Psychiatry Review Course
Stress , Trauma & Related Lecture outlines
Disorders.
Grief
Presented and updated by: Simon Ovanessian, MD
Assistant professor of Psychiatry
Associate Director: Walden Behavioral care, Rockville CT
Trauma & Stress related Disorders
Disorders in which exposure to a traumatic or stressful event is listed
explicitly as a diagnostic criteria
❑ Reactive Attachment disorder (RAD)
❑ Disinhibited Social engagement Disorder
❑ Acute stress Disorder
❑ PTSD
❑ Adjustment Disorder
❑ Other specified trauma and Stressor-related Disorders.
⚫ The first two share the absence of adequate caregiving during
childhood, RAD is internalizing disorder with depressive symptom
and the latter is marked disinhibition with externalizing behavior.
Depersonalization Experience of being an outside observer of or
detached from oneself (e.g., feeling as if "this is not happening to me"
or one were in a dream).
Derealization Experience of unreality, distance, or distortion (e.g.,
"things are not real").
Risk factors / Etiology
❑ Trauma in the past or repeated trauma
❑ Younger age, woman > men, women experienced high levels of war-
zone stress compared to men - 39.9 percent versus 23.5 percent
❑ Presence of identified psychosocial & environmental problem
❑ Previous psychiatric history or suicidal attempt
❑ Shorter length of previous treatment
❑ The stressors in AD, different than in PTSD may be less traumatic or
relatively minor, like loss of a girlfriend/boyfriend, or moving.
❑ Genetics: Panic and generalized anxiety disorders and PTSD share
60% of the same genetic variance. Alcohol, nicotine, drug
dependence share greater than 40% genetic similarities
Approximately 30% of the variance in PTSD is caused from genetics
alone. For twin pairs exposed to combat in Vietnam, a monozygotic
(identical) twin with PTSD was associated with an increased risk of the
co-twin's having PTSD compared to twins that were dizygotic .
❑ African American Veterans has 2.5 time more risk ,Hispanic 3 times to
suffer from PTSD
Y}Ovanessian (8/23/2021) Trauma and Stressor Related Disorders
The Osler Institute ©2021
❑ Definition of Trauma
❑ Response to Trauma
❑ Risk Factors for PTSD/ASD
❑ Adjustment Disorder
❑ Reactive attachment Disorder
❑ Disinhibited Social engagement Disorder
❑ PTSD
❑ Acute stress Disorder/ PTSD
❑ Treatment and Prognosis
❑ Grief Work and management
❑ Case Vignette / Q& A
Response to Trauma
❑ After traumatic experience, mind & body are in shock.
❑ As one makes sense of the trauma process emotions, can come out of
it , as in non complicated bereavement.
❑ With post-traumatic stress disorder (PTSD), it is believed that patients
remain in psychological shock.
❑ Memory of what happened and the feelings about it are disconnected.
❑ In order to move on, it’s important, may be, to face and feel memories
and emotions, (in the right time)
❑ The brain’s normal recovery process is somehow disrupted in
complicated grief and if continues can lead to Depression or PTSD.
❑ The response vary. Anxiety and fear in the form of anhedonia
Dysphoric symptoms , in some after a catastrophic event, may
develop externalizing angry or aggressive symptoms or dissociative
symptoms in others
❑ Mutations in a gene known as NLGN1 may be associated with more
severe response
Adjustment Disorder (AD)
❑ Is "situational" or "reactive" and does not imply a major
underlying brain disease.
❑ It is diagnosed up to 50% in psychiatric consultation setting,
and 5-20% in outpatients
❑ Acute: Duration of Symptoms is less than 6 months
❑ Chronic: More than 6 months, when the stress is chronic and
continuous will still be additional 6 month period diagnosis.
❑ The condition is different from anxiety disorder, which lacks the
presence of a stressor, or PSTD and acute stress disorder, which
usually are associated with a more intense stressor
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Adjustment Disorder Diagnosis
