MODULE 5: TRAUMA- AND STRESSOR-RELATED

DISORDERS

Module Overview

In Module 5, matters related to trauma- and stressor-related disorders to include their

clinical presentation, epidemiology, comorbidity, and etiology will be discussed. It will
include PTSD, acute stress disorder, and adjustment disorder.

Module Outline

 5.1. Clinical Presentation

 5.2. Epidemiology
 5.3. Comorbidity
 5.4. Etiology

Module Learning Outcomes

 Explain what stressors are.

 Describe the clinical presentations of trauma- and stressor-related disorders.
 Describe the epidemiology, comorbidity and etiology of trauma- and stressor-
related disorders.

5.1. Stressors

Section Learning Objectives

 Define stressor.
 Describe common stressors.

There are 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.
 5.2. Clinical Presentation and DSM Criteria

Section Learning Objectives

 Describe the clinical presentations of PTSD, acute stress disorder, and

adjustment disorder.

5.2.1. 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 center, etc.). It should be understood
that while the presentation of these symptoms varies among individuals, to meet
criteria for a diagnosis of PTSD, individuals need to report symptoms among the four
different categories of symptoms:

Recurrent experiences of the traumatic event. This 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. The recurrent experiences can last a short time- several
seconds- or extend for several days. They are often initiated by physical sensations
similar to those experienced during the traumatic events, or even 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.

Avoidance of stimuli that is 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.

Negative alterations in cognitions or mood. This is often reported as difficulty

remembering an important aspect of the traumatic event. The amnesia is 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. Individuals with PTSD may report a reduced interest in participation of
previously enjoyable activities, as well as the desire to socially engage with others.
Alterations in arousal and reactivity. Because of the negative mood and increased
irritability, individuals with PTSD may be quick tempered and act out in aggressive
manners, both verbally and physically. It is believed these behaviors occur due to the
heightened sensitivity to potential threats. 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. Individuals with PTSD also experience
significant sleep disturbances, with difficulty falling asleep, as well as staying asleep
due to nightmares.

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.

5.2.2. 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 1 month, the individual would then meet
criteria for PTSD. Additionally, if symptoms present immediately following the
traumatic event but resolve by day 3, an individual would not meet 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 a 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 criteria for acute
stress disorder.

5.2.3. Adjustment Disorder

Adjustment disorder is the least intense of the three stress related disorders. An
adjustment disorder occurs following an identifiable stressor that has occurred 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 to 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. It should be noted that
bereavement can be diagnosed as an adjustment disorder in extreme cases where an
individual’s grief exceeds the intensity or persistence that is expected.

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 for behaviors that do
not meet criteria for one of the aforementioned categories.

5.3. Epidemiology

Section Learning Objectives

 Describe the epidemiology of PTSD, acute stress disorder, and adjustment

disorders.

5.3.1. PTSD

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).
Between one-third and one-half of all PTSD cases consist of rape survivors, military
combat and captivity, and ethically or politically motivated genocide.

PTSD is more prevalent among females than males, likely due to their greater
likelihood of exposure to traumatic experiences such as rape, domestic abuse, and
other forms of interpersonal violence.

5.3.2. Acute Stress Disorder

Approximately 50% of those with acute stress disorder do eventually develop. Acute
stress disorder is more common in females than males because of the increased
exposure to traumatic events among females.

5.3.3. Adjustment Disorder

Adjustment disorders are fairly common as they describe individuals who are having
difficulty adjusting to life after a significant stressor. In fact, in a psychiatric hospital,
adjustment disorders accounts for roughly 50% of the admissions, ranking number
one for the most common diagnosis.
 5.4. Comorbidity

Section Learning Objectives

 Describe the comorbidity of PTSD, acute stress disorder, and adjustment

disorder.

5.4.1. PTSD

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.

There is also a strong relationship between PTSD and major neurocognitive disorders,
which may be due to the overlapping symptoms between these disorders

5.4.2. Acute Stress Disorder

30 days after the traumatic event, ASD becomes PTSD (or the symptoms remit). ASD
and PTSD cannot be comorbid disorders but several studies have explored the
relationship between ASD and PTSD in efforts to identify individuals most at risk for
developing PTSD.

5.4.3. Adjustment Disorder

Adjustment disorders have a high comorbidity rate with various other medical
conditions. Often following a critical or terminal medical diagnosis, an individual will
meet 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 depressive features must not
meet criteria for a major depressive episode, otherwise, the diagnosis of major
depression should be made over the adjustment disorder.

5.5. Etiology

Section Learning Objectives

 Describe the biological, cognitive, social, socio-cultural causes of trauma- and

stressor-related disorders.

5.5.1. Biological
The hypothalamic-pituitary-adrenal (HPA) axis is involved in the fear
producing response and a dysfunction within this axis is to blame for the development
of trauma symptoms.

5.5.2. Cognitive

Pre-existing conditions of depression and/or anxiety may predispose an individual to

develop PTSD or other stress disorders. These individuals may ruminate, or over
analyze the traumatic event, thus bringing more attention to the traumatic event which
in return leads 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.

5.5.3. Social

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 prior to
the rape, report fewer trauma symptoms and faster psychological improvement.

5.5.4. Sociocultural

Cultural groups also interpret traumatic events differently, and therefore, may be more
vulnerable to the disorder.

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 related to
PTSD.