ma and Stressor- Related
(e.g., the disturbances in Criterion A began following the lack of
rders Jose Gerardo Los Banos, MD
/2019
Psychiatry 2 AY
2019-2020 2nd
Shifting Exam
OUTLINE I.
Introduction II. Reactive Attachment Disorder III. Disinhibited
Social Engagement Disorder IV. Posttraumatic Stress Disorder V.
Acute Stress Disorder VI. Adjustment Disorder VII. Treatment
VIII. Sample Prescriptions IX. Summary Table of Trauma &
Stressor-Related Disorders
I. TRAUMA AND STRESS RELATED DISORDERS
• Include disorders in which exposure to a traumatic or stressful
event is listed explicitly as a diagnostic criterion
• Psychological distress following exposure to a traumatic or stressful
event is quite variable → Symptoms can be well understood within an
anxiety- or fear-
based context → Many individuals who have been
exposed to a traumatic or stressful event exhibit anhedonic and
dysphoric symptoms as the most prominent clinical
characteristics, externalizing angry and aggressive symptoms, or
dissociative symptoms → Not uncommon for the clinical picture
to include some combination of the above symptoms.
II. REACTIVE ATTACHMENT DISORDER A.
DIAGNOSTIC CRITERIA (DSM-V CRITERIA) A. A
consistent pattern of inhibited, emotionally withdrawn
behavior toward adult caregivers, manifested by both of the
following: 1. The child rarely or minimally seeks comfort when
distressed. 2. The child rarely or minimally responds to comfort
when distressed. B. A persistent social and emotional
disturbance characterized by at least two of the following: 1.
Minimal social and emotional responsiveness to others. 2. Limited
positive affect. 3. Episodes of unexplained irritability, sadness, or
fearfulness that are evident even during nonthreatening
interactions with adult caregivers. C. The child has experienced a
pattern of extremes of
insufficient care as evidenced by at least one of the following: 1.
Social neglect or deprivation in the form of persistent lack of having
basic emotional needs for comfort, stimulation, and affection met by
caregiving adults. 2. Repeated changes of primary caregivers that
limit opportunities to form stable attachments (e.g., frequent
changes in foster care). 3. Rearing in unusual settings that severely
limit opportunities to form selective attachments (e.g., institutions
with high child-to-caregiver ratios). D. The care in Criterion C is
S2 T3 3B Psych Transers : Espinosa, Marcelino, Pacheco, Tusing 1 of 8
presumed to be responsible for the disturbed behavior in Criterion A
adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder. F. The
disturbance is evident before age 5 years. G. The child has a
developmental age of at least 9 months. Specify if:
• Persistent: The disorder has been present for more than 12
months. → Specify current severity:
▪ Reactive attachment disorder is specified as severe when a
child exhibits all symptomS of the disorder, with each
symptom manifesting at relatively high levels.
III. DISINHIBITED SOCIAL ENGAGEMENT
DISORDER
A. DIAGNOSTIC CRITERIA (DSM-V CRITERIA) A. A
pattern of behavior in which a child actively approaches
and interacts with unfamiliar adults and exhibits at least two
of the following: 1. Reduced or absent reticence (reserve) in
approaching
and interacting with unfamiliar adults. 2. Overly familiar verbal
or physical behavior (that is not consistent with culturally
sanctioned and with age- appropriate social boundaries). 3.
Diminished or absent checking back with adult caregiver
after venturing away, even in unfamiliar settings. 4. Willingness
to go off with an unfamiliar adult with minimal
or no hesitation. B. The behaviors in Criterion A are not
limited to impulsivity (as in attention-deficit/hyperactivity
disorder) but include socially disinhiblted behavior. C. The
child has experienced a pattern of extremes of
insufficient care as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack
of having basic emotional needs for comfort, stimulation, and
affection met by caregiving adults. 2. Repeated changes of
primary caregivers that limit
opportunities to form stable attachments (e.g., frequent
changes in foster care). 3. Rearing in unusual settings that
severely limit
opportunities to form selective attachments (e.g., institutions with
high child-to-caregiver ratios). D. The care in Criterion C is
presumed to be responsible for the disturbed behavior in Criterion
A (e.g:, the disturbances in Criterion A began following the
pathogenic care in Criterion C). E. The child has a developmental
age of at least 9 months. Specify if:
• Persistent: The disorder has been present for more than 12
months. → Specify current severity:
▪ Disinhibited social engagement disorder is specified as
severe when the child exhibits all symptoms of the disorder,
with each symptom manifesting at relatively high levels.
