Specific Trauma and Stressor-Related Disorders DSM-5 309.8 (F43)
DSM-5 Category: Trauma- and Stressor-Related Disorders
Introduction
The category of “Trauma and Stressor-related Disorders” is a new rubric for the variously-named forms of post-traumatic stress disorder, shell shock, combat neurosis and the like. Although historically related to war, these conditions may be triggered by a variety of intensely traumatic events, and have in common persistent re-experiencing, avoidance, emotional numbing and a state of arousal after exposure to a dangerous or horrifying situation. The new classification is centered upon the iconic post-traumatic stress disorder (PTSD), but also includes a subtype for young children (preschool type) and one in which experiential detachment or unreality are prominent (dissociative type). The category also includes short-lived reactions to traumatic events (acute stress disorder) and adjustment disorder, a stress-response syndrome that has some features of PTSD along with elements of depression and anxiety (American Psychiatric Association, 2013).
Physical breakdown and mental illness during and after war was recognized by the ancient Egyptians, and Herodotus described incapacitation by the events of war in the 5th Century BCE. Swiss and German military physicians in the 17th Century identified two illnesses that caused combat soldiers to experience melancholy, weakness, anxiety, insomnia, palpitations and incessant thoughts of home, and termed them Sehnsucht (nostalgia) and Heimweh (homesickness). The American Civil War, felt by many historians to be the first “modern” war, produced an unprecedented surge of inexplicable illness and psychiatric morbidity, leading to the description of “soldier’s heart” and “neurasthenia” and to the observation that soldiers on leave often collapsed with mental illness at home even if they had been well during the fighting.The Russian Army in the Russo-Japanese War of 1905 was the first to recognize that battlefield catastrophe, of which they had plenty, could cause mental collapse. Enormous numbers of mental casualties resulted from World War I, and these were at first wrongly attributed to brain concussion from large-caliber artillery, hence the term “shell shock”. Freud suggested that mental symptoms represented “combat neurosis”, caused by the conflict between a soldier’s “war ego” and “peace ego”. In World War II and the Korean War, “combat neurosis” was replaced by “combat fatigue”, although rest usually did not alleviate the symptoms (Jones, 2013).
The mental sequelae of terrible events were early recognized in civilian life as well. The English diarist Samuel Pepys was incapacitated after the Great Fire of London in 1666, even though his home was not affected; Pepys recorded inability to sleep, dreams of burning and falling houses, months of anger and discontent and later being frightened by news of a distant chimney fire. Charles Dickens was in the famous Staplehurst railway disaster in 1865, spent hours tending the grievously wounded and dying and was “not quite right within…an effect of the railway shaking” thereafter. That accident and the protracted period of investigation and litigation that followed led to the enunciation of “compensation neurosis” and “railway spine” as pejorative explanations for post-traumatic symptoms (Trimble, 1985). Similar symptoms consistent with stressor-induced disorders were experienced by 20th century concentration camp survivors (Frankl, 1959). At about the same time, the acute and chronic physiological effect s of mental and situtional stress were elucidated (Selye, 1956).
The “stress reaction” was first identified as a psychiatric diagnosis by the Veterans Administration after World War II. The first edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1952) included “gross stress reaction”, mental symptoms in previously normal people in response to exceptional physical or mental stress, which subsides in days to weeks. This diagnosis was not retained in the first revision of the Manual (American Psychiatric Association , 1968). The recurrence of post-traumatic disability in the Vietnam War, as in World War II and the Korean conflict, provided an impetus for the recognition in the DSM-3 of stress-induced disorders, and the diagnosis was generalized to include non-military stressors by the requirement that the causative stress be “ outside the range of normal human experience” and severe enough to “produce symptoms in almost anyone” (American Psychiatric Association, 1980).The next revision of the criteria (DSM-4, American Psychiatric Association, 2000) broadened the definition of stressors to include harm to others as well as self, and recognized that acute stress could produce a short-term mental disorder, and could lead to a dissociative reaction.
The stress-induced disorders have previously been classified with the anxiety disorders. A new category was created in DSM-5 because a variety of clinical phenotypes meet PTSD criteria, and because anxiety symptoms are not always prominent, particularly in children. It has been suggested that the trauma and stressor-related disorders may represent a spectrum like many other psychiatric conditions (Friedman et al., 2011).
