Module 6: Trauma- and Stressor-Related Disorders
LEARNING OBJECTIVES
At the end of this lesson, the students are expected to:

identify trauma and stressor-related disorders based on their main features and symptoms,

explain the development of trauma and stressor-related disorders from biological,
psychological, social, and socio-cultural perspectives, and

recognize established ways or approaches used to treat trauma and stressor-related
disorders disorders.
MODULE OUTLINE
A. Trauma- and Stressor-Related Disorders

Adjustment Disorders

Acute Stress Disorder

Posttraumatic Stress Disorder (PTSD)
B. Causes of Trauma- and Stressor-Related Disorders
C. Treatment for Trauma- and Stressor-Related Disorders
A. Trauma- and Stressor-Related Disorders
Basic Terminologies:
-
Stressors are external events or situations that place physical or psychological
demands on us.
-
Stress is the internal psychological or physiological response to a stressor.
After exposure to traumatic incidents, there are four common outcomes or trajectories:
-
Resilience—relatively stable functioning and few symptoms resulting from the
trauma
-
Recovery—initial distress with reduction in symptoms over time
-
Delayed symptoms—few initial symptoms followed by increasing symptoms over time
-
Chronic symptoms—consistently high trauma-related symptoms that begin soon
after the event
1. Adjustment Disorder (AD)
-
It occurs when someone has difficulty coping with or adjusting to a specific life
stressor—the reactions to the stressor are disproportionate to the severity or
intensity of the event or situation.
-
Common stressors such as interpersonal or family problems, divorce, academic
failure, harassment or bullying, loss of a job, or financial problems may lead to an
AD.
-
Diagnostic Criteria
a.
The development of emotional or behavioral symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the
stressor(s).
b. These symptoms or behaviors are clinically significant, as evidenced by one
or both of the following:
-
Marked distress that is out of proportion to the severity or
intensity of the stressor, taking into account the external context
and the cultural factors that might influence symptom severity and
presentation.
-
Significant impairment in social, occupational, or other important
areas of functioning.
c.
The stress-related disturbance does not meet the criteria for another
mental disorder and is not merely an exacerbation of a preexisting mental
disorder.
d. The symptoms do not represent normal bereavement.
e.
Once the stressor or its consequences have terminated, the symptoms do
not persist for more than an additional 6 months.
2. Acute Stress Disorder
- Diagnostic Criteria
a. A. Exposure to actual or threatened death, serious injury, or sexual violation
in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or
close friend. Note: In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., first responders collecting human
remains, police officers repeatedly exposed to details of child
abuse). Note: This does not apply to exposure through electronic
media, television, movies, or pictures, unless this exposure is work
related.
b. Presence of nine (or more) of the following symptoms from any of the five
categories of intrusion, negative mood, dissociation, avoidance, and arousal,
beginning or worsening after the traumatic event(s) occurred:
1. Intrusion symptoms
- Recurrent, involuntary, and intrusive distressing memories of
the traumatic event(s). Note: In children, repetitive play may
occur in which themes or aspects of the traumatic event(s)
are expressed.
- Recurrent distressing dreams in which the content and/or
affect of the dream are related to the event(s). Note: In
children, there may be frightening dreams without
recognizable content.
- Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness
of present surroundings.) Note: In children, trauma-specific
reenactment may occur in play.
- Intense or prolonged psychological distress or marked
physiological reactions in response to internal or external
cues that symbolize or resemble an aspect of the traumatic
event(s).
2. Negative Mood
- Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings).
3. Dissociative Symptoms
- An altered sense of the reality of one’s surroundings or
oneself (e.g., seeing oneself from another’s perspective,
being in a daze, time slowing).
- Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to
other factors such as head injury, alcohol, or drugs).
4. Avoidance Symptoms
- Efforts to avoid distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s).
Efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
5. Arousal Symptoms
- Sleep disturbance (e.g., difficulty falling or staying asleep,
restless sleep).
- Irritable behavior and angry outbursts (with little or no
provocation), typically expressed as verbal or physical
aggression toward people or objects.
- Hypervigilance.
- Problems with concentration.
- Exaggerated startle response.
c. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month
after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but
persistence for at least 3days and up to a month is needed to meet disorder
criteria.
d. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
e. The disturbance is not attributable to the physiological effects of a
substance (e.g., medication or alcohol) or another medical condition (e.g., mild
traumatic brain injury) and is not better explained by brief psychotic
disorder.
3. Post-Traumatic Stress Disorder (PTSD)
-
-
Diagnostic Criteria

