Posttraumatic Stress Disorder and Effects of Trauma

Posttraumatic Stress Disorder and Effects of Trauma


Trauma-Related Disorders is a category of psychiatric disorders in which exposure to a traumatic event is listed explicitly as a diagnostic criterion. Although, historically, these diagnoses were classified as Anxiety Disorders, the DSM-5 now contains a section of trauma- and stressor-related disorders including posttraumatic stress disorder (PTSD), reactive attachment disorder (RAD), disinhibited social engagement disorder (DSED), acute stress disorder, adjustment disorders, and other unspecified trauma-related disorders. These diagnoses are distinct from other disorders in the DSM in that their etiology is specifically linked to adverse life experiences. Children and adolescents who suffer abuse, neglect, or trauma are at increased risk for a range of mental health difficulties. Psychological symptoms following exposure to a traumatic event can vary among individuals and include a number of emotional and behavioral reactions that present similarly to fear or anxiety. However, the heterogenous group of emotional or behavioral symptoms following an identifiable stressor may be best captured by the diagnosis of an adjustment disorder.

Attachment disorders can follow periods of severe abuse or neglect during the critical development period (see Chapter 24 for more details). In the current diagnostic classification, attachment disorders and PTSD are discussed in the chapter on trauma- and stress-related disorders to underscore the common etiologic feature of exposure to traumatic events. RAD has also been formally distinguished from DSED in DSM-5 to clearly recognize the difference between grossly underdeveloped attachment to caregivers and socially disinhibited behavior with relative strangers. However, both disorders require a developmental age of at least 9 months and duration of symptoms of more than 12 months. However, children with RAD demonstrate a consistent pattern of inhibition or emotional withdrawal around adult caregivers as well as significant negative emotional regulation and limited reciprocity. Specifically, children with RAD do not seek comfort from an attachment figure when distressed and are not calmed when comfort is offered. These difficulties in social or affective interactions may present as minimal social or emotional responsiveness to other people, a lack of positive affect, and periods of sadness, distress, or irritability that do not seem to be related to typical triggers. In DSED, children exhibit pervasive social disinhibition. In novel situations, these children are overly familiar with strangers. They do not demonstrate social reticence when meeting new adults, they tend not to check back with a caregiver in new
situations, and caregivers report the child might go off with a stranger. In addition to physical intrusiveness, preschool children may exhibit verbal intrusiveness, asking overly personal questions of unfamiliar adults. These behaviors are often experienced by others as excessive and inappropriate rather than social or friendly. Although some of these features may be seen in children with other disorders, it is their presentation in the context of a lack of attachment patterns that distinguishes RAD and DSED from other disorders (Nelson et al., 2014).

Chapter 24 provides further details on the diagnosis and treatment of attachment disorders. When appropriate care is provided, infants usually rapidly develop new attachments (Wade et al., 2020). The Bucharest Early Intervention Project demonstrated that young children who were randomly selected to be removed from institutions and placed in foster care showed an early and substantial decrease in signs of RAD compared to children who remained institutionalized for longer periods of time. Children who remained in institutional care the longest had the most persistently high signs of RAD over time. In other studies of children adopted out of institutions, there have been no cases of RAD in follow-ups conducted months to years after adoption (Croft et al., 2007).


Terms such as shell shock and battle fatigue began to be used in the early 1900s to describe the difficulties experienced by soldiers in war time. Although these problems had, in some ways, been noted for many years (e.g., during the Civil War), they became particularly noteworthy after the protracted, highly stressful trench warfare of World War I. But soldiers were not the only victims of wartime trauma. The experience of children in London suffering through World War II led Anna Freud to consider the nature of traumatic experience in children (Midgley, 2007). In Freud’s original theories of neurosis, he had speculated about the role of traumatic events in producing neurotic phenomena. Anna Freud’s work was concerned with the impact of stress on children and the potential, in some cases, for children to find alternative comfort figures to mitigate the effects of stressful events. In children and adolescents, violence within the family is the most common source of PTSD, although it can also emerge in the context of natural disaster, accidents, terrorism, war, and other stresses (Hoover & Kaufman, 2018).

Diagnosis, Definition, and Clinical Features

Various changes have been made to the criteria for PTSD since its inclusion in the DSM-III in 1980. These changes related to emerging data on the duration of symptoms, the level of trauma required, and so forth. Adoption of a minimum duration criterion (i.e., for symptoms to be present for at least 1 month) created some difficulties because a diagnosis and potential intervention were thus delayed. This was dealt with in DSM-IV by including a new acute stress disorder category. DSM-5 criteria for PTSD added a new symptom cluster—negative alteration of cognition and mood symptom cluster and the reckless and the self-destructive behavior item in the hyperarousal symptom cluster (American Psychiatric Association, 2013). The diagnosis in children over age 6 and in adults requires at least one reexperiencing, one avoidance, two negative alteration of cognition and mood, and two hyperarousal symptoms. For the diagnosis of acute stress disorder, the child must exhibit symptoms for at least 3 days up to a maximum of 1 month after the traumatic event; at that time, continued symptoms would require that the diagnosis be changed to PTSD. The differentiation between the two conditions rests largely on the time course. In acute stress disorder, the problems last for at least 3 days and up to 1 month, but in PTSD, the symptoms have lasted more than 1 month. It is also possible for a child not to exhibit an acute stress disorder right away but to develop PTSD sometime after the event.