Symptoms of Specific Trauma and Stressor-Related Disorders
Post-traumatic stress disorder (PTSD) is characterized by recurrent disturbing flashbacks to a traumatic event, avoidance or numbing of memories of the event and a state of hyperarousal. Most people do not develop PTSD after traumatizing events, and children are less likely than adults to develop it, particularly if less than 10 years of age at the time of the trauma. Women are more likely to experience traumatic life events than men, and more likely to have PTSD, although men predominate among military trauma survivors. PTSD can result from the threat of death or harm to onself, witnessing the death or injury or others or a situation causing intense feelings of fear, horror or powerlessness, although the latter is no longer a required feature for diagnosis. Individuals often experience “survivor’s guilt” at remaining alive while others died.
Acute stress disorder can involve emotional numbing, detachment and derealization, continued re-experiencing of the stress through dreams or flashbacks and avoidance of stimuli that recall the event. These symptoms are similar to PTSD but of briefer duration. Adjustment disorder results from inability to adjust to a stressor, such as a major life event. It is characterized by emotional or behavioral features of depression, anxiety and post-traumatic stress in various combinations, and may represent a subthreshold syndrome. Emotional symptoms can include sadness, hopelessness, anhedonia, crying, anxiety, worry, insomnia, feeling overwhelmed and suicidal thoughts; behavioral symptoms can include recklessness, ignoring family and friends, neglecting tasks and duties and suicide attempts.
Diagnostic Criteria
Diagnosis of PTSD requires the satisfaction of several criteria reflecting the components of the disorder: exposure to a traumatic event (A), persistent re-experiencing of the event (B), persistent avoidance of reminders of the event (C), negative alteration of cognition and mood related to the event (D), increased arousal (E), symptoms present for at least a month (F), symptoms cause clinically significant distress or impairment (G) and disturbance is not due to the effect of a substance or another medical condition (H). If dissociative symptoms are present and not due to a medication or drug, criteria must be met for (1) depersonalization or (2) derealization. The condition can also have delayed expression: the full criteria were not met until 6 months or more after the event. There are two additional subtypes of PTSD: preschool, affecting children under 6 years of age; and dissociative, in which depersonalization (being outside one’s body or in a dream) or derealization (unreality or distortion of reality) are experienced.
The event (A) must have involved “loss of physical integrity” or risk to self or others of injury or death. Exposure must have been direct or witnessed at first hand, through learning of the injury or the accidental or violent death of a close relative or friend or by repeated or extreme professional exposure to aversive details of the event. The exposure cannot simply have been through the media.The traumatic event in the preschool population may be something that would not necessarily terrify an adult, such as a medical procedure, a large dog or a scary movie. Intrusion (B) is experienced through recurrent, involuntary or intrusive memory, or by nightmares or dissociative reactions (flashbacks); reminders of the trauma cause intense or prolonged distress, and there is a prolonged physiological reaction (sweating, palpitations, etc.) to such stimuli. Avoidance (C) involves persistent effortful avoidance of either thoughts and feelings related to the event or people, places and things connected with the event. At least 2 negative alterations in cognition and mood (D) must be present: amnesia not due to head injury, drugs or alcohol; persistent and often distorted negative beliefs about oneself or the world; persistent blaming of oneself or others for causing the event or its consequences; persistent negative emotions related to the event; marked reduction in interest in pre-traumatic activities; feelings of detachment and estrangement from others; or constricted affect and inability to express positive emotions. To have persistent arousal (E), patients must have had at least 2 of the following since the event: irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, difficulty concentrating or sleep disturbance.
Acute stress disorder has the same criteria as PTSD but a shorter time course. Symptoms of intrusion, avoidance, negative cognitive and mood alteration and persistent arousal appear within 4 weeks of the trauma and last for 2 days to 4 weeks.
Diagnosis of adjustment disorder requires emotional or behavioral symptoms that develop within 3 months of an identifiable stressor. This must be accompanied by marked distress out of proportion to the severity of the stressor, significant social or functional impairment, or both. The stress-related disturbance cannot be an exacerbation of a previous mental disorder or meet criteria for another mental disorder. The symptoms also cannot be due to normal bereavement, and should not persist for more than 6 months after the resolution of the stressor or its consequences. There are 6 subtypes specifying mood and behavior: with depressed mood, with anxious mood, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct and unspecified type.
