[ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
POST TRAUMATIC STRESS DISORDER
INTRODUCTION: Essential Features of
Posttraumatic Stress Disorder
- Something truly awful has happened. One
patient has been gravely injured or perhaps
sexually abused; another has been closely
involved in the death or injury of someone
else; a third has only learned that someone
close experienced an accident or other
violence, whereas emergency workers
(police, firefighters) may be traumatized
through repeated exposure.
- DSM-5 describes the setting event for PTSD
as exposure to a traumatic event during
which an individual experiences or witness’s
death or threatened death, actual or
threatened serious injury, or actual or
threatened sexual violation.
- Frequently, an individual’s reaction to a
trauma initially meets criteria for acute
stress disorder in the immediate aftermath
of the trauma.
- In DSM-IV a disorder called acute stress
disorder was introduced. This is like PTSD,
occurring within the first month after the
trauma, but the different name emphasizes
the severe reaction that some people have
immediately.
o According to a recent survey,
approximately 50% of individuals
with acute stress disorder went on
to develop PTSD.
POSTTRAUMATIC STRESS DISORDER IN PRESCHOOL
CHILDREN
Duration
There are also PTSD in Preschool children,
- There can be no doubt that preschool
children are sometimes exposed to
traumatic events. Mostly, these are car
accidents, natural disasters, and war—in
short, all the benefits contemporary life has
to offer.
- The best evidence would seem to indicate
that they do, but with a likelihood much
lower (0–12%) than for older children.
Statistics
- Determining the prevalence rates for PTSD
seems relatively straightforward: Simply
observe victims of a trauma and see how
many are suffering from PTSD.
- PTSD is more prevalent among females than
among males across the lifespan.
- Females in the general population
experience PTSD for a longer duration than
do males. At least some of the increased
risk for PTSD in females appears to be
attributable to a greater likelihood of
exposure to traumatic events, such as rape,
and other forms of interpersonal violence.
Within populations exposed specifically to
such stressors, gender differences in risk for
PTSD are attenuated or nonsignificant.
- Results are presented in Table 5.8. found in
Barlow, As you can see, the highest rates
are associated with experiences of rape;
being held captive, tortured, or kidnapped;
or being badly assaulted. The rates of PTSD
after these experiences, which under the
heading of “assaultive violence,” are far
higher than other categories.
- Again, those who experienced the disaster
most personally and directly seemed to be
the ones most affected.
- Investigators have now concluded that
during air raids (war events), many people
may not have directly experienced the
horrors of dying, death, and direct attack.
Close exposure to the trauma seems to be
necessary to developing this disorder.
- We also know that once it appears, PTSD
tends to last (i.e., it runs a chronic course).
Since a diagnosis of PTSD predicts suicidal
attempts independently of any other
problem, such as alcohol abuse, every case
should be taken very seriously.
- PTSD symptoms change over time, more for
some people than for others, which may be
due to individual differences in resiliency,
coping skills, levels of trauma exposure,
early adversities, ongoing stress, and even
the presence of mild traumatic brain
injuries.
- Since many individuals experience strong
reactions to stressful events that typically
disappear within a month, the diagnosis of
PTSD cannot be made until at least one
month after the occurrence of the
traumatic event. In PTSD with delayed
onset, individuals show few or no
symptoms immediately or for months after
a trauma, but at least 6 months later, and
perhaps years afterward, develop full-
blown PTSD.
- 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. There is abundant
evidence for what DSM-IV called “delayed
onset” but is now called “delayed
expression,” with the recognition that some
symptoms typically appear immediately and
that the delay is in meeting full criteria.
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
Distress or disability
- Developmental regression, such as loss of
language in young children, may occur.
Auditory pseudo-hallucinations, such as
having the sensory experience of hearing
one’s thoughts spoken in one or more
different voices, as well as paranoid
ideation, can be present.
- Following prolonged, repeated, and severe
traumatic events (e.g., childhood abuse,
torture), the individual may additionally
experience difficulties in regulating
emotions or maintaining stable
interpersonal relationships, or dissociative
symptoms. When the traumatic event
produces violent death, symptoms of both
problematic bereavement and PTSD may be
present.
- PTSD is associated with high levels of social,
occupational, and physical disability, as well
as considerable economic costs and high
levels of medical utilization. Impaired
functioning is exhibited across social,
interpersonal, developmental, educational,
physical health, and occupational domains.
In community and veteran samples, PTSD is
associated with poor social and family
relationships, absenteeism from work,
lower income, and lower educational and
occupational success.
Differential diagnosis
- Adjustment disorders
- Other posttraumatic disorders and
conditions
- Acute stress disorder
- Anxiety disorders and obsessive-compulsive
disorder.
- Major depressive disorder
- Personality disorders.
- Dissociative disorders.
- Conversion disorder (functional
neurological symptom disorder)
- Psychotic disorders.
- Traumatic brain injury.
DIAGNOSTIC CRITERIA
Posttraumatic Stress Disorder
Note: The following criteria apply to adults,
adolescents, and children older than 6 years. For
children 6 years and younger, see corresponding
criteria below.
A. Exposure to actual or threatened death,
serious injury, or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic
event(s).
2. Witnessing, in person, the event(s) as it
occurred to others.
3. Learning that the traumatic event(s)
occurred to a close family member or
close friend. In cases of actual or
threatened death of a family member or
friend, the event(s) must have been
violent or accidental.
4. Experiencing repeated or extreme
exposure to aversive details of the
traumatic event(s) (e.g., first responders
collecting human remains; police
officers repeatedly exposed to details of
child abuse). Note: Criterion A4 does
not apply to exposure through
electronic media, television, movies, or
pictures, unless this exposure is work
related.
B. Presence of one (or more) of the following
intrusion symptoms associated with the
traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s). Note: In children older than 6
years, repetitive play may occur in
which themes or aspects of the
traumatic event(s) are expressed.
2. Recurrent distressing dreams in which
the content and/or affect of the dream
are related to the traumatic event(s).
