Trauma and Stressor-Related
Disorders
Moataz M. Ragheb, MD, PhD
Introduction
Some ground “agreements”
Participation; truly didactic
Assignments 
Debates
Questions
Pre-”Quez”
Learning Objectives of series
List trauma-related disorders
Be able to make a clinical DSM-5 DX/DDX of ASD,
PTSD
Be familiar with:
Epidemiology
Neurobiology
Make treatment decisions
Sources and Further study
1- Culture and PTSD: Trauma in Global and Historical Perspective. 2016
2- Mass General Comprehensive Clinical Psychiatry (2nd edition ) 2015
3- Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition: DSM-5, 2013.
4- An Annotated bibliography of DSM-III. 1987.
5- Articles cited
What Are They?
1- Acute Stress Disorder
2- Post Traumatic Stress Disorder
3- Reactive Attachment Disorder
4- Disinhibited Social Engagement Disorder
5- Other specified trauma and stress related disorders
6- Unspecified trauma and stress related disorders
Child
Psychiatry
Main Topics
1- Historical background
2- Epidemiology
3- Diagnosis
4- Clinical features
5- Differential diagnosis
7- Pathogenesis
8- Neurobiology
9- Treatment
Prequez
1- Evolution of the Definition of Trauma (criterion A)
in DSM
2- Lifetime prevalence of PTSD
3-Most common comorbidity in civilian trauma
4- Most common comorbidity in Veterans
Historical Background
Psychological Trauma
Is PTSD timeless?
Evolution of the Concept of trauma in the DSM
The subjectivity question
Effect/role of culture (in place and time; Rome)
DSM-5: PTSD
Criterion A.:
The person was exposed to: death, threatened death, actual
or threatened serious injury, or actual or threatened sexual
violence, as follows:
1. Direct exposure
2. Witnessing, in person
3. Indirectly, by learning that a close relative or close friend
was exposed to trauma. If the event involved actual or
threatened death, it must have been violent or accidental.
DSM-5: PTSD
Criterion A (continued):
4. Repeated or extreme indirect exposure to aversive details
of the event(s), usually in the course of professional duties
(e.g., first responders, collecting body parts; professionals
repeatedly exposed to details of child abuse). This does not
include indirect non-professional exposure through electronic
media, television, movies or pictures
DSM-5: PTSD
B. Intrusion symptoms
C. Persistent avoidance of stimuli associated with the
trauma
D. Negative alterations in cognitions and mood
that are associated with the traumatic event
E. Alterations in arousal and reactivity that are
associated with the traumatic event
DSM-5: PTSD
F. Persistence of symptoms (in Criteria B, C, D
and E) for more than one month
G. Significant symptom-related distress or
functional impairment
H. Not due to medication, substance or illness
Epidemiology
Lifetime Prevalence
8-12% BUT:
Men (5-6%) vs Women 10-14%)
Special Population – Veterans, Psychiatric,
Type of Trauma
Trauma Exposure – NCS
Risk Factors
Comorbidity … PTS Syndrome vs Disorder
Trauma exposure
Life Time Prevalence Rate of trauma
exposure by trauma type and gender
50-60
5
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060
Trauma exposure
Conditional probability of developing PTSD by
Gender and Trauma Type
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060
Trauma exposure
Type of Trauma
Lifetime Prevalence of PTSD
Men
Rape
Molestation
Women
Conditional
62.1 (11.6)probability of developing
74.4 PTSD
(4.1) by
Gender
and Trauma Type
26.9 (6.2)
61.4 (2.8)
Physical attack
35.7 (5.1)
42.0 (7.7)
Combat
57.7 (6.7)
0
Shock
44.8 (4.7)
55.4 (4.0)
Threat with weapon
32.9 (3.0)
36.4 (4.8)
Accident
44.6 (3.6)
44.5 (4.1)
Natural disaster with fire
35.9 (2.8)
44.4 (4.4)
Witness
52.4 (2.7)
47.1 (4.2)
Neglect
27.8 (5.8)
28.1 (5.8)
Physical abuse
50.4 (4.7)
37.0 (5.0)
Other qualifying trauma
77.6 (7.8)
80.8 (5.0)
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060
Risk Factors
Pre-Traumatic (Patient-specific)
Genetic ?