Management
Treatment of PTSD and related disorders in adults usually requires a combination of medications and nonpharmacological therapy: pharmacological treatment alleviates physiological symptoms and allows psychotherapy to proceed. The emphasis is usually on psychotherapy in children and adolescents. Comorbid substance abuse and depression are frequent complicating factors: alcohol and drug abuse should be addressed early, while the treatment response of depression will be better after initial intervention for PTSD. A variety of psychotherapeutic techniques have been studied (individual, family and group therapy, cognitive behavioral therapy, art and play therapy, hypnotism relaxation techniques and eye movement desensitization and reprocessing). Pharmacologic treatment with a variety of agents has chiefly focused on alleviation of anxiety, impulsivity and emotional lability and improvement of sleep disturbance and prevention of nightmares.
Meta-analyses of PTSD studies suggest that eye movement desensitization and reprogramming, which derives from empirical observations that disturbing thoughts are accompanied by rapid eye movements and uses therapist-directed eye movements to diminish negative cognition and increase positive thoughts during psychotherapy, and trauma-focused cognitive behavioral therapy are most effective (Högberg et al., 2008). Internet-based cognitive behavioral therapy and supportive psychotherapy were both effective in symptoms experienced by military personnel with PTSD after the Iraq War and 9/11, but cognitive behavioral therapy was more so (Litz et al., 2007). As few as one cognitive behavioral treatment for sleep disturbance can improve daytime PTSD symptoms (Germain et al., 2007). Psychodynamic psychotherapy and flooding (prolonged exposure to aversive stimuli) have also been used with benefit (Ponniah and Hollen, 2009).
Pharmacological studies have suggested that fluoxetine may be effective for intrusion, avoidance and arousal symptoms (Connor et al., 1999). Atypical antipsychotics and eszopiclone have been used for refractory symptoms (Lambert, 2006; Pollack et al., 2011). Prazosin and other alpha-1 adrenergic antagonists may ameliorate sleep-related symptoms (Raskind et al., 2007), and low-dose glucocorticoids may decrease the recall of traumatic memories (deQuervain and Margraf, 2008). Beta-blockers, particularly propranolol, decrease hyperarousal, particularly when given within 6 hours of a traumatic event (Brunet, 2008). Several anticonvulsants, particularly carbamazepine and lamotrigine, decrease impulsivity and emotional lability (Davis et al., 2006).
Acute stress disorder is usually addressed with psychotherapy, particularly in traumatized children. Debriefing is one of the most common interventions and reduces distress, but has not been shown to prevent depression or anxiety and can increase the arousal of traumatized survivors if not carefully performed. One or two sessions of operational debriefing, which attempts to normalize emotional responses, support traumatized individuals generally and inform them of available services and options, is recommended (Bisson and Deahl, 1994). Cognitive behavioral therapy reduces the likelihood of developing PTSD after a traumatic event from 70 per cent with supportive or no therapy to 10 to 20 per cent. Re-experiencing and avoidance are particularly reduced by interventions designed to replace “malignant schemata” with “constructive schemata” (Bryant et al., 2006). Pharmacologic therapy is used chiefly to reduce hyperarousal and insomnia, and beta blockers, alpha-adrenergic antagonists, and less frequently, SSRI antidepressants are recommended for core symptoms (Famularo et al., 1988), while sedating antihistamines and if necessary benzodiazepines are used for sleeplessness (Gelpin et al., 1996).
Psychotherapy of adjustment disorder aims to reduce or eliminate the stressor, improve coping mechanisms for stressors that will persist and foster more adaptive emotional states. Psychodynamic psychotherapy, family and group therapy, and cognitive-behavioral therapy, particularly in a time-limited course, have been found to be beneficial (Strain and Diefenbacher, 2008). Antidepressants may help with adjustment disorder, but the condition often resolves before psychotherapeutic options have been exhausted (Stewart et al., 1992). Benzodiazepines are helpful for insomnia and anxiety, but in some studies have not done as well as non-benzodiazepine alternatives (Razavi et al., 1999). Natural remedies, particularly kava-kava and valerian, have been shown to ameliorate adjustment disorder symptoms (Bourin et al., 1997; Volz and Kieser, 1997).
Author: Miles E. Drake, Jr., M.D.
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