Approach to trauma and stressor-related disorders: Clinical sciences

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Introduction0:00–0:36

Trauma and stressor related disorders are psychiatric conditions, which develop following exposure to stressful or traumatic events.
Stressors can include any experience that causes change, loss, or distress, while trauma is a specific type of stressful experience that involves significant danger or violence.
For example, losing a job is a stressor, while a serious car crash is considered traumatic. Major disorders in this category include adjustment disorder, acute stress disorder, and post-traumatic stress disorder.

Focused H&P0:36–0:58

When a patient presents with a chief concern suggesting a trauma or stressor related disorder, first obtain a focused history and physical examination.
Your patient will report past exposure to stressful events, along with a change in mood or behavior. During the physical exam, you might notice that the patient has a constricted or labile affect.

DSM-5 criteria for trauma exposure0:58–2:13

With these findings, consider trauma or related disorders, and then assess the DSM-5 criteria for trauma exposure. To qualify as a traumatic exposure, a patient must have been exposed to life-threatening danger, serious bodily injury, actual death, or sexual violence.
There are a few ways the patient can be exposed to trauma. First, the patient may have experienced it firsthand as either the direct victim or a first-hand witness of someone else being threatened or harmed.
It might also be through witnessing the direct aftermath of the danger or violence, such as with first responders. Finally, it is also considered traumatic if the person is a second-hand witness, in other words, learned about the danger second-hand, only if the victim was a very close family member or friend.
In addition, if the trauma occurred second-hand, the danger must have been either violent or accidental. For example, learning that one’s parent died of complications of an illness would not meet criteria for trauma, but learning they died in a shooting would.
Like other stressors, trauma can be a single event, such as being victim of a mugging, or repeated or chronic events, such as domestic violence.

Adjustment Disorder2:13–3:59

If these criteria are not met, trauma is absent, so you should consider adjustment disorder, and assess the DSM-5 criteria for this condition.
First, the patient must have experienced behavioral changes, emotional changes, or both in response to a stressor. Stressors can be a single event like moving, or it can a combination of multiple events or repeated exposures such as ongoing interpersonal conflicts with neighbors, or a chronic experience like living with a disability.
Such stressors can lead to a wide range of emotional changes including irritability, depression, anxiety, social withdrawal, or interpersonal conflict.
Next, symptoms must cause either distress or functional impairment for the patient. Finally, the symptoms must resolve within six months once the stressor is absent.
If these criteria are met, you can diagnose your patient with an adjustment disorder. For diagnostic clarity, adjustment disorder can be further specified as having depressed mood, anxious features, disturbance of conduct, or a combination, depending on the patient’s symptoms.
Here is your very first clinical pearl! To diagnose adjustment disorder, symptoms must not meet criteria for another psychiatric condition.
If symptoms match another psychiatric condition, diagnose that one instead. For example, if your patient has a history of major depressive episodes, and becomes depressed after a stressful event, you should consider diagnosing major depressive disorder, rather than adjustment disorder with depressed mood.
Additionally, consider diagnosing prolonged grief disorder if the stressor is loss of a loved one that occurred over a year ago, and the symptoms include daily preoccupation or intense yearning for the lost loved one.
Now, let’s switch gears and talk about when criteria for trauma exposure are met. In this case, you should consider an acute stress disorder, or a post-traumatic stress disorder, PTSD.

Stress response symptoms3:59–5:31

To work these out further, start by assessing your patient’s stress response symptoms. These symptoms fall into five major categories.
First, there are intrusion symptoms, which include repeated, unwanted memories, flashbacks, or nightmares about the trauma.
The second category includes avoidance symptoms, characterized by patients’ attempts to avoid external or internal reminders of the trauma.
For example, the patient may have quit their job to avoid seeing the coworker who assaulted them or might take a much longer driving route to avoid passing the site of their past car accident.
The third category refers to changes in mood, which can include irritability, depression or anxiety, and changes in cognition, which can include persistently negative thoughts like “the world is a dangerous place”.
Next, we have arousal symptoms, which might include hypervigilance or an exaggerated startle response. Finally, there is dissociation, which is often classified as either depersonalization, which is an out of body sensation, or derealization, which is feeling detached from the world, as if in a dream.
If these symptoms are absent, you should consider an alternative diagnosis, such as adjustment disorder, anxiety, or depression.

