Trauma- and stressor-related disorders

Trauma- and stressor-related disorders are a group of psychiatric disorders that arise following a stressful or traumatic event. They include acute stress disorder, posttraumatic stress disorder (PTSD), and adjustment disorder. These three conditions often present similarly to other psychiatric disorders, such as depression and anxiety, although the presence of a trigger event is necessary to confirm a diagnosis. Because trauma- and stressor-related disorders share many common features, it is imperative to understand the nature of the triggering event, the temporal relationship between the triggering event and symptom occurrence, and the severity of symptoms. Treatment generally consists of both psychotherapy and pharmacotherapy.

Acute stress disorder and PTSD are covered in detail in acute and posttraumatic stress disorders.

References:^[1]

Overview

Definition

• A maladaptive emotional (e.g., anxiety) or behavioral (e.g., outburst) response to a stressor, lasting ≤ 6 months following resolution of the stressor

Epidemiology

• Occurs in ∼ 5–20% of individuals undergoing outpatient mental health treatment
• Up to one-third of patients with a cancer diagnosis develop this disorder. ^[2]

Etiology

• A combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)

Diagnostic criteria (DSM-5) ^[1]

• Emotions or behaviors in response to a stressor that occur within 3 months of onset
• Clinically significant responses that include ≥ 1 of the following:
  • A level of distress that is disproportionate to the expected response to the stressor
  • Impaired functioning in social, occupational, and/or other important areas
• Symptoms are not explained by another mental disorder.
• Symptoms are not explained by a normal response to grief.
• Symptoms last ≤ 6 months following resolution of the stressor.

Differential diagnosis

• Normal stress reaction
• Major depressive disorder: Although some symptoms can be shared between the two conditions, the criteria for MDD are not met. (See Diagnostic criteria for major depressive disorder.)
• Generalized anxiety disorder : If symptoms of adjustment disorder last > 6 months the diagnosis is changed to GAD.

Treatment and prognosis ^[2]

• Psychotherapy
  • First-line treatment: cognitive-behavioral therapy or psychodynamic psychotherapy
  • May be provided as individual, family, or group support therapy
  • Interpersonal psychotherapy
• Pharmacotherapy
  • SSRIs: depressed mood
  • Benzodiazepines: anxiety or panic attacks
  • Benzodiazepines or other sedative-hypnotic agents (e.g., zolpidem): insomnia

Although psychotherapy alone is usually sufficient in patients with adjustment disorder who have no other disabling symptoms, pharmacotherapy may be used when psychotherapy has little or no effect.

References:^[1][2][3]

• Description
  • A psychiatric disorder characterized by inhibited, emotionally withdrawn interactions with caregivers and associated with social neglect during early childhood
  • An inability to relate interpersonally with peers and adults leads to impaired social development throughout early childhood (e.g. cognitive and/or language delays, academic difficulties, and pervasive anger/resentment)
• Diagnostic criteria (DSM-V) ^[1]
  • Emotionally withdrawn and inhibited behavior towards caregivers as manifested by the child rarely seeking or responding to comfort when upset.
  • A consistent emotional disturbance and social inhibition characterized by two or more of the following:
    • Limited response to the social and emotional cues of others
    • Blunted affect
    • Caregivers note irritable, fearful, or emotional behavior, even in the absence of a threatening situation.
  • A history of neglect in early childhood (< 2 years of age) as indicated by at least one of the following:
    • Persistent social neglect (inadequate comfort, stimulation, and affection provided by caregivers)
    • Repeated changes in primary caregivers (e.g., foster carers) that impede the development of selective social attachments
    • Childrearing settings with a high child-to-caregiver ratio
  • The inhibited behavior begins after the onset of insufficient or inconsistent care.
  • Not due to other psychiatric disorders (e.g., autistic spectrum disorder)
  • Onset: symptoms manifest before the age of 5 years
  • Developmental age of 9 months or more
  • Specifiers
    • Persistent: duration of disorder > 12 months
    • Severe: presence of all symptoms at high levels of severity
• Treatment ^[4]
  • Ensuring the presence of an emotionally available attachment figure
    • If the caregiver is emotionally available and not overwhelmed: Encourage sensitive responsiveness and offer coaching the caregiver as a co-therapist in the child's treatment.
    • If the caregiver is emotionally unavailable and/or too overwhelmed: child–parent psychotherapy and/or attachment and biobehavioral catch-up
  • Pharmacotherapy: not recommended and should only be considered with a high degree of caution for related psychiatric comorbidities such as ADHD, mood disorders, and anxiety disorders.
• Complications: developmental delays associated with neglect (for more information, see “Child neglect”)

• Description
  • A psychiatric disorder characterized by uninhibited interactions with unfamiliar adults and associated with social neglect during early childhood
  • Affected adolescents are less likely to experience stable peer relationships (e.g., more frequent conflicts)
• Diagnostic criteria (DSM-V) ^[1]
  • Consistent pattern of disinhibited behavior characterized by at least two of the following:
    • Lack of restraint in approaching and engaging with unfamiliar adults
    • Excessively familiar behavior towards strangers that is inconsistent with age-appropriate or culturally accepted norms
    • Venturing away without checking back with adult caregiver, even in unfamiliar settings
    • Little or no hesitation to accompany unfamilar adults away from caregiver
  • Disinhibited behavior is not marked exclusively by impulsivity (as seen in ADHD) but must have a social component.
  • A history of neglect in early childhood (< 2 years of age) ^[4]
    • Persistent social neglect (inadequate comfort, stimulation, and affection provided by caregivers)
    • Repeated changes in primary caregivers (e.g., foster carers) impede the development of selective social attachments.
    • Childrearing settings with a high child-to-caregiver ratio
  • The disinhibited behavior begins after the onset of insufficient or inconsistent care
  • Developmental age of at least 9 months
• Treatment ^[4]
  • Psychotherapy: parent-child interaction therapy, family therapy
  • Coaching techniques for primary caregivers
• Complications: developmental delays associated with neglect (for more information, see “Child neglect”)