Trauma- and Stressor-

Related Disorders
 exposure to a traumatic or stressful event is listed explicitly as a diagnostic
criterion, including
1) Reactive attachment disorder
2) Disinhibited social engagement disorder
3) Posttraumatic stress disorder (PTSD)
4) Acute stress disorder
5) Adjustment disorders
6) Prolonged grief disorder

Presentation title 2
Reactive Attachment Disorder
 Diagnostic Criteria
• A) A consistent pattern of inhibited, emotionally withdrawn behavior toward
adult caregivers, manifested by 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

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

Presentation title 4
 • 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)
Presentation title 5
 • 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 month

Associated Features
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).

Presentation title 6
 can be distinguished based on differential histories of neglect and on the
presence of restricted interests or ritualized behaviors, specific deficit in
social communication, and selective attachment behaviors

Children with intellectual developmental disorder should exhibit social

and
emotional skills comparable to their cognitive skills and do not
demonstrate the profound reduction in positive affect and emotion
regulation difficulties evident in children with reactive attachment
disorder.

respond to comforting efforts by caregivers.

Presentation title 7
Presentation title
Disinhibited Social Engagement 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 reticence 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.

Presentation title 10
 • 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, 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)
Presentation title 11
 • 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.
Associated Features
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 these other signs of neglect are no longer present.

Presentation title 12
 Children with disinhibited social engagement disorder can be
distinguished
from those with ADHD accompanied by social impulsivity, as the former
do not show difficulties with attention or hyperactivity.

Presentation title 13
Presentation title 14
Posttraumatic Stress Disorder
 Diagnostic Criteria
• A) 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).
Presentation title 16
 • 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).
2) Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s).
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.)
Presentation title 17
 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 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
Presentationevent(s).
title 18
 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.

Presentation title 19
 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.

Presentation title 20
 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.
Presentation title 21
H) The disturbance is not attributable to the physiological effects of a
 Associated Features
• Developmental regression, such as loss of language in young children,
may occur. Auditory pseudo-hallucinations 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 involves the violent death of someone with
whom the individual had a close relationship, symptoms of both
prolonged grief disorder and PTSD may be present

Presentation title 22
Presentation title 23
Presentation title
 Treatment
Psychological treatments are generally preferred in the treatment of
PTSD, although pharmacotherapy has a role in patients presenting with
significant comorbid depression or where psychological approaches are not
beneficial. Where alcohol or substance use disorders coexist with PTSD, it
may be advisable to treat the substance misuse prior to offering
psychological treatment for PTSD.
1) Cognitive behavioural treatment
Cognitive behaviour therapy is the most appropriate treatment. This
treatment has several components:

Presentation title 25
 • Information about the normal response to severe stress, and the
importance of confronting situations and memories related to the
traumatic events.
• Self-monitoring of symptoms.
• Exposure in imagination and then in vivo to situations that are being
avoided.
• Recall of images of the traumatic events, to integrate these with the rest
of the patient’s experience. When first recalled these images are often
fragmentary and are not clearly related in time to the other contents of
memory.
• Cognitive restructuring through the discussion of evidence for and against
the appraisals and assumptions.
• Anger management for people who still feel angry about the traumatic
events and their causes.
Presentation title 26
 Eye movement desensitization and reprocessing
• A structured therapy that encourages the patient to
briefly focus on the trauma memory while simultaneously
experiencing bilateral stimulation (typically eye
movements), which is associated with a reduction in the
vividness and emotion associated with the trauma
memories.
• EMDR is an individual therapy typically delivered one to
two times per week for a total of 6-12 sessions, although
some people benefit from fewer sessions. Sessions can be
conducted on consecutive days.
• EMDR therapy focuses directly on the memory, and is
intended to change the way that the memory is stored in
the
Presentation title brain, thus reducing and eliminating the problematic 27
Presentation title
 Narrative exposure therapy (NET)
• This treatment helps individuals establish a coherent
life narrative in which to contextualize traumatic
experiences. It is known for its use in group treatment
with refugees.
• particularly in individuals suffering from complex and
multiple trauma.
• Often, small groups of people receive four to 10
sessions of NET together, although it can be provided
individually as well.
• It is understood that the story a person tells himself or
herself about their life influences how the person
perceives their experiences and wellbeing.
Presentation title 29
 Medication
• Anxiolytic drugs such as benzodiazepines should be avoided in patients
with established PTSD, because prolonged use may lead to
dependence.
• A number of antidepressant drugs have shown efficacy in clinical trials,
including selective serotonin reuptake inhibitors (SSRIs), serotonin and
noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants
(TCAs), and mono-amine oxidase inhibitors (MAOIs).
• There are also more preliminary data supporting the efficacy of
mirtazapine, and augmentation with atypical antipsychotic drugs such
as olanzapine may have a place in treatment-resistant patients,
particularly those with marked sleep disturbance.