 IV. POST-TRAUMATIC STRESS DISORDER (PTSD)
A. DIAGNOSTIC CRITERIA (DSM-V CRITERIA) (For
adults, adolescents, and children > 6 years old) A.
Exposure to actual or threatened death, serious injury, or
sexual violence in one (or more) of 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 accident. 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 Note: Criterion A4 does not apply to
exposure through electronic media, television, movies, or
pictures, unless this exposure is work related. B. Presence of one
(or more) of the following intrusion symptoms associated with
the traumatic event(s), beginning after the traumatic event(s)
occurred: 1. Recurrent, involuntary, and intrusive distressing
memories of the traumatic event(s). Note: In children older
than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed 2. Recurrent
distressing dreams in which the content
and/or affect of the dream are related to the traumatic
event(s). Note: In children, there may be frightening dreams
without recognizable content. 3. Dissociative reactions
(e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness
of present surroundings.) Note: In children, trauma-specific
reenactment may occur in play. 4. Intense or prolonged
psychological distress at
exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s). 5. Marked
physiological reactions to internal or external
cues that symbolize or resemble an aspect of the traumatic
event(s). C. Persistent avoidance of stimuli associated
with the
traumatic event(s), beginning after the traumatic event(s)
occurred, as evidenced by one or both of the following: 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
associated with the traumatic event(s). D. Negative alterations in
cognitions and mood associated
with the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following: 1. Inability to remember an important aspect of
the
Psych 2 Trauma and Stressor- Related Disorders 2 of 8
B. DIAGNOSTIC CRITERIA (DSM-V CRITERIA) (For
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 (e.g., "I am
bad," "No one can be trusted," ''The world is completely
dangerous," "My whole nervous system is permanently
ruined"). 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).
E. Marked alterations in arousal and reactivity associated
with the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more) of
the following: 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). F. Duration of the disturbance
(Criteria B, C, D, and E) is more
than 1 month. G. The disturbance causes clinically
significant distress or
impairment in social, occupational, or other important areas of
functioning. H. The disturbance is not attributable to the
physiological effects of a substance (e.g., medication, alcohol)
or another medical condition. Specify whether:
• With dissociative symptoms: The individual's symptoms meet
the criteria for posttraumatic stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or
recurrent symptoms of either of the following: 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). Note: To
use this subtype, the dissociative symptoms must not be
attributable to the physiological effects of a substance (e.g.
blackouts, behavior during alcohol intoxication) or another medical
condition (e.g., complex partial seizures). Specify if:
• With delayed expression: If the full diagnostic criteria are not
met until at least 6 mos. after the event (though the onset and
expression of some symptoms may be immediate).
children < 6 years old) A. Exposure to actual or threatened
death, serious injury, or sexual violence in one (or more) of the
following ways: 1. Directly experiencing the traumatic event(s). 2.
Witnessing, in person, the event(s) as it occurred to
others, especially primary caregivers. Note: Witnessing
does not include events that are witnessed only in electronic
media, television, movies, or pictures. 3. Learning that the
traumatic event(s) occurred to a
parent or caregiving figure. B. Presence of
one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred: 1. Recurrent, involuntary, and
intrusive distressing
memories of the traumatic event(s). Note:
Spontaneous and intrusive memories may not necessarily
appear distressing and may be expressed as play
reenactment. 2. Recurrent distressing dreams in which the
content
and/or affect of the dream are related to the traumatic
event(s). Note: It may not be possible to ascertain that the
frightening content is related to the traumatic event. 3.
Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness
of present surroundings.) Such trauma-specific reenactment
may occur in play. 4. Intense or prolonged psychological
distress at
exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s). 5. Marked
physiological reactions to internal or external
cues that symbolize or resemble an aspect of the traumatic
event(s). C. One (or more) of the following symptoms,
representing
either persistent avoidance of stimuli associated with the
traumatic event(s) or negative alterations in cognitions and
mood associated with the traumatic event(s), must be present,
beginning after the event(s) or worsening after the
event(s):
• Persistent Avoidance of Stimuli 1. Avoidance of
or efforts to avoid activities, places, or
physical reminders that arouse recollections of the traumatic
event(s). 2. Avoidance of or efforts to avoid people,
conversations,
or interpersonal situations that arouse recollections of
the traumatic event(s).
• Negative Alterations in Cognitions 1.
Substantially increased frequency of negative
emotional states (e.g., fear, guilt, sadness, shame,
confusion). 2. Markedly diminished interest or participation
in
significant activities, including constriction of
play. 3. Socially withdrawn behavior. 4. Persistent
reduction in expression of positive
emotions. D. Alterations in arousal and
reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of the following:
1. Irritable behavior and anger outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects (including extreme
temper tantrums). 2. Hypervigilance. 3. Exaggerated startle
response. 4. Problems with concentration. 5. Sleep
disturbance (e.g., difficulty falling or staying
asleep or restless sleep). E. The duration of the
disturbance is more than 1 month. F. The disturbance causes
clinically significant distress or
impairment in relationships with parents, siblings, peers, or other
caregivers or with school behavior. G. The disturbance is not
attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
Specify whether:
• With dissociative symptoms
1. Depersonalization 2.
Derealization Specify if:
• With delayed expression - If the full diagnostic criteria are not
met until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).
V. ACUTE STRESS DISORDER A. DIAGNOSTIC
CRITERIA (DSM-V CRITERIA) A. Exposure to actual or
threatened death, serious injury, or sexual violation in one (or
more) of 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 event(s) occurred to a close
family
member or close friend. Note: 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). Note: This does not apply to exposure
through electronic media, television, movies, or pictures, unless
this exposure is work related. B. Presence of nine (or more) of the
following symptoms
from any of the five categories of intrusion, negative mood,
dissociation, avoidance, and arousal, beginning or worsening
after the traumatic event(s) occurred:
• Intrusion Symptoms 1. Recurrent, involuntary, and
intrusive distressing memories of the traumatic event(s).
Note: In children, repetitive play may occur in which
themes or aspects of the traumatic event(s) are
expressed. 2. Recurrent distressing dreams in which the
content and/or affect of the dream are related to the
event(s). Note: in children, there may be frightening
dreams without recognizable content. 3. Dissociative
reactions (e.g., flashbacks) in which the individual feels or
acts as if the traumatic event(s) were recurring. (such
reactions may occur on a continuum,
Psych 2 Trauma and Stressor- Related Disorders 3 of 8
with the most extreme expression being a complete
loss of awareness of present surroundings.)
Note: in children, trauma-specific reenactment may occur in
play. 4. Intense or prolonged psychological distress or marked
physiological reactions in response to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
→ Negative Mood
5. Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings). → Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or
oneself (e.g., seeing oneself from another’s perspective, being
in a daze, time slowing). 7. 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). → Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s). 9.
Efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s). → Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep,
restless sleep). 11. Irritable behavior and angry outbursts (with
little or no provocation), typically expressed as verbal or physical
aggression toward people or objects. 12. Hypervigilance. 13.
Problems with concentration. 14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in criterion B) is 3
days to 1 month after trauma exposure. →
Note: symptoms typically begin immediately after the
trauma, but persistence for at least 3 days and up to a month is
needed to meet disorder criteria. D. The disturbance causes
clinically significant distress or impairment in social,
occupational, or other important areas of functioning. E. The
disturbance is not attributable to the physiological
effects of a substance (e.g., medication or alcohol) or
another medical condition (e.g., mild traumatic brain
injury) and is not better explained by brief psychotic
disorder.
