Lecture 4: stress and health (non-infectious diseases)

Stress and Health

Stress in itself is not an illness, despite being an unpleasant experience. However, stress may
lead to various physical and mental health consequences. Some surveys show that stress is
the number one threat for health in the USA and about 70-90% of doctor’s visits are related to
stress (Harvard business Review, 2011).

Mind-Body connections can explain the relationships between the stress and health. The
17th-century French philosopher René Descartes (1596–1650) proposed the idea of mind-
body dualism (separation between the mind and body). However, modern research clearly
indicate that the mind and body are closely connected to each other and can influence each
other.

The mind-body connection was evident when we discussed the biology of stress.

Psychosomatic diseases

Psychosomatic diseases are the physical diseases that are caused or deteriorated by mental
factors such as stress, anxiety, depression etc. In fact, a branch of psychology called health
psychology investigates the role of psychological factors such as stress, emotions, beliefs etc.
on physical health and illness.

Historical Background
Claude Bernard (1878) used the concept of “dynamic equilibrium” to understand the disease.
The dynamic equilibrium is the stability/consistency of the inner environment. The
disturbances of this equilibrium may adversely affect our health.

Walter Canon (1929) used the term “homeostasis” as an extension of Bernard’s concept of
dynamic equilibrium. It also means the maintenance of a constant inner condition. He further
stated that conditions such as stress can disrupt homeostasis and lead to fight-or-flight
response.

Hans Selye (1956) in his model of general adaptation syndrome (GAS) described changes in
the physiological responses in the body as a result of chronic stress. Initially, Alarm stage is
associated with the activation of sympathetic NS. The resistance stage is associated with the
release of glucocorticoids (such as cortisol) from the HPA axis. The exhaustion stage is
associated with the diseases of adaption (psychosomatic diseases) due to chronic release of
stress hormones such as cortisol.
Psychoneuroimmunology (PNI) is a relatively new field of study that revealed that there is a
constant interactions between our central nervous system (CNS) and immune system. Many
studies indicated that psychological factors such as stress can influence our central nervous
system and which in turn influences our immune functions.

Pathways linking stress and health

Infectious and non-infectious diseases

Stress can lead to both infectious and non-infectious diseases. Infectious diseases occur due
to the attack of an external gents such as bacteria, viruses etc. and can be transmitted by
direct physical contact. Non-infectious diseases occur due to internal factors such as wear and
tear/malfunctioning of an organ and is not transmitted by physical contact. E.g., cardiovascular
diseases. It was evident that the physiological responses to stress is very complex and is
primarily carried out by activating two major physiological pathways-

The sympathetic adrenal medullary (SAM) system which leads to the secretion of the two
catecholamines-adrenaline (epinephrine) and noradrenaline (norepinephrine).

The hypothalamic pituitary adrenocortical (HPA) system which leads to the secretion of
corticosteroids such as cortisol.

Stress and Non-infectious/Non-communicable Diseases

Stress can contribute to the development of diverse non-infectious diseases that were
believed to be purely physiological in origin such as cardiovascular diseases. Stress related
non-communicable diseases (NCDs) such as coronary heart diseases, diabetes, chronic
pulmonary diseases, neuropsychiatric diseases etc. are the major health crisis in the 21 st
century (Narayan, Ali, & Koplan, 2010).

According to the Centers for Disease Control and Prevention (CDC) Division of Global Health
Protection, the NCDs are responsible for more than 68% of deaths worldwide, and 75% of
deaths in low- and middle-income countries. NCDs are generally preceded by stress-related
metabolic syndrome such as hypertension, high cholesterol, reduced responsiveness to insulin
(Fricchione, 2018). Stress-related chronic NCDs continue to plague primary care practitioners,
resulting in enormous mortality, morbidity, and suffering and contributes to the expanding of
health care costs (Fricchione, 2018).

