Trauma- and Stressor-

Related Disorders
DR. FATIMA AL AFFI
THE CLINICAL PRESENTATION

Persons suffering from one of these disorders develop emotional and behavioral symptoms in
response to a significant stressor or traumatic event.
 Posttraumatic Stress Disorder and Acute
Stress Disorder
Persons who have PTSD or acute stress disorder have increased stress and anxiety following exposure to a
traumatic or stressful event.
Traumatic or stressful events may include experiencing a violent accident or crime, military combat, assault,
being kidnapped, being involved in a natural disaster, being diagnosed with a life-threatening illness, or
experiencing systematic physical or sexual abuse.
A PTSD patient experience negative thoughts and moods about the event and feel hyper aroused or
hyperactive.
The patient may relive the trauma in their dreams or experience “flashbacks” or waking thoughts about the
ordeal.
The stressors causing both acute stress disorder and PTSD are sufficiently overwhelming to affect almost
everyone.
Clinical Features:
Individuals with PTSD relive distressing instances of the traumatic event, with vivid emotional proximity and
high, imperative intensity.
They organize their lives trying to contain and mitigate the persistent effects of the traumatic experience.
For those traumatized in a war zone, they often feel as if the war never ended.
Victims of rape, assault, or torture describe difficulties engaging and trusting other humans.
Constantly reliving the trauma in the present, PTSD patients’ lives become a series of effortful attempts to
avoid reminders of the traumatic event.
They scan the environment for threat signals, which they fearfully expect, and remain on guard, tense,
restless, and exhausted.
Another core feature is the involuntary, uncontrollable, and intense nature of symptoms.
 Adjustment Disorders
People with adjustment disorders have an emotional response to a stressful event.
It is one of the few diagnostic entities that directly links an external stressor to the development of symptoms.
Typically, the stressor involves financial issues, a medical illness, or a relationship problem.
The symptoms must begin within 3 months of the stressor.
 EPIDEMIOLOGY (PTSD)
Posttraumatic Stress Disorder About 6.8 percent of the general population has a lifetime prevalence of PTSD.
The lifetime prevalence rate is 9.7 percent in women and 3.6 percent in men.
According to the National Vietnam Veterans Readjustment Study (NVVRS), 30.9 percent of men developed
full-blown PTSD after having served in the war, and 26.9 percent of women developed the disorder.
The disorder is most likely to occur in those who are single, divorced, widowed, socially withdrawn, or of low
socioeconomic level.
The most important risk factors, however, for this disorder are the severity, duration, and proximity of a
person’s exposure to the actual trauma.
A familial pattern seems to exist for this disorder, and first-degree biologic relatives of persons with a history
of depression have an increased risk for developing PTSD following a traumatic event.
EPIDEMIOLOGY (Adjustment Disorders)
Few studies have examined the prevalence of adjustment disorder in community samples.
A study examined the prevalence of adjustment disorder in a primary care setting and found
that 2.94 percent of the sample met the criteria for adjustment disorder.
There is a higher prevalence of adjustment disorder in the medical setting—especially patients
with cancer and those receiving palliative care.
For example, one study found that 11 percent of individuals with mixed cancer diagnoses had an
adjustment disorder.
ETIOLOGY (PTSD)
Even when faced with overwhelming trauma, most persons do not experience PTSD symptoms.
The National Comorbidity Study found that 60 percent of males and 50 percent of females had
experienced some significant trauma.
Evidence indicates a dose–response relationship between the degree of trauma and the
likelihood of symptoms.
Genetics and Risk for PTSD.
Genes account for about 30 percent of the variance in the risk for PTSD.
A study of Vietnam veteran twin pairs reported that monozygotic twins of veterans with combat-
related PTSD had more significant mood disorder symptoms than monozygotic co-twins of
combat controls or dizygotic co-twins of veterans with PTSD.
The findings suggest a shared genetic vulnerability to PTSD and mood disorders.
Several common genetic variants are associated with PTSD.
Also, the s/s genotype of the serotonin transporter gene may interact with childhood adversity
to increase PTSD risk.
