Trauma and Stressor-Related Disorders

Chapter 10
Trauma and Stressor-Related Disorders
Posttraumatic Stress Disorder, Acute Stress Disorder, and Adjustment Disorders


Anouk L. Grubaugh


The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) includes a chapter titled “Trauma and Stress-Related Disorders,” which contains posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and the adjustment disorders. Both PTSD and ASD were previously classified under the “Anxiety Disorders” chapter of the DSM-IV, whereas adjustment disorders were classified separately as a residual diagnostic category (APA, 1994). PTSD is broadly characterized as a psychiatric disorder resulting from a life-threatening event and requires a history of exposure to a traumatic event (Criterion A) that results in a minimum threshold of symptoms across four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity (Criterion B through E). Additional criteria concern duration of symptoms (Criterion F), functioning (Criterion G), and differential diagnosis due to a substance or other co-occurring condition (Criterion H).


For Criterion A, an event associated with PTSD must include actual or threatened death, serious injury, or sexual violation resulting from one or more of the following scenarios:



  • Directly experiencing the traumatic event.
  • Witnessing the traumatic event in person.
  • Experiencing the actual or threatened death of a close family member or friend that is either violent or accidental.
  • Directly experiencing repeated and extreme exposure to aversive details of the event (i.e., the type of exposures frequently encountered by police officers and first responders).

With regard to criteria B through E, an individual must report symptoms from each of the four symptom clusters. Intrusion symptoms (Criterion B) include repetitive, involuntary, and intrusive memories of the event; traumatic nightmares; dissociative reactions (i.e., flashbacks) along a broad continuum; intense prolonged distress after exposure to reminders of the trauma; and heightened physiological reactivity to reminders of the trauma. Avoidance symptoms (Criterion C) include avoidance of trauma-related thoughts or feelings; and avoidance of people, places, activities, and so forth that cue distressing thoughts or feelings about the traumatic event. Negative alterations in cognitions and mood symptoms (Criterion D) include a persistent and distorted sense of self or the world; blame of self or others; persistent trauma-related emotions such as anger, guilt, shame; feeling estranged or detached from others; marked lack of interest in pretrauma activities; restricted range of affect; and difficulty or inability remembering important parts of the traumatic event. Finally, alterations in arousal and reactivity symptoms (Criterion E) include irritability and aggressiveness self-destructive or reckless behaviors, sleep difficulties, hypervigilance, marked startle response, concentration difficulties, and sleep disturbance.


For a diagnosis of PTSD an individual must exhibit at least one symptom from Criterion B, one symptom from Criterion C, two symptoms from Criterion D, and two symptoms from Criterion E, and the symptoms endorsed in categories B through E must persist for 1 month or longer (Criterion F). The symptoms must also be accompanied by significant distress or impairment in social, occupational, or other important life domains (Criterion G), and symptoms cannot be better explained by another medical or psychiatric illness (Criterion H).


The DSM-5 includes two additional specifiers or associated features that can be added to a PTSD diagnosis: “with dissociated symptoms” and “with delayed expression.” The dissociated symptoms specifier includes either depersonalization (i.e., experience of being an outside observer to one’s experience or feeling detached from oneself) or derealization (i.e., experience of unreality or distortion) in response to trauma-related cues. The delayed onset specifier includes an onset of symptoms that can occur immediately after the trauma, but that may not meet full criteria for PTSD until at least six months after the trauma.


Some notable changes were made to the diagnostic criteria for PTSD from DSM-IV (APA, 1994) to DSM-5. In addition to the inclusion of specifiers for depersonalization and derealization, the DSM-5 provides greater specification regarding what events constitute a traumatic event (i.e., what events constitute a Criterion A event); and excludes the need for an individual to have experienced intense fear, helplessness, or horror at the time of the trauma due to its lack of predictive utility. Additionally, the avoidance/numbing symptom cluster found in the DSM-IV is divided into two distinct clusters in the DSM-5: avoidance and negative alterations in cognitions and mood. The latter of these clusters retain most of the DSM-IV numbing symptoms while also including a broader range of emotional reactions. Last, Criterion E, alterations in arousal and reactivity, retains the majority of DSM-IV arousal symptoms but also includes additional symptoms regarding aggressive or reckless behavior.