Presentation title 30
Acute Stress Disorder
 Diagnostic Criteria
• 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 event(s) occurred to a close family member or close
friend.
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).

Presentation title 32
 • 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:

1) Recurrent, involuntary, and intrusive distressing memories of the traumatic

event(s)
2) Recurrent distressing dreams in which the content and/or affect of the dream
are related to the event(s).
3) Dissociative reactions (e.g., flashbacks)
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)

Presentation title 33
 5) Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings)

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

Presentation title 34
 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).

10) Sleep disturbance

11) Irritable behavior and angry outbursts (tgfv with little or no
provocation)
12) Hypervigilance
13) Problems with concentration.
Presentation title 35
 • C) Duration of the disturbance (symptoms in Criterion B) is 3 days to 1
month after trauma exposure.
• 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.

Presentation title 36
 • The core symptoms of an acute psychological response to stress are anxiety or
depression. Anxiety is the response to threatening experiences, and depression
is the response to loss. Anxiety and depression often occur together, because
stressful events often combine danger and loss.
• Other symptoms include feelings of being numb or dazed, difficulty in
remembering the whole sequence of the traumatic event, insomnia,
restlessness, poor concentration, and physical symptoms of autonomic arousal,
especially sweating, palpitations, and tremor.
• Coping strategies and defence mechanisms are also part of the acute response
to stressful events. Avoidance is the most frequent coping strategy, where the
person avoids talking or thinking about the stressful events, and avoids
reminders of them. The most frequent defence mechanism is denial.

Presentation title 37
 • If anxiety is severe, an anxiolytic drug may be prescribed for a day or two,
and if sleep is severely disrupted a hypnotic drug may be given for one or
two nights.
• It is good practice to offer a follow-up appointment around two weeks
after the trauma to identify people whose symptoms are not settling and
who are therefore at increased risk of developing the more long-term and
disabling PTSD

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 Prolonged Exposure Therapy
• Prolonged exposure teaches individuals to gradually
approach their trauma-related memories, feelings and
situations.
• Most people want to avoid anything that reminds
them of the trauma they experienced, but doing so
reinforces their fear. By facing what has been avoided,
a person can decrease symptoms of PTSD by actively
learning that the trauma-related memories and cues
are not dangerous and do not need to be avoided.
• Prolonged exposure is typically provided over a period
of about three months with weekly individual sessions,
resulting in eight to 15 sessions overall.
Presentation title 39
Presentation title
Adjustment Disorders
 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 and the cultural
factors that might influence symptom severity and presentation.
2) Significant impairment in social, occupational, or other important areas
of
functioning.
Presentation title 42
 • 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 and are not
better explained by prolonged grief disorder.
• E) Once the stressor or its consequences have terminated, the symptoms
do not persist for more than an additional 6 months

Presentation title 43
 Specifiers
• Acute: This specifier can be used to indicate persistence of symptoms for less
than 6 months.
• Persistent (chronic): This specifier can be used to indicate persistence of
symptoms for 6 months or longer. By definition, symptoms cannot persist for
more than 6 months after the termination of the stressor or its consequences.
The persistent specifier therefore applies when the duration of the disturbance
is
longer than 6 months in response to a chronic stressor or to a stressor that has
enduring consequences.

