevalence rates for acute stress
disorder are difficult to determine as patients must seek treatment within
30 days of the traumatic event, but it is estimated that anywhere
between 7-30% of individuals experiencing a traumatic event will develop
acute stress disorder (National Center for PTSD). While acute stress
disorder is not a good predictor of who will develop PTSD, approximately
50% of those with acute stress disorder do eventually develop PTSD
(Bryant, 2010; Bryant, Friedman, Speigel, Ursano, & Strain, 2010).

Similar to PTSD, acute stress disorder is more common in females than

males; however, unlike PTSD, there may be some neurobiological
differences in the stress response that contribute to females developing
acute stress disorder more often than males (APA, 2013). With that said,
the increased exposure to traumatic events among females may also be a
strong reason why women are more likely to develop acute stress
disorder.

Adjustment Disorder

Adjustment disorders are relatively common as they describe individuals

who are having difficulty adjusting to life after a significant stressor. In
psychiatric hospitals, adjustment disorders account for roughly 50% of
the admissions, ranking number one for the most common diagnosis
(APA, 2013). As for the general public, it is estimated that anywhere from
5-20% of outpatient referrals are due to an adjustment disorder (APA,
2013).

COMORBIDITY

PTSD

Given the traumatic nature of the disorder, it should not be surprising

that there is a high comorbidity rate between PTSD and other
psychological disorders. Individuals with PTSD are 80% more likely than
those without PTSD to report clinically significant levels of depressive,
bipolar, anxiety, or substance abuse-related symptoms (APA, 2013).

There is also a strong relationship between PTSD and major

neurocognitive disorders, which may be due to the overlapping
symptoms between these disorders (Neurocognitive Disorders will be
covered in Module 14). There has also been an increase in PTSD and
traumatic brain injuries (TBI) due to the recent wars in Afghanistan and
Iraq. US military personnel and combat veterans report a comorbidity
rate between PTSD and TBI at nearly 50% (APA, 2013).
Acute Stress Disorder

Because 30 days after the traumatic event, ASD becomes PTSD (or the
symptoms remit), the comorbidity of ASD with other psychological
disorders has not been studied. While ASD and PTSD cannot be comorbid
disorders, several studies have explored the relationship between ASD
and PTSD in efforts to identify individuals most at risk for developing
PTSD. Research studies indicate roughly 80% of motor vehicle accident
survivors, as well as assault victims, who met the criteria for ASD went
on to develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Bryant &
Harvey, 1998; Harvey & Bryant, 1998). While some researchers indicated
ASD is a good predictor of PTSD, others argue further research between
the two and confounding variables should be further explored to
determine more consistent findings.

Adjustment Disorder

Unlike most of the disorders we have reviewed thus far, adjustment

disorders have a high comorbidity rate with various other medical
conditions (APA, 2013). Often following a critical or terminal medical
diagnosis, an individual will meet the criteria for adjustment disorder as
they process the news about their health and the impact their new
medical diagnosis will have on their life. Other psychological disorders
are also diagnosed with adjustment disorder; however, symptoms of
adjustment disorder must be met independently of the other
psychological condition (APA, 2013). For example, an individual with
adjustment disorder with depressive features must not meet the criteria
for a major depressive episode; otherwise, the diagnosis of major
depression should be made over the adjustment disorder.

ETIOLOGY

Biological

HPA axis. One theory for the development of trauma and stress-related
disorders is the over-involvement of the hypothalamic-pituitary-
adrenal (HPA) axis. The HPA axis is involved in the fear-producing
response, and some speculate that dysfunction within this axis is to
blame for the development of trauma symptoms. Within the brain,
the amygdala serves as the integrative system that inherently elicits the
physiological response to a traumatic/stressful environmental situation.
The amygdala sends this response to the HPA axis in an effort to prepare
the body to “fight or flight.” The HPA axis then releases hormones—
epinephrine and cortisol—to help the body to prepare to respond to a
dangerous situation (Stahl & Wise, 2008). While epinephrine is known to
cause physiological symptoms such as increased blood pressure,
increased heart rate, increased alertness, and increased muscle tension,
to name a few, cortisol is responsible for returning the body to
homeostasis once the dangerous situation is resolved.