Note: In children, there may be
frightening dreams without
recognizable content.
3. Dissociative reactions (e.g., flashbacks)
in which the individual feels or acts as if
the traumatic event(s) were recurring.
(Such reactions may occur on a
continuum, with the most extreme
expression being a complete loss of
awareness of present surroundings.)
Note: In children, trauma-specific
reenactment may occur in play.
4. Intense or prolonged psychological
distress at exposure to internal or
external cues that symbolize or
resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to
internal or external cues that symbolize
or resemble an aspect of the traumatic
event(s).
C. Persistent avoidance of stimuli associated
with the traumatic event(s), beginning after
the traumatic event(s) occurred, as
evidenced by one or both of the following:
1. Avoidance of or efforts to avoid
distressing memories, thoughts, or
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
feelings about or closely associated with
the traumatic event(s).
2. Avoidance of or efforts to avoid external
reminders (people, places,
conversations, activities, objects,
situations) that arouse distressing
memories, thoughts, or feelings about
or closely associated with the traumatic
event(s).
D. Negative alterations in cognitions and mood
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important
aspect of the traumatic event(s)
(typically due to dissociative amnesia
and not to other factors such as head
injury, alcohol, or drugs).
2. Persistent and exaggerated negative
beliefs or expectations about oneself,
others, or the world (e.g., “I am bad,”
“No one can be trusted,” “The world is
completely dangerous,” “My whole
nervous system is permanently ruined”).
3. Persistent, distorted cognitions about
the cause or consequences of the
traumatic event(s) that lead the
individual to blame himself/herself or
others.
4. Persistent negative emotional state
(e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or
participation in significant activities.
6. Feelings of detachment or
estrangement from others.
7. Persistent inability to experience
positive emotions (e.g., inability to
experience happiness, satisfaction, or
loving feelings).
E. Marked alterations in arousal and reactivity
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts
(with little or no provocation) typically
expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling
or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D,
and E) is more than 1 month.
G. The disturbance causes clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
H. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication, alcohol) or another medical
condition.
Specify whether:
With dissociative symptoms: The individual’s
symptoms meet the criteria for posttraumatic
stress disorder, and in addition, in response to the
stressor, the individual experiences persistent or
recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent
experiences of feeling detached from, and
as if one were an outside observer of, one’s
mental processes or body (e.g., feeling as
though one were in a dream; feeling a
sense of unreality of self or body or of time
moving slowly).
2. Derealization: Persistent or recurrent
experiences of unreality of surroundings
(e.g., the world around the individual is
experienced as unreal, dreamlike, distant,
or distorted).
Note: To use this subtype, the dissociative
symptoms must not be attributable to the
physiological effects of a substance (e.g.,
blackouts, behavior during alcohol intoxication)
or another medical condition (e.g., complex
partial seizures).
Specify if:
With delayed expression: If the full diagnostic
criteria are not met until at least 6 months after
the event (although the onset and expression of
some symptoms may be immediate).
Posttraumatic Stress Disorder for Children 6 Years
and Younger
A. In children 6 years and younger, exposure
to actual or threatened death, serious
injury, or sexual violence in one (or more) of
the following ways:
1. Directly experiencing the traumatic
event(s).
2. Witnessing, in person, the event(s) as it
occurred to others, especially primary
caregivers. Note: Witnessing does not
include events that are witnessed only
in electronic media, television, movies,
or pictures.
3. Learning that the traumatic event(s)
occurred to a parent or caregiving
figure.
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
B. Presence of one (or more) of the following
intrusion symptoms associated with the
traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s). Note: Spontaneous and
intrusive memories may not necessarily
appear distressing and may be
expressed as play reenactment.
2. Recurrent distressing dreams in which
the content and/or affect of the dream
are related to the traumatic event(s).
Note: It may not be possible to ascertain
that the frightening content is related to
the traumatic event.
3. Dissociative reactions (e.g., flashbacks)
in which the child feels or acts as if the
traumatic event(s) were recurring. (Such
reactions may occur on a continuum,
with the most extreme expression being
a complete loss of awareness of present
surroundings.) Such trauma-specific
reenactment may occur in play.
4. Intense or prolonged psychological
distress at exposure to internal or
external cues that symbolize or
resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to
reminders of the traumatic event(s).
C. One (or more) of the following symptoms,
representing either persistent avoidance of
stimuli associated with the traumatic
event(s) or negative alterations in
cognitions and mood associated with the
traumatic event(s), must be present,
beginning after the event(s) or worsening
after the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid
activities, places, or physical reminders
that arouse recollections of the
traumatic event(s).-
2. Avoidance of or efforts to avoid people,
conversations, or interpersonal
situations that arouse recollections of
the traumatic event(s).
Negative Alterations in Cognitions
3. Substantially increased frequency of
negative emotional states (e.g., fear,
guilt, sadness, shame, confusion).
4. Markedly diminished interest or
participation in significant activities,
including constriction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of
positive emotions.
D. Alterations in arousal and reactivity
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts
(with little or no provocation) typically
expressed as verbal or physical
aggression toward people or objects
(including extreme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling
or staying asleep or restless sleep).
E. The duration of the disturbance is more
than 1 month.
F. The disturbance causes clinically significant
distress or impairment in relationships with
parents, siblings, peers, or other caregivers
or with school behavior.
G. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication or alcohol) or another medical
condition.
Specify whether:
With dissociative symptoms: The individual’s
symptoms meet the criteria for posttraumatic
stress disorder, and the individual experiences
persistent or recurrent symptoms of either of the
following:
1. Depersonalization: Persistent or recurrent
experiences of feeling detached from, and
as if one were an outside observer of, one’s
mental processes or body (e.g., feeling as
though one were in a dream; feeling a
sense of unreality of self or body or of time
moving slowly).
2. Derealization: Persistent or recurrent
experiences of unreality of surroundings
(e.g., the world around the individual is
experienced as unreal, dreamlike, distant,
or distorted).