ETIOLOGY (Adjustment Disorders)
The severity of the stressor or stressors does not always predict the severity of the disorder; the
stressor severity is a complex function of degree, quantity, duration, reversibility, environment,
and personal context.
For example, the loss of a parent is different for a child 10 years of age than for a person 40
years of age.
Personality organization and cultural or group norms and values also contribute to the
disproportionate responses to stressors.
Stressors may be single, such as the death of a loved one, divorce, losing a job, or medical
illness.
Alternatively, they can be a combination of any of these.
Stressors may be recurrent, such as seasonal business difficulties, or continuous, such as chronic
illness or poverty.
Sometimes, adjustment disorders occur in a group or community setting, and the stressors
affect several persons, as in a natural disaster or racial, social, or religious persecution.
Psychodynamic Factors.
Pivotal to understanding adjustment disorders is an understanding of three factors: the nature of the stressor,
the conscious and unconscious meanings of the stressor, and the patient’s pre-existing vulnerability.
A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment
disorders.
Some patients commonly place all the blame on a particular event when a less apparent event may have had
more significant psychological meaning for the patient.
Current events may reawaken past traumas or disappointments from childhood, so patients should be
encouraged to think about how the current situation relates to similar past events.
When adolescents leave home for college, for example, they are at high developmental risk for reacting with
a temporary symptomatic picture.
Similarly, if the young person who leaves home is the last child in the family, the parents may be particularly
vulnerable to a reaction of adjustment disorder.
Moreover, middle-aged persons who are confronting their mortality may be especially sensitive to the effects
of loss or death.
DIAGNOSIS ( PTSD, ASD)
The diagnosis includes several categories of symptoms, including symptoms of intrusion,
avoidance, negative mood or cognitions, and hyperarousal.
These symptoms cause significant functional impairment and are present for more than a
month.
As with most disorders, substance use or a medical condition should not better explain the
symptoms.
Posttraumatic Stress Disorder Diagnoses
in DSM-5
Symptoms:
1. History of exposure to (directly experiencing, repeated exposure witnessing in person,
learning of occurrence in close acquaintance) actual threatened death, severe injury, or sexual
trauma
2. Intrusive symptoms • Involuntary intrusive memories • In children < 6 years may see
reenactment of event through play • Recurrent nightmares/dreams of the event • In children <
6 years, frightening dreams without identifiable content may be present • Dissociative
responses or reliving of prior experience (i.e., flashbacks) • In children < 6 years, may see
reenactment of event through play • Psychological distress related to exposure to stimuli that
are reminders of prior trauma • Presence of physiologic response to stimuli that are reminders
of prior trauma
3. Pattern of avoidance of stimuli associated with prior experience of trauma • Avoidance of
memories related to trauma • Avoidance of external reminders of trauma
4. Negative mood or cognitions related to trauma • Impairment in memories related to event •
Negative perceptions of self and others • Cognitive distortions related to event • Excessive guilt,
anger or fear • Diminished interest and social withdrawal • Subjective detachment from others •
Difficulty experiencing positive feelings in response to previously pleasurable stimuli
5. Altered level of arousal • Irritability and/or anger • Risk taking • Hypervigilance • Increased
startle response • Difficulties with concentration • Sleep disturbances
Required number of symptoms In addition to history of exposure to trauma, must have • at least
one symptom of intrusion • at least one symptom of avoidance • at least two symptoms of
negative mood/cognition • at least two symptoms of arousal alterations
Psychosocial consequences of symptoms Marked distress and impairment in functioning
Exclusions • Exposure through media, electronics, movie, or photo • Related to substance use •
Related to another medical condition
Course specifiers With delayed expression: • All diagnostic criteria not met until 6 mo or more
after initial traumatic event
With acute stress disorder, the primary feature differentiating this disorder from PTSD is the
time course, with the symptoms of acute stress disorder occurring 3 days to 1 month following a
traumatic event.
Acute stress disorder can have any of the symptoms of PTSD; however, they do not have to have
all the domains.
A person who experiences a minimum of nine symptoms from any of these domains within 3
days to 1 month of a traumatic event meets the criteria for acute stress disorder.