Cardiovascular diseases

The cardiovascular system includes heart, blood and the blood vessels of the body and is
regulated by the autonomic nervous system. Cardiovascular diseases (CVDs) are the leading
cause of death globally and causing an estimated 17.9 million lives each year (WHO, 2020).
The diseases related to cardiovascular system primarily include coronary artery disease
(CAD)/coronary heart diseases (CHD) and hypertension. CHD develops when the coronary
arteries (blood vessels that supply oxygen and blood to the heart) becomes narrow due to fatty
deposits/cholesterol in the arterial wall resulting in reduced blood flow to the heart. This
process is called as atherosclerosis.

Hypertension also called as high blood pressure is a condition in which the force of the blood
against the wall of the artery is higher than the usual and can lead to heart diseases, strokes,
kidney damage or death. The ideal blood pressure is usually considered to be between
90/60mmHg and 120/80mmHg whereas high blood pressure is considered to be 140/90mmHg
or higher.

How stress contributes to cardiovascular diseases?

The answer is still not completely clear. However, there are many possible pathways that can
be linked to cardiovascular diseases. Some are discussed below-

The experience of stress can cause high level of physiological arousal leading to erratic and
rapid heart beat, which can cause stroke, cardiac arrest or even death to a person especially
to individuals with pre-existing heart diseases (Herbert & Cohen 1994). Stress hormones that
are released during stressful situations (cortisol, epinephrine, and norepinephrine) promotes
atherosclerosis by increases the build up of fatty patches or plaques on arterial wall leading
to the narrowing down of the artery. This narrow artery decreases the blood flow resulting in
the increase of blood pressure. This decrease in flood flow causes less oxygen flow to the
heart muscle which may result in chest pain/angina and heart attack (Herbert & Cohen 1994).

Broken Heart Syndrome

Stress can cause “Broken Heart Syndrome”, particularly in women following a
stressful/traumatic event.

According to John Hopkins medicine website-

“the “broken heart syndrome,” is a condition in which intense emotional or physical stress can
cause rapid and severe heart muscle weakness (cardiomyopathy)….. With stress
cardiomyopathy, we believe that the heart muscle is overwhelmed by a massive amount of
adrenaline that is suddenly produced in response to stress. The precise way in which
adrenaline affects the heart is unknown. It may cause narrowing of the arteries that supply the
heart with blood, causing a temporary decrease in blood flow to the heart.”
Broken heart syndrome, also called stress-induced cardiomyopathy can strike even if you’re
healthy.

According to the American Heart association website (heart.org)-

 “Women are more likely than men to experience the sudden, intense chest pain-the reaction to
a surge of stress hormones-that can be caused by an emotionally stressful event. It could be
the death of a loved one or even a divorce, breakup or physical separation, betrayal or
romantic rejection. It could even happen after a good shock (like winning the
lottery.)…..Broken heart syndrome may be misdiagnosed as a heart attack because the
symptoms and test results are similar. But unlike a heart attack, there’s no evidence of blocked
heart arteries in broken heart syndrome.”

Stress and Cholesterol

Stress can increase the bad cholesterol level in the body directly or indirectly through
unhealthy behaviors. A study by Catalina-Romero et al. (2013) collected data from 91,593
participants and found a positive correlation between those who experienced job stress and
unhealthful cholesterol levels in their body. Another study by Assadi (2017) found that
psychological stress led to higher levels of bad cholesterol (low-density lipoproteins, LDL), and
decreasing levels of good cholesterol (high-density lipoproteins, HDL).
Stress hormones such as adrenaline and cortisol can trigger the production of cholesterol (a
waxy, fatty substance the liver makes to provide the body with energy and repair damaged
cells). However, excess cholesterol may gradually be accumulated as fats in the body and can
clog the arteries and cause heart attack (verywellhealth.com).

Stress may induce behavioral changes such as eating unhealthy foods (high carbohydrate)
which may further increase cholesterol levels.

Personality Traits and Cardiovascular diseases

Friedman and Rosenman (1974) suggested that people with certain personality traits are more
pre-disposed to suffer from stress than others. Consequently, they are more likely to have
coronary heart diseases. They identified two types of personality traits in this context-Type A
and Type B people.

They asked questions like-

Do you feel guilty if you use spare time to relax?
Do you need to win in order to derive enjoyment from games and sports?
Do you generally move, walk and eat rapidly?
Do you often try to do more than one thing at a time?