For individuals above 6 years old
a.
Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
1.
Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s)occurred to a close
family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s)
must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s) (e.g., first responders
collecting human remains: police officers repeatedly exposed
to details of child abuse).
b. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
1.
Recurrent, involuntary, and intrusive distressing memories of
the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s)were
recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness
of present surroundings.)
4. Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues
that symbolize or resemble an aspect of the traumatic
event(s).
c.
Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s)occurred, as
evidenced by one or both of the following:
1.
Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings about or closely associated with the
traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings about or
closely associated with the traumatic event(s).
d. Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1.
Inability to remember an important aspect of the traumatic
event(s) (typically due to dissociative amnesia and not to
other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations
about oneself, others, or the world (e.g., “I am bad, ”“No one
can be trusted,” ‘The world is completely dangerous,” “My
whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
4. Persistent negative emotional state(e.g., fear, horror, anger,
guilt, or shame).
5. Markedly diminished interest or participation in significant
activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings).
e.
Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1.
Irritable behavior and angry outbursts(with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
f.
Duration of the disturbance (Criteria B,C, D, and E) is more than 1
month.
g.
The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
h. The disturbance is not attributable to the physiological effects of a
substance (e.g., medication, alcohol) or another medical condition.
o
Specify whether:
- With dissociative symptoms: The individual’s
symptoms meet the criteria for posttraumatic stress
disorder, and in addition, in response to the stressor,
the individual experiences persistent or recurrent
symptoms of either of the following:
1.
Depersonalization: Persistent or recurrent
experiences of feeling detached from, and as
if one were an outside observer of, one’s
mental processes or body (e.g., feeling as
though one were in a dream; feeling a sense
of unreality of self or body or of time moving
slowly).
2. Derealization: Persistent or recurrent
experiences of unreality of surroundings (e.g.,
the world around the individual is experienced
as unreal, dreamlike, distant, or distorted).
- Note: To use this subtype, the dissociative symptoms
must not be attributable to the physiological effects
of a substance (e.g., blackouts, behavior during
alcohol intoxication) or another medical condition
(e.g., complex partial seizures).
o
Specify if:
- With delayed expression: If the full diagnostic
criteria are not met until at least 6 months after the
event (although the onset and expression of some
symptoms may be immediate).