Female
Social/educational/intellectual
Prior Trauma exposure
Psychiatric disorders (Pt or family)
Child Abuse (25-45% of Vets with PTSD)
Risk for Trauma Exposure ?
Liability to develop PTSD with
exposure?
Both?
Risk Factors
Peri-traumatic
Trauma Type
Assaultive violence
Combat
Rape
Torture
Child abuse
20% (35% in women, 6% in men)
40%
50%
50%
25-50%
Patient’s experience
Severe dissociation, arousal or feeling shame/anger
Risk Factors
After (post)-traumatic
Quality of Social Support
Presence or absence of positive social responses
Negative social responses
Persistent feelings of shame, anger
Comorbidity
Rule rather than Exception;
90% in men, 80% in women
45-60% report 3 events or more
Primary or Secondary?
Most Common
Depression …. 50%
Alcohol Abuse
Nicotine
Phobias
TBI
General medical
BPD
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity
Survey. Archives of General Psychiatry, 52, 1048-1060
Comorbidity
Depression;
Different “biological” type
Most common comorbidity in civilian trauma ….50%
Before – risk factor 3 fold increase
With or After – Shared vulnerability
Does trauma increase risk for depression without PTSD?
Breslau, N., Davis, G. C., Peterson, E. L., & Schultz, L. R. (2000). A second look at comorbidity in victims of trauma: the posttraumatic
stress disorder-major depression connection. Biological Psychiatry, 48, 902-909
Comorbidity
Alcohol and other substance abuse;
Most common comorbidity in Veterans – up to 75%,
43% in civilians
Before – risk factor, shared vulnerability
With or After – self medication?
The “Lifestyle” theory
Challenging findings in longitudinal studies
Breslau, N., G. C. Davis, et al. (2003). Posttraumatic stress disorder and the incidence of nicotine, alcohol, and other drug disorders in
persons who have experienced trauma.. Archive of General Psychiatry 60, 289-94.
Comorbidity
Personality Disorders
Very Common especially …… ??
45% to 79% in veterans
39% to 68% in Civilians
Lifestyle? Again?
The BPD Dilemma
Yen, S., Shea, M. T., Battle, C. L., Johnson, D. M., Zlotnick, C., Dolan-Sewell, R., et al. (2002). Traumatic exposure and posttraumatic
stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative
longitudinal personality disorders study. Journal of Nervous and Mental Disease, 190(8), 510-518.
Comorbidity
Phobias
Which?
Why?
TBI
Medical Conditions
Comorbidity
Phobias
Which?
Why?
TBI
Medical Conditions
Something
Missing?
SUICIDE
Risk
3-6 Times (ideas, attempt)
Lethality?
Lifetime Conditional Probability
PTSD Alone
17%
Plus MDD OR SUD 26
Plus Both
31%
Comorbidity
Research findings limitations
Retrospective – recall bias
Wide variability in design
Wide variability in findings
PROGNOSIS/COURSE
One Week
76-94% have all PTSD symptoms
Remission?
Average 2-3 years
One Month
98% !
6 Months
Down by 5%
One Year
Down by 40%
1/3
………
Acute Stress Disorder
First introduced in DSM-IV
Shorter duration (2 days to 4 weeks),
Less restrictive set of PTSD symptoms in each cluster + addition of
dissociative symptom.
ASD symptom cluster occurs in 10% to 30% of individuals exposed to
trauma.
72% to 83% of ASD go on to develop PTSD 6 months after trauma,
63% to 80% have PTSD 2 years after the trauma.