 Acute Stress Disorder Diagnoses in DSM5
Symptoms:
1. History of exposure to (directly experiencing, repeated exposure witnessing in person, learning of
occurrence in close acquaintance) actual threatened death, severe injury, or sexual trauma
2. Presence of symptoms in the following categories (same as PTSD categories) • Intrusion • Negative
mood/cognition • Dissociation • Avoidance • Arousal
Required number of symptoms: Nine symptoms from among the above five categories
Psychosocial consequences of symptoms: Marked distress and impairment in functioning
 Adjustment Disorders
Clinicians tend to use the diagnostic category of adjustment disorders liberally.
Although this disorder must follow a stressor, the symptoms do not necessarily begin immediately.
Symptoms do not always subside as soon as the stressor ceases; if the stressor continues, the disorder
may be chronic.
The disorder can occur at any age, and its symptoms vary considerably, with depressive, anxious, and
mixed features most common in adults.
Duration: Occurring within 3 month of an acute stressor and resolving within 6 month of resolution of
stressor
Adjustment Disorder with Depressed Mood. In adjustment disorder with depressed mood,
symptoms may manifest as depression, hyposomnia, low self-esteem, or suicidal ideation. We
should distinguish this disorder from a major depressive disorder and uncomplicated
bereavement.
Adjustment Disorder with Anxiety. Symptoms such as generalized anxiety, increased motor
activity, and situational anxiety are present in adjustment disorder with anxiety, which we
should differentiate from anxiety disorders.
Adjustment Disorder with Mixed Anxiety and Depressed Mood. In adjustment disorder with
mixed anxiety and depressed mood, patients exhibit features of both anxiety and depression
that do not meet the criteria for an already established anxiety disorder or depressive disorder.
Adjustment Disorder with Disturbance of Conduct. In adjustment disorder with disturbance of
conduct, symptoms include impulsivity, lack of insight, and violent behavior. We should
differentiate this category from conduct disorder and antisocial personality disorder.
Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. A combination of
disturbances of emotions and conduct sometimes occurs. Examples include excessive alcohol
ingestion, suspiciousness, hostility, defrauding behavior, and homicidal ideation. Clinicians are
encouraged to try to make one or the other diagnosis in the interest of clarity.
Adjustment Disorder Unspecified: A residual category for atypical maladaptive reactions to
stress. Examples include inappropriate responses to the diagnosis of physical illness, such as
massive denial, severe noncompliance with treatment, and social withdrawal, without
significant depressed or anxious mood.
Adjustment Disorder Diagnoses in DSM-5
Symptoms 1. Emotional or behavioral changes 2. Marked distress/impairment that is felt to be
out of proportion to the stressor itself
Required number of symptoms All of the above
Psychosocial consequences of symptoms Marked distress/functional impairment
Exclusions (not result of): Exacerbation of existing mental illness/ Normal bereavement/ Other
psychiatric illness
DIFFERENTIAL DIAGNOSIS
Generally, the time requirements and diagnostic criteria help to differentiate PTSD, acute stress
disorder, and other psychiatric disorders.
With adjustment disorder, one of the challenges is that there are no clear criteria that define the
stressors that are required to make this diagnosis.
PTSD and acute stress disorder have the nature of the stressor better characterized and include
a defined constellation of affective, cognitive, and autonomic symptoms.
In contrast, the stressor in adjustment disorder can be of any severity, with a wide range of
possible symptoms.
When the response to an extreme stressor does not meet the acute stress or posttraumatic
disorder threshold, the adjustment disorder diagnosis would be appropriate.
Symptoms of PTSD can be difficult to distinguish from both panic disorder and generalized
anxiety disorder because all three syndromes are associated with prominent anxiety and
autonomic arousal.
PTSD is also associated with intrusion symptoms and avoidance of anything that reminds the
person of the trauma, something not usually present in panic or generalized anxiety disorder.
Major depression is also a frequent concomitant of PTSD. Although the two syndromes are not
generally difficult to distinguish phenomenologically, it is essential to note the presence of
comorbid depression because this can influence the treatment of PTSD.
We also must differentiate PTSD from several related disorders that can look similar, including
borderline personality disorder, dissociative disorders, and factitious disorders.