VI. ADJUSTMENT DISORDER A.
DIAGNOSTIC CRITERIA (DSM-V CRITERIA) A. The
development of emotional or behavioral symptoms in response to
an identifiable stressor(s) occurring within 3 months of the
onset of the stressor(s). B. These symptoms or behaviors are
clinically significant,
as evidenced by one or both of the following: 1. Marked
distress that is out of proportion to the
severity or intensity of the stressor, taking into account the
external context and the cultural factors that might influence
symptom severity and presentation. 2. Significant
impairment in social, occupational, or
other important areas of functioning. C. The stress-related
disturbance does not meet the criteria
for another mental disorder and is not merely an
exacerbation of a preexisting mental disorder. D. The
symptoms do not represent normal bereavement. E. Once the
stressor or its consequences have terminated,
the symptoms do not persist for more than an
additional 6 months. Specify whether:
• With depressed mood – Low mood, tearfulness, or
feelings of hopelessness are predominant.
• With anxiety – Nervousness, worry, jitteriness, or
separation anxiety is predominant.
• With mixed anxiety and depressed mood – A
combination of depression and anxiety is predominant.
• With disturbance of conduct – Disturbance of conduct is
predominant.
• With mixed disturbance of emotions and conduct – Both
emotional symptoms (e.g., depression, anxiety) and a
disturbance of conduct are predominant.
• Unspecified – For maladaptive reactions that are not
classifiable as one of the specific subtypes of adjustment
disorder
• Characterized by an emotional response to a stressful event.
• It is one of the few diagnostic entities in which an external
stressful event is linked to the development of symptoms.
• Typically, the stressor involves financial issues, a medical
illness, or relationship problem.
• The symptom complex that develops may involve anxious or
depressive affect or may present with a disturbance of conduct.
• Symptoms must begin within 3 months of the stressor.
• From Kaplan & Saddocks: → The presence of a stressor is a
requirement in the diagnosis of adjustment disorder, PTSD, and acute
stress disorder.
▪ PTSD and acute stress disorder have the nature of the
stressor better characterized and are accompanied by a
defined constellation of affective and autonomic symptoms.
▪ In contrast, the stressor in adjustment disorder can be of any
severity, with a wide range of possible symptoms. → When the
response to an extreme stressor does not meet
the acute stress or posttraumatic disorder threshold, the
adjustment disorder diagnosis would be appropriate.
• Notes from 2020 Trans: → Stressors in adjustment disorder are
perceived to be more subjective, unlike sa PTSD na may actual
threat talaga. → Yung stressor sa iyo ay pwedeng hindi stressor sa
iba.
VII.
TREATMENT
• For patients who has experienced trauma → Approaches are
support, encouragement to discuss the
event, and education about a variety of coping mechanisms
(e.g., relaxation)
• Use of sedatives and hypnotics can also be helpful in some
 cases asignificant trauma, the major approaches are support,
• From Kaplan: → When a clinician is faced with a patient who has encouragement to discuss the event, and education about a
experienced variety of coping mechanisms (e.g., relaxation). → Allow the
patient to proceed at his or her own pace.

Psych 2 Trauma and Stressor- Related Disorders 4 of 8

symptoms similar to those of depression or other anxiety normally healthy
disorder persons who have had little experience with illness's capacity to
• Buspirone → Serotonergic and may also be of use free them from responsibility. Thus, patients can find therapists'
for PTSD attention, empathy, and understanding, which are necessary for
success, rewarding in their own right, and therapists may thereby
• Tricyclic Agents → Alternative drug for PTSD → Dosages
reinforce patients' symptoms → This event must be considered
should be the same as those used to treat
before starting psychotherapy
depressive disorders, and an adequate trial should last at least
• Crisis intervention → Short-term treatments aimed at
8 weeks → Patients who respond well should probably continue
helping persons with
the
adjustment disorders resolve their situations quickly
pharmacotherapy for at least 1 year before an attempt is made
to withdraw the drug → Some studies indicate that ▪ Supportive techniques
pharmacotherapy is more effective in treating the depression, ▪ Suggestion
anxiety, and hyperarousal than in treating the avoidance, ▪ Reassurance
denial, and emotional numbing → Examples ▪ En
▪ Imipramine (Tofranil) − Usual daily dose: 75-300 mg; 8• Transer’s
wks; Note → May summary table sa baba for treatment na
may continue for 1 almost exactly
year the same as this so if gipit na sa oras you can use that hehe.
