AssessmentsTrauma- and stress-related disorders: Pathology review
USMLE® Step 1 style questions USMLE
A 23-year-old woman comes to her primary care physician to evaluate recurrent nightmares. The patient was sexually assaulted two weeks ago, and since that time, reports recurrent nightmares surrounding the event. She states, “Ever since the incident, I can’t return to campus. The thought of being back at school after what happened is unbearable.” The patient avoids thinking about the incident and feels depressed, irritable, and distracted throughout the day. The patient has not had any suicidal ideation or thoughts. The patient has no past medical history. Which of the following is the most likely diagnosis?
Content Reviewers:Antonella Melani, MD
A 31 year old female named Amelia comes to the mental health clinic complaining of trouble sleeping due to vivid nightmares recounting an armed bank robbery she witnessed 4 months ago.
Ever since that event, she has avoided going to crowded places that remind her of the bank, to the point where she had to give up her job at the mall.
Suddenly, your phone starts ringing and Amelia jumps from her seat. You apologize, and she then mentions that this happens whenever she hears sudden or loud noises.
Okay, based on the initial presentation, Amelia seems to have some form of trauma or stress-related disorder.
Many individuals at some point in their lives experience trauma, which can be thought of as a distressing event that causes an overwhelming amount of stress, exceeding one’s ability to cope or process the emotions caused by that experience.
Trauma can be caused by one single event, such as a serious car crash or sexual assault or abuse; or can last for a more prolonged period of time, such as experiencing poverty, neglect during early childhood, or military combat.
Most of the time, with support from loved ones, individuals are able to recover from a traumatic experience.
Unfortunately, some individuals may develop trauma and stress-related disorders, where traumatic experiences lead to symptoms like flashbacks, nightmares, and anxiety, all of which can interfere with day-to-day activities like working, studying, eating, and sleeping.
Now, the underlying cause of trauma and stress-related disorders is poorly understood; but what you need to remember is that individuals affected usually have altered levels and response to stress hormones like adrenaline and cortisol.
For your exams, the most high-yield trauma and stress-related disorders are post-traumatic stress disorder, acute stress disorder, and adjustment disorder. Okay, let’s start with post-traumatic stress disorder, or PTSD for short.
This usually occurs in individuals who have either directly experienced a traumatic event or witnessed as it happened to others, but it can also affect someone who just heard that a close family member or friend was involved.
In a test question, make sure to also keep an eye out for someone with prolonged or extreme exposure to graphic details of traumatic events, such as a police officer or paramedic, as well as a military veteran.
Now, symptoms of PTSD must last for at least one month and they mainly include recurrent, involuntary, and intrusive memories of the traumatic experience through nightmares or flashbacks.
When exposed to physical or mental reminders of their trauma, these individuals typically experience intense psychological distress or physical reactions, such as sweating and heart palpitations.
For your exams, what’s important to remember is that this may cause them to feel a sense of hypervigilance, meaning that they are constantly on guard, as well as hyperarousal, where they have this exaggerated startle response to the smallest of triggers, such as sudden or loud noises.
Another high yield fact is that individuals with PTSD may start avoiding environments and situations that remind them of their trauma, such as certain places, activities, or even other people.
Finally, thinking and mood might be negatively affected, so individuals may have exaggerated negative beliefs about oneself, others, or the world, like thinking the world is completely dangerous and no one can be trusted; or persistent negative emotions such as fear, distress, or shame.
Moving on to acute stress disorder, this also occurs in individuals who have either directly experienced or witnessed one or repeated traumatic events, or heard about it through a close family member or friend.
Acute stress disorder causes many of the same trauma-related symptoms as PTSD, but a key difference you need to remember for your exams is that the symptoms only last between 3 days and up to 1 month following the traumatic event.
Last but not least, there’s adjustment disorders, which are a group of disorders that occur after an individual goes through a stressful or life-changing event, to which they have a hard time adjusting or coping.
Now, events can range from a divorce or losing a job to being diagnosed with an illness.
- "Robbins Basic Pathology" Elsevier (2017)
- "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
- "Diagnostic and Statistical Manual of Mental Disorders" NA (1980)
- "Post-traumatic stress disorder" BMJ (2015)
- "Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis" Social Psychiatry and Psychiatric Epidemiology (2014)
- "Current status on behavioral and biological markers of PTSD: A search for clarity in a conflicting literature" Neuroscience & Biobehavioral Reviews (2013)
- "Wilderness and Rescue Medicine" Jones & Bartlett Publishers (2012)
- "Adjustment disorder as proposed for ICD-11: Dimensionality and symptom differentiation" Psychiatry Research (2015)
- "Adjustment Disorder: Current Developments and Future Directions" International Journal of Environmental Research and Public Health (2019)