Types of trauma- and stressor-related disorders

Posttraumatic Stress Disorder (PTSD)

Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the development of
physiological, psychological, and emotional symptoms following a traumatic event.

 The essential feature of PTSD is described as “the development of characteristic symptoms

following exposure to one or more traumatic events”. Individuals must have been exposed to a
situation where actual or threatened death occurred. People with PTSD have intense, disturbing
thoughts and feelings related to their experience that last long after the traumatic event has
ended.
 The trauma may be experienced by the individual or witnessed as it occurred to others, or the
symptoms may be in response to having learned about a traumatic event that has occurred to a
significant other. So the exposure could be also indirect rather than first hand. For example,
PTSD could occur in an individual learning about the violent death of a close family or friend.
 Symptoms of the disturbance must be or have been endured for more than 1 month; or, in the
event of delayed expression, the full diagnostic criteria may not have occurred until at least 6
months after the trauma.

It is important to understand that while the presentation of these symptoms varies among individuals,
to meet the criteria for a diagnosis of PTSD, individuals need to report symptoms among the four
different categories of symptoms. (recurrent experiences; avoidance; negative alterations in cognition or
mood; and alterations in arousal and reactivity).

Acute Stress Disorder

 According to DSM-5, acute stress disorder (ASD) is a trauma-related disorder similar to PTSD.
The similarities between the two disorders occur in terms of precipitating traumatic events and
symptomatology; however, in ASD, the symptoms are time-limited, from up to 1 month
following the trauma. By definition, if the symptoms last longer than 1 month, the diagnosis
would be PTSD.

- Additionally, if symptoms present immediately following the traumatic event but resolve by day 3, an
individual would not meet the criteria for acute stress disorder. However, a person may be diagnosed
with PTSD without having been previously diagnosed with ASD. Recognizing acute stress symptoms is a
critical first step in the path towards preventing PTSD.

Adjustment Disorder

 An adjustment disorder is characterized by a maladaptive reaction to an identifiable stressor or

stressors that results in the development of clinically significant emotional or behavioral
symptoms (APA, 2013). The response occurs within 3 months after the onset of the stressor and
has persisted for no longer than 6 months after the stressor or its consequences have ended.

Unlike PTSD and acute stress disorder, adjustment disorder does not have a set of specific symptoms an
individual must meet for diagnosis, rather, whatever symptoms the individual is experiencing must be
related to the stressor and must be significant enough to impair social, occupational, or other important
areas of functioning. Bereavement can be diagnosed as an adjustment disorder in extreme cases where
an individual’s grief exceeds the intensity or persistence that is expected.

1. Adjustment Disorder With Depressed Mood

 This category is the most commonly diagnosed adjustment disorder.

 The clinical presentation is one of predominant mood disturbance, although less pronounced
than that of major depressive disorder.
 The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what
is an expected or normative response to an identified stressor.

2. Adjustment Disorder With Anxiety

 This category denotes a maladaptive response to a stressor in which the predominant

manifestation is anxiety. This mainly include nervousness, worry, difficulty concentrating or
remembering things, and feeling overwhelmed.
 The clinician must differentiate this diagnosis from anxiety disorders.

3. Adjustment Disorder With Mixed Anxiety and Depressed Mood

 The predominant features of this category include disturbances in mood (depression, feelings of
hopelessness, and sadness) and manifestations of anxiety (nervousness, worry, jitteriness) that
are more intense than what would be expected or considered to be a normative response to an
identified stressor.

4. Adjustment Disorder With Disturbance of Conduct

 This category is characterized by conduct in which there is a violation of the rights of others or
of major age-appropriate societal norms and rules.
 Differential diagnoses must be made from conduct disorder or antisocial personality disorder.

5. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct

 The predominant features of this category include emotional disturbances (e.g., anxiety or
depression) as well as disturbances of conduct in which there is a violation of the rights of
others or of major age-appropriate societal norms and rules (e.g., truancy, vandalism, fighting).

6. Adjustment Disorder Unspecified

 This subtype is used when the maladaptive reaction is not consistent with any of the other
categories. The individual may have physical complaints, withdraw from relationships, or exhibit
impaired work or academic performance but without significant disturbance in emotions or
conduct.
Trauma-Informed Care

Trauma-informed care is a form of care that takes into consideration trauma that individuals
experienced in the past.

 It is essential to improving the quality of care for clients both in and outside of
behavioral healthcare settings as emphasized by experts (Hopper, Bassuk, & Olivet,
2010; Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). 
 It generally describes a philosophical approach that values awareness and
understanding of trauma when assessing, planning, and implementing care. SAMHSA
advances the following principles in defining this approach. Trauma-informed care:
 Realizes the widespread impact of trauma and various paths for recovery.
 Recognizes the signs and symptoms of trauma in clients, families, staff, and all
those involved with the system.
 Responds by fully integrating knowledge about trauma in policies, procedures,
and practices.
 Seeks to actively resist retraumatization.

NOTE: Health-care providers may unwittingly retraumatize patients if they do not fully understand the
impact of previous trauma on the patient’s current health concerns. Even interventions such as
seclusion and restraint, which have been designed to protect patients’ safety when they are at imminent
risk of harm to themselves or others, may be retraumatizing to a patient with a history of trauma.

Diagnotic Criteria for PTSD

All of the criteria are required for the diagnosis of PTSD.

Criterion A: stressor (one required)

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or
threatened sexual violence, in the following way(s):

 Direct exposure
 Witnessing the trauma
 Learning that a relative or close friend was exposed to a trauma
 Indirect exposure to aversive details of the trauma, usually in the course of professional duties
(e.g., first responders, medics)

Individuals need to report symptoms among the four different categories of symptoms.

Criterion B: intrusion symptoms (one required)

The traumatic event is persistently re-experienced in the following way(s):

 Unwanted upsetting memories

 Nightmares
 Flashbacks
 Emotional distress after exposure to traumatic reminders
 Physical reactivity after exposure to traumatic reminders
Criterion C: avoidance (one required)

Avoidance of trauma-related stimuli after the trauma. Examples of which are:

 Trauma-related thoughts or feelings

 Trauma-related external reminders

Criterion D: negative alterations in cognitions and mood (two required)

Negative thoughts or feelings that began or worsened after the trauma, such as:

 Inability to recall key features of the trauma

 Overly negative thoughts and assumptions about oneself or the world
 Exaggerated blame of self or others for causing the trauma
 Negative affect
 Decreased interest in activities
 Feeling isolated
 Difficulty experiencing positive affect

Criterion E: alterations in arousal and reactivity

Trauma-related arousal and reactivity that began or worsened after the trauma, including:

 Irritability or aggression
 Risky or destructive behavior
 Hypervigilance
 Heightened startle reaction
 Difficulty concentrating
 Difficulty sleeping

Criterion F: duration (required)

Symptoms must last for more than 1 month.

Criterion G: functional significance (required)

Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H: exclusion (required)

Symptoms are not due to medication, substance use, or other illness.