Approach to trauma and stressor-related disorders: Clinical sciences

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.

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.

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.

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. 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.