Note: To use this subtype, the dissociative
symptoms must not be attributable to the
physiological effects of a substance (e.g.,
blackouts) or another medical condition
(e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic
criteria are not met until at least 6 months after
the event (although the onset and expression of
some symptoms may be immediate).
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Causal Determinants:
- PTSD is the one disorder for which we know
the cause at least in terms of the
- Aside from traumatic event itself, other
precipitating event: Someone personally
experiences a trauma and develops a
disorder, we have Pre-traumatic,
Peritraumatic and Posttraumatic factors.
Pre-traumatic factors
A. Temperamental. These include childhood
emotional problems by age 6 years (e.g.,
prior traumatic exposure, externalizing or
anxiety problems) and prior mental
disorders (e.g., panic disorder, depressive
disorder, PTSD, or obsessive-compulsive
disorder [OCD]).
B. Environmental. These include lower
socioeconomic status; lower education;
exposure to prior trauma (especially during
childhood); childhood adversity (e.g.,
economic deprivation, family dysfunction,
parental separation or death); cultural
characteristics (e.g., fatalistic or self-
blaming coping strategies); lower
intelligence; minority racial/ethnic status;
and a family psychiatric history. Social
support prior to event exposure is
protective.
C. Genetic and physiological. These include
female gender and younger age at the time
of trauma exposure (for adults). Certain
genotypes may either be protective or
increase risk of PTSD after exposure to
traumatic events.
Peritraumatic factors
A. Environmental. These include severity
(dose) of the trauma (the greater the
magnitude of trauma, the greater the
likelihood of PTSD), perceived life threat,
personal injury, interpersonal violence
(particularly trauma committed by a
caregiver or involving a witnessed threat to
a caregiver in children), and, for military
personnel, being a perpetrator, witnessing
atrocities, or killing the enemy. Finally,
dissociation that occurs during the trauma
and persists afterward is a risk factor.
Posttraumatic factors
A. Temperamental. These include negative
appraisals, inappropriate coping strategies,
and development of acute stress disorder.
B. Environmental. These include subsequent
exposure to repeated upsetting reminders,
subsequent adverse life events, and
financial or other trauma-related losses.
Social support (including family stability, for
children) is a protective factor that
moderates outcome after trauma.
factors may play a role in the development
of PTSD.
a. Intensity of exposure to assaultive
violence contributes to the etiology of
PTSD.
o Exposure to a traumatic event may
create profound fear and
helplessness. People who suffer
from PTSD may reexperience such
feelings in flashbacks, involuntarily
reliving the horrifying event.
o Example: children experiencing
severe burns are likely to develop
PTSD in proportion to the severity of
the burns and the pain associated
with them.
b. Generalized biological and psychological
vulnerabilities with us – Individual
factors.
o The greater the vulnerability, the
more likely we are to develop PTSD.
If certain characteristics run in your
family, you have a much greater
chance of developing the disorder. A
family history of anxiety suggests a
generalized biological vulnerability
for PTSD.
o Person’s innate character structure
and genetic inheritance
▪ there is little or no evidence
that genes directly cause
PTSD. Rather, the stress–
diathesis model comes into
play again since genetic
factors predispose
individuals to be easily
stressed and anxious, which
then make it more likely that
a traumatic experience will
result in PTSD.
c. Relative low intelligence and low
educational attainment are positively
associated with PTSD.
o Characteristics such as a tendency to
be anxious, as well as factors such as
minimal education, predict exposure
to traumatic events in the first place
and therefore an increased risk for
PTSD.
o Higher intelligence predicted
decreased exposure to these types
of traumatic events. This is
reminiscent of the studies on
reciprocal gene–environment
interactions in which existing
vulnerabilities, some of them
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
heritable, may help determine the
kind of environment in which
someone lives and, therefore, the
type of psychological disorder that
person may develop.
d. Generalized psychological vulnerability
and environmental influences.
o Describes in the context of other
disorders based on early
experiences with unpredictable or
uncontrollable events.
o Family instability is one factor that
may instill a sense that the world is
an uncontrollable, potentially
dangerous place, so it is not
surprising that individuals from
unstable families are at increased
risk for developing PTSD if they
experience trauma.
▪ Family instability was found
to be a pre-war risk factor for
the development of PTSD .
e. Social factors
o Social factors play a major role in
the development of PTSD.
o Social support from parents, close
friends, classmates, and teachers is
an important protective factor.
o Several studies are consistent in
showing that, if you have a strong
and supportive group of people
around you, it is much less likely you
will develop PTSD after a trauma.
o Similarly, positive coping strategies
involving active problem solving
seemed to be protective, whereas
becoming angry and placing blame
on others were associated with
higher levels of PTSD.
ACUTE STRESS DISORDER
INTRODUCTION: Essential Features of Acute Stress
Disorder
- Something truly awful has happened—
grave injury or sexual abuse, or perhaps the
traumatic death or injury of someone else.
Based on the observation that some people
develop symptoms immediately after a
traumatic stress is called acute stress
disorder (ASD).
- The essential feature of acute stress
disorder is the development of
characteristic symptoms lasting from 3 days
to 1 month following exposure to one or
more traumatic events.
- Traumatic events that are experienced
directly include, but are not limited to,
exposure to war as a combatant or civilian,
threatened, or actual violent personal
assault (e.g., sexual violence, physical
attack, active combat, mugging, childhood
physical and/or sexual violence, being
kidnapped, being taken hostage, terrorist
attack, torture), natural or humanmade
disasters (e.g., earthquake, hurricane,
airplane crash), and severe accident (e.g.,
severe motor vehicle, industrial accident).
- For children, sexually traumatic events may
include inappropriate sexual experiences
without violence or injury.
- A life-threatening illness or debilitating
medical condition is not necessarily
considered a traumatic event. But…
- Medical incidents that qualify as traumatic
events involve sudden, catastrophic events
(e.g., waking during surgery, anaphylactic
shock).
