Trauma- and Stressor-Related

Disorders
Nabil Numan, MD. Ph.D
Professor of Psychiatry
 Trauma- and Stressor-Related Disorders

• Posttraumatic Stress Disorder

• Acute Stress Disorder
• Adjustment Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
 Posttraumatic Stress Disorder
• Exposure to actual or threatened death, serious or sexual
violence in one or more of the following ways:
– Direct experiencing of traumatic event(s)
– Witnessed in person the events as it occurred to others
– Learning that the traumatic events occurred to person close
to them
– Experiencing repeated or extreme exposure to aversive
details of trauma

Duration of disturbance is more than one month AND causes

significant impairment in function
 Posttraumatic Stress Disorder
Presence of 1 or more intrusive
sx after the event
• Recurrent, involuntary and
intrusive memories of event
• Recurrent trauma-related
nightmares
• Dissociative reactions
• Intense physiologic distress
at cue exposure
• Marked physiological
reactivity at cue exposure
Persistent avoidance by 1 or
both:
• Avoidance of distressing
memories, thoughts or
feelings of the event(s)
• Avoidance of external
reminders of that arouse
memories of event(s) e.g.
people, places, activities
 Negative alterations in cognitions and Marked alterations in arousal
mood associated with the traumatic and reactivity with 2 or more
event(s) as evidenced by 2 or more of of:
the following:
• Inability to remember an important • Irritable behavior and and
aspect of the traumatic event(s) angry outbursts
• Persistent distorted cognitions about • Reckless or self-
cause or consequence of event that destructive behavior
lead to blame of self or others • Hypervigilance
• Persistent negative emotional state • Exaggerated startle
• Marked diminished interest response
• Feeling detached from others • Problems with
• Persistent inability to experience concentration
positive emotions • Sleep disturbance
Epidemiology
• 7-9% of general population
• 60-80% of trauma victims
• 30% of combat veterans
• 50-80% of sexual assault victims
• Increased risk in women, younger people
• Risk increases with “dose” of trauma, lack of social
support, pre-existing psychiatric disorder
Comorbidities
• Depression
• Other anxiety disorders
• Substance use disorders
• Somatization
• Dissociative disorders
 Post Traumatic Stress Disorder Etiology

• Conditioned fear
• Genetic/familial vulnerability
• Stress-induced release
– Norepinephrine, CRF, Cortisol
• Autonomic arousal immediately after trauma
predicts PTSD
 Acute Stress Disorder

• Similar exposure as in PTSD

• Presence of >9 of 5 categories of intrusion,
negative mood, dissociation, avoidance, and
arousal related to the trauma.
• Duration of disturbance is 3 days to 1 month
after trauma
• Causes significant impairment
 Adjustment Disorders in DSM-5
Criterion 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).
• Criterion B – These symptoms or behaviors are clinically significant, as evidenced by one or both of the
following:
• Distress is out of proportion to the severity or intