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

2. Posttraumatic Stress Disorder: DSM-5
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)

3. PTSD: DSM-5 cont.
Intrusion symptoms include repetitive, involuntary, and intrusive memories of the event; traumatic nightmares; dissociative reactions (i.e., flashbacks); intense prolonged distress after exposure to reminders of the trauma; and heightened physiological reactivity to reminders of the trauma
Avoidance symptoms include avoidance of trauma-related thoughts or feelings; and avoidance of people, places, activities, etc. that cue distressing thoughts or feelings about the traumatic event
Negative alterations in cognitions and mood symptoms 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 pre-trauma activities; restricted range of affect; and difficulty or inability remembering important parts of the traumatic event
Alterations in arousal and reactivity symptoms include irritability and aggressiveness; self-destructive or reckless behaviors; sleep difficulties; hypervigilance; marked startle response; concentration difficulties; and sleep disturbance

4. PTSD: DSM-5 cont. For a diagnosis of PTSD an individual must endorse:
At least one intrusion symptom from Criterion B
One avoidance symptom from Criterion C
Two symptoms related to negative alterations in cognition and mood from Criterion D
Two symptoms related to alterations in arousal and reactivity from Criterion E
The symptoms endorsed in categories B through E must persist for one 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)
Symptoms cannot be better explained by another medical or psychiatric illness (Criterion H)

5. PTSD: DSM-5 cont.
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 6 months after the trauma

6. Acute Stress Disorder: DSM-5
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, etc.  

7. ASD: DSM-5 cont.
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)

8. Adjustment Disorder: DSM-5
Specific DSM-5 criteria for an adjustment disorder include:
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)
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
In addition, the stress response:
Cannot be better accounted for by another disorder and is not an exacerbation of a preexisting condition
Is not indicative of normal bereavement (if this is the precipitating event)
Once the stressor is removed, the symptoms do not persist for more than 6 additional months

9. Adjustment Disorder: DSM-5 cont.
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
Diagnostic specifiers for the adjustment disorders include with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, and unspecified

10. PTSD, ASD, and AD
Whereas PTSD and ASD emphasize fear and anxiety responses, adjustment disorders can accommodate a broader range of stress reactions
Although there is an explicit potential for ASD to predict subsequent impairment (i.e., to predict PTSD), an adjustment disorder is typically viewed as a discrete disorder that has 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

11. Epidemiology Prevalence of PTSD in general population
6.8% lifetime prevalence; 12-month prevalence is 3.5%
Prevalence among U.S. combat veterans
6% to 31% lifetime prevalence (depends on sample and measurement)
Less is known regarding prevalence of ASD
Rates of ASD in community and clinical samples range from 7% to 28% with a mean rate of 13%
Rates of ASD are typically higher among victims of violent versus nonviolent traumas
Adjustment disorders
Few reliable findings

12. Psychological Assessment
(CAPS)
Acute Stress Disorder Interview
SCID-IV contains an optional module for ASD and a section for adjustment disorders if no other diagnosis has been made
Clinician- and self-report measures
PTSD Checklist
Mississippi Scale for Combat-Related PTSD
PTSD Symptoms Scale
Acute Stress Disorder Scale

13. Etiology: 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
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
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

14. Etiology: Behavioral and Molecular Genetics cont.
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
In terms of specific genetic markers, the 5-HTTLPR polymorphism has been associated with an increased risk of developing PTSD in specific groups of trauma survivors
A similar interaction has been reported for variants of polymorphisms in the FK506 binding protein 5 (FKBP5) gene, which is involved in regulating the intracellular effects of cortisol
This gene was underexpressed among survivors of the September 11, 2001, attacks on the World Trade Center who developed PTSD compared to those who did not
There is evidence for candidate genes in other systems (e.g., the dopamine system), but findings have been limited or inconsistent

