Trauma &

Stressor
Related
Disorders
PSY 348
Introduction
• A new group of disorders introduced in the DSM-5
• Pairs a mental disorder with the presence of an external event
• However, we cannot ascribe the cause of the disorder only to the external
event: many other mental disorders, including major depression,
schizophrenia, and specific phobia, also are more likely to begin after a
stressor (de Graaf et al., 2002)
 Stressors are quite common: lifetime
Stressors prevalence of 60.7% for men and 51.2% of
women in a representative U.S. sample
and (Kessler et al., 1995)

Natural
After a traumatic event, psychological
Recovery reactions that most people experience
(insomnia, irritability, reactivity to
reminders) usually abate within the first 3
months and continue to decline over time
(Foa & Rigs, 1995)
Natural recovery trajectories:
patterns of natural recovery for
individuals experiencing sexual or
non-sexual assault up to one year
following trauma exposure
Stressors Continued
• Not all stressors confer the same degree of risk for developing a disorder: events such as
being a prisoner of war, experiencing combat, or experiencing sexual assault confer a much
higher risk of PTSD than witnessing an event or experiencing a natural disaster (Breslau et
al., 1999)
• Pre-existing predictive factors associated with PTSD include a history of psychopathology,
previous child abuse, and being female (Brewin et al., 2000)
• Stronger predictors of PTSD tend to be trauma-specific or post-event factors: severity of the
event, lack of social support, and ongoing post-event stress
Prevalence
• Lifetime prevalence of PTSD in the U.S. is 10.4% in women and 6.8% in men
(Kessler et al., 1995)
• Global rates are difficult to estimate due to varying diagnostic method and the
varying incidence of trauma exposure across regions: one study in Sierra
Leone reported that 99% of individuals meet PTSD criteria (de Jong et al.,
2000)
• Rates from the WHO suggest an overall prevalence of 3.9%-5.6% among the
trauma-exposed (Koenen et al., 2017)
Prevalence & Co-occurrence
• Rates of PTSD vary across specific samples, with higher rates in veterans,
active duty military service members, sexual assault survivors, and refugees.
• PTSD shows a high degree of co-occurrence with a variety of other mental
disorders; in the National Comorbidity Study, 88% of men and 79% of women
with a diagnosis of PTSD at some point in their lives had at least one other
mental disorder (Kessler et al., 1995)
• Nearly half of all those diagnosed with PTSD also experience a major
depressive episode at some point in their lives
Genetic Factors
• Few genome-wide association studies of
PTSD have been conducted to date, and
accordingly few robust genetic variants
have been identified (Nievergelt et al.,
2018)
• Candidate genes are associated with the
serotonergic, noradrenergic, and
dopaminergic systems (Solovieff et al.,
2014)
Brain Regions of Interest
• Two of the most recurrent findings in individuals with PTSD are
decreased mPFC activation and increased amygdala activation
(Francati et al., 2007; Patel et al., 2013)
• Increased hippocampal activation to trauma and emotional
stimuli has been observed, as well as slightly lower hippocampal
volume compared to trauma-exposed individuals without PTSD
(Logue et al., 2017)
Psychosocial Models: Classical
Conditioning and Extinction

• In conditioning model, presence of a perceived danger (US) leads to

development of learned danger signals (CS); previously neutral stimuli
become paired with traumatic event and lead to development of anxiety-
based reactions
• PTSD may involve impairments in extinction learning, with individuals
impaired in their ability o learn new inhibitory associations to trauma-related
reminders
 • Exposure therapies focusing on

Interventions: approaching the trauma memory and

trauma-related reminders help alter
maladaptive beliefs

Exposure-Based • Prolonged exposure and imaginal

exposure are often used, and have been
empirically supported in a number of
samples (Foa et al., 1999)
• Eye movement desensitization and
reprocess (EMDR) shows large
improvement on PTSD symptoms,
although the underlying mechanism is not
clear (Davidson & Parker, 2001)
Interventions: • Focus on changing the person’s
understanding of the trauma and its
meaning in their life

Cognitive • Trauma-focused cognitive therapy:

adaptive information is introduced via

Treatments
cognitive restructuring and behavioral
experiments to incorporate the trauma
memory
• RCTs are less plentiful than for exposure
therapies, but large and consistent effect
sizes have been found across samples with
mixed traumatic experiences (Ehlers et al.,
2014)
Biological and SSRIs are considered the first-line
pharmacological treatments with a large
Pharmacologic evidence base (Stein et al., 2006)
al Interventions
SNRIs have been less studied, but show
comparable benefits to SSRIs

Side effects of benzodiazepines and

antipsychotics may outweigh their
benefits, for which the evidence is mixed
(Hamner et al., 2009)
Conclusion
• Trauma and stressor exposures occur often, but only a minority of individuals who
experience these events develop chronic psychopathology
• Pre-trauma factors are not strong predictors of who will develop psychopathology
• Vulnerability likely has genetic markers and contributing environmental factors; fear
conditioning and extinction learning processes are also likely at play
• Questions remain about key mechanisms that promote therapeutic change