1. Trauma and stressor related disorders
Dr Nesif Al-Hemiary

2. Definition
Disorders in which exposure to traumatic or stressful events is listed explicitly as a diagnostic criterion.
They include: reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder(PTSD), acute stress disorder, and adjustment disorders.

3. Definition
Psychological distress following exposure to a traumatic or stressful event is quite variable.
The symptoms may vary from fear-anxiety to anhedonic-dysphoric to externalizing angry and aggressive symptoms, or dissociative symptoms.

4. Reactive attachment disorder
Reactive attachment 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 putative care giving adults.
The disorder is associated with the absence of expected comfort seeking and response to comforting behaviors.
The disorder is caused by severe social neglect.

5. Disinhibited Social Engagement Disorder
The essential feature 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.
It is caused by severe social neglect.

6. Posttraumatic Stress Disorder
The essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events.
The clinical presentation of PTSD varies.
In some individuals, fear based re-experiencing , emotional and behavioral symptoms may predominate.
In others anhedonic or dysphoric mood states and negative cognitions may be most distressing,
In some other individuals, arousal and reactive-externalizing symptoms are prominent, while in others dissociative symptoms predominate.
Finally , some individuals exhibit combination of these symptom patterns.

7. Exposure to traumatic events
The direct exposure to a traumatic event: include exposure to war circumstances, threatened or actual physical assault, threatened or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, , natural or human made disasters, and severe motor, vehicle accidents.
Witnessed events include: observing threatened or serious injury, unnatural death, physical or sexual abuse of another person, domestic violence, accident, war or disaster , or a medical catastrophe in one’s child.
Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental.

8. Re-experiencing of the event
The traumatic event can be re-experienced in various ways.
Commonly the individual has recurrent, involuntary , and intrusive recollections of the event.
Recurrent memories of the event usually include sensory, emotional , and physiological components.
It might occur during dreams.
Flash-backs: dissociative states that last from few seconds to several hours or even days, during which components of the event are relived and the individual behaves as if the event were occurring at that moment.
Intense psychological distress or physiological reactivity often occur when the individual is exposed to a triggering event that resemble or symbolize an aspect of the traumatic event .

9. Avoidance
Stimuli associated with the trauma are persistently (always or almost always) avoided.
The individual commonly makes deliberate efforts to avoid thoughts, memories ,feelings, or talking about the traumatic event and to avoid activities, objects, situations or people who arouse recollections of it.

10. Cognitive/mood symptoms
Negative alterations in cognitions or mood associated with the event begin or worsen after exposure to the event. These can take several forms including an inability to remember an important aspect of the traumatic event, or negative expectations regarding important aspects of life, persistent erroneous self-blame or blame of others for the occurrence of the event.
Persistent negative mood state( fear, horror, anger, guilt, shame)
Markedly diminished interest or participation in previously enjoyed activities, feeling detached, or estranged from other people.
Persistent inability to feel positive emotions ( happiness, joy, satisfaction, intimacy, etc…)

11. Behavioral symptoms
Individuals with PTSD may be quick tempered and may even engage in aggressive verbal and/or physical behavior with little or no provocation(e.g., yelling at people, getting into fights, destroying objects)
Reckless or self destructive behavior such as dangerous driving, excessive alcohol or drug abuse or self injurious suicidal behavior.
Over sensitivity to potential threats to stimuli that are related or not related to the traumatic event,
Over reactivity to expected stimuli displaying heightened startle response or jumpiness, to loud noises or unexpected movements
Concentration difficulties, including difficulty remembering daily events, or attending to focused tasks, .
Problems with sleep onset and maintenance are common and may be associated with night mares and safety concerns or elevated arousal that interferes with adequate sleep.

12. Prevalence Lifetime prevalence is 1-3% of the general population.
Most prevalent in young age adults although it can appear at any age.

13. Course and Prognosis
Delay in appearance of the symptoms can be as short as one week and as long as 30 years.
Symptoms are fluctuating overtime but most intense during periods of stress.
30% of patients recover completely.
40% continue with mild symptoms.
20% moderate symptoms.
10% unchanged or become worse.

14. Differential Diagnosis
Adjustment disorders
Acute stress disorder
Anxiety disorders and obsessive-compulsive disorder
Major depressive disorder
Personality disorders
Dissociative disorders
Conversion disorder
Psychotic disorders
Traumatic brain injury

15. Treatment Major Approaches are: A- Support
B- Encouragement to discuss the event
C- Education about a variety of coping skills( like relaxation) . Drugs:
Tricyclics( like imipramine & amitriptyline), SSRIs, MAOIs, trazodone and anticonvulsants(carbamazepine and valproate)

16. Treatment Psychotherapy: cognitive psychotherapy behavioral therapy
group & family therapy
psychodynamic psychotherapy
Eye movement desensitization and reprocessing (EMDR).

17. Acute stress disorder
The disorder is similar to PTSD in many aspects like the occurrence after exposure to a traumatic event, the similar symptoms.
Symptoms include: intrusive, negative mood, dissociative, avoidance , and arousal symptoms. They are the same as symptoms of PTSD.
The difference is only the duration of the illness. It typically begins immediately after the trauma , and persists for at least 3 days and up to a month.

18. Adjustment Disorders
The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature of adjustment disorders.
The stressor may be a single event like termination of a romantic relationship, or there may be multiple stressors ( marked business difficulties and marital problems), .
Stressors may be recurrent or continuous.
Stressors may affect one individual ,an entire family, or a large group or community.
Some stressors may accompany specific developmental events (going to school, getting married, becoming a parent, or retirement )
Adjustment disorders are associated with an increased risk of suicide.

19. Symptoms
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.
Significant impairment in social, occupational, or other important areas of functioning.
Symptoms begin within 3 months of the onset of the stressor and lasts no longer than 6 months after the stressor or its consequences have ceased.

20. Prevalence They are common
Prevalence vary widely in different populations
In outpatient psychiatric populations it ranges between 5-20%

21. Differential diagnosis
Major depressive disorder
PTSD and acute stress disorder
Personality disorders

22. Treatment Support and reassurance
Psychotherapy : Cognitive –behavioral therapy, relaxation therapy, counseling, etc…
Symptomatic treatments : medications to decrease anxiety and improving of sleep and mood can be used for short period of time.