A-The development of emotional and behavioral symptoms in
response to an identifiable stress(s), occurring within 3
months of the onset of the stress and improvement of
symptoms within 6 months after the stressor or stressors are
removed.
B- These symptoms are significant enough to cause marked
distress in excess of what would be expected from exposure
C- Significant impairment in social and occupational
functioning
D- It does not meet the criteria for any other diagnosis. It can
be diagnosed in the presence of other mental disorder only if
not related to stress. (OCD, ADHD)
E- The symptoms do not represent Bereavement
F- Once stress (or its consequences) has terminated the
symptoms disappears,
The Definition of Trauma in
PTSD/ASD
❑ Exposure to actual threatened death, serious injury, or
sexual violence in one or more of the following ways:
❑ Directly experiencing traumatic event(s)
❑ Witnessing in person, the events as it occurred to others
❑ Learning that traumatic event(s)occurred to a close family
member or close friend in cases of death the event must
have been violent or accidental
❑ Experiencing repeated or extreme exposure to aversive
details of the traumatic event, e.g. first responders
collecting human remains.
❑ It dose not apply to exposure through electronic media, TV
, unless this exposure is work related
Acute Stress Disorder
❑ Recurrent distressing dreams in which the content are
related to the event. In children there may be
frightening dream without recognizing the content.
❑ Dissociative reaction (i.e. flash backs), the individual
feels or acts as if the traumatic events were recurring, it
may be continuous with the most extreme being
complete loss of the surrounding or reenactment in
play in children. Dissociation during trauma (time
distortion, depersonalization/derealization, out of body,
watching a movie, not feeling pain)
❑ Intense or prolonged psychological distress or marked
physiological reaction to in response to internal or
external cues that symbolize or resemble the event
Y}Ovanessian (8/23/2021) Trauma and Stressor Related Disorders
The Osler Institute ©2021
Treatment
❑ Psychotherapy: The most trusted treatment plan for an
adjustment disorder as the patient begins to come to terms
with how the external stressor affects them. Behavioral
therapy and CBT
❑ Self-help & Support groups: To hear others going
through similar circumstances can help depressed individual
come to terms with their own suffering.
❑ Anxiety medication: for a short time, antidepressant to
treat co morbid conditions,
❑ Address Substance: abuse co-morbidity
Acute Stress Disorder
❑ The same criteria for trauma as in PTSD. ( e.g. directly
experiencing or witnessing the event, or learning that
it occurred to close relative or friend, etc.)
❑ Symptoms typically begin immediately after the trauma,
but persist for at least 3 days and up to a month
❑ Presence of 9 or more of 5 categories of 14 symptoms
(Intrusion symptoms, Negative mood , Dissociative
Symptoms. Arousal Symptoms, Avoidance symptoms).
Intrusion Symptoms Include:
❑ Recurrent, involuntary and intrusive distressing
memories of the events. In children repetitive play in
which the theme and aspects of events are expressed.
Acute stress Disorder
❑ Negative mood: Persistent inability to experience positive
mood (happiness, satisfaction or loving feelings)
❑ Dissociative Symptoms: Altered sense of reality, (being in a
daze or time slowing)
❑ Inability to remember important trauma event. (typically due
to dissociative amnesia & not due to TBI or drugs)
❑ Avoidance Symptoms: Avoid distressing memories, thoughts
or reminders (people, places, objects , situations)
❑ Arousal Symptoms:
o Sleep disturbances,
o Irritability
o Hypervigilance
o Problems with concentration
o Exaggerated Startle response
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Acute Stress Disorder/PTSD Co-Morbidity