Acute Stress Disorder
DSM-5 Diagnostic Criteria
A. PTSD A Criterion A1 & A2 symptoms
B. 9 or more from any of FIVE categories (not just Four)
Intrusion -- 4
Avoidance -- 2
“Negative” Mood -- ONE
Arousal -- 5
AND
Acute Stress Disorder
DSM-5 Diagnostic Criteria-2
Dissociative -- 2
1. Altered sense of reality (out f body, time slowing, in a daze)
2. Dissociative Amnesia (not 2ry to TBI)
F. Clinically Significant Distress or Impairment
G. Duration >2 days; <1 month
H. Not due to other cause (Intoxication, medical condition, etc.)
Acute Stress Disorder
Dissociative -- 2
1. Altered sense of reality (out f body, time slowing, in a daze)
2. Dissociative Amnesia (not 2ry to TBI)
F. Clinically Significant Distress or Impairment
G. Duration >2 days; <1 month
H. Not due to other cause (Intoxication, medical condition, etc.)
Psychopathology
The word ‘trauma' is derived from the Greek term for ‘wound'.
Frightening or distressing events may result in a psychological
wound or injury - a difficulty in coping or functioning normally
following a particular event or experience; a potentially
traumatic event (PTEs).
Differential Diagnosis
Differential Diagnosis
1- Depression
2- Agoraphobia
3- Specific Phobias
How are they similar?
How to tell them apart?
4- Psychotic Disorders
5- Personality Disorders
Schillaci, Jeanne; Yanasak, Elisia; Adams, Jennifer et al: Guidelines for Differential Diagnoses in a Population With
Posttraumatic Stress Disorder. Professional Psychology: Research and Practice, Vol 40(1), Feb 2009, 39-45.
Differential Diagnosis
6- TBI
Ruff, R. L., Riechers, R. G., & Ruff, S. S. (2010). Relationships between mild traumatic brain injury sustained in combat and post-traumatic stress disorder. F1000
Medicine Reports, 2, 64. http://doi.org/10.3410/M2-64
Differential Diagnosis
Differential Diagnosis
Differential Diagnosis
Integrated Neuroscience Perspective
A- Neurobiological Substrates
-
Major Cerebral Areas
Circuitry
Neurotransmitters
Neuropeptides
Hormones
- Cortisol and other steroids (Prog, DHEA, Allopregnanolone)
Integrated Neuroscience Perspective
A- Neurobiological Substrates
- Neurotransmitters
1. NA --- Yohimbine (α2 Blocker), Prazosin
2. 5-HT ----- mCPP (5HTa Agonist)
(α1 Blocker)
- Neuropeptides
1. NPY
2. CRF
(low, blunted response; BUT
is associated with …… )
(extr-hyptholamic)
3. CB1 (endo-THC) receptors more available
From: Ross, D et al: An
Integrated Neuroscience
Perspective on Formulation
and Treatment Planning for
Posttraumatic Stress
Disorder: An Educational
Review. JAMA Psychiatry.
2017;74(4):407-415
Integrated Neuroscience Perspective
B- How they fit together with CP?
Theme 1:
Fear Conditioning
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
Integrated Neuroscience Perspective
B- How they fit together with CP?
Theme 2: Dysregulated circuits
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
w/o STRESS
STRESSED
HPA Axis
Integrated Neuroscience Perspective
B- How they fit together with CP?
Theme 3: Memory Reconsolidation
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
Integrated Neuroscience Perspective
B- How they fit together with CP?
Theme 4: Epigenetic Consideration
- Low cortisol
High PTSD risk,
BUT ONLY
Subjects with a history of
in
childhood trauma.
- A childhood developmental window
for epigenetic dysregulation of FKBP5
Galatzer-Levy, I.R., Karstoft, K.I., Statnikov, A., & Shalev, A.Y. (2014). Quantitative forecasting of PTSD from early trauma responses: A Machine Learning
application. Journal of Psychiatric Research. 59, 68-76
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
From: Ross, D et al: An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA Psychiatry. 2017;74(4):407-415
Integrated Neuroscience Perspective
B- How they fit together with CP?