Type A: They exhibit following characteristics-

-Excessive competitiveness and achievement orientation leading to extreme self-criticism
-An exaggerated sense of time urgency leading to a constant struggle against the cloak and a
compulsion to try to do more than one thing at a time.
-Anger/hostility that may or may not be openly expressed.

Type B: They show opposite characteristics of Type A being more easygoing and much less
demanding of self and others and with no exaggerated sense of time urgency.

Friedman and Rosenman conducted a longit-udinal study over a period of eight and half years
with a sample of 3524 men aged 39-59 years. They found that Type A individuals were twice
as likely to develop CHD than Type B individuals in part due to the higher physiological
reactivity that type A people show.

Later research indicated that only some aspects of Type A behavior, especially anger/hostility
are more important for understanding the risk of heart diseases (McCann and Matthews 1988).
Some research also indicated that particularly anger which is suppressed rather than expressed
could be a significant risk factor for higher physiological reactivity and CHD. It was reported that
individuals who suppress their anger are twice vulnerable to mortality than who express anger
(Contrada, 1989).

Behavioral pathways
Stress can adversely affect health by increasing the frequency of unhealthy behaviors, or by
decreasing the frequency of health behaviors, or by disrupting prescribed healthy behavior
patterns (Herbert & Cohen 1994).

Stress may induce many behavioral changes and disruptions in life style and routines.
Common behavioral changes include-
-Disturbances in sleep
-Disturbances in food intake (unhealthy/over-eating)
-Excessive smoking
-Physical inactivity
- excessive drinking of alcohol and so on.
-Such behaviors can be especially problematic for the individuals having pre-existing illnesses
such as heart diseases. These behaviors can increase blood pressure and damage arteries of
the heart.
 References
Narayan KM, Ali MK, Koplan JP (2010). Global non-communicable diseases – where worlds
meet. The New England Journal of Medicine, 363(13):1196–98

Fricchione, G.L. (2018). The Challenge of Stress-Related Non-Communicable Diseases.

Medical Science Monitor Basic Research, 24: 93–95
Herbert, T.B., & Cohen, S. (1994). Stress and illness. Encyclopedia of human behavior, Vol. 4,
Page 325-332.
Catalina-Romero, C., et al. (2013). The relationship between job stress and dyslipidemia.
Scandinavian Journal of Public Health, 41(2):142-9

Assadi, S.N. (2017). What are the effects of psychological stress and physical work on blood
lipid profiles? Medicine, 96(18): e6816. doi: 10.1097/MD.0000000000006816.

McCann, B. S., & Matthews, K. A. (1988). Influences of potential for hostility, Type A behavior,
and parental history of hypertension on adolescents' cardiovascular responses during
stress. Psychophysiology, 25(5), 503–511. https://doi.org/10.1111/j.1469-8986.1988.tb01885.x

Contrada, R. J. (1989). Type A behavior, personality hardiness, and cardiovascular responses

to stress. Journal of Personality and Social Psychology, 57(5), 895-
903. https://doi.org/10.1037/0022-3514.57.5.895
 Lecture 5: Stress and Infectious Diseases

Stress and Infectious Diseases

Stressful events such as the death of a loved ones can weaken immune system and lead to
various infectious diseases. An interdisciplinary field of study called “Psychoneuroimmunology”
studies this relationship between the psychological factors, neurological factors, and immune
system.

Classic experiment that led to the birth of psychoneuroimmunology

In the early 1970s, Ader and Cohen were studying taste aversion using rats as subjects. The
researchers had been giving rats a saccharin solution (sweet taste) accompanied by an
injection of cyclophosphamide, an immunosuppressive drug that also induces gastrointestinal
upset. When the injections stopped, the rats had become conditioned to avoid consuming the
sweet solution. To complete the experimental protocol, they forced the rats to take the
saccharin solution using eye droppers. A surprising observation they made was that some of
the animals they had force-fed with the saccharin later died. The magnitude of the avoidance
response and the mortality rate of the rats was directly related to the volume of solution
consumed.