Researchers have studied the amygdala and HPA axis in individuals with
PTSD, and have identified heightened amygdala reactivity in stressful
situations, as well as excessive responsiveness to stimuli that is related to
one’s specific traumatic event (Sherin & Nemeroff, 2011). Additionally,
studies have indicated that individuals with PTSD also show a diminished
fear extinction, suggesting an overall higher level of stress during non-
stressful times. These findings may explain why individuals with PTSD
experience an increased startle response and exaggerated sensitivity to
stimuli associated with their trauma (Schmidt, Kaltwasser, & Wotjak,
2013).

Cognitive

Preexisting conditions of depression or anxiety may predispose an

individual to develop PTSD or other stress disorders. One theory is that
these individuals may ruminate or over-analyze the traumatic event, thus
bringing more attention to the traumatic event and leading to the
development of stress-related symptoms. Furthermore, negative
cognitive styles or maladjusted thoughts about themselves and the
environment may also contribute to PTSD symptoms. For example,
individuals who identify life events as “out of their control” report more
severe stress symptoms than those who feel as though they have some
control over their lives (Catanesi et al., 2013).

Social

While this may hold for many psychological disorders, social and family
support have been identified as protective factors for individuals prone to
develop PTSD. More specifically, rape victims who are loved and cared
for by their friends and family members as opposed to being judged for
their actions before the rape, report fewer trauma symptoms and faster
psychological improvement (Street et al., 2011).

Sociocultural

As was mentioned previously, different ethnicities report different

prevalence rates of PTSD. While this may be due to increased exposure
to traumatic events, there is some evidence to suggest that cultural
groups also interpret traumatic events differently, and therefore, may be
more vulnerable to the disorder. Hispanic Americans have routinely been
identified as a cultural group that experiences a higher rate of PTSD.
Studies ranging from combat-related PTSD to on-duty police officer
stress, as well as stress from a natural disaster, all identify Hispanic
Americans as the cultural group experiencing the most traumatic
symptoms (Kaczkurkin et al., 2016; Perilla et al., 2002; Pole et al., 2001).

Women also report a higher incidence of PTSD symptoms than men.

Some possible explanations for this discrepancy are stigmas related to
seeking psychological treatment, as well as a greater risk of exposure to
traumatic events that are associated with PTSD (Kubiak, 2006). Studies
exploring rates of PTSD symptoms for military and police veterans have
failed to report a significant gender difference in the diagnosis rate of
PTSD suggesting that there is not a difference in the rate of occurrence
of PTSD in males and females in these settings (Maguen, Luxton, Skopp,
& Madden, 2012).

TREATMENT

Psychological Debriefing

One way to negate the potential development of PTSD symptoms is

thorough psychological debriefing. Psychological debriefing is
considered a type of crisis intervention that requires individuals who
have recently experienced a traumatic event to discuss or process their
thoughts and feelings related to the traumatic event, typically within 72
hours of the event (Kinchin, 2007). While there are a few different
methods to a psychological debriefing, they all follow the same general
format:

1. Identifying the facts (what happened?)

2. Evaluating the individual’s thoughts and emotional reaction to the
events leading up to the event, during the event, and then
immediately following
3. Normalizing the individual’s reaction to the event
4. Discussing how to cope with these thoughts and feelings, as well as
creating a designated social support system (Kinchin, 2007).