❑ PTSD has the same categories of symptoms with the
exception of Dissociative Symptoms but all are included not
❑ Major Depressive Disorder
only 9 of 14 as in Acute Stress Disorder. ❑ Substance Related Disorders
❑ The disturbance causes clinically significant distress or
impairment in social, occupational or other important areas ❑ Panic Disorder
of functioning. ❑ Agoraphobia
❑ The disturbance is not attributable to the effect of
substances or other medical condition (TBI) ❑ Obsessive Compulsive Disorder
❑ Acute Stress Disorder occurring weekly predicts PTSD.
❑ Generalized Anxiety Disorder
❑ PTSD can occur without ASD
❑ One month cut off arbitrary, 3-6 months is better ❑ Social Phobia
❑ During high stress, the hippocampus, which is associated ❑ Specific Phobia
with placing memories in the correct context of space and
time and memory recall, is suppressed. This suppression ❑ Bipolar Disorder
may be the cause of the flashbacks that can occur people
with PTSD. ❑ Sleep Disorder

PTSD
❑ Exposure to actual or threatened death, serious injury
or sexual violation. Duration of symptoms is >1 month.
(ASD if it is between 3 days -month)
PTSD/ Symptoms
❑ The amygdalo centric model of PTSD proposes that the amygdala is very
much aroused and insufficiently controlled by the medial prefrontal
cortex and the hippocampus, in particular during extinction
❑ This is consistent with an interpretation of PTSD as a syndrome of
deficient extinction ability
❑ Exposure to trauma and definition of trauma is the same as in ASD.

❑ PTSD has two specifiers. ❑ In children, age 6 and under, experiencing repeated and extreme exposure
is not included in the diagnostic symptoms of Traumatic Event definition.
1- With dissociative symptoms: A- Must have one or more of the intrusive symptoms. (Children,
Depersonalization: feeling of detachment as though dreaming from own mind may have trauma specific reenactment in play)
and body B- Negative alteration of mood and cognition of evens associated
with the trauma as evident by 2 or more of negative symptoms or
De realization: Persistent or recurrent experiences of unreality of the inability to remember important aspects of the event, persistent or
surrounding experienced as unreal , dream like, distant or distorted exaggerated negative belief
1. Distorted cognition about the causes
2- With delayed exposure: if the full diagnostic symptoms do not develop until
6 months after the trauma. 2. Markedly diminished interest in significant activities
3. Feeling if detachment or estrangement
❑ The 3 brain areas with changed function are the prefrontal cortex, amygdala,
4. Alteration in the arousal and reactivity with traumatic events
and hippocampus. The amygdala is strongly involved in forming emotional
memories, especially fear-related memories. Neuroimaging studies in humans
have revealed aspects of PTSD morphology and function

PTSD/Symptoms
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).
PTSD/Symptoms
▪ D- Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidence 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).
▪ E- Duration of the disturbance (Criteria B, C, D, and F) is more
than 1 month.
▪ F- The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning

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PTSD/SYMPTOMS Rapid Eye movement Sleep

❑ Clingy or labile attachments (relationships) Behavior Disorder
❑ Dissociative symptoms in PTSD (are in ASD criteria)
❑ Primitive and immature defenses including splitting, denial,
devaluation/idealization, regression ❑ Repeated episodes of arousal during sleep with vocalization
❑ Unclear if psychosis (hallucinations) can be (conceptually) a post traumatic and /or complex motor behavior
syndrome. Low levels of dopamine can contribute ❑ Upon awakening during this dream the individual is
anhedonia, apathy, impaired attention, and motor deficits. Increased levels of completely awake and not confused or disoriented.
dopamine can cause psychosis, agitation, and restlessness
❑ More frequent during the later portion of the sleep
❑ Brain catecholamine levels are high, and corticotropin-releasing factor (CRF)
concentrations are high, suggesting an abnormality in the hypothalamic- ❑ During REM sleep, 90 minutes after sleep onset.
pituitary-adrenal (HPA) axis.
❑ History suggestive of either
❑ The maintenance of fear has been shown to include the HPA axis, the locus
coeruleus-noradrenergic systems, and the connections between the limbic 1. REM Sleep without atonia on polysomnographic recording
system and frontal cortex. 2. History suggestive of REM Sleep behavior disorder or
❑ Because cortisol is normally important in restoring homeostasis after the Synucleinopathy (i.e. Parkinsonism, multiple system atrophy)
stress response, it is thought that trauma survivors with low cortisol
experience a poorly contained - that is, longer and more distressing -
response, setting the stage for PTSD