A diagnosis of acute stress disorder (ASD) requires an antecedent event (Criterion A event) in which the person:



  • Experienced an event or events that involved a threat of death, actual or threatened serious injury, or actual or threatened physical or sexual violation.
  • Witnessed an event or events that involved the actual or threatened death, serious injury, or physical or sexual violation of others.
  • Learned of such harm coming to a close relative or friend.
  • Experienced repeated or extreme exposure to aversive details of unnatural death, serious injury, or serious assault or sexual violation of others that were not limited to electronic media, television, video games, and so forth.

Individuals must then exhibit a minimum of 9 out of 14 symptoms across a broad spectrum of posttraumatic reactions (Criterion B). This spectrum includes symptoms related to negative mood, intrusive thoughts, dissociation, avoidance, and anxiety. Aside from a greater emphasis on dissociative symptoms, the other Criterion B symptoms for ASD largely mirror the Criterion B through E symptoms for PTSD. Additional criteria for ASD concern duration of symptoms (Criterion C), functioning (Criterion D), and differential diagnosis due to a substance or other co-occurring condition (Criterion E).


Changes to the diagnostic criteria of ASD from DSM-IV to DSM-5 include less emphasis on dissociative criteria (i.e., feeling detached from one’s body, emotions, or the world). Rather than being required for a diagnosis as was the case in the DSM-IV, dissociative symptoms in DSM-5 are viewed as one of several possible posttraumatic reactions that an individual may experience. Comparable to changes to the diagnostic criteria for PTSD, the DSM-5 provides more specification regarding the qualifying traumatic event for ASD; and the criterion requiring a subjective reaction to the trauma (i.e., fear, helplessness, horror) was eliminated.


Adjustment disorders are classified in the DSM-5 as a range of stress response syndromes. This differs from the DSM-IV in which adjustment disorders were part of a residual category for individuals experiencing clinically significant distress that did not fit diagnostic criteria for other psychiatric disorders. Specific DSM-5 criteria for an adjustment disorder include: (a) the development of emotional or behavioral problems in response to an identifiable stressor occurring within 3 months of exposure to the stressor (this feature is considered the core feature of adjustment disorders; (b) symptoms or behaviors are clinically significant and out of proportion to the severity of the stressor once cultural and contextual factors are taken into account. Additionally, the stress response (a) cannot be better accounted for by another disorder and is not an exacerbation of a preexisting condition; (b) is not indicative of normal bereavement (if this is the precipitating event); and (c) once the stressor is removed, the symptoms do not persist for more than 6 additional months. Diagnostic specifiers for the adjustment disorders include depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified.


Whereas PTSD and ASD emphasize fear and anxiety responses, adjustment disorders can accommodate a broader range of stress reactions. Second, although there is an explicit potential for ASD to predict subsequent impairment (i.e., to predict the development of PTSD), an adjustment disorder is typically viewed as a discrete disorder that has a fairly immediate onset and is relatively short in duration. A third distinction between PTSD, ASD, and adjustment disorders regards the timing of diagnosis. Adjustment disorders can be diagnosed immediately after the event, ASD can be diagnosed from 2 days to up to 1 month after the event, and PTSD can be diagnosed from 1 month to several years after the trauma.


Clinical Features


The clinical expression of PTSD can vary significantly in terms of severity. Although the diagnosis is categorical, there is evidence of a dimensional structure to PTSD (Broman-Fulks et al., 2006; Forbes, Haslam, Williams, & Creamer, 2005; Ruscio, Ruscio, & Keane, 2002). An implication of this dimensional structure is that milder symptoms of PTSD may cause significant distress and impairment. Indeed, one study found that veterans with subthreshold PTSD underutilize mental health care, despite increased psychiatric comorbidity and impairment relative to veterans without PTSD (Grubaugh et al., 2005). Yet other studies using samples of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans have found an association between subthreshold PTSD and elevated levels of anger and hostility, physical health functioning, and an increased likelihood of hopelessness and suicidal ideation relative to those without PTSD (Jakupcak et al., 2011). Among civilians, subthreshold PTSD has likewise been associated with levels of impairment and suicidality that are equivalent to those with full PTSD (Zlotnick, Franklin, & Zimmerman, 2002).