For children 6 years and younger
a.
Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:
-
Directly experiencing the traumatic event(s).
-
Witnessing, in person, the event(s) as it occurred to others,
especially primary caregivers.
-
Learning that the traumatic event(s)occurred to occurred to
a parent or caregiving figure.
b. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
1.
Recurrent, involuntary, and intrusive distressing memories of
the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the child
feels or acts as if the traumatic event(s) were recurring.
(Such reactions may occur on a continuum, with the most
extreme expression being a complete loss of awareness of
present surroundings.) Such trauma-specific reenactment
may occur in play.
4. Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic
event(s).
c.
One (or more) of the following symptoms, representing either
persistent avoidance of stimuli associated with the traumatic
event(s) or negative alterations in cognitions and mood associated
with the traumatic event(s), must be present, beginning after the
event(s) or worsening after the event(s):
-
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or
physical reminders that arouse recollections of the
traumatic event(s).
2. Avoidance of or efforts to avoid people,
conversations, or interpersonal situations that arouse
recollections of the traumatic event(s).
-
Negative Alterations in Cognitions
3. Substantially increased frequency of negative
emotional states (e.g., fear, guilt, sadness, shame,
confusion).
4. Markedly diminished interest or participation in
significant activities, including constriction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive
emotions.
d. Alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two (or more) of the following:
1.
Irritable behavior and angry outbursts(with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects (including extreme
temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
e.
The duration of the disturbance is more than 1 month.
f.
The disturbance causes clinically significant distress or impairment
in in relationships with parents, siblings, peers, or other caregivers
or with school behavior.
g.
The disturbance is not attributable to the physiological effects of a
substance (e.g., medication, alcohol) or another medical condition.
o
Specify whether:
- With dissociative symptoms: The individual’s
symptoms meet the criteria for posttraumatic stress
disorder, and in addition, in response to the stressor,
the individual experiences persistent or recurrent
symptoms of either of the following:
1.
Depersonalization: Persistent or recurrent
experiences of feeling detached from, and as
if one were an outside observer of, one’s
mental processes or body (e.g., feeling as
though one were in a dream; feeling a sense
of unreality of self or body or of time moving
slowly).
2. Derealization: Persistent or recurrent
experiences of unreality of surroundings (e.g.,
the world around the individual is experienced
as unreal, dreamlike, distant, or distorted).
- Note: To use this subtype, the dissociative symptoms
must not be attributable to the physiological effects
of a substance (e.g., blackouts, behavior during
alcohol intoxication) or another medical condition
(e.g., complex partial seizures).
o
Specify if:
- With delayed expression: If the full diagnostic
criteria are not met until at least 6 months after the
event (although the onset and expression of some
symptoms may be immediate).
B. Causes of Trauma- and Stressor-Related Disorders
a. Biological
Many individuals who develop trauma-related disorders have a nervous system that
is more reactive to fear and stress when compared to people who are exposed to
trauma but do not develop a disorder.
-
Although our biological systems are designed for rapid recovery from
traumatic events and for homeostasis (physiological balance), some people
are more prone to the physiological reactivity associated with chronic stress
reactions.
-
The normal response to a fear-producing stimulus is quite rapid, occurring in
milliseconds, and involves the amygdala, the part of the brain that is the
major interface between events occurring in the environment and
physiological fear responses. In response to a potentially dangerous
situation, the amygdala sends out a signal to the sympathetic nervous
system, preparing the body for action (i.e., to fight or to flee).
-
The hypothalamic-pituitary-adrenal (HPA) axis (the system involved in stress
and trauma reactions) then releases hormones, including epinephrine and
cortisol. These hormones prepare the body for “fight or flight” by raising
blood pressure, blood sugar levels, and heart rate; the body is thus prepared
to react to the potentially dangerous situation. Cortisol also helps the body
return to normal (i.e., restore homeostasis) after the stressor is removed.
-
However, people who develop a trauma- or stressor-related disorder, their
amygdala and HPA axis are overreactive and continue to demonstrate
physiological stress reactions even when the stressor is no longer present.
Individuals with trauma-related disorders also show minimal fear extinction (i.e., a
decline in fear responses associated with the trauma).
-
Researchers believe that deficiencies in fear extinction occur when the
medial prefrontal cortex is unable to adequately inhibit fear responses;
when fear extinction does not occur, various trauma-related cues continue to
trigger fear reactions
-
Impaired fear inhibition and difficulty discriminating safe situations is a
hallmark of PTSD
-
Those with PTSD demonstrate an enhanced startle response, exaggerated
physiological sensitivity to stimuli associated with the traumatic event, and
diminished ability to inhibit fear responses.
Why does this reactivity occur in the first place (i.e., why homeostasis is not
restored soon after the trauma)?

Possible Reasons:
-
It is possible that the chronic release of stress hormones such as
cortisol alters brain structures associated with stress regulation.
The brain is particularly vulnerable to the effects of cortisol during
childhood, a time when the brain is still developing. Disruptions
caused by excess cortisol can lead to neuronal loss and affect brain
areas such as the hippocampus, amygdala, and cerebral cortex.
-
Genetic differences are also implicated in vulnerability to traumarelated disorders.

Genetic research involving PTSD focuses on individuals with
two short alleles (SS genotype) of the serotonin transporter
gene (5-HTTLPR). Those with this genotype appear to have
increased stress sensitivity and are more prone to the
heightened anxiety reactions associated with PTSD.
b. Psychological
-
Threat Perception

The severity of perceived life threat, rather than actual life threat,
may be the best predictor of whether a person will develop PTSD.

Perceived threat, more than actual threat, is a better predictor of
many of the symptoms of PTSD.
-
Locus of Control

The person’s beliefs about whether she or he can control future
events are also important.

Victims who perceive (perhaps with justification) that future
negative events are uncontrollable are much more likely to have
severe PTSD symptoms than those victims who perceive some future
control.
-
Suppression of Anger

Victims who suppress their feelings of anger may have an increased
risk of developing PTSD after a traumatic experience (e.g., rape).

Intense anger may interfere with the modification of the traumatic
memory (to make it more congruent with previous feelings of safety).
Anger also inhibits fear, so the victim cannot habituate to the fear
response.
-
Individuals with pre-existing conditions (e.g., depression and higher anxiety)
or negative emotions (e.g., hostility and anger)

They may react more intensely to a traumatic event because they
ruminate about the event and overestimate the probability that
aversive events will follow.
-
A tendency to generalize trauma-related stimuli to other situations (e.g., a
rape survivor avoiding contact with men) and to avoid situations associated
with the trauma can maintain the fear response because the person is not
able to learn that such situations are not dangerous; in other words, there is
less opportunity for fear extinction.
-
Negative cognitive styles and dysfunctional thoughts

Example: I feel so helpless; The world is so dangerous

They may interpret stressors in a catastrophic manner and thereby
increase the psychological impact of trauma.