- For many years it was termed “shell shock.”
Like PTSD, ASD can also be found among
civilians.
- Patients with ASD are likely to have severe
depressive symptoms (“survivor’s guilt”), to
the point that a concurrent diagnosis of
major depressive disorder may sometimes
be justified;
- Acute stress disorder was included in DSM-
IV because many people with severe early
reactions to trauma could not otherwise be
diagnosed and, therefore, could not receive
insurance coverage for immediate
treatment.
Statistics
- Overall rates of ASD, depending on the
nature of the trauma and personal
characteristics of the individual, center on
20%.
- Acute stress disorder is more prevalent
among females than among males. Sex-
linked neurobiological differences in stress
response may contribute to females’
increased risk for acute stress disorder. The
increased risk for the disorder in females
may be attributable in part to a greater
likelihood of exposure to the types of
traumatic events with a high conditional
risk for acute stress disorder, such as rape
and other interpersonal violence.
- There are many patients will be rolled over
into a diagnosis of PTSD as this is the fate of
as many as 80% of patients with ASD.
Duration
- 3 days to 1 month
- The symptoms usually begin as soon as the
patient is exposed to the event (or learns
about it), but they must be experienced
farther out than 3 days after the stressful
event to fulfill the criterion for duration.
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
- This gets us to a period beyond the stressful
event itself and its immediate aftermath.
- Should symptoms last longer than 1 month,
they are no longer acute and no longer
constitute ASD.
Distress or disability
- Individuals with acute stress disorder
commonly engage in catastrophic or
extremely negative thoughts about their
role in the traumatic event, their response
to the traumatic experience, or the
likelihood of future harm.
o For example, an individual with
acute stress disorder may feel
excessively guilty about not having
prevented the traumatic event.
Individuals with acute stress
disorder may also interpret their
symptoms in a catastrophic manner,
Differential diagnosis
such that flashback memories or
emotional numbing may be
interpreted as a sign of diminished
mental capacity.
- It is common for individuals with acute
stress disorder to experience panic attacks
in the initial month after trauma exposure
that may be triggered by trauma reminders
DIAGNOSTIC CRITERIA
or may apparently occur spontaneously.
- Additionally, individuals with acute stress
disorder may display chaotic or impulsive
behavior. For example, individuals may
drive recklessly, make irrational decisions,
or gamble excessively.
- In children, there may be significant
separation anxiety, possibly manifested by
excessive needs for attention from
caregivers.
- In the case of bereavement following a
death that occurred in traumatic
circumstances, the symptoms of acute
stress disorder can involve acute grief
reactions.
- In such cases, reexperiencing, dissociative,
and arousal symptoms may involve
reactions to the loss, such as intrusive
memories of the circumstances of the
individual’s death, disbelief that the
individual has died, and anger about the
death.
- Post-concussive symptoms (e.g., headaches,
dizziness, sensitivity to light or sound,
irritability, concentration deficits), which
occur frequently following mild traumatic
brain injury, are also frequently seen in
individuals with acute stress disorder.
o Post-concussive symptoms are
equally common in brain-injured
and non–brain-injured populations,
and the frequent occurrence of
post-concussive symptoms could be
attributable to acute stress disorder
symptoms.
- Impaired functioning in social,
interpersonal, or occupational domains has
been shown across survivors of accidents,
assault, and rape who develop acute stress
disorder.
- The extreme levels of anxiety that may be
associated with acute stress disorder may
interfere with sleep, energy levels, and
capacity to attend to tasks.
- Avoidance in acute stress disorder can
result in generalized withdrawal from many
situations that are perceived as potentially
threatening, which can lead to
nonattendance of medical appointments,
avoidance of driving to important
appointments, and absenteeism from work.
- Adjustment disorders
- Dissociative disorders
- PTSD
- Obsessive-compulsive disorder
- Psychotic disorders
- Traumatic brain injury
A. Exposure to actual or threatened death,
serious injury, or sexual violation in one (or
more) of the following ways:
1. Directly experiencing the traumatic
event(s).
2. Witnessing, in person, the event(s) as it
occurred to others.
3. Learning that the event(s) occurred to a
close family member or close friend.
Note: In cases of actual or threatened
death of a family member or friend, the
event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme
exposure to aversive details of the
traumatic event(s) (e.g., first responders
collecting human remains, police
officers repeatedly exposed to details of
child abuse). Note: This does not apply
to exposure through electronic media,
television, movies, or pictures, unless
this exposure is work related.
B. Presence of nine (or more) of the following
symptoms from any of the five categories of
intrusion, negative mood, dissociation,
avoidance, and arousal, beginning or
worsening after the traumatic event(s)
occurred:
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s). Note: In children, repetitive
play may occur in which themes or
aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which
the content and/or affect of the dream
are related to the event(s). Note: In
children, there may be frightening
dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks)
in which the individual feels or acts as if
the traumatic event(s) were recurring.
(Such reactions may occur on a
continuum, with the most extreme
expression being a complete loss of
awareness of present surroundings.)
Note: In children, trauma-specific
reenactment may occur in play.
4. Intense or prolonged psychological
distress or marked physiological
reactions in response to internal or
external cues that symbolize or
resemble an aspect of the traumatic
event(s).
Negative Mood
5. Persistent inability to experience
positive emotions (e.g., inability to
experience happiness, satisfaction, or
loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one’s
surroundings or oneself (e.g., seeing
oneself from another’s perspective,
being in a daze, time slowing).
7. Inability to remember an important
aspect of the traumatic event(s)
(typically due to dissociative amnesia
and not to other factors such as head
injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories,
thoughts, or feelings about or closely
associated with the traumatic event(s).
9. Efforts to avoid external reminders
(people, places, conversations,
activities, objects, situations) that
arouse distressing memories, thoughts,
or feelings about or closely associated
with the traumatic event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling
or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts
(with little or no provocation), typically
expressed verbal or physical aggression
toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in
Criterion B) is 3 days to 1 month after
trauma exposure. Note: Symptoms typically
begin immediately after the trauma, but
persistence for at least 3 days and up to a
month is needed to meet disorder criteria.