15. Etiology: Neuroanatomy and Neurobiology
Several brain structures have been implicated in PTSD, including the amygdala, the medial prefrontal cortex, and the hippocampus
First, PTSD is associated with increased activation in the amygdala in response to trauma-related stimuli; this increased activity likely represents the neural substrates of exaggerated fear acquisition and expression and may explain the salience of trauma memories in PTSD
Second, PTSD is associated with deficient functioning in the medial prefrontal cortex; this deficiency is thought to underlie inadequate top-down modulation of the amygdala. Moreover, the medial prefrontal cortex is thought to regulate processes that are important for habituation and extinction of fear responses, including emotional appraisal
Third, PTSD is associated with abnormalities in the hippocampus. These abnormalities may underlie difficulties contextualizing memories (e.g., recognizing that certain contexts are safe)

16. Etiology: Neuroanatomy and Neurobiology cont.
PTSD severity is associated with decreased volume of the hippocampus, as well as decreased volume in the amygdala and the anterior cingulate, a structure in the medial prefrontal cortex
Decreased hippocampal volume likely represents a risk factor for developing PTSD, as opposed to a neurobiological effect of trauma; indeed, hippocampal volume does not change over time following trauma exposure
The neurochemical underpinnings of PTSD likely involve catecholamines and cortisol, a hormone involved in the neuroendocrine response to stress
PTSD may also be characterized by disturbance of the HPA axis, arising primarily from hypersensitivity of glucocorticoid (i.e., cortisol) receptors
There are few data specifically reporting on neurobiological models of ASD or adjustment disorders

17. Etiology: Learning, Modeling, and Life Events
Clearly, traumatic life events contribute to PTSD
Rates of PTSD vary based on the type of traumatic event, with assaultive violence and sexual assault being associated with the highest rates
Furthermore, rates of PTSD among Vietnam era veterans roughly correspond to degree of combat exposure
However, PTSD severity has not been found to correspond to severity of exposure in other trauma samples, such as motor vehicle accident survivors and political prisoners
Exposure to childhood physical or sexual abuse is associated with an increased risk of future trauma exposure, as well as the development of PTSD in response to those subsequent traumas
Pre-trauma risk factors for PTSD include having a previous psychiatric history, experiencing childhood abuse or neglect
Post-trauma risk factors include a lack of social support and additional stressors

18. Etiology: Cognitive Influences
Cognitive influences of PTSD include maladaptive beliefs that one holds about the meaning of the traumatic event that is experienced (e.g., self-blame, guilt)
Consistent with this view, cognitive reprocessing therapy (CPT) emphasizes the importance of identifying and revising maladaptive beliefs about the trauma and promoting a more balanced integration of the traumatic event
Other possible cognitive mechanisms of PTSD include attentional or memory-related biases toward threat-related stimuli or trauma-related material, which may specifically reflect a cognitive vulnerability to developing PTSD
PTSD may also be influenced by perceived seriousness of threat

19. Gender and Racial/Ethnic Considerations
Women are more likely to report sexual assault or child molestation
Men are more likely to report physical assault, combat exposure, or being threatened or attacked with a weapon
Women are more likely to develop PTSD relative to men (at a 2:1 ratio) given exposure to a traumatic event
Most studies have found comparable rates of PTSD between African Americans and Caucasians
Relative to non-Hispanic Caucasians, Hispanics often have higher rates of PTSD in both community and clinical samples
Cultural context may influence some aspects of PTSD, but the disorder generally presents as a coherent group of symptoms across cultures
Parallel efforts to study the relationship between race/ethnicity in both ASD and adjustment disorders are lacking

20. Treatment
Cognitive behavioral interventions are the most effective treatment approach for PTSD
Typically include elements of psychoeducation, stress reduction, exposure to trauma-related cues and memories, and cognitive restructuring, with the latter two components being considered the “active ingredients” for PTSD symptom reduction
Two specific manualized treatments for adults with PTSD:
Prolonged exposure (PE), an exposure-based intervention
Cognitive processing therapy (CPT), predominantly a cognitive restructuring intervention that includes elements of exposure
The focus in PE is on habituation to graded fear exposures, whereas the focus in CPT is on modification of maladaptive trauma-related beliefs (e.g., denial or self-blame)
However, CPT often includes exposure exercises, and PE often includes elements of cognitive restructuring