Trauma- and Stressor-Related Disorders

Post-Traumatic Stress Disorder

PTSD is a disorder that develops after exposure to a traumatic event that involves actual or threatened death or serious injury.

Learning Objectives

Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options between post-traumatic stress disorder and complex post-traumatic stress disorder

Key Takeaways

Key Points

  • In psychology, trauma is a type of damage to the psyche that occurs as a result of an overwhelming amount of stress that exceeds one’s ability to cope or integrate the emotions involved with that experience.
  • Situations where an individual is exposed to a severely stressful experience involving threat of death, injury, or sexual violence can result in the development of post-traumatic stress disorder ( PTSD ).
  • In order to be diagnosed with PTSD, a person must experience a traumatic event along with symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.
  • A number of psychotherapies have demonstrated usefulness in the treatment of PTSD, such as cognitive behavioral therapy (CBT), exposure therapy, eye-movement desensitization and reprocessing (EMDR), and stress inoculation training (SIT).
  • Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from exposure to prolonged social and/or interpersonal trauma. Though distinct from PTSD, it has not yet been included as a formal diagnosis in the DSM.

Key Terms

  • physical integrity: The inviolability of the physical body; emphasises on the importance of personal autonomy and the self-determination of human beings over their own bodies.
  • cognitive therapy: A type of therapy that seeks to help the patient overcome difficulties by identifying and changing dysfunctional thinking and emotional responses.
  • stress inoculation training (SIT): A cognitive-behavioral treatment approach that provides people with added psychological resilience against the effects of stress through a program of managed successful exposure to stressful situations.

Defining Trauma

In psychology, trauma is a type of damage to the psyche that occurs as a result of a severely distressing event. Trauma is often the result of an overwhelming amount of stress that exceeds one’s ability to cope or integrate the emotions involved with that experience. A traumatic event can involve one experience or repeated events or experiences over time.

Traumatizing, stressful events can have a long-term impact on mental and physical health. Situations where an individual is exposed to a severely stressful experience involving threat of death, injury, or sexual violence can result in the development of post-traumatic stress disorder (PTSD). With this disorder, the trauma experienced is severe enough to cause stress responses for months or even years after the initial incident. The trauma overwhelms the victim’s ability to cope psychologically, and memories of the event trigger anxiety and physical stress responses, including the release of cortisol. People with PTSD may experience flashbacks, panic attacks and anxiety, and hypervigilance (extreme attunement to stimuli that remind them of the initial incident).

DSM-5 Diagnostic Criteria

To be diagnosed with PTSD according to the DSM-5 (2013), a person must first have been exposed to a traumatic event that involves a loss of physical integrity, or risk of serious injury or death, to self or others. In addition, the person must experience intrusions (persistent re-experiencing of the event through flashbacks, distressing dreams, etc.); avoidance (of stimuli associated with the trauma, talking about the trauma, etc.); negative alterations in cognitions and mood (such as decreased capacity to feel certain feelings or distorted self-blame); and alterations in arousal and reactivity (such as difficulty sleeping, problems with anger or concentration, reckless behavior, or heightened startle response). These symptoms must last for more than 1 month and result in clinically significant distress or impairment in multiple domains of life, such as relationships, work, or other daily functioning.

Etiology

PTSD is believed to be caused by the experience of a traumatic event. A person may experience or witness a stressful event involving death, serious injury, or such threat to the individual or others in a situation in which the individual felt intense fear, horror, or powerlessness. PTSD can occur in individuals with no predisposing conditions; however persons considered at-risk include combat military personnel, rape survivors, victims of natural disasters, concentration camp survivors, and victims of violent crime such as domestic or sexual abuse.

While men are more likely to experience a traumatic event, women are more likely to experience the kind of high-impact traumatic event that can lead to PTSD, such as interpersonal violence and sexual assault. Not everyone who experiences trauma will develop PTSD: according to the National Center for PTSD, approximately 20% of women and 8% of men who experience a traumatic event will develop PTSD.

Rates of PTSD are higher in combat veterans than than the average rate for men, with a rate estimated at up to 20% for veterans returning from Iraq and Afghanistan.

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PTSD and Combat Exposure: Many veterans of the wars in Iraq and Afghanistan have faced significant physical, emotional, and relational disruptions. Veterans are at a higher risk than the normal male population for developing PTSD.

Treatment

A number of psychotherapies have demonstrated usefulness in the treatment of PTSD and other trauma-related problems. Basic counseling practices common to many treatment responses for PTSD include education about the condition and provision of safety and support. The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral therapy (CBT), variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement desensitization and reprocessing (EMDR), and many combinations of these procedures.

EMDR and trauma-focused cognitive behavioral therapy (TFCBT) were recommended as first-line treatments for trauma victims in a 2007 review. Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns of thinking and/or behavior responsible for negative emotions. In CBT, individuals learn to identify thoughts that make them feel afraid or upset and replace them with less distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.