Theme 4: Epigenetic Consideration
- Relevance to treatment outcome
- Who will respond
- Markers of response
Neuroradiological findings
1- Reduced hippocampal volume
Neuroradiological findings
2- fMRI findings
TREATMENT
1- Pharmacological
- SSRIs
- Prazosin
- ?BDZ?
- Other; Cortisol, B-blockers, D-Cycloserine, Opiates
- Epigenetics
2- Non-Pharmacological
- SOCIAL
- PE
- Cognitive [re]-processing
- EMDR
- Resilience
TREATMENT
Considerations in treatment
- Acute vs. established ?
- Time to respond, how long to stay in treatment ?
- Which one is better ?
- Can you combine? How? Which one first?
- Which cluster of symptoms respond to which treatment modality?
Foa E.B. & Rothbaum B.A. (1998) Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford Press
TREATMENT
General Guidelines in Psychotherapy of trauma survivors
- Reserve Judgment (who knows what you would’ve really done)
- Display comfortable attitude “not scared to listen”
- Demonstrate your knowledge and expertise about PTSD
- Express confidence in the efficacy of treatment
Foa E.B. & Rothbaum B.A. (1998) Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford Press
TREATMENT
General Guidelines in Psychotherapy of trauma survivors
- Highlight patient’s personal resources and praise her courage
- Normalize patient’s response to trauma;
“you’re not weak, or crazy”
- DO:
be active and directive
be supportive and sensitive
be a little flexible
Foa E.B. & Rothbaum B.A. (1998) Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford Press
TREATMENT
Finally, BE HUMBLE:
- Only 7% of patients make treatment contact in 1st year
- Drop out rates: 25-40%
- No type of psychotherapy was shown to be superior
- 17-30% of psychologists use PE!
Foa E.B. & Rothbaum B.A. (1998) Treating the trauma of rape: Cognitive behavioral therapy for PTSD. New York: Guilford Press;
Becker CB, Zayfert C, Anderson E. A survey of psychologists' attitudes towards and utilization of exposure therapy for PTSD.
Behav Res Ther. 2004 Mar;42(3):277-92. PMID: 14975770.
The Resilience Question
Innate vs acquired
Limitless? Even with prolonged trauma?
Can you improve resilience after disorder develops?
The Resilience Question
- Adapting and bouncing back from adversity
(and many other definitions)
- Not simple, nor static
- Applies to individuals, families, organizations,
Communities, societies and cultures
- Different determinants in different ……
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.
The Resilience Question
Measurement
Connor Davidson Resilience scale
25 self report items assessing:
hardiness,
personal competence,
tolerance of negative affect,
acceptance of change,
personal control
and spirituality.
• Response to Stressful Experiences Scale
• Resilience Scale for Children
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.
The Resilience Question
Factors Associated with Resilience
1- BIOLOGICAL:
Neural circuitry, neurochemicals
2- DEVELOPMENTAL
3- PSYCHOSOCIAL
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.
The Resilience Question
Factors Associated with Resilience
3- PSYCHOSOCIAL
positive emotions and optimism,
active problem-focused coping,
moral courage and altruism,
attention to physical health and fitness,
capacity to regulate emotions,
cognitive flexibility,
religiosity/spirituality,
high level of positive social support and commitment
to a valued and meaningful cause, purpose or mission.
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.
The Resilience Question
Resilience-Enhancing Interventions
1- CHILDREN
provide children with a supportive, protective, and
appropriately stimulating and challenging environment in which to
grow
2- ADULTS
Modify appraisal of threats and adversity
Increase attention control (Cognitive Control Training, Mindfulness)
Positive cognitive reappraisal
Increase coping self-efficacy (gradual, increasing challenges)
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.
The Resilience Question
Resilience-Enhancing Interventions
2- ADULTS
Comprehensive Programs
Stress inoculation training
Hardiness training; Control Commitment Challenge
Psychoeducational Resilience Training Program
Neurobiological approaches
Southwick, SM; Pietrzak, RH; Tsai, J; Krystal, JH and Charney, D (2015) Resilience: An Update. PTSD Research Quarterly 25:4.
National Center for PTSD.