Suicidality is elevated among individuals with PTSD (Panagioti, Gooding, & Tarrier, 2009; Jakupcak et al., 2011), and particular types of trauma, such as childhood abuse, military sexual trauma, and combat, may be more strongly associated with suicidality than others (Afifi et al., 2008; Kimerling, Gima, Smith, Street, & Frayne, 2007). Additionally, increased risk of suicidality is uniquely associated with PTSD (Sareen, Houlahan, Cox, & Asmundson, 2005; Sareen et al., 2007). That is, this association is not solely accounted for by the presence of other psychiatric conditions commonly found with PTSD. Of course, an increased risk of suicidality is present in a number of other psychiatric conditions to a comparable or greater degree than that found in PTSD (Nock, Hwang, Sampson, & Kessler, 2010).


The clinical picture of acute stress disorder (ASD) is similar to that of PTSD. Additionally, a review on the topic found that at least half of trauma survivors with ASD subsequently met criteria for PTSD (Bryant, Friedman, Spiegel, Ursano, & Starin, 2011). This finding suggests that individuals with ASD are, in fact, at higher risk of subsequently developing PTSD. Conversely, however, the majority of individuals who subsequently develop PTSD do not initially meet criteria for ASD, suggesting that ASD (using DSM-IV criteria) is not highly specific with regard to its predictive utility. Additional findings suggest that the predictive power of ASD is increased when subthreshold symptoms are used and the dissociative symptoms required for DSM-IV are relaxed (Bryant et al., 2011). These and similar findings likely influenced the decreased emphasis in DSM-5 on dissociation symptoms in favor of accepting a broader symptom presentation and one that more closely mirrors the symptoms associated with PTSD.


Due to the conceptualization of adjustment disorders as fairly time limited, as well as their history as a nebulous, catch-all diagnostic category, they have not been well studied in the psychiatric literature. The findings that do exist largely consist of non-U.S. samples, focus on children or adolescents, and/or were published in the 1980s and early 1990s. Some commonly agreed upon emotional signs of adjustment disorders are sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, worry, trouble sleeping, difficulty concentrating, feeling overwhelmed, and thoughts of suicide. Some behavioral signs of adjustment disorders include fighting, reckless behaviors, neglecting important tasks or responsibilities, and avoiding family or friends. Although the presence of an adjustment disorder has been linked to increased suicidal ideation and risk of suicide (e.g., Portzky, Audenaert, & Vanheeringen, 2005; Taggart et al., 2006), they are often considered less severe than other psychiatric disorders. Supporting this view, one study found that adjustment disorders range in severity between no psychiatric disorder and the presence of a mood or anxiety disorder (Fernandez et al., 2012).


Diagnostic Considerations


Comorbidity is a concern when diagnosing PTSD. Large nationally representative samples have found that PTSD is significantly correlated with the majority of mood and anxiety disorders, as well as alcohol use disorders (National Comorbidity Survey Replication [NCS-R]; Kessler, Chiu, Demler, & Walters, 2005; National Comorbidity Survey [NCS]; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Data from the NCS-R found that approximately half of those who met criteria for PTSD also met criteria for at least three additional psychiatric diagnoses (Kessler et al., 1995). Although there is some degree of symptom overlap between PTSD and other psychiatric diagnoses (e.g., sleep and concentration difficulties and diminished interest in activities are common to both depression and PTSD), this overlap does not account for the high rate of comorbidity (Elhai, Grubaugh, Kashdan, & Frueh, 2008). When comorbid with mood disorders, PTSD is more likely to be primary, whereas it is more likely to be secondary when comorbid with anxiety disorders (Kessler et al., 1995). Importantly, PTSD and comorbid diagnoses may change over time within a given individual. A study of trauma survivors found that half of those who reported PTSD only at 3-month follow-up reported depression only at 12-month follow-up; likewise, half of those with depression only at 3-month follow-up reported PTSD only at 12-month follow-up (O’Donnell, Creamer, & Pattison, 2004).