They hypothesized-Conditioning of immunosuppressive effects (of cyclophosphamide) was

happening in addition to conditioning the taste avoidance response. They added that the taste
of saccharin alone was enough to stimulate neural signals that suppressed the rats' immune
systems, just as if they had been overdosed with the immunosuppressant. They later found
that behavioural conditioning process could suppress immune responses as measured by
antibody concentrations revealing connections between the brain and the immune system.

Immune System

The immune system protects us from infections and illness from outside microorganisms and
harmful substances. The immune system is very complex and carry out sophisticated
coordinated responses to protect our body. The Key player of immune system is white blood
cells specifically lymphocytes (one type of WBC). There are mainly two types of lymphocytes:
B and T cells.B cells secrete antibodies into the body fluids to destroy antigens. Each B cells
produce a specific antibody when triggered by an antigen. It can recognize free floating
antigens. T cells recognizes specific infected or cancerous cells. T cells are of two types:
helper and killer T cells. Helper T cells (also known as CD4 cells) coordinate immune
responses by communicating with other cells. Killer T cells (also called cytotoxic T
lymphocytes or CD8 cells) directly attack other cells carrying certain foreign or abnormal
molecules on their surfaces.

Other major components include natural killer cells (NK), phagocytes, and cytokines.
 Important organs which are store house of immune cells include bone marrow (soft tissue in
the hollow centers of bones), thymus (lies behind breastbone) and spleen (flattened organ at
the upper left of the abdomen).

Stress and Immune System

Hans Selye (1975) suggested that stress globally suppresses the immune system and
proposed one of the first model relating stress and immune response. He found that in the
stage of exhaustion of GAS, body runs out of reserve energy and immunity which may result in
various diseases and even death. Many early studies have supported Selye’s findings by
reporting association of chronic stress with decrease in natural killer cell, suppression of
lymphocyte responses (Herbert & Cohen, 1993).

In the early 1980s, psychologist Janice Kiecolt-Glaser and immunologist Ronald Glaser were
intrigued by animal studies that linked stress and infection. From 1982 through 1992, they
studied medical students. they found that the students' immunity went down every year under
the simple stress of the three-day exam period. The students had less number of natural killer
cells, which fight tumors and viral infections. They also had fewer infection-fighting T-cells.

Pressman and Cohen (2005) found that social isolation and feelings of loneliness each
independently weakened first-year students' immunity. Loneliness and social isolation may
lead to higher and more intense experience of stress.

Dhabhar and McEwen (1997, 2001) proposed a biphasic model which takes account of type of
stress (acute or chronic) and their affect on immune response. This model states that acute
stress enhances while chronic stress suppresses the immune response. They found that acute
stress increases the immune functions by helping in the redistribution of immune cells in the
body. However, chronic stress exhausts resources and weakens immune responses.

Segerstrom and Miller (2004) conducted an extensive meta-analysis on 293 independent

studies reported from 1960 to 2001 (N=18,941). Analysis of the results confirmed that stress
changes immune functions. Results of the meta-analysis was in line with the proposition of
biphasic model, i.e., the short term stress may enhance immune function as an adaptive
response, but chronic stress suppresses immune response as a result of too much exhaustion
of body resources.

More specifically they found that-

-Acute time limited stressors such as public speaking enhanced natural immunity (defense
against non-specific foreign invaders). However, some aspects of specific immunity (attacks
specific invaders) were suppressed.

-Focal stressful events such as natural disaster or loss of spouse was not strongly associated
with immune changes when taken as a whole. However, specific category such as loss of a
spouse was associated with a decline in natural immune responses.
-Chronic stressors such as living with a handicap, dementia care giving, and unemployment
have negative effects on almost all functional measures of the immune system (both natural and
specific immunity) irrespective of demographic variables such as gender and age.

Further, meta-analysis also showed that the older and sick people are more vulnerable to
stress related immune change.

Stress and Immune System: Mechanisms

Stress Hormones

The relationship between stress and immune function is very complex and many mechanisms
are yet to be discovered. However, research indicated that the stress hormones (pathways
already discussed) such as cortisol, epinephrine, and norepinephrine may make us more
resistant to stressors in short term, but are generally found to impair immune systems in long
term (Boneau et al. 1993). For example, Talbott and Kreamer (2007) found that cortisol-

-Hinder the production as well as activity of white blood cells.