Presentation title 44
 Treatment
• help the patient to resolve the stressful problems if this is possible, and to
aid the natural processes of adjustment.
• by reducing denial and avoidance of the stressful events
• encouraging problem-solving
• discouraging maladaptive coping responses
• Occasionally, an anxiolytic or hypnotic drug is needed for a few days
• Problem-solving counselling encourages the patient to seek solutions to
stressful problems, and to consider the advantages and disadvantages of
various kinds of action

Presentation title 45
Prolonged Grief Disorder
 Diagnostic Criteria
• A) The death, at least 12 months ago, of a person who was close to the
bereaved individual (for children and adolescents, at least 6 months ago)
• B) Since the death, the development of a persistent grief response
characterized
by one or both of the following symptoms, which have been present most
days
to a clinically significant degree. In addition, the symptom(s) has occurred
nearly
every day for at least the last month:
1) Intense yearning/longing for the deceased person.
2) Preoccupation with thoughts or memories of the deceased person (in
children
Presentation title 47
 • C) Since the death, at least three of the following symptoms have been present
most days to a clinically significant degree. In addition, the symptoms have
occurred nearly every day for at least the last month:
1) Identity disruption (e.g., feeling as though part of oneself has died) since
the death.
2) Marked sense of disbelief about the death.
3) Avoidance of reminders that the person is dead
4) Intense emotional pain related to the death.
5) Difficulty reintegrating into one’s relationships and activities after the
death
6) Emotional numbness
7) Feeling that life is meaningless as a result of the death
8) Intense loneliness as a result of the death.
Presentation title 48
 • D) The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• E) The duration and severity of the bereavement reaction clearly exceed
expected social, cultural, or religious norms for the individual’s culture
and context.
• F) The symptoms are not better explained by another mental disorder,
such as major depressive disorder or posttraumatic stress disorder, and
are not
attributable to the physiological effects of a substance (e.g., medication,
alcohol) or another medical condition.

Presentation title 49
 Prolonged grief disorder is distinguished from normal grief by the
presence of severe grief reactions that persist at least 12 months (6 months
in children or adolescents) after the death of a person who was close to the
bereaved individual. In evaluating the requirement for clinically significant
symptoms to be present most days over the past month, it should be noted
that marked increases in grief severity can be seen in normal grieving
around calendar days that are reminders of the loss, such as the
anniversary of the death, birthdays, wedding anniversaries, and holidays;
this exacerbation of grief severity does not by itself, in the absence of
persistent grief at other times, constitute evidence of prolonged grief
disorder.
Presentation title 50
 Prolonged grief disorder, major depressive disorder, and persistent
depressive disorder share several symptoms, including low mood, crying,
and suicidal thinking. However, in prolonged grief disorder the distress is
focused on feelings of loss and separation from a loved one rather than
reflecting generalized low mood. Major depressive disorder may also be
preceded by the death of a loved one, with or without comorbid prolonged
grief disorder

Presentation title 51
 - Individuals who experience bereavement as a result of violent or
accidental death may develop both PTSD and prolonged grief disorder. Both
conditions can involve intrusive thoughts and avoidance. Whereas
intrusions in PTSD revolve around the traumatic event (which may have
caused the death of a loved one), intrusive memories in prolonged grief
disorder focus on thoughts about many aspects of the relationship with the
deceased, including positive aspects of the relationship and distress over
the separation.

Presentation title 52
Dissociative Disorders

Dr. Muhammad Haziq bin Zolkapli

 - characterized by a disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion, perception,
body representation, motor control, and behavior.
- frequently found in the aftermath of a wide variety of psychologically
traumatic experiences in children, adolescents, and adults.
1) Dissociative identity disorder
2) Dissociative amnesia
3) Depersonalization/derealization disorder

Presentation title 54
Presentation title
Dissociative Identity Disorder
 Diagnostic Criteria
• A) Disruption of identity characterized by two or more distinct personality
states, which may be described in some cultures as an experience of
possession. The disruption in identity involves marked discontinuity in
sense of self and sense of agency, accompanied by related alterations in
affect, behavior, consciousness, memory, perception, cognition, and/or
sensory-motor functioning. These signs and symptoms may be observed
by others or reported by the individual.
• B) Recurrent gaps in the recall of everyday events, important personal
information, and/or traumatic events that are inconsistent with ordinary
forgetting.