Although uncomplicated bereavement often produces temporarily impaired social and
occupational functioning, the person’s dysfunction remains within the expectable bounds of a
reaction to the loss of a loved one and, thus, is not considered adjustment disorder.
Patients with an adjustment disorder are impaired in social or occupational functioning and
show symptoms beyond the usual and expectable reaction to the stressor.
Because no absolute criteria help to distinguish an adjustment disorder from another condition,
clinical judgment is necessary.
Some patients may meet the criteria for both an adjustment disorder and a personality disorder.
If the adjustment disorder follows a physical illness, the clinician must make sure that the
symptoms are not a continuation or another manifestation of the illness or its treatment.
COMORBIDITY
Posttraumatic Stress Disorder:
Comorbidity rates are high among patients with PTSD, with about two-thirds having at least two
other disorders.
Common comorbid conditions include depressive disorders, substance-related disorders, anxiety
disorders, and bipolar disorders.
Adjustment Disorders:
Most psychiatric disorders can co-occur with adjustment disorder.
However, it is critical to ensure that another psychiatric disorder does not best explain the
person’s response to the stressor.
COURSE AND PROGNOSIS (PTSD)
Untreated, about 30 percent of patients recover completely, 40 percent continue to have mild
symptoms, 20 percent continue to have moderate symptoms, and 10 percent remain unchanged
or become worse.
After 1 year, about 50 percent of patients will recover.

Positive Prognostic Factors for PTSD: Rapid onset of the symptoms/ Short duration of the
symptoms (less than 6 months)/ Good premorbid functioning/ Strong social supports/ Absence
of other psychiatric, medical, or substance-related disorders or other risk factors
In general, the very young and the very old have more difficulty with traumatic events than do
those in midlife.
Presumably, young children do not yet have adequate coping mechanisms to deal with the
physical and emotional insults of the trauma.
Likewise, older persons are likely to have more rigid coping mechanisms than younger adults
and to be less able to muster a flexible approach to dealing with the effects of trauma.
Furthermore, physical disabilities typical of late life can exacerbate the symptoms.
PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and
may be challenging to treat.
The availability of social supports may also influence the development, severity, and duration of
PTSD.
COURSE AND PROGNOSIS (Adjustment
Disorders)
With appropriate treatment, the overall prognosis of an adjustment disorder is generally
favorable.
Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later
have mood disorders or substance-related disorders.
Adolescents usually require a longer time to recover than adults.
Some studies suggest that a high proportion of patients with adjustment disorders have had
past suicide attempts and recent suicidality. This data is difficult to interpret, given the extensive
and sometimes inconsistent use of this diagnosis; however, it is critical to evaluate for suicidality
in patients with this disorder.
TREATMENT APPROACH (PTSD)
TREATMENT APPROACH (Adjustment
Disorders )
Psychotherapy:
Psychotherapy remains the treatment of choice for adjustment disorders.
Group therapy can be particularly useful for patients who have had similar stresses—for
example, a group of retired persons or patients having renal dialysis.
Individual psychotherapy interventions include supportive psychological approaches, cognitive-
behavioral, problem-solving techniques, and psychodynamic interventions.
Psychotherapy can help persons adapt to stressors that are not reversible or time-limited and
can serve as a preventive intervention if the stressor does remit.
Crisis Intervention:
Crisis intervention and case management are short-term treatments aimed at helping persons
with adjustment disorders resolve their situations quickly by supportive techniques, suggestion,
reassurance, environmental modification, and even hospitalization, if necessary.
The frequency and length of visits for crisis support vary according to patients’ needs; daily
sessions may be required, sometimes two or three times each day.
Pharmacotherapy:
There is limited evidence for the efficacy of pharmacologic interventions in persons with adjustment
disorder.
Still, it may be reasonable to use medication to treat specific symptoms for a brief time.
Depending on the type of adjustment disorder, a patient may respond to an antianxiety agent or an
antidepressant.
It is often helpful and important to treat insomnia and severe anxiety with pharmacologic
interventions in the short run.
Clinicians have found some SSRIs to be useful for treating some subthreshold depressive symptoms
and may benefit certain subtypes of adjustment disorders.
Pharmacologic intervention in this population should mainly augment psychosocial strategies and not
serve as the primary modality.