-Suppresses white blood cells to produce chemical messenger that facilitate communication
with other immune cells.

-Can also signal many immune cells to shut and stop working

Behavioral pathways

Research also indicated that the behavioral component associated with stressful experiences
has detrimental effect on immune functions. For example-

excessive drinking of alcohol,

lack of exercise,

sleep difficulties

(Kiecolt-Glaser & Glaser, 1988; Venjatraman & Fernandes, 1997; Savard, Laroche, Simard,
Ivers, & Morin, 2003).

Implications

One important implications of of these findings are that the interventions aimed at stress
reduction (especially chronic stress) such as relaxation, emotion regulation, social support etc.
may attenuation of stress related immune suppression and may help to fight germs (Zakowski,
Hall, & Baum, 1992).
 The relaxation response may elicit the secretion of health-promoting chemicals such as
dehydroepiandrosterone (DHEA) and which may lead to homeostatic physiologic changes.
Further, the use of self-regulation techniques that calms the mind lowers the activity of
sympathetic nervous system's response to stress and promotes healing process (Gertz &
Culbert, 2009).

In a recent metaanalysis by Shields, Spahr, and Slavich (2020) involving 56 unique

randomized clinical trials and 4060 participants found that-

-psychosocial interventions such as cognitive behavior therapy were associated with positive
changes in immunity over time, including improvements in beneficial immune system function
and decreases in harmful immune function.

-This enhanced immune functions persisted for at least 6 months following treatment for
participants.

Psychotherapies are aimed at reducing distress and enhancing emotional and mental health.
Therefore, this study indicates that stress management and working towards enhancing
emotional health can increase our immune functions that are long lasting.

References

Herbert TB, Cohen S. (1993). Stress and immunity in humans: a meta-analytic review.
Psychosomatic Medicine, 55(4):364-79. doi: 10.1097/00006842-199307000-00004.

Kiecolt-Glaser JK, Garner W, Speicher C, Penn GM, Holliday J, Glaser R. (1984). Psychosocial
modifiers of immunocompetence in medical students. Psychosomatic Medicine, 46(1):7-14. doi:
10.1097/00006842-198401000-00003. PMID: 6701256.

Pressman SD, Cohen S, Miller GE, Barkin A, Rabin BS, Treanor JJ. (2005). Loneliness, social
network size, and immune response to influenza vaccination in college freshmen. Health
Psychology, 24(3):297-306. doi: 10.1037/0278-6133.24.3.297.

Dhabhar FS, McEwen BS (1997). Acute stress enhances while chronic stress suppresses cell-
mediated immunity in vivo: a potential role for leukocyte trafficking. Brain, Behaviour and
Immunity, 11(4):286-306. doi: 10.1006/brbi.1997.0508.
Segerstrom SC, Miller GE. (2004). Psychological stress and the human immune system: a
meta-analytic study of 30 years of inquiry. Psychological Bulletin,130(4):601-30. doi:
10.1037/0033-2909.130.4.601.

Janice K. Kiecolt-Glaser, Ronald Glaser. (1986). Psychological influences on immunity.

Psychosomatics, Volume 27, Issue 9, Pages 621-624.

Sandra Zakowski, M. Helon Hall, Andrew Baum (1992). Stress, stress management, and the
immune system, Applied and Preventive Psychology,Volume 1, Issue 1, Pages 1-13.

Shields GS, Spahr CM, Slavich GM. (2020). Psychosocial Interventions and Immune System
Function: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA
Psychiatry. 77(10):1031-1043. doi: 10.1001/jamapsychiatry.2020.0431.
 Lecture 6: Stress and Psychological Disorders

Stress and Psychological Disorders

Stress may contribute to the development of various psychological disorders such as

depression, Schizophrenia, anxiety disorders, eating disorders, and posttraumatic stress
disorder (PTSD) (Weiten and Lloyd, 2007). Acute stress disorder (ASD) and PTSD will be
discussed in more detail as it directly results from exposure to extremely stressful or traumatic
events.