Presentation title 57
 • C) The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
• D) The disturbance is not a normal part of a broadly accepted cultural or
religious practice.
• E) The symptoms are not attributable to the physiological effects of a
substance(e.g., blackouts or chaotic behavior during alcohol intoxication)
or another medical condition (e.g., complex partial seizures).

Presentation title 58
 Associated Features
• Individuals with dissociative identity disorder typically present with
comorbid depression, anxiety, substance abuse, self-injury, or another
common symptom.
• Among personality features, avoidant personality features most often
rate highest in individuals with dissociative identity disorder, and some
individuals with dissociative identity disorder are so avoidant that they
prefer to be alone.
• When decompensated, some individuals with dissociative identity
disorder display features of borderline personality disorder (i.e., self
destructive high-risk behaviors, and mood instability)

Presentation title 59
Dissociative Amnesia
 Diagnostic Criteria
• A) An inability to recall important autobiographical information, usually of
a traumatic or stressful nature, that is inconsistent with ordinary
forgetting
• B) The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• C) The disturbance is not attributable to the physiological effects of a
substance (e.g., alcohol or other drug of abuse, a medication) or a
neurological or other medical condition (e.g., partial complex seizures,
transient global amnesia, sequelae of a closed head injury/traumatic brain
injury, other neurological condition).
• D) The disturbance is not better explained by dissociative identity
disorder, posttraumatic stress disorder, acute stress disorder, somatic
symptom
Presentation title disorder, or major or mild neurocognitive disorder. 61
 Diagnostic Features
• The defining characteristic of dissociative amnesia is an inability to recall
important autobiographical information that
1) should be successfully stored in memory and
2) ordinarily would be freely recollected
• A variety of types of dissociative amnesia may manifest. In general, the
memory deficit in dissociative amnesia is retrograde and, except in rare
cases, is not associated with ongoing amnesia for contemporary life
events. Retrospective memory impairments include not only lost
memories of traumatic experiences but also lost memories of everyday
life during which no trauma occurred.

Presentation title 62
Depersonalization/Derealization Disorder
 Diagnostic Criteria
• A) The presence of persistent or recurrent experiences of
depersonalization, derealization, or both:
1) Depersonalization: Experiences of unreality, detachment, or being an
outside observer with respect to one’s thoughts, feelings, sensations,
body,
or actions (e.g., perceptual alterations, distorted sense of time, unreal or
absent self, emotional and/or physical numbing).
2) Derealization: Experiences of unreality or detachment with respect to
surroundings (e.g., individuals or objects are experienced as unreal,
dreamlike, foggy, lifeless, or visually distorted)
Presentation title 64
 • B) During the depersonalization or derealization experiences, reality
testing remains intact.
• C) The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• D) The disturbance is not attributable to the physiological effects of a
substance(e.g., a drug of abuse, medication) or another medical
condition (e.g., seizures).
• E) The disturbance is not better explained by another mental disorder,
such as schizophrenia, panic disorder, major depressive disorder, acute
stress disorder, posttraumatic stress disorder, or another dissociative
disorder

Presentation title 65
 Associated Features
• Individuals with depersonalization/derealization disorder may have
difficulty describing their symptoms and may think they are “crazy” or
“going crazy.” Another common experience is the fear of irreversible brain
damage.
• A commonly associated symptom is a subjectively altered sense of time
(i.e., too fast or too slow), as well as a subjective difficulty in vividly
recalling past memories and owning them as personal and emotional.
• Vague somatic symptoms, such as head fullness, tingling, or
lightheadedness, are not uncommon.

Presentation title 66
 Treatment
• When depersonalization is secondary to another disorder, treatment
should be directed to the primary condition.
• Supportive interviews can help the patient to function more normally
despite the symptoms, and any stressors should be addressed
• No specific pharmacological or psychological treatments are well
established.
• It is better to give adequate time for supportive care.

Presentation title 67
 REFERENCES
• DSM-5-TR
• Shorter Oxford Textbook Of Psychiatry – 7th Edition

Presentation title 68
Thank you