Abstract
Trauma derives from the Greek τραῦμα, meaning “wound.” Although it has been used for centuries as a medical term to designate “an injury to living tissue caused by an extrinsic agent,” it was not until 1889 that this word endorsed a psychological meaning with the first clinical descriptions of “traumatic neuroses” in victims of railroad accidents by Oppenheim. Stress was first a mechanics term used to describe the pressure or tension exerted on a material object. It was then been applied to mental health to describe a feeling of psychological strain and pressure. Both psychological trauma and stress can result in psychiatric disorders.
Introduction
Trauma derives from the Greek τραũμα, meaning “wound.” Although it has been used for centuries as a medical term to designate “an injury to living tissue caused by an extrinsic agent,” it was not until 1889 that this word endorsed a psychological meaning with the first clinical descriptions of “traumatic neuroses” in victims of railroad accidents by Oppenheim. Stress was first a mechanics term used to describe the pressure or tension exerted on a material object. It was then been applied to mental health to describe a feeling of psychological strain and pressure. Both psychological trauma and stress can result in psychiatric disorders.
The Spectrum of Disorders Related to Stress and Trauma
ASD, PTSD, Adjustment Disorders
Although the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), defined traumatic events as “events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others” (criterion A1) that are accompanied by a feeling of “intense fear, helplessness, or horror” (criterion A2), its fifth edition (DSM-V) has dropped the required subjective reaction to the trauma (A2). Trauma can consist of direct exposure (i.e., being a victim), witnessing a traumatic event, or learning that it occurred to someone close. The new definition also includes extreme and repeated exposure to trauma details (e.g., first responders) but excludes exposure through the media.
Exposure to traumatic events can result in a variety of reactions, ranging from relatively mild, with no or minor disruptions, to more severe and debilitating. Most traumatized individuals will develop some level of a brief psychological stress response. However, for a minority of individuals, this stress response becomes clinically significant, persistent, and interfering. Reactions to trauma are defined according to their timeframe: immediate or peritraumatic reactions (lasting minutes to hours), acute stress disorder (ASD; between three days to one month), and posttraumatic stress disorder (PTSD; more than one month). Although exposure to trauma might induce other psychiatric disorders, including major depression and other anxiety conditions, those disorders are not specific to trauma and will not be reviewed in this chapter.
Similar to PTSD and ASD, adjustment disorder (AD) requires the presence of a stressful (yet not necessarily traumatic) event, which results in clinically significant distress or impairment.
Epidemiology and Impact
Traumatic Events
The lifetime prevalence of exposure to any traumatic event in North America has been estimated to range between 39 percent and 90 percent, depending on the study; however, different traumatic events confer different risks for PTSD. For example, learning about traumas to others is the most frequent traumatic event (approximately 60 percent) but is associated with a low risk for PTSD (about 2 percent), whereas being held captive, tortured, or kidnapped is much less frequent (approximately 2 percent), but is associated with a more than 50 percent risk for developing PTSD.
Acute Stress Disorder
Prevalence rates of ASD reported within a month of trauma exposure are somewhat inconsistent, with estimates ranging from 7 to 59 percent and a mean rate falling around 17 percent.
Posttraumatic Stress Disorder
In North America, 7 to 10 percent of individuals will suffer from PTSD in their lifetime, while the twelve-month prevalence rate is approximately 4 percent. Conditional rates of PTSD following a trauma vary based on a wide range of risk and protective factors, such as trauma type and severity, previous childhood or other trauma, the presence of prior mood or anxiety disorders, and social support. PTSD is associated with varying, and sometimes severe, impairment across domains of functioning. Specifically, PTSD has been associated with increased risk for academic failures, marital instability, and unemployment. In addition, PTSD is a risk factor for developing secondary psychiatric disorders including mood, anxiety, and substance use disorders, with an increased risk for suicide. In addition, PTSD is associated with a mean work loss of nine days per month. This level of associated impairment in occupational functioning is greater than that found in a number of somatic diseases including heart disease.
Adjustment Disorders
The prevalence of ADs in the general population has never been assessed in large epidemiologic studies of mental health conditions; however, some data suggest a prevalence rate of 1 percent. Despite the lack of robust epidemiological studies, it has been estimated that 9 to 36 percent of patients seen in psychiatry are diagnosed with an AD.
Some early evidence suggests that initial AD diagnosis in adolescents might precede the development of a major mental disorder, and it is possible that ADs may be a risk factor for other mood and anxiety disorders. ADs have also been shown to be associated with suicidality.