Normal trauma response5:31–5:48

On the other hand, if stress response symptoms are present, you should assess the timeline of traumatic exposure. If the symptoms occur in less than 3 days after the patient experienced the trauma, no diagnosis is needed, as this is considered within the normal range of trauma response.
On the contrary, if your patient reports stress response symptoms lasting 3 days to one month after the trauma, consider acute stress disorder.

Acute Stress Disorder5:48–7:01

To confirm the diagnosis, assess the DSM-5 criteria. To meet the criteria, your patient must have trauma exposure, as already established.
They must also have 9 total symptoms that fall within the following categories: intrusion, avoidance, changes to mood, arousal, or dissociation.
Keep in mind that they might present with any combination of these symptoms; it is not necessary for all the categories to be present in any individual patient.
These symptoms must cause distress or functional impairment, and last at least 3 days, but less than 1 month. If these criteria are met, you can diagnose your patient with acute stress disorder.
Here’s a clinical pearl! Sometimes acute stress disorder is a transient condition which resolves over time after the trauma.
On the other hand, it can sometimes progress to Posttraumatic Stress Disorder, which is why close monitoring is recommended.

Posttraumatic Stress Disorder7:01–9:07

Let’s switch gears and talk about patients who have had stress response symptoms for more than one month. In this case, you should consider Posttraumatic Stress Disorder, and then assess the DSM-5 criteria for this condition.
First, your patient must have met criteria for traumatic exposure. After the trauma, they must report at least one intrusive symptom, such as flashbacks and nightmares.
Next, they should also describe some effort to avoid reminders of the trauma. Reminders can be external, like encountering people or places related to the event, or internal, like memories or conversations about the event.
Additionally, at least one negative change to mood or cognition must be present. This symptom category varies a lot, but common examples of mood changes are chronic guilt or depression, while cognitive changes might include amnesia about the traumatic event, or persistently negative beliefs, like “I am damaged goods”.
Finally, the patient must also report at least two arousal symptoms, which typically include hypervigilance, exaggerated startle response, emotional reactivity, or explosive anger.
Lastly, symptoms must last at least one month. Also, keep in mind that dissociative symptoms might be present, but are not required to meet criteria for PTSD.
Here’s another clinical pearl to keep in mind! Trauma-related disorders can present differently in pediatric patients compared to adults.
For example, children with PTSD are unlikely to report intrusive symptoms. Instead, these symptoms can often be better understood by observing how they reenact the trauma during play.
For children presenting with caregiver neglect, other trauma-related disorders might be present, such as reactive attachment disorder and disinhibited social engagement disorder.
In Reactive Attachment Disorder, children show withdrawn behavior, and avoid seeking care from adults. On the other hand, children with Disinhibited Social Engagement Disorder lack normal stranger anxiety and can be overly attached to any adult, regardless of familiarity.
Alright, as a quick recap... Trauma and stressor related disorders are conditions that develop after exposure to a stressful event or series of events.

Review9:07–9:54

To qualify as a traumatic exposure, a patient must have been exposed to life-threatening danger, serious bodily injury, actual death, or sexual violence, either directly, as first-hand witness, as a witness to the direct aftermath, or as a second-hand witness if the victim was a close family member or a friend.
Traumatic exposure often leads to stress response symptoms, which occur across 5 categories: intrusion, avoidance, changes to mood or cognition, arousal and dissociation.
These symptoms are normal within the first 3 days after a trauma, but sometimes develop into Acute Stress Disorder
Approach to trauma and stressor-related disorders | Osmosis