Due to the lack of epidemiological studies specific to ASD or the adjustment disorders, there are few reliable data on the clinical comorbidity associated with these disorders. Given the conceptual overlap between ASD and PTSD, it is likely that individuals with ASD experience high rates of mood, anxiety, and substance disorders relative to the general population, as well as an increased risk of suicidality. As noted elsewhere, adjustment disorders in the DSM-IV served as a residual “catch-all” diagnostic category once other psychiatric conditions were ruled out. As such, they are seldom diagnosed with other psychiatric conditions. With this restriction in mind, adjustment disorders have most often been linked in adult samples to a comorbid diagnosis of a personality disorder, substance use disorder, and increased suicidality (Dowrick et al., 1998; Greenberg, Rosenfeld, & Ortega, 1995; Polyakova, Knobler, Ambrumova, & Lerner, 1998; Strain et al., 1998).


Epidemiology


In the general population, the 12-month and lifetime prevalence of PTSD is 3.5 and 6.8%, respectively (Kessler, Burglund, Demler, et al., 2005; Kessler et al., 2005). Point prevalence of PTSD among U.S. combat veterans is estimated to be between 2% and 17%, depending on the characteristics of the sample and the measurement strategies that were used (Richardson, Frueh, & Acierno, 2010). There are different conditional probabilities of developing PTSD by trauma type. For example, combat exposure and physical and sexual abuse are more often associated with PTSD than other types of trauma. Despite this variability, the symptom expression of PTSD remains fairly consistent regardless of the type of trauma experienced.


Little is known regarding the prevalence of ASD and the adjustment disorders in the general population. Large-scale epidemiological studies, such as the World Health Organization (WHO) Mental Health Epidemiologic Survey, the Epidemiologic Catchment Area study, and the National Comorbidity Survey Replication, did not report on these disorders. Rates of ASD in community and clinical samples range from 7% to as high as 28% with a mean rate of 13% (Bryant et al., 2011), and rates of ASD are typically higher among victims of violent versus nonviolent traumas. When subsyndromal cases of ASD are included, estimates of the disorder increase from 10% to 32% with a mean rate of 23% (Bryant et al., 2011).


There are few reliable findings on the prevalence of adjustment disorders. This gap in knowledge is likely influenced by the poor delineation between adjustment disorders and normal or adaptive stress responses, as well as the use of adjustment disorders as a residual “last resort” diagnostic category in the DSM-IV. One epidemiological study, the European Outcome of Depression International Network, found a 1% prevalence of adjustment disorder with depressed mood (ODIN; Ayuso-Mateos et al., 2001). More circumscribed samples of adults suggest adjustment disorders are more common in hospital psychiatric consultation settings (12%; Strain et al., 1998; 18.5%; Foster & Oxman, 1994) and among psychiatric inpatient admissions (Koran et al., 2002). A recent meta-analysis found prevalence rates of 15.4% and 19.4% in palliative care and oncology settings, respectively (Mitchell et al., 2011).


Psychological and Biological Assessment


There are a number of diagnostic measures for assessing PTSD.