Traumatic events are life threatening events that may overwhelm the capacity to cope and
people generally responds with “intense fear, helplessness, and horror”.

Acute Stress Disorder (ASD)

“Acute stress disorder is an intense, unpleasant, and dysfunctional reaction beginning shortly
after an overwhelming traumatic event and lasting less than a month. If symptoms persist
longer than a month, people are diagnosed as having posttraumatic stress disorder (PTSD)”
(Barnhill, 2020). According to the American Institute of Stress, between 5 and 20 percent of
people exposed to trauma such as a car accident, assault, or witnessing a mass shooting
develop ASD. And approximately half of those go on to develop PTSD. ASD was reclassified
in the Trauma- and Stressor-Related Disorders in DSM 5.

Acute stress disorder (ASD) is a psychiatric diagnosis that may occur in patients after
witnessing, hearing about, or being directly exposed to a traumatic event, such as motor
vehicle crashes, acts of violence, work-related injuries, natural or man-made disasters, or
sudden and unexpected bad news. (Kavan & Elsasser, 2012).

Symptoms

It may occur in patients within four weeks of a traumatic event. Symptoms include-

anxiety,

intense fear or helplessness,

dissociative symptoms,

re-experiencing the event, and

avoidance behaviors.

Persons with this disorder are at increased risk of developing posttraumatic stress disorder.
(Kavan & Elsasser, 2012). Symptoms must be present for a minimum of two days, but not
longer than four weeks; patients with persistent symptoms may develop PTSD. Symptoms of
ASD typically peak in the days or weeks after a patient is exposed to trauma, then gradually
decrease over time (U.S. Department of Veterans Affairs)
PTSD

PTSD is a mental disorder that may occur among people after experiencing or witnessing
extremely stressful/traumatic events such as war, disasters, accidents, rape etc. PTSD had
many names. It was called as “shell shock” during the world war I and “combat fatigue” during
the world war II. Serious attention to PTSD was given after the end of Vietnam war in 1975
which resulted in return of many psychologically disturbed US military veterans. Some studies
suggested that about half million Vietnam veterans were suffering from PTSD even after a
decade of the end of war (Schlenger et al., 1992). The American Psychiatric Association
(APA) added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental
Disorders (DSM-III) in 1980.

DSM-5 Criteria for PTSD

Criterion A (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)

Criterion B (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 (one required): Avoidance of trauma-related stimuli after the trauma, in the
following way(s):

Trauma-related thoughts or feelings

Trauma-related reminders

Criterion D (two required): Negative thoughts or feelings that began or worsened after the
trauma, in the following way(s):
 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 (two required): Trauma-related arousal and reactivity that began or worsened after
the trauma, in the following way(s):

Irritability or aggression

Risky or destructive behavior

Hypervigilance

Heightened startle reaction

Difficulty concentrating

Difficulty sleeping

Criterion F (required): Symptoms last for more than 1 month.

Criterion G (required): Symptoms create distress or functional impairment (e.g., social,
occupational).
Criterion H (required): Symptoms are not due to medication, substance use, or other illness.

The symptoms of PTSD are very common after the exposure to a traumatic event. However,
the majority of the people do not develop clinical disorder. According to American Psychiatric
Association website, approximately 3.5% of US adults experiences PTSD and 1 in 11 people
is likely to be diagnosed with PTSD in their life time and women are twice as likely as men to
have PTSD. PTSD can occur to people of any ethnicity, nationality, culture, and age.

It is very common that many other conditions may co-occur with PTSD such as depression,
anxiety and substance abuse. PTSD can occur to children as well. In some cases, PTSD
symptoms may surface after many months or even years after the traumatic event (Holen,
2000).

PTSD can be treated with psychotherapies and medication. We will discuss few therapeutic
approaches while discussing coping strategies.
 PTSD in children

When children experience severe stress may develop long term symptoms (longer than one
month) and can be diagnosed with PTSD. Studies indicate that children can develop PTSD
after exposure to traumatic events such as violent crime, sexual abuse, natural disasters, and
war (Kaminer, Seedat, & Stein, 2005) .