A variety of medications have shown adjunctive benefit in reducing PTSD symptoms; however, there is no clear drug treatment for PTSD. Positive symptoms (those that most individuals do not normally experience but are present in people with PTSD, such as re-experiencing or increased arousal) generally respond better to medication than negative symptoms (deficits of normal emotional responses or thought processes, such as avoidance or withdrawal).

Complex PTSD

Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from exposure to prolonged social and/or interpersonal trauma in the context of dependence, captivity, or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Examples include people who have experienced chronic maltreatment, neglect, or abuse by a care-giver; hostages; prisoners of war; concentration camp survivors; and survivors of some religious cults. C-PTSD is distinct from, but similar to, PTSD; however, C-PTSD was not accepted by the American Psychiatric Association as a mental disorder in the DSM-5. It was first described in 1992 by Judith Herman in her book Trauma & Recovery and an accompanying article.

Six clusters of symptoms have been suggested for diagnosis of C-PTSD: (1) alterations in regulation of affect and impulses; (2) alterations in attention or consciousness; (3) alterations in self-perception; (4) alterations in relations with others; (5) somatization, and (6) alterations in systems of meaning. PTSD descriptions fail to capture some of the core characteristics of C-PTSD, such as captivity; psychological fragmentation; the loss of a sense of safety, trust, and self-worth; and the tendency to be revictimized. C-PTSD is also characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment—elements that are not adequately described by the diagnosis of PTSD.

Reactive Attachment Disorder

Reactive attachment disorder is a childhood condition characterized by markedly disturbed ways of relating socially to others.

Learning Objectives

Summarize the diagnostic criteria, etiology, and treatment of reactive attachment disorder

Key Takeaways

Key Points

  • Reactive attachment disorder (RAD) is a childhood disorder in which the child shows a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way.
  • In order to be diagnosed with RAD, a child under the age of 5 must exhibit emotionally withdrawn and inhibited behaviors in relation to their caregivers (for example, not seeking comfort when they are sad or upset).
  • While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect.
  • RAD arises from a failure to form normal attachments to primary caregivers in early childhood. This type of  failure could result from severe early experiences of neglect, abuse, frequent change of caregivers, or a lack of caregiver responsiveness.
  • Assessing the child’s safety is an essential first step in addressing RAD. Further mainstream treatment and prevention programs for RAD are usually based on attachment theory.

Key Terms

  • affect regulation: The ability to respond to the ongoing demands of experience with a range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions, as well as the ability to delay spontaneous reactions as needed.
  • temperament: Those aspects of an individual’s personality, such as introversion or extroversion, that are often regarded as innate rather than learned.
  • Attachment Theory: A psychological model that attempts to describe the dynamics of long-term interpersonal relationships between humans.

Defining Reactive Attachment Disorder

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. Previously in the DSM-IV-TR, RAD was divided into two different types: inhibited type took the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way, while disinhibited type presented itself as indiscriminate sociability, such as excessive familiarity with relative strangers. In the recent revisions to the DSM-5 (2013), however, RAD was narrowed to encompass only the symptoms of the inhibited form, and a new diagnosis of disinhibited social engagement disorder (DSED) was created to encompass the symptoms previously known as RAD-disinhibited type. Both RAD and DSED are categorized in the DSM-5 as types of trauma and stressor-related disorders.

Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism, and assessment of disorders of attachment and led to efforts from the late-1990s to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.

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Attachments in childhood: Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary caregivers in early childhood.

DSM-5 Diagnostic Criteria

Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child’s developmental and chronological age, although it always involves a disturbance in social interaction. The core feature is severely inappropriate social relating by affected children. In order to be diagnosed with RAD under the DSM-5 criteria, a child under the age of 5 must:

  • exhibit emotionally withdrawn and inhibited behaviors in relation to their caregivers (for example, not seeking comfort when they are sad or upset);
  • exhibit some kind of emotional or social disturbance (for example, limited responsiveness, lack of positive affect, inexplicable instances of irritability or sadness, etc.); and
  • have a history of significant neglect and/or unstable living situations in which they were unable to form stable and secure attachments.

While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. In addition, the disturbance cannot be accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder or autism spectrum disorder.

Etiology

Although increasing numbers of childhood mental health problems are being attributed to genetics, reactive attachment disorder is by definition based on a problematic history of care and social relationships. RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child’s communicative efforts. Not all, or even a majority, of such experiences result in the disorder.

It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and responsive caregivers, it appears that some children are particularly vulnerable to developing attachment disorders. In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology—including RAD, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD)—can be found in disturbances in affect regulation (i.e., the ability to regulate one’s emotions).

Treatment

Assessing the child’s safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing, and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child’s safety within the family environment.

Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory. These approaches concentrate on increasing the responsiveness and sensitivity of the caregiver—or if that is not possible, placing the child with a different caregiver. These approaches are mostly in the process of being evaluated.