▪ Amitriptyline (Elavil) − Usual daily dose: 75-300 mg; 8 wks;
may continue for 1 POST-TRAUMATIC STRESS
year DISORDER Non-Pharmacologic Treatment
• Other drugs may include: → MAOIs: Phenelzine (Nardil) • Psychotherapy after a traumatic event should follow a model of crisis
→ Anti-convulsants: Carbamazepine (Tegretol) → intervention with support, education, and the development of
Valproate (Depakene) → Reversible monoamine oxidase coping mechanisms and acceptance of the event → The short-term
inhibitors (RIMAs) → Anti-adrenergic agents nature of psychotherapy minimizes the risk of dependence and
▪ Clonidine (Catapres) chronicity, but issues of suspicion paranoia, and trust often adversely
▪ Propanolol (Inderal) affect compliance.
→ Haloperidol • When PTSD has developed, two major psychotherapeutic
▪ reserved for short-term control of severe aggressionapproaches
and can be taken. → Exposure therapy
agitation due to no positive data on the use of antipsychotic ▪ The patient re-experiences the traumatic event through
drugs in PTSD imaging techniques or in vivo exposure.
▪ The exposures can be intense, as in implosive therapy, or graded,
ADJUSTMENT as in systematic desensitization. → Teach the patient methods of
stress management,
DISORDER Non-Pharmacologic
including relaxation techniques and cognitive approaches, to
Treatment
coping with stress.
• Remains the treatment of choice for adjustment disorders• Data shows stress management to be more effective; but
• Can help persons adapt to stressors that are not reversible orexposure
time techniques last longer
• Others → Behavior
limited and can serve as a preventive intervention if the stressor
does remit therapy → Cognitive
• Individual psychotherapy → Offers the opportunity to explore therapy
the → Hypnosis →
meaning of the stressor Group therapy
to the patient so that earlier traumas can be worked through →▪ Sharing of traumatic experiences and support from other group
After successful therapy, patients sometimes emerge from members → Family therapy
an adjustment disorder stronger than in the premorbid ▪ Helps sustain a marriage through periods of exacerbated
period symptom → Time-limited psychotherapy
• Group therapy → For patients with similar stresses (e.g. ▪ For the victims of trauma
Group of retired ▪ Usually takes a cognitive approach
persons or patients having renal dialysis) ▪ Also provides support and security
• Psychiatrists treating adjustment disorders must be wary of ▪ Minimizes the risk of dependence and chronicity, but issues of
SECONDARY GAIN → The iIlness role maybe rewarding to somesuspicion, paranoia, and trust often adversely affect compliance
 → Abreaction relaxation
▪ Experiencing the emotions associated with the traumatic
event Pharmacologic
▪ May be helpful for some patients to overcome trauma • Selective serotonin reuptake inhibitors (SSRIs) → Considered
▪ Amobarbital (Amytal) is used to facilitate this first-line treatments for PTSD, owing to their
process → Eye Movement Desensitization and efficacy, tolerability, and safety
Reprocessing rating → Examples
(EMDR)
▪ Sertraline (Zoloft)
▪ Patient focuses on the lateral movement of the clinician's
▪ Paroxetine (Paxil) → Reduce symptoms from all
finger while maintaining a mental image of the trauma
PTSD symptom clusters and are effective in improving symptoms
experience
unique to PTSD, not just
▪ General belief is that symptoms can be relieved as patients
work through the traumatic event while in a state of deep

Psych 2 Trauma and Stressor- Related Disorders 5 of 8

▪ Hospitalization (if necessary) abnormal dreams including nightmares, dizziness, tremor, dry mouth
• Frequency and length of visits for crisis support vary according to and headaches occur.