D. The disturbance causes clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
E. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication or alcohol) or another medical
condition (e.g., mild traumatic brain injury)
and is not better explained by brief
psychotic disorder.
CAUSAL DETERMINANT
A. Temperamental.
- Risk factors include prior mental disorder,
high levels of negative affectivity
(neuroticism), greater perceived severity of
the traumatic event, and an avoidant,
coping style.
- Catastrophic appraisals of the traumatic
experience, often characterized be
exaggerated appraisals of future harm,
guilt, or hopelessness, are strongly
predictive of acute stress disorder.
B. Environmental.
- Individual must be exposed to a traumatic
event to be at risk for acute stress disorder.
- Risk factors for the disorder include a
history of prior trauma.
C. Genetic and physiological.
- Females are at greater risk for developing
acute stress disorder. Elevated reactivity, as
reflected by acoustic startle response, prior
to trauma exposure increases the risk for
developing acute stress disorder.
ADJUSTMENT DISORDER
INTRODUCTION: Essentia Features of Adjustment
Disorder
- In clinical situations, the stressor has usually
affected only one person, but it can affect
many (think flood, fire, and famine).
- The essential feature of adjustment
disorders is the presence of emotional or
8
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
behavioral symptoms in response to an
identifiable stressor.
- The stressor may be a single event (e.g., a
termination of a romantic relationship), or
there may be multiple stressors (e.g.,
marked business difficulties and marriage
problems).
- Stressors may be recurrent (e.g., associated
with seasonal business crises, unfulfilling
sexual relationships) or continuous (e.g., a
persistent painful illness with increasing
disability, living in a crime-ridden
neighborhood).
- Stressors may affect a single individual, an
entire family, or a larger group or
community (e.g., a natural disaster).
- Some stressors may accompany specific
developmental events (e.g., going to school,
leaving a parental home, reentering a
parental home, getting married, becoming a
parent, failing to attain occupational goals,
retirement).
- Adjustment disorders may be diagnosed
following the death of a loved one when
the intensity, quality, or persistence of grief
reactions exceeds what normally might be
expected, when cultural, religious, or age-
appropriate norms are considered.
o Adjustment disorders describe
anxious or depressive reactions to
life stress that are generally milder
than one would see in ASD or PTSD
but are nevertheless impairing in
terms of interfering with work or
school performance, interpersonal
relationships, or other areas of
living.
- Patients with adjustment disorder (AD) may
be responding to one stress or to many; the
stressor may happen once or repeatedly. If
the stressor goes on and on, it can even
become chronic,
- Adjustment disorders are associated with
an increased risk of suicide attempts and
completed suicide.
Statistics
- The percentage of individuals in outpatient
mental health treatment with a principal
diagnosis of an adjustment disorder ranges
from approximately 5% to 20%.
- In a hospital psychiatric consultation
setting, it is often the most common
diagnosis, frequently reaching 50%.
- AD has been reported in 10% or more of
adult primary care patients.
o one recent study found a prevalence
of only 3%
o many of these patients were being
inappropriately treated with
psychotropic medications, and in
only two cases had the AD diagnosis
been made. The discrepancies
probably rest on the rather poorly
developed criteria and on the
(mistaken) view of AD as a residual
diagnosis.
Duration
- the disturbance in adjustment disorders
begin within 3 months of onset of a stressor
and lasts no longer than 6 months after the
stressor or its consequences have ceased.
- If the stressor is an acute event: the onset
of the disturbance is usually immediate, and
the duration is relatively brief.
- If the stressor or its consequences persist,
the adjustment disorder may also continue
to be present and become the persistent
form.
Distress or disability
- This disorder are pathological reactions to
early extreme stress.
o result is failure to meet the child’s
basic emotional needs for affection,
comfort, or even providing for the
necessities of daily living.
- The subjective distress or impairment in
functioning associated with adjustment
disorders is frequently manifested as:
decreased performance at work or school
and temporary changes in social
relationships.
- An adjustment disorder may complicate the
course of illness in individuals who have a
general medical condition (e.g., decreased
compliance with the recommended medical
regimen; increased length of hospital stay).
Differential diagnosis
D. Major Depressive disorder
E. PTST and acute stress disorder
F. Personality disorders
G. Psychological Factors affecting other
medical conditions.
H. Normative stress reactions
DIAGNOSTIC CRITERIA
A. The development of emotional or
behavioral symptoms in response to an
identifiable stressor(s) occurring within 3
months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically
significant, as evidenced by one or both of
the following:
1. Marked distress that is out of proportion
to the severity or intensity of the stressor,
taking into account the external context
9
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
and the cultural factors that might influence
symptom severity and presentation.
2. Significant impairment in social,
occupational, or other important areas of
functioning.
C. The stress-related disturbance does not
meet the criteria for another mental
disorder and is not merely an exacerbation
of a preexisting mental disorder.
D. The symptoms do not represent normal
bereavement.
E. Once the stressor or its consequences have
terminated, the symptoms do not persist
for more than an additional 6 months.
Specify whether:
309.0 (F43.21) With depressed mood: Low mood,
tearfulness, or feelings of hopelessness are
predominant.
309.24 (F43.22) With anxiety: Nervousness, worry,
jitteriness, or separation anxiety is predominant.
309.28 (F43.23) With mixed anxiety and depressed
mood: A combination of depression and anxiety is
predominant.
309.3 (F43.24) With disturbance of conduct:
Disturbance of conduct is predominant.
309.4 (F43.25) With mixed disturbance of emotions
and conduct: Both emotional symptoms (e.g.,
depression, anxiety) and a disturbance of conduct
are predominant.
309.9 (F43.20) Unspecified: For maladaptive
reactions that are not classifiable as one of the
specific subtypes of adjustment disorder.