Clinical Features and Course
Acute Stress Disorder
The clinical features of ASD include exposure to a traumatic event, as defined previously. Whereas in DSM-IV, the diagnosis required at least three dissociative symptoms – one reexperiencing symptom, one avoidance symptom, and one increased arousal symptom – DSM-V no longer requires symptoms from each of these three clusters. To meet criteria, a person must now have nine of fourteen symptoms, including symptoms of intrusion, marked by recurrent distressing memories of the traumatic event(s), recurrent distressing dreams, dissociative reactions (e.g., flashbacks), intense or prolonged distress at exposure to reminders, physiological reactions to reminders; dissociative symptoms, marked by a persistent inability to experience positive emotions (e.g., emotional numbing), an altered sense of the reality of one’s surroundings or oneself, inability to remember an aspect of the traumatic event(s) (typically dissociative amnesia); avoidance symptoms, marked by avoidance of internal, or external, reminders that arouse recollections of the traumatic event(s); and arousal symptoms, marked by sleep disturbance, irritable or aggressive behavior, hypervigilance, problems with concentration, and exaggerated startle. The duration of the symptoms runs from three days (formally two days in DSM-IV) to four weeks after trauma exposure, with clinically significant distress or impairment.
Posttraumatic Stress Disorder
The diagnosis of PTSD was modified in DSM-V to include the same exposure criteria as ASD (i.e., exposure to death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation). In addition, the diagnosis requires (a) one symptom of intrusion as described above for ASD; (b) persistent avoidance of stimuli associated with the traumatic event(s) – reminders; (c) two symptoms of negative alterations in cognitions and mood associated with the traumatic event(s), such as persistent, distorted blame of self or others, persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame), diminished interest or participation in significant activities, detachment or estrangement from others, or persistent inability to experience positive emotions (e.g., emotional numbing); (d) two symptoms of alterations in arousal and reactivity, such as irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle, problems with concentration, or sleep disturbance. The diagnosis also requires a duration of more than one month, and clinically significant distress or impairment, and that the symptoms not be associated with the effects of a substance or medical condition.
Course of ASD and PTSD
The course of both ASD and PTSD varies across the lifespan, with the effects generally longer lasting in younger individuals. Populations at risk also include the elderly, females, the injured or medically ill, refugees, survivors of genocide or disasters, combat veterans, and those with serious mental illness or economic disadvantage. In most studies, symptoms have been found to be most intense proximal to the time of the exposure, but for some individuals, the impact is chronic and resistant to existing treatments. Responses to trauma vary according to the degree of exposure, and to the stage of neurobiological, psychological, and overall development. Research has identified risk and protective factors, such as premorbid emotional functioning, prior trauma, level of social support, and psychiatric disorders.
Adjustment Disorders
In DSM-IV, adjustment disorders were conceptualized as a residual category for individuals who exhibit clinically significant distress without meeting diagnostic criteria for a discrete disorder. In DSM-V, they now comprise a heterogeneous group of stress-response syndromes that may occur after exposure to a distressing event, which may or may not be sufficiently severe to be termed traumatic. As opposed to most psychiatric disorders, no specific symptoms are required for the diagnosis of AD. Although this nonspecificity can make standardized assessments of AD difficult, it may provide a useful tool for clinicians to characterize individuals who are clinically distressed by a stressful event. The main requirements are that the symptoms must arise in response to a stressful event within three months of exposure to the stressor, be clinically significant, and resolve within six months of the offset of the stressor or its consequences. There are three subtypes, depending on the symptoms: (a) with depressed mood, (b) with anxious symptoms, and (c) with disturbances in conduct.
Differential Diagnosis
Contrary to PTSD diagnosis that requires four symptom clusters, including re-experiencing, avoidance, persistent negative alterations in cognitions and mood, and hyperarousal, ASD diagnosis requires nine out of fourteen symptoms. Further, the time frame differs between ASD and PTSD, with ASD diagnosed during the first month after trauma exposure, while PTSD is diagnosed beyond that.
The distinction between ADs and ASD/PTSD is that the diagnosis of AD does not require the stressor to be “traumatic,” nor does it specify required symptoms. The ADs differ from normative stress responses in that they result in clinically significant symptoms (i.e., significant distress and/or functional impairment).
Although trauma exposure as well as other stressors can precipitate the onset of a range of mood or anxiety disorders, the causal nexus is not as tight as with PTSD, ASD, and ADs. Moreover, they can be differentiated from ASD and PTSD. For example, although patients with anxiety disorders, including panic disorder, general anxiety disorder, or social anxiety disorder, may exhibit hyperarousal and avoidance, the clinical presentation lacks both a focus around a traumatic event and re-experiencing symptoms. A major depressive episode triggered by a stressful experience may similarly include concentration difficulties, insomnia, social withdrawal or detachment, and anhedonia, but it will lack trauma re-experiencing or related avoidance.
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