Trauma and Stressor Related Disorders

What is Trauma?

Trauma is a nonspecific term to describe deeply distressing or disturbing experiences. Trauma can be physical (e.g., bone fracture, head trauma, etc.) or emotional. Emotional trauma occurs following a stressful event or physical injury and can have debilitating long-term effects on moods, thoughts, and behaviors.

Alterations in arousal, reactivity, mood, thoughts, and behaviors can occur following traumatic experiences. When these alterations are persistent or cause impairment in important areas of functioning, we use the term “trauma disorder.”

There are many types of trauma and not all of them are included in the Diagnostic and Statistical Manual (DSM). Each type of trauma has different presentation and associated symptoms and in no way can we simplify traumatic experiences to one type (in other words, there is tremendous overlap).  Below we review Post Traumatic Stress Disorder (PTSD) as described in DSM-5.

Post Traumatic Stress Disorder (PTSD)

Terms Used Throughout History to Describe what we now call PTSD:

  • Irritable Heart (Jacob DaCosta, 1871)
  • Soldier’s Heart
  • Effort Syndrome
  • Neurocirculatory Asthenia
  • Compensation Neurosis
  • Shell Shock
  • War Neurosis
  • Battle Fatigue
  • Vietnam Syndrome

What are common signs and symptoms of Post Traumatic Stress Disorder (PTSD)?

Exposure to actual or threatened death, serious in injury, or sexual violence in 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).

Intrusion symptoms such as:

  1. Recurrent, involuntary, and intrusive distressing memories of 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 (on a continuum).
  4. Intense or prolonged psychological distress at  exposure to internal or external cues.
  5. Marked physiological reactions to internal or external cues.

Avoidance symptoms such as: 

  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 with the traumatic event(s).

Negative alterations in cognitions and mood such as:

  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.
  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).

Marked alterations in arousal and reactivity such as:

  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).

Other symptoms that might occur include:

  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).

Quick Facts

  • The highest rates of PTSD occur among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and/or genocide
  • Combat is the most common traumatic event for men
  • Rape/sexual assault and physical assault are the most common traumatic events in women
  • Natural disasters (earthquakes, storms, floods), terrorist attacks, mass killings, and child abuse are also common traumatic events
  • PTSD has a familial pattern
  • If left untreated, 30% of patients with PTSD will experience remission, 40% will develop mild symptoms, 20% will develop moderate symptoms, and 10% will develop worse/severe symptoms
  • Good prognostic factors: Rapid onset of symptoms, Short duration of symptoms, Good functioning prior to the traumatic event, Strong social support, and Absence of substance use or other psychiatric disorders
  • PTSD is more likely to occur in individuals who are Single/divorced/widowed, Socially withdrawn, or in a lower socioeconomic status

Risk Factors

  • Severity, duration, proximity of exposure
  • Childhood trauma
  • Borderline/antisocial/dependent/paranoid personality traits
  • Inadequate support system
  • Female gender
  • Recent stressful life changes
  • Recent excessive alcohol intake

Traumatized individuals may be at increased risk for developing the the following:

  • Depression
  • Bipolar Disorder
  • Panic Disorder
  • Social Phobia
  • Generalized Anxiety Disorder
  • Alcohol Abuse/Dependency
  • Substance Abuse/Dependency
  • Medical Problems: cerebrovascular disease, Congestive Heart Failure, Peripheral Vascular Disease, and Myocardial Infarction (heart attacks)

Neurobiology

  • Hypothalamic Pituitary Adrenal (HPA) Axis Dysregulation (altered cortisol levels and biological rhythms)
  • Decreased volume of the hippocampus has been reported in combat veterans
  • Noradrenergic (Norepinephrine), Opioid, Glutamate, GABA, and Endocannabinoid system have been implicated in PTSD
  • Sleep disturbances in individuals suffering from PTSD: Decreased REM latency (i.e., decreased time between falling asleep and the first Rapid Eye Movement Cycle). 

Treatment

Psychotherapy

  • Prolonged Exposure Therapy
  • Exposure Therapy
  • CBT
  • Psychodynamic Psychotherapy
  • Eye Movement Desensitization Reprocessing (EMDR)
  • Family therapy
  • Group therapy

Medication

  • SSRIs: Sertraline (FDA Approved), Paroxetine (FDA Approved), Citalopram, Escitalopram, Fluoxetine
  • SNRIs: Venlafaxine, Duloxetine
  • Mirtazapine
  • Buspirone (as augmentation) 
  • Imipramine
  • Amitriptyline
  • Tazodone
  • Carbamazepine
  • Depakote
  • Clonidine
  • Propranolol (hypervigilance)
  • Prazosin (for trauma related nightmares)

Emerging Treatments

  • MDMA/Ecstasy with guided psychotherapy
  • Medical Cannabis
  • TMS

Concluding Comments

  • PTSD is a disorder of hyperarousal and overgeneralization of specific memories
  • PTSD is associated with changes to specific brain regions that process and interpret sensory stimuli
  • Paroxetine (Paxil) and Sertraline (Zoloft) are FDA approved for PTSD
  • Prazosin may help trauma related nightmares and hyper vigilance
  • Exposure Therapy is the therapy of choice for PTSD
  • Acute Stress Disorder is diagnosed when symptoms occur within one (1) month of the traumatic event. After one month, PTSD is diagnosed. 

Neurobiology of Fear, Reviewed

References

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