CASUAL DETERMINANTS
A. Environmental.
- Individuals from disadvantaged life
circumstances experience a high rate of
stressors and may be at increased risk for
adjustment disorders.
- However, almost any relatively
commonplace event could be a stressor for
someone.
- Those most often cited for adults are
getting married or divorced, moving, and
financial problems.
- For adolescents, they are problems at
school. Whatever the nature of the stressor,
patients feel overwhelmed by the demands
of something in the environment.
REACTIVE ATTACHMENT DISORDER &
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
- Each disorder is conceived as a reaction to
an environment in which the child
experiences caregiving that is inconstant
(frequent change of parent or surrogate) or
pathological (abuse, neglect). One of two
patterns then develops.
INTROCTION: Essential Features of Reactive
Attachment Disorder
- Reactive attachment disorder of infancy or
early childhood is characterized by a
pattern of markedly disturbed and
developmentally inappropriate attachment
behaviors, in which a child rarely or
minimally turns preferentially to an
attachment figure for comfort, support,
protection, and nurturance.
- The essential feature is absent or grossly
underdeveloped attachment between the
child and supposed caregiving adults.
- In reactive attachment disorder (RAD), even
young infants withdraw from social
contacts, appearing shy or distant.
- Inhibited children will resist separation by
tantrums or desperate clinging.
- In severe cases, infants may exhibit failure-
to-thrive syndrome, with head
circumference, length, and weight hovering
around the 3rd percentile on standard
growth charts.
- Adverse childcare (abuse, neglect,
caregiving insufficient or changed too
frequently) has apparently caused a child to
withdraw emotionally; the child neither
seeks nor responds to soothing from an
adult. Such children will habitually show
little emotional or social response; far from
having positive affect, they may experience
periods of unprovoked irritability or
sadness.
- The child will very seldom seek out a
caregiver for protection, support, and
nurturance and will seldom respond to
offers from caregivers to provide this kind
of care.
- As such, children with reactive attachment
disorder show diminished or absent
expression of positive emotions during
routine interactions with caregivers.
- In addition, their emotion regulation
capacity is compromised, and they display
episodes of negative emotions of fear,
sadness, or irritability that are not readily
explained.
Statistics
- The prevalence of reactive attachment
disorder is unknown, but the disorder is
seen relatively rarely in clinical settings.
- The disorder has been found in young
children exposed to severe neglect before
being placed in foster care or raised in
institutions.
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 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
- However, even in populations of severely
neglected children, the disorder is
uncommon, occurring in less than 10% of
such children.
Duration
- A diagnosis of reactive attachment disorder
should not be made in children who are
developmentally unable to form selective
attachments. the child must have a
developmental age of at least 9 months.
- begins before age 5; child has
developmental age of at least 9 months.
Distress/ Disability
- lack of responsivenesss, limited positive
affect, and additional heightened
emotionality, such as fearfulness and
intense sadness.
- Children with reactive attachment disorder
are believed to have the capacity to form
selective attachments.
o significantly impairs young children’s
abilities to relate interpersonally to
adults or peers.
- It also affects the functional impairment of
the child across many domains of early
childhood.
- fail to show the behavioral manifestations
of selective attachments.
o Due to limited opportunities during
early development, and
- When distressed: they show no consistent
effort to obtain comfort, support,
nurturance, or protection from caregivers
as well as they do not respond more than
minimally to comforting efforts of
caregivers.
Differential diagnosis
- autism spectrum disorder, intellectual
disability, depressive disorders
DIAGNOSTIC CRITERIA
A. A consistent pattern of inhibited,
emotionally withdrawn behavior toward
adult caregivers, manifested by both of the
following:
1. The child rarely or minimally seeks
comfort when distressed.
2. The child rarely or minimally responds
to comfort when distressed.
B. A persistent social and emotional
disturbance characterized by at least two of
the following:
1. Minimal social and emotional
responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability,
sadness, or fearfulness that are evident
even during nonthreatening interactions
with adult caregivers.
C. The child has experienced a pattern of
extremes of insufficient care as evidenced
by at least one of the following:
1. Social neglect or deprivation in the form
of persistent lack of having basic
emotional needs for comfort,
stimulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers
that limit opportunities to form stable
attachments (e.g., frequent changes in
foster care).
3. Rearing in unusual settings that severely
limit opportunities to form selective
attachments (e.g., institutions with high
child-to-caregiver ratios).
D. The care in Criterion C is presumed to be
responsible for the disturbed behavior in
Criterion A (e.g., the disturbances in
Criterion A began following the lack of
adequate care in Criterion C).
E. The criteria are not met for autism
spectrum disorder.
F. The disturbance is evident before age 5
years.
G. The child has a developmental age of at
least 9 months.
Specify if:
Persistent: The disorder has been present
for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as
severe when a child exhibits all symptoms of the
disorder, with each symptom manifesting at
relatively high levels.
CASUAL DETERMINANTS
- Because of the shared etiological
association with social neglect, reactive
attachment disorder often co-occurs with
developmental delays, especially in delays
in cognition and language. Other associated
features include stereotypies and other
signs of severe neglect (e.g., malnutrition or
signs of poor care).
- Environmental. Serious social neglect is a
diagnostic requirement for reactive
attachment disorder and is also the only
known risk factor for the disorder.
However, the majority of severely
neglected children do not develop the
disorder. Prognosis appears to depend on
11
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
the quality of the caregiving environment
following serious neglect.
- The presumption of causality stems from
the temporal relationship of the traumatic
childcare to the disturbed behavior.
INTRODUCTION: Essential Features of Disinhibited
Social Engagement Disorder
- By contrast, a child’s response in
disinhibited social engagement disorder
(DSED) borders on the promiscuous. Small
children avoid normal wariness and boldly
approach strangers; instead of clinging, they
may instead appear indifferent to the
departure of a parent. In both subtypes, the
abnormal responses are more obvious
when the main caregiver is absent.