Throughout the last few decades, there has been a debate on the
effectiveness of psychological debriefing. Those within the field argue
that psychological debriefing is not a means to cure or prevent PTSD, but
rather, psychological debriefing is a means to assist individuals with a
faster recovery time posttraumatic event (Kinchin, 2007). Research
across a variety of traumatic events (natural disasters, burns, war)
routinely suggests that psychological debriefing is not helpful in either
the reduction of posttraumatic symptoms nor the recovery time of those
with PTSD (Tuckey & Scott, 2014). One theory is these early
interventions may encourage patients to ruminate on their symptoms or
the event itself, thus maintaining PTSD symptoms (McNally, 2004). In
efforts to combat these negative findings of psychological debriefing,
there has been a large movement to provide more structure and training
for professionals employing psychological debriefing, thus ensuring that
those who are providing treatment are properly trained to do so.

Exposure Therapy

While exposure therapy is predominately used in anxiety disorders, it has

also shown great success in treating PTSD-related symptoms as it helps
individuals extinguish fears associated with the traumatic event. There
are several different types of exposure techniques—imaginal, in
vivo, and flooding are among the most common types (Cahill,
Rothbaum, Resick, & Follette, 2009).

In imaginal exposure, the individual mentally re-creates specific details

of the traumatic event. The patient is then asked to repeatedly discuss
the event in increasing detail, providing more information regarding
their thoughts and feelings at each step of the event. During in vivo
exposure, the individual is reminded of the traumatic event through the
use of videos, images, or other tangible objects related to the traumatic
event that induces a heightened arousal response. While the patient is re-
experiencing cognitions, emotions, and physiological symptoms related to
the traumatic experience, they are encouraged to utilize positive coping
strategies, such as relaxation techniques, to reduce their overall level of
anxiety.

Imaginal exposure and in vivo exposure are generally done in a gradual

process, with imaginal exposure beginning with fewer details of the
event, and slowly gaining information over time. In vivo starts with
images or videos that elicit lower levels of anxiety, and then the patient
slowly works their way up a fear hierarchy, until they are able to be
exposed to the most distressing images. Another type of exposure
therapy, flooding, involves disregard for the fear hierarchy, presenting
the most distressing memories or images at the beginning of treatment.
While some argue that this is a more effective method, it is also the most
distressing and places patients at risk for dropping out of treatment
(Resick, Monson, & Rizvi, 2008).

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy, as discussed in the mood disorders

chapter, has been proven to be an effective form of treatment for
trauma/stress-related disorders. It is believed that this type of treatment
is effective in reducing trauma-related symptoms due to its ability to
identify and challenge the negative cognitions surrounding the traumatic
event, and replace them with positive, more adaptive cognitions (Foa et
al., 2005).
Trauma-focused cognitive-behavioral therapy (TF-CBT) is an
adaptation of CBT that utilizes both CBT techniques and trauma-sensitive
principles to address the trauma-related symptoms. According to the
Child Welfare Information Gateway (CWIG; 2012), TF-CBT can be
summarized via the acronym PRACTICE:

 P: Psycho-education about the traumatic event. This includes

discussion about the event itself, as well as typical emotional and/or
behavioral responses to the event.
 R: Relaxation Training. Teaching the patient how to engage in various
types of relaxation techniques such as deep breathing and progressive
muscle relaxation.
 A: Affect. Discussing ways for the patient to effectively express their
emotions/fears related to the traumatic event.

 C: Correcting negative or maladaptive thoughts.

 T: Trauma Narrative. This involves having the patient relive the
traumatic event (verbally or written), including as many specific
details as possible.
 I: In vivo exposure (see above).
 C: Co-joint family session. This provides the patient with strong social
support and a sense of security. It also allows family members to learn
about the treatment so that they are able to assist the patient if
necessary.
 E: Enhancing Security. Patients are encouraged to practice the coping
strategies they learn in TF-CBT to prepare for when they experience
these triggers out in the real world, as well as any future challenges
that may come their way.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR is a controversial treatment for a few reasons; however, the fact