patients' needs
Notes:
• Flexibility is essential in this approach
• For depression: → 20 mg/day → May be increased by 10 mg/day
increments w/in 2-3 wk of
Pharmacologic
initiation of therapy & wkly
• No studies have assessed the efficacy of pharmacological thereafter → Max: 50 mg/day
interventions in individuals with adjustment disorder, but it may be • For PTSD: → 20 mg/day for not >12 wk →
reasonable to use medication to treat specific symptoms for a brief increased by 10 mg/day increments → Max:
time 50 mg/day
• Depending on the type of adjustment disorder, a patient may Sertraline HCl
(Zoloft)
respond to an antianxiety agent or to an antidepressant.
50mg/tab #7
• Anxiolytics → Diazepam (valium) → For patients with tablets
severe anxiety bordering on panic
• Short course of psychostimulant medication → Sig: Take 1/2 tab daily for 1 week, then increase to 1 tablet daily.
For those in withdrawn or inhibited states May be taken with or without food. Take in the morning or evening.
Refill: None Warning: Seek consultation if decreased appetite,
• Antipsychotic drugs → May be used if there are signs of
blurred vision, insomnia, agitation, abnormal dreams including
decompensation or nightmares, dizziness, tremor, dry mouth and headaches occur.
impending psychosis
• Selective serotonin reuptake inhibitors (SSRIs) → Found Notes:
useful in treating symptoms of traumatic grief • For depression: → Initially 50 mg/day → Dose changes should be
made at intervals of at least 1 wk. → Max: 200 mg/day

VIII. SAMPLE PRESCRIPTIONS (LIFTED FROM 2020) • For PTSD: → Initially 25 mg/day, increased to 50 mg/day after 1
wk. → Dose changes should be made at intervals of at least 1 wk. →
Max: 200 mg/day

Paroxetine HCl
(Xet20)
20mg/tab #7
tablets
REFERENCE
Sig: Take 1 tab daily for not more than 12 weeks; may be increased S Dr. Joge’s lecture 2020 Trans DSM V
in 10mg increments weekly. Refill: None Warning: Seek
Kaplan & Saddocks
consultation if decreased appetite, blurred vision, insomnia, agitation,
Psych 2 Trauma and Stressor- Related Disorders 6 of 8
IX. SUMMARY TABLE OF TRAUMA & STRESSOR-RELATED DISORDERS Disorder Definition Required No. of Symptoms Duration Differential D
Remarks Reactive Attachment Disorder
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers
Criterion A: Both Criterion B: 2 or more Criterion C: 1 or more
---
Disinhibited Social Engagement Disorder
A child actively approaches and interacts with unfamiliar adults
Criterion A: 2 or more Criterion C: 1 or more
---
Post-traumatic Stress Disorder
Marked by increased stress and anxiety following exposure to a traumatic or stressful event.
Criterion A: 1 or more Criterion B: 1 or more Criterion C: 1 or both Criterion D: 2 or more Criterion E: 2 or more
Review: Criterion A: Exposure Criterion B: Intrusion Symptoms Criterion C: Avoidance Symptoms Criterion D: Negative Mood Criterion E: Arousal Sympto
>1 month • Adjustment disorders
• Other posttraumatic disorders and conditions
• Acute stress disorder
• Anxiety disorders and obsessive- compulsive disorder
• Major depressive disorder
• Personality disorders
• Dissociative disorders
• Conversion disorder (functional neurological symptom disorder)
• Psychotic disorders
• Traumatic brain injury
• A stressor is the prime causative factor in development of PTSD
• Stressor alone dose not suffice to cause disorder
• The response to the traumatic event must involve intense fear and horror
Acute Stress Disorder
Development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events.