Diagnosis of PTSD in children

Diagnosis of PTSD in children is very difficult. Kaminer, Seedat, and Stein (2005) reported
following reasons-

(1) PTSD criteria require a verbal description of internal states and experiences, a task beyond
the cognitive and expressive language skills of young children. The clinician must infer from
behavioral observations.

(2) Traumatized children often display many other symptoms apart from the core PTSD
symptoms which are not assessed by standardized scales.
These additional symptoms may include-

-the loss of recently acquired developmental skills (regression),

-the onset of new fears or the re-activation of old ones,

-accidents and reckless behavior,

-separation anxiety (often manifested in anxious clinging), and

-psychosomatic complaints such as stomach aches and headaches

(3) Young children may sometime express post-traumatic anxiety through hyperactivity,
distractibility and increased impulsivity. These symptoms may be confused with attention
deficit/ hyperactivity disorder.

According to Center for disease control and prevention website, PTSD symptoms in children
may include-

Reliving the event over and over in thought or in play or drawings

Nightmares and sleep problems

Becoming very upset when something causes memories of the event

Lack of positive emotions

Intense ongoing fear or sadness

Have trouble focusing

Irritability and angry outbursts

Constantly looking for possible threats, being easily startled

Acting helpless, hopeless or withdrawn

Denying that the event happened or feeling numb

Avoiding places or people associated with the event

Acute stress disorder occurs immediately following the source of trauma, and post-
traumatic stress disorder occurs as a long-range effect of this trauma. ASD and PTSD share
many core symptoms, but ASD includes dissociative symptoms such as detachment, reduced
awareness of surroundings, derealization, depersonalization, and dissociative amnesia (APA,
2000)

Complex PTSD (C-PTSD)

CPTSD was originally formulated by Judith Herman, in 1992 to describe distinctive

psychological responses arising from events where an individual is under the sustained and
coercive control of a perpetrator (i.e., torture). Complex PTSD, which has been recently
introduced in the International classification of diseases (ICD)‐11. However, it has not found
place in DSM yet.

CPTSD was excluded from the DSM-5 following the argument of some commentators that the
symptoms of CPTSD can be accommodated within the framework of existing definitions of
PTSD (Resick et al., 2012). This assertion stems from the expansion of the diagnosis of PTSD
in the DSM-5 to encompass symptoms such as self-blame, negative beliefs about the self and
feeling alienated from others (American Psychiatric Association, 2013). CPTSD is considered
to be especially likely to occur following exposure to repeated, prolonged, interpersonal trauma
exposure (Nickerson, et al. 2016) rather than a single traumatic event.

The exposure to traumatic events could be over a period of months or even years such as
torture, prisoner of war situations, long term childhood sexual abuse, prolonged physical or
emotional abuse, or sex trafficking situations. Although most commonly seen in the wake of
prior prolonged childhood abuse, this disorder can also occur in survivors of other severe
traumas, such as torture (Bryant, 2019)

Symptoms

In addition to core PTSD symptoms, CPTSD may include (Bryant, 2019)-

experience disturbances in self‐identity (e.g., negative self‐concept),

emotional dysregulation (e.g., emotional reactivity, violent outbursts), and

 persistent difficulties in relationships

It may also include-

periods of amnesia or dissociation,

distorted perspective about the perpetrator, and

feelings of guilt, shame or lack of self worth.

References
W. Weiten, and M. A. Lloyd, Psychology Applied to Modern Life: Adjustment in the 21st
Century, Wadsworth Publishing, 2007

Barnhill (2020). PTSD. Accessed from https://www.msdmanuals.com/professional/psychiatric-

disorders/anxiety-and-stressor-related-disorders/posttraumatic-stress-disorder-ptsd

Kavan MG, Elsasser GN, Barone EJ. (2012). The physician's role in managing acute stress
disorder. American Family Physician, 86(7):643-9.

Kaminer D, Seedat S, Stein DJ. (2005). Post-traumatic stress disorder in children. World
Psychiatry, 4(2):121-5.
Herman, Judith Lewis (1992). Trauma and Recovery: The Aftermath of Violence. New York:
Basic Books

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and

challenges, World Psychiatry, https://doi.org/10.1002/wps.20656