For both conditions, exposure to a traumatic event is required (this can include experience of a traumatic event personally or witnessing it); the response to the traumatic event includes intense feelings of fear, helplessness, and horror. For acute stress disorder, three or more dissociative symptoms (feelings of derealization or depersonalization, absent or detached
emotional response, or even amnesia) must be present, and the traumatic event must be reexperienced (e.g., as flashbacks). In PTSD, the traumatic event is reexperienced in some way (e.g., with recurrent recollections or, in children, repetitive play, in dreams, or flashbacks with feelings of reliving the event). In both conditions, avoidance of stimuli that might trigger memories of the event is present (this is more marked in PTSD). Other symptoms in both conditions may include problems with irritability, anxiety, and exaggerated startle response. In both conditions, significant distress or impairment must be present (Smith et al., 2019).

The exposure and reexperiencing criteria for PTSD are essentially unchanged from the adult and older child criteria. However, the diagnosis of PTSD in children ages 6 and younger requires only one symptom from a combined set of items including the two avoidance symptoms and four of the seven symptoms included in the adult and older child negative alteration of cognition and mood symptom items. Symptoms that pertain to exaggerated negative beliefs, distorted cognitions, and an inability to remember events are not required for the diagnosis of PTSD in young children because of limitations in young children’s ability to describe nuanced internal experiences. The DSM also allows for developmental differences in the presentation of symptoms in children. For example, nightmares need not be specifically trauma focused in children. Symptoms might present in children through repetitive play rather than repeated verbalization. Similarly, traumatic reenactment may be observed (e.g., inappropriate sexual behavior in sexually abused children). Despite these important changes, problems can arise in making the diagnosis in children, particularly in very young children.

Epidemiology and Demographics

In the National Comorbidity Survey for Adolescents, out of 6400 participants the rate of trauma exposure was 60%, and the lifetime prevalence of PTSD was 4.7% (McLaughlin et al., 2013). Two-thirds of adolescents in the Great Smoky Mountains Study cohort (N = 1420) had been exposed to trauma by the age of 16, but the point prevalence estimate for PTSD in this study was <0.5% (Copeland et al., 2007). Although the incidence of PTSD varies across studies, recent reviews estimate that approximately 16% of trauma-exposed children develop PTSD and children with symptoms of PTSD that do not reach the threshold for diagnosis may still show distress and impairment (Smith et al., 2019). Of note, trauma-exposed children are also at much greater risk of developing disorders other than PTSD. For example, in a recent epidemiologic study, prevalence rates of depression were reported to be as high as 30% and rates of conduct disorder as high as 23% (Lewis et al., 2019).

Etiology and Pathogenesis

A growing body of work on traumatic stress in children and adults has identified several important psychosocial and biologic risk factors of PTSD. These include temperamental risk factors such as early childhood emotional problems and environmental factors such as lower socioeconomic status and lack of social support. Neurobiologic characteristics including reduced volume of the hippocampus, the ventromedial prefrontal cortex, may possibly be a potential source of vulnerability (Boccia et al., 2016). Genetic factors can explain why some children exposed to trauma develop PTSD and others do not, although these genetic markers are likely to predispose individuals to a wide range of psychopathology rather than one specific disorder (Montalvo-Ortiz et al., 2016). The type of traumatic events as well as the severity and chronicity of exposure to trauma are among the most researched predictors of onset and severity of PTSD (Brewin et al., 2000).

Differential Diagnosis and Assessment

Competent assessment of PTSD or exposure to traumatic events requires collection of information from multiple sources. Incidents of sexual or physical abuse are frequently denied
by parents and children. Domestic violence is the form of violence exposure reported most frequently by parents. There is considerable potential for traumatic exposures to be missed if only one or two sources are relied on for reporting. Several excellent measures are available to help assess childhood trauma. For example, the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) is a structured interview for diagnostic assessment of PTSD in 8 to 15-year-old children. It is one of the most frequently used interviews in research studies and was recently updated to accommodate the DSM-5 diagnoses (Pynoos et al., 2015) (Table 23.1). The Child PTSD Symptom Scale (CPSS) (Foa et al., 2018) is widely used measure for 8-to-15-year-old children.

A number of issues can arise during assessment of potential trauma in children. At times, children may deny the experience of a traumatic event that is well documented. In such instances, the child can be carefully informed of what is known from other sources and inquiry can be made regarding PTSD symptoms without necessarily asking for a detailed review of their experience of the event. The discussion can start with symptoms related to overarousal before moving on to the avoidance symptoms and finally to reexperiencing symptoms that are most challenging for children to talk about. The clinician should be particularly aware of symptoms that are less likely to be noted by parents, foster parents, or other caregivers. For example, “acting out” or disruptive behavior symptoms are more likely to be noticed by third parties than internalizing symptoms.

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Jun 19, 2022 | Posted by in PSYCHOLOGY | Comments Off on Posttraumatic Stress Disorder and Effects of Trauma
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