Example:
o
Among child and adolescent survivors of assault and motor
vehicle accidents, those with thoughts such as “I will never
be the same” were more likely to develop PTSD symptoms.
o
Negative thoughts such as these may produce sustained and
heightened physiological reactivity, making the development
of PTSD more likely.
o
On the other hand, a positive cognitive style that results in
active problem-solving, reframing traumatic events in a more
positive light, and optimistic thinking can increase resilience
and reduce risk of PTSD.
c. Social
-
Availability of social support

Protective factors such as the person’s level of social support may
help to prevent or limit the development of PTSD and other
psychological consequences.

Unfortunately, simply having a social support network may not be
enough. The tendency of the victim to withdraw and avoid situations
is an inherent part of the disorder. This avoidance may mean that
victims do not take advantage of social support, even if it is available
to them.

The reactions of one's family members and friends may lead to
further problems and may make a person feel less in control and
more alienated from other people.

Those victims with extensive social support networks were less likely
to be anxious or depressed, but social support did not specifically
reduce the frequency or severity of PTSD symptoms. This pattern
suggests that the needs of trauma survivors must be addressed
broadly.

Nevertheless, social support may dampen the anxiety associated with
a trauma or prevent negative cognitions from occurring.
-
Social Isolation
-
Less than optimal social support during childhood
-
Exposure to childhood traumas (sexual and/or physical abuse)
-
Severe bullying
-
Preexisting family conflict, maltreatment, or overprotectiveness
d. Sociocultural
-
The attitudes that society holds toward victims of sexual assault are also
important in relation to social support.
-
Some people apparently believe that certain women somehow deserved to be
raped. These women undoubtedly receive less social support than other
victims.
-
People may also be more supportive after hearing the details of an assault
that was clearly nonconsensual—one in which the victim violently fought back
when attacked by a stranger—than when the circumstances surrounding the
assault were more ambiguous.
-
Perceived discrimination based on race or sexual orientation is also
associated with increased risk for PTSD.

Experiences or perceptions of discrimination can increase anxiety
and lead to the development of negative thoughts about oneself and
the world.
-
Greater prevalence of trauma-related disorders in women was due, in part,
to more frequent exposure to violent interpersonal situations.
C. Treatment for Trauma- and Stressor-Related Disorders
-
The most effective forms of treatment for PTSD involve the use of either
cognitive-behavior therapy or antidepressant medication, alone or in combination.
-
Certain antidepressant Medications

They help in altering serotonin levels, decreasing reactivity of the amygdala
and desensitizing the fear network.
-
The psychological intervention that has been used and tested most extensively is
prolonged exposure.

This procedure starts with initial sessions of information gathering.

These are followed by several sessions devoted to reliving the traumatic
scene in the client’s imagination.

Clients are instructed to relive the event by imagining it and describing it to
the therapist, as many times as possible, during the 60-minute sessions.

Sessions are recorded, and patients are instructed to listen to the tape at
least once a day.

Patients are also required to participate in situations outside the therapy
sessions that are deemed to be safe but also elicit fear or avoidance
responses.

https://www.youtube.com/watch?v=rHg_SlEqJGc
-
Another therapy that is being used is trauma-focused cognitive-behavioral therapy
(TF-CBT)

It focuses on helping clients identify and challenge dysfunctional cognitions
about the traumatic event and current beliefs about themselves and others.

This therapy addresses underlying dysfunctional thinking or pervasive
concerns about safety.

For example, battered women with PTSD often have thoughts associated
with guilt or self-blame.

Cognitions such as “I could have prevented it,” “I never should have . . . ,” or
“I’m so stupid” can maintain PTSD symptoms.

Therapy involving education about PTSD, developing a solution-oriented
focus, reducing negative self-talk, and receiving therapeutic exposure to
fear triggers (such as photos of their abusive partner or movies involving
domestic violence) reduced PTSD symptoms

-
https://www.youtube.com/watch?v=Jqj5zDbkPxY
Eye movement desensitization and reprocessing (EMDR)

Clients are asked to visualize their traumatic experience while following a
therapist’s fingers moving from side to side.

The therapist prompts the client to substitute positive cognitions (e.g., “I
am in control”) for negative cognitions associated with the experience (e.g.,
“I am helpless”).

https://www.youtube.com/watch?v=8552cfDn8pQ