- The essential feature of disinhibited social
engagement disorder is a pattern of
behavior that involves culturally
inappropriate, overly familiar behavior with
relative strangers. This overly familiar
behavior violates the social boundaries of
the culture.
- Adverse childcare (abuse, neglect,
caregiving insufficient or changed too
frequently) has apparently caused a child to
become unreserved in interactions with
strange adults. Such children, rather than
showing typical first-acquaintance shyness,
will little hesitate to leave with a strange
adult; they do not “check in” with familiar
caregivers, and readily become excessively
familiar. In so doing, they may cross normal
cultural and social boundaries.
- Might engage in inappropriately intimate
behavior by showing a willingness to
immediately accompany an unfamiliar adult
figure somewhere without first checking
back with a caregiver.
Statistics/ Prevalence
- The prevalence of disinhibited social
attachment disorder is unknown.
- Nevertheless, the disorder appears to be
rare, occurring in a minority of children,
even those who have been severely
neglected and subsequently placed in foster
care or raised in institutions.
- In such high-risk populations, the condition
occurs in only about 20% of children. The
condition is seen rarely in other clinical
settings.
Demographics and duration (?)
- A diagnosis of disinhibited social
engagement disorder should not be made
before children are developmentally able to
form selective attachments. (the same for
RAD)
- For this reason, the child must have a
developmental age of at least 9 months.
Distress/Disability
- Because of their shared etiological
association with social neglect, disinhibited
social engagement disorder may co-occur
with developmental delays, especially
cognitive and language delays, stereotypies,
and other signs of severe neglect, such as
malnutrition or poor care. However, signs
of the disorder often persist even after
other signs of neglect are no longer present.
Therefore, it is not uncommon for children
with the disorder to present with no current
signs of neglect. Moreover, the condition
can present in children who show no signs
of disordered attachment. Thus,
disinhibited social engagement disorder
may be seen in children with a history of
neglect who lack attachments or whose
attachments to their caregivers range from
disturbed to secure.
- Disinhibited social engagement disorder
significantly impairs young children’s
abilities to relate interpersonally to adults
and peers.
Differential diagnosis
- Attention-deficit/hyperactivity disorder.
DIAGNOSTIC CRITERIA
A. A pattern of behavior in which a child
actively approaches and interacts with
unfamiliar adults and exhibits at least two
of the following:
1. Reduced or absent restraint in
approaching and interacting with
unfamiliar adults.
2. Overly familiar verbal or physical
behavior (that is not consistent with
culturally sanctioned and with age-
appropriate social boundaries).
3. Diminished or absent checking back
with adult caregiver after venturing
away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar
adult with minimal or no hesitation.
B. The behaviors in Criterion A are not limited
to impulsivity (as in attention-
deficit/hyperactivity disorder) but include
socially disinhibited behavior.
C. The child has experienced a pattern of
extremes of insufficient care as evidenced
by at least one of the following:
1. Social neglect or deprivation in the form
of persistent lack of having basic
emotional needs for comfort,
12
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
stimulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers
that limit opportunities to form stable
attachments (e.g., frequent changes in
foster care).
3. Rearing in unusual settings that severely
limit opportunities to form selective
attachments (e.g., institutions with high
child-to-caregiver ratios).
D. The care in Criterion C is presumed to be
responsible for the disturbed behavior in
Criterion A (e.g., the disturbances in
Criterion A began following the pathogenic
care in Criterion C).
E. The child has a developmental age of at
least 9 months.
Specify if:
Persistent: The disorder has been present for
more than 12 months.
Specify current severity:
Disinhibited social engagement disorder is
specified as severe when the child exhibits all
symptoms of the disorder, with each symptom
manifesting at relatively high levels.
CASUAL DETERMINANTS
A. Environmental.
- Serious social neglect is a diagnostic
requirement for disinhibited social
engagement disorder and is also the only
known risk factor for the disorder.
However, the majority of severely
neglected children do not develop the
disorder.
- Neurobiological vulnerability may
differentiate neglected children who do and
do not develop the disorder. However, no
clear link with any specific neurobiological
factors has been established. The disorder
has not been identified in children who
experience social neglect only after age 2
years.
- Caregiving quality seems to moderate the
course of disinhibited social engagement
disorder. Nevertheless, even after
placement in normative caregiving
environments, some children show
persistent signs of the disorder, at least
through adolescence.
- The presumption of causality stems from
the temporal relationship of the traumatic
childcare to the disturbed behavior.
In summary Factors that indicate increased risk for
either RAD or DSED include:
- being reared in an orphanage or other
institution
- protracted hospitalizations
- multiple and frequent changes in caregivers
- severe poverty
- abuse (the gamut of physical, emotional,
and sexual)
- family riven by death, divorce, or discord.
- Complications associated with these
disorders include stunted physical growth,
low self-esteem, delinquency, anger
management issues, eating disorders,
malnutrition, depression or anxiety, and
later substance misuse.
OTHER SPECIFIED TRAUMA – OR STRESSOR-
RELATED DISORDER
- This diagnosis will serve to categorize those
patients for whom there is an evident
stressor or trauma, but who for a specific,
stated reason do not fulfill criteria for any
of the Other Specified Trauma- or Stressor-
Related Disorder standard diagnoses
already mentioned above. DSM-5 gives
several examples, including two forms of
adjustment-like disorders (one form with
delayed onset and another with prolonged
duration relative to adjustment disorder).
UNSPECIFIED TRAUMA – OR STRESSOR-RELATED
DISORDER
- This diagnosis will serve to categorize those
patients for whom there is an evident
stressor or trauma, but who do not fulfill
criteria for any of the standard diagnoses
already mentioned above, and for whom
the clinician chooses not to specify the
reason that the criteria are not met for a
specific trauma- and stressor related
disorder, and includes presentations in
which there is insufficient information to
make a more specific diagnosis (e.g., in
emergency room settings).
TREATMENT
- From the psychological point of view, most
clinicians agree that victims of PTSD should
face the original trauma, process the
intense emotions, and develop effective
coping procedures to overcome the
debilitating effects of the disorder.