Treatment
❑ Eye Movement Desensitization & Reprocessing
(EMDR): The goal is to process distressing memories,
reducing their long lasting effects and allowing the
person to develop more adaptive coping mechanisms.
This is done in an eight-phase approach that includes
having the person recall distressing images while
receiving one of several types of bilateral sensory input,
including side to side eye movements (developed by
Francine Shapiro, PhD).
❑ Virtual Exposure Therapy: is considered to be a
behavioral treatment for PTSD. It targets behaviors
that people engage in (most often the avoidance).
Treatment
❑ CBT
❑ Support Group
❑ Psychodynamic psychotherapy: Focuses on numerous factors
that may influence or cause a person's symptoms, such as
early childhood experiences, current relationships and the
things people do to protect themselves from upsetting
thoughts and feelings.
❑ The synthetic cannabinoid nabilone is sometimes used off-
label for nightmares in PTSD. Although some short-term
benefit was shown, adverse effects are common and it has
not been adequately studied to determine efficacy
❑ Cultural Factors: Comprehensive evaluation of and treatment
should include assessment of these factors
❑ NIMH-funded trial in New York City compared interpersonal
psychotherapy, prolonged exposure therapy and relaxation
therapy - were all equally effective

Medication Stages of Grief (Loss)

.

❑ Antidepressants: Evidence provides support for a small or ❑ By Elisabeth Kubler Ross (1969)
modest improvement with sertraline, fluoxetine, paroxetine,
❑ People grieve differently . Some in 5 stages some even
and venlafaxine. Thus, these four medications are
considered to be first-line medications for PTSD. expands the stages to 7 stages
▪ They may help to treat the depressive aspects or anxiety. 1. Denial and Isolation: It is a defense mechanism that
❑ Prazosin (Minipress, generic), a drug that was developed to buffers the immediate shock.
treat high blood pressure, has been found to be useful in
managing sleep-related problems caused by trauma. It works 2. Anger: Reality and its pain re-emerge, not ready for
by blocking certain alpha-1receptors in the brain, which intense emotion is deflected, redirected and
might lead to better, deeper sleep
▪ In addition to preventing nightmares and insomnia, it can help expressed instead as anger.
improve symptoms, such as flashbacks, and irritability or 3. Bargaining: This is a weaker line of defense
anger.
▪ Treatment of hyperarousal and associated anxiety and 4. Depression
Psychotic Symptoms 5. Acceptance

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Bereavement & Grief in DSM V Diagnosis

❑ The criteria of Depression with Bereavement is similar to Major Depressive
Disorder.
DSM V is changing to diagnosis of Major Depressive
❑ No Bereavement exclusion in DSM V
Disorder if it fulfills the criteria in two weeks.
❑ Bereavement can last 1- 2 years
DSM IV required not to make diagnosis of Depressive
❑ Bereavement can precipitate major depressive episode – Disorder within 2 months of the loss, unless
❑ Major depression in bereavement worsens clinical course – -It causes marked functional impairment
❑ Depressive symptoms with bereavement respond to same interventions as
-If includes certain conditional features
no bereavement associated depression
1. Suicide
Major Depression Grief 2. Morbid preoccupation with worthlessness
Expression of mood is despair and Loss or emptiness 3. Psychotic symptoms
hopelessness 4. Psychomotor retardation
Time course: Steady and waxing Surges and retreats The uncomplicated bereavement does not include the
Content of thoughts; unreleased of Memories and thoughts of departed conditional features of suicide, morbid preoccupation with
own misery worthlessness, psychotic symptoms, and psychomotor
Death wishes; Wishes of own death Life is still worth of living, but I think of retardation, is of shorter duration.
suicidal plans death

Uncomplicated Bereavement in
DSM V How to interview
❑ When a person grieves a loss with anxiety, depression ❑Empathy
and preoccupation with guilt. ❑Facilitation
❑ DSM V allows the diagnosis of uncomplicated
Bereavement. The following symptoms will help you ❑Validation
decide if, in addition to being bereaved, the patient is
suffering from Major Depressive Disorder ❑Support
❑Guilt feelings (other than about actions that might have ❑Explanation
prevented the death)
❑Slowed down Psychomotor activity ❑Summation
❑Death wishes (other than wishing to have died with the loved
one) ❑Silence, listen
❑Severe preoccupation with worthlessness
❑Engage
❑Severely persistent impairment in functioning for a long time
❑Hallucinations (other than seeing or hearing the dead) ❑Body Language