Criterion A: 1 or more Criterion B: 9 or more from any of 5 categories
• Five Categories 1. Intrusion Symptoms 2. Negative Mood 3. Dissociative Symptoms 4. Avoidance Symptoms 5. Arousal Symptoms
3 days to 1 month
• Posttraumatic stress disorder
• Adjustment Disorders
• Panic Disorder
• Dissociative Disorder
• Obsessive-compulsive disorder
• Psychotic disorders
• Traumatic brain injury
• The same with PTSD except for the time duration
• Requires 9 or more symptoms from the entire list of symptoms regardless of the category
Adjustment Disorder
The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.
Criterion B: 1 or both Within 3
months
• Major Depressive Disorder
• Posttraumatic stress disorder
• Acute stress disorder
• Personality disorder
• Normative stress reactions
• Characterized by an emotional response to a stressful event.
• Typically, the stressor involves financial issues, a medical illness, or relationship problem.
• The symptom complex that develops may involve anxious or depressive affect or may present with a disturbance of conduct.
• Symptoms must begin within 3 months of the stressor.
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Disorder Pharmacological Treatment Non-Pharmacological Treatment Post-traumatic Stress Disorder
• SSRI → first line treatment (Dosage from MIMS) → Reduces symptoms from all PTSD symptom clusters → Safe, tolerable → Examples:
▪ 1. Sertraline (Zoloft) − Initial dose: 25 mg/day → increased to 50 mg/day after 1 week − Dose changes should be made at intervals of at least 1 week −
▪ 2. Paroxetine (Paxil) − Initial dose: 20 mg/day; increase if needed: 10 mg increments − Max: 50 mg/day
• Buspirone → Serotonergic and may also be of use for PTSD
• TCA (Dosage from Kaplan) → Imipramine (Tofranil)
▪ Usual daily dose: 75-300 mg; 8 wks; may continue for 1 year → Amitriptyline (Elavil)
▪ Usual daily dose: 75-300 mg; 8 wks; may continue for 1 year
• Other drugs may include: → MAOIs: Phenelzine (Nardil) → Anti-convulsants: Carbamazepine (Tegretol) → Valproate (Depakene) → Reversible mon
inhibitors (RIMAs) → Anti-adrenergic agents
▪ Clonidine (Catapres)
▪ Propanolol (Inderal)
▪ Haloperidol- reserved for short-term control of severe aggression and agitation due to no positive data on the use of antipsychotic drugs in PTSD.
• Psychodynamic psychotherapy → Minimizes the risk of dependence and chronicity
• Behavior therapy
• Cognitive therapy
• Hypnosis
• 2 major psychotherapeutic approaches: 1. Exposure therapy
▪ patient re-experiences the traumatic event 2. Teach the patient methods of stress management (e.g., relaxation
techniques and cognitive approaches)
• Eye movement desensitization and reprocessing (EMDR) → Symptoms can be relieved as patients work through the traumatic
event while in a state of deep relaxation
Adjustment Disorder • No studies have assessed the efficacy of pharmacologic agents in individuals with
adjustment disorders
• May be reasonable to used medication to treat specific symptoms for brief time.
• Drugs: → Anxiolytic:
▪ Benzodiazepine (Dosage from MIMS)- Given to patients with severe anxiety bordering on panic − Diazepam (Valium)
o 2 mg to 10 mg tablet, 2 to 4 times daily if needed o Max: 30 mg/day → Short course of psychostimulant medication
▪ For those in withdrawn or inhibited states → Antipsychotic drugs
▪ May be used if there are signs of decompensation or impending psychosis → Selective serotonin reuptake inhibitors (SSRIs)
▪ Found useful in treating symptoms of traumatic grief
• Psychotherapy → Remains the treatment of choice for adjustment disorders → Can help persons adapt to stressors that are not reversible or time
limited and can serve as a preventive intervention if the stressor does remit
• Individual Psychotherapy → Offers the opportunity to explore the meaning of the stressor to the
patient so that earlier traumas can be worked through
• Group Therapy → For patients with similar stresses
• Crisis intervention → Short-term treatments aimed at helping persons with adjustment
disorders resolve their situations quickly → Includes: supportive techniques, suggestion, reassurance, environmental
modification, and hospitalization (if necessary); Flexibility is essential in this approach → Frequency and length of visits for crisis support vary according to
patients' needs
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