- Reliving emotional trauma to relieve
emotional suffering is called catharsis.
- The trick is in arranging the re-exposure so
that it will be therapeutic rather than
traumatic. Unlike the object of a specific
phobia, a traumatic event is difficult to
recreate, and few therapists want to try.
13
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
A. Telephone hotlines
- National and local telephone hotlines
provide help for people under severe stress
and for people who are suicidal.
- How skilled and knowledgeable the
volunteer is, plays an important role in how
satisfied users are with the hotline.
- Studies also suggest that the most positive
outcomes are seen when helpers show
empathy and respect for callers.
B. Crisis intervention
- This has emerged in response to especially
stressful situations, be they disasters or
family situations that have become
intolerable.
- Short-term crisis therapy is of brief duration
and focuses on the immediate problem
with which an individual or family is having
difficulty.
- A central assumption in crisis-oriented
therapy is that the individual is functioning
well psychologically before the trauma.
Thus, therapy is focused only on helping the
person through the immediate crisis, not on
“remaking” his or her personality.
- A therapist is usually very active, helping to
clarify the problem, suggesting plans of
action providing reassurance, and
otherwise providing needed information
and support.
C. Psychological debriefing
- These approaches are designed to help and
speed up the healing process in people who
have experienced disasters or been exposed
to other traumatic situations.
- As centra strategy: traumatized victims are
provided with emotional support and
encouraged to talk about their experiences
during the crises.
- The discussion is usually quite structured,
and common reactions to the trauma are
normalized.
- One form of psychological debriefing is
Critical Incident Stress Debriefing (CISD). A
single session of CISD lasts between 3 and 4
hours and is conducted in a group format,
usually 2 to 10 days after a “critical
incident” or trauma.
- Psychological debriefing is current quite
controversial. Reviews of the literature have
generally failed to support the clinical
effectiveness of the approach. Although
those who experience the debriefing
sessions often report satisfaction with the
procedure and with the organization’s
desire to provide assistance, no well-
controlled study has shown that it reduces
symptoms of PTSD or hastens recovery in
civilians.
- Providing the right kind of social support
may facilitate recovery. The most beneficial
interventions may be those that focus
explicitly on the needs of the individual and
time their approaches accordingly.
- In the aftermath of a trauma, survivors
should follow their own mutual inclination
and talk (or not talk) with the people they
want to talk. In a related vein, therapists
should take their lead from the trauma
survivor, engaging in active listening, being
supportive, but not directing or pushing for
more information than the survivor wishes
to provide.
o Caring, kindness, and common sense
can go a long way to helping trauma
survivors along the path to healing.
D. Cognitive Behavioral therapy treatments
- It is to correct negative assumptions about
the trauma—such as blaming oneself in
some way, feeling guilty, or both—is
another part of treatment.
- Trauma victims often repress the emotional
side of their memories of the event and
sometimes, the memory itself. This happens
automatically and unconsciously.
- Occasionally, with treatment, the memories
flood back, and the patient dramatically
relives the episode. Although this may be
frightening to both patient and therapist, it
can be therapeutic if handled appropriately.
- Therefore, imaginal exposure, in which the
content of the trauma and the emotions
associated with it are worked through
systematically, has been used for decades
under a variety of names.
- At present, the most common strategy
(prolonged exposure therapy).
o Prolonged exposure therapy
involves persuading clients to
confront the traumatic memories
they fear, the therapeutic
relationship may be of great
importance in this kind of clinical
intervention. The client must trust in
the therapist enough to engage in
the exposure treatment. In all
clinical work, the therapist needs to
provide a safe, warm, and
supportive environment that can
facilitate clinical change.
o Prolonged exposure therapy is an
effective treatment for PTSD.
o The effects of the exposure practices
may be strengthened by
strategically timing the exposure
treatment with sleep. Patients in the
14
 [ABNORMAL PSYCHOLOGY] TRAUMA AND STRESS RELATED DISORDERS
study were asked to take a nap soon
after an exposure, because
extinction learning appears to take
place during slow wave sleep and
because sleep quality reduces
anxiety.
- Cognitive therapy for PTSD is designed to
modify excessively negative appraisals of
the trauma or its consequences, decrease
the threat that patients experience when
they have memories of the traumatic event,
and remove problematic cognitive and
behavioral strategies.
o In general, DCS appears to have a
narrow therapeutic window and
may not only augment extinction
learning but may also enhance a
process called fear memory
reconsolidation (referring to the
process when fear memory is
reactivated and stored back into
long-term memory again). This can
make “good” exposures better but
also “bad” exposures worse.

E. Structured interventions
- delivered as soon after the trauma, to those
who require help. It is useful in preventing
the development of PTSD and these
preventive psychological approaches seem
more effective than medications.
- there is evidence that subjecting trauma
victims to a single debriefing session, in
which they are forced to express their
feelings as to whether they are distressed
or not, can be harmful.
- A series of experiences was arranged from
least to most intense.

F. Medications: Drugs can also be effective for

symptoms of PTSD.
- Some of the drugs, such as SSRIs (e.g.,
fluoxetine [Prozac] and paroxetine [Paxil]
and venlafaxine [Effexor]).
o They are effective for anxiety
disorders in general have been
shown to be helpful for PTSD,
perhaps because they relieve the
severe anxiety and panic attacks
which is prominent in this disorder.
- Promising, but mixed, results have been
reported for the use of d-cycloserine (DCS)
as an augmentation strategy of CBT for
PTSD.
o A study suggests that DCS
augmentation can lead to even
worse outcome than placebo if
exposure during CBT was
unsuccessful.
o They did not find an overall
augmentation effect at the end of
therapy, but DCS was more
beneficial for individuals who had
more severe PTSD before therapy
and who needed longer treatment.
o It was showed that for people who
are slow responders to CBT,
augmentation with DCS may set
them on a course for better
response by the end of treatment.

15