Case Vignette
Case Vignette

A 38 years old female had lost her father in a car accident 3

Q2-Which of the following doesn’t constitute as stressor or trauma by
weeks ago. She experiences waves of sad moods, especially definition in DSM V for PTSD or Acute Stress Disorder.
when she walks by the office where her father worked. For the
A)- Witnessing in an individual die in a tragic accident
last 2 weeks she has also felt guilty and has very low energy.
She did seek out support from a fireman she knew and who B)- Learning about your father’s death
came to the accident scene. She says it is very stressful for C)- Repeatedly exposure to human remains in a disaster area soon after it
happens
her. She experiences intrusive thoughts and flash backs that
interfere with her daily routine. In addition, she sleeps poorly, D)- Exposure to train accident in your town the night before on TV
has lost weight. –Q1-Which of the following symptoms E)- Previously (last month) being attacked by robbers at work place who
necessitate the need to start treatment for major Depressive threatened to killing her
Disorder in future? Q3-If she is diagnosed with PTSD 6 months later, what specifier in DSM V
would be used.
A)- Persistent & marked functional impairment with sad mood A)- With anxiety symptoms
and morbid preoccupation > 2 weeks. B)- With chronic onset
B)- Presence of sad mood and guilt in waves > 10 days C)- With Delayed Exposure
C)- Anxiety & flash backs and memories > 2 weeks. D)- With dissociative symptoms
D)- Presence of poor appetite and wishes to be with the E)- With Grief
deceased for a week
E)- Persistence of intrusive memories for more than two weeks.

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Vignette Answer 1 Vignette Answers

A)-Symptoms of marked functional impairment and morbid Answer 2 D)- Espouser by TV to a plain crash. According to
preoccupation persisting for 2 weeks. DSM V, exposure through electronic media, television, movies
❑ The presence of sad mood, guilt, anxiety or flashbacks and memories are is not considered enough of a to cause PTSD or Acute Stress
all non-specific symptoms of depression and are part of what is called in Disorder, unless it is work related
DSM V as uncomplicated bereavement. Dominant affect is feelings of
emptiness and loss. Capacity for positive emotional experiences and self- Answer 3 C)- with delayed expression
esteem preserved. Fleeting thoughts of joining deceased may occur.
❑ Dysphoria in Grief tends to occur in waves and tends to be connected with
thoughts and reminders of the loss.
The ICD-10 Clinical Descriptions and Diagnostic Guidelines (3, p. 150) state that “normal
bereavement reactions, appropriate to the culture of the individual concerned and not
usually exceeding 6 months in duration” should not be coded in the chapter on mental
disorders, but in chapter XXI (“Factors influencing health status & contacts with health
services”).

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Reference: American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing. pp. 271–280. ISBN 978-0-89042-555-8.
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Reference: American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing. pp. 271–280. ISBN 978-0-89042-555-8.

Question 1 Question 2
A 68 years old man, with no previous history of mental Which of the following sleep disorder was found to
illness, who lost his wife due to terminal illness is angry be common in Veterans with PTSD and violence?
at the doctor who diagnosed her illness. His emotion is
best explained as: A)- Narcolepsy
A)- Reaction to inner feeling of insecurity B)- Sleep epilepsy
B)- As part of anxiety and fear of his own demise C)- Less percentage of REM episodes
C)- Is one of the stages of bereavement & loss D)- REM Behavior Disorder
D)- The anger is a manifestation of late onset Bipolar disorder.
E)- Longer total time of deep sleep with
E)- It is a brief psychotic disorder due to shock.
nightmares

Answer 1 Answer 2
C)- Is one of the stages of bereavement & loss D)- REM Behavior Disorder
Normal bereavement is exclusion criteria in DSM V for This is a parasomnia characterized by the actual enactment of
diagnosis of Adjustment Disorder dream sequences during REM sleep. In addition, PTSD sleep
pattern is characterized by
❑ Higher percentage of REM sleep, more REM density, with
greater likelihood of periodic limb movement in sleep.
❑ Shortened duration of total sleep with increased awakening
time
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Reference : Kübler-Ross, Elisabeth; Kessler, David (June 5, 2007). "On Grief ❑ Lower rate of co-morbid depression tends to have more
and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss". PTSD sleep disturbances
Scribner. Retrieved November 27, 2016 – via Amazon.

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