that the treatment emerged from a personal observation over a theory is
among the most argued reasons. In the late 1980s, psychologist
Francine Shapiro found that by focusing her eyes on the waving leaves
during her daily walk, her troubling thoughts resolved on their own.
From this observation, she concluded that lateral eye movements
facilitate the cognitive processing of traumatic thoughts (Shapiro, 1989).
While EMDR has evolved somewhat since Shapiro’s first claims, the basic
components of EMDR consist of lateral eye movement induced by the
therapist moving their index finger back and forth, approximately 35 cm
from the client’s face, as well as components of cognitive-behavioral
therapy and exposure therapy. The following 8-step approach is the
standard treatment approach of EMDR (Shapiro & Maxfield, 2002):

1. Patient History and Treatment Planning – Identify trauma

symptoms and potential barriers to treatment.
2. Preparation – Psychoeducation of trauma and treatment.
 3. Assessment- Careful and detailed evaluation of the traumatic event.
Patient identifies images, cognitions, and emotions related to the
traumatic event, as well as trauma-related physiological symptoms.
4. Desensitization and Reprocessing – Holding the trauma image,
cognition, and emotion in mind, while simultaneously assessing
their physiological symptoms, the patient must track the clinician’s
finger movement for approximately 20 seconds. At this time, the
patient must “blank it out” and let go of the memory.
5. Installation of Positive Cognitions – Once the negative image,
cognition, and emotions are reduced, the patient must hold onto a
positive image or thought while again tracking the clinician’s finger
movement for approximately 20 seconds.
6. Body Scan – Patient must identify any lingering bodily sensations
while again tracking the clinician’s fingers for a third time to
discard any remaining trauma symptoms.
7. Closure – Patient is provided with positive coping strategies and
relaxation techniques to assist with any recurrent cognitions or
emotions related to the traumatic experience.
8. Reevaluation – Clinician assesses if treatment goals were met. If
not, schedules another treatment session and identifies remaining
symptoms.

As you can see from above, only steps 4-6 are specific to EMDR; the
remaining treatment is essentially a combination of exposure therapy and
cognitive-behavioral techniques. Because of the high overlap between
treatment techniques, there have been quite a few studies comparing the
treatment efficacy of EMDR to TF-CBT and exposure therapy. While
research initially failed to identify a superior treatment, often citing
EMDR and TF-CBT as equally efficacious in treating PTSD symptoms
(Seidler & Wagner, 2006), more recent studies have found that EMDR
may be superior to that of TF-CBT, particularly in psycho-oncology
patients (Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While
meta-analytic studies continue to debate which treatment is the most
effective in treating PTSD symptoms, the World Health Organization’s
(2013) publication on the Guidelines for the Management of Conditions
Specifically Related to Stress, identified TF-CBT and EMDR as the only
recommended treatment for individuals with PTSD.

Psychopharmacological Treatment

While psychopharmacological interventions have been shown to provide

some relief, particularly to veterans with PTSD, most clinicians agree
that resolution of symptoms cannot be accomplished without
implementing exposure and/or cognitive techniques that target the
physiological and maladjusted thoughts maintaining the trauma
symptoms. With that said, clinicians agree that psychopharmacology
interventions are an effective second line of treatment, particularly when
psychotherapy alone does not produce relief from symptoms.
Among the most common types of medications used to treat PTSD
symptoms are selective serotonin reuptake inhibitors (SSRIs; Bernardy &
Friedman, 2015). As previously discussed in the depression chapter,
SSRIs work by increasing the amount of serotonin available to
neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine
oxidase inhibitors (MAOIs) are also recommended as second-line
treatments. Their effectiveness is most often observed in individuals who
report co-occurring major depressive disorder symptoms, as well as
those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately,
due to the effective CBT and EMDR treatment options, research on
psychopharmacological interventions has been limited. Future studies
exploring other medication options are needed to determine if there are
alternative medication options for stress/trauma disorder patients.