Although revisions are underway, these measures reflect DSM-IV, rather than DSM-5, criteria for PTSD. The Clinician-Administered PTSD Scale (CAPS; Weathers, Keane, & Davidson, 2001) is the most common interviewer-based instrument for PTSD and has robust psychometric properties (Weathers et al., 2001). The CAPS includes a detailed assessment of each traumatic event, frequency and severity ratings for each symptom, and overall distress and impairment ratings. Several CAPS scoring algorithms have demonstrated good diagnostic utility (Weathers, Ruscio, & Keane, 1999). A common scoring method is to score a symptom as present if the frequency is greater than or equal to 1 and the intensity is greater than or equal to 2, and to further require the endorsement of a sufficient number of symptoms for each symptom cluster. This method favors sensitivity (0.91) over specificity (0.71), and thus may be better for screening purposes. Using a total dimensional cut-score of greater than or equal to 65, on the other hand, favors specificity (0.91) over sensitivity (0.82), and thus may be better for confirming a diagnosis (Weathers et al., 1999). Other interview measures include the PTSD Symptom Scale–Interview (PSS-I; Foa & Tolin, 2000) and the Structured Interview for PTSD (SI-PTSD; Davison, Smith, & Kudler, 1989). Additionally, the Structured Clinical Interview for DSM-IV (SCID-IV; First, Spitzer, Gibbon, & Williams, 1996) and the Anxiety Disorders Interview Schedule (ADIS-IV; Brown, Di Nardo, & Barlow, 1994) contain a module for assessing the presence or absence of PTSD.


Self-report questionnaires may also be used to assess PTSD. Commonly used measures include the PTSD Checklist (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996), the PTSD Symptom Scale–Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993), and the Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997). An extensive list of measures used to assess PTSD is available from the National Center for PTSD (www.ptsd.va.gov). As already noted, these measures are being revised to reflect recent changes to the diagnostic criteria of PTSD in DSM-5.


Aside from interview and self-report measures of PTSD, several physiological variables have been found to distinguish current PTSD from lifetime PTSD and the absence of PTSD. These include an increased resting heart rate, an increased response to non-trauma-related stressors, and increased heart rate, skin conductance, and diastolic blood pressure in response to trauma cues (Pole, 2007). However, the diagnostic utility of these physiological variables is limited in that they tend to be less accurate in predicting PTSD than interview-based and self-report assessments.


There are few empirically validated diagnostic measures for ASD or adjustment disorders. Measures designed specifically for ASD include the Acute Stress Disorder Interview and the Acute Stress Disorder Scale, both developed by the same group of investigators (ASDI, ASDS; Bryant, Harvey, Dang, Sackville, & Basten, 1998). The SCID-IV contains an optional module for ASD, as well as a section on adjustment disorders that specifies the diagnosis should not be made if the criteria for any other psychiatric disorders are met (First et al., 1996). With regard to physiological measures, there are some data indicating that individuals who subsequently develop PTSD have higher heart and respiration rates immediately post-trauma relative to those who do not (Bryant et al., 2011). However, these data are not limited to individuals with ASD, and are likely hampered by the same classification precision of these measures for PTSD.


Etiological Considerations


A number of causal mechanisms have been implicated in the development of PTSD. These include genetic factors, brain structure and neurochemical abnormalities, pre- and post-trauma life events, cognitive appraisals and attentional biases, and sociodemographic variables such as gender.


Behavioral and Molecular Genetics


Among Vietnam era veterans, the risk of developing PTSD has been explained by (a) a genetic factor common to alcohol use and PTSD, (b) a genetic factor associated with PTSD but not with alcohol use, and (c) unique environmental effects (Xian et al., 2000). Yet another twin study of Vietnam era veterans found that the genetic factors that accounted for the relationship between combat exposure and PTSD also accounted for the relationship between combat exposure and alcohol use (McLeod et al., 2001). Genetic factors contributed more to the relationship between combat exposure and PTSD as compared to environmental factors, whereas genetic and environmental factors contributed equally to the relationship between combat exposure and alcohol use. Interestingly, the genetic factors that account for the presence of PTSD may also influence exposure to certain types of traumatic events. Concordance of both interpersonal violence and PTSD is higher among monozygotic twins compared to dizygotic twins, whereas other types of trauma (i.e., natural disasters, motor vehicle accidents) are not accounted for by genetic factors (Stein, Jang, Taylor, Vernon, & Livesley, 2002).

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Jun 10, 2016 | Posted by in PSYCHOLOGY | Comments Off on Trauma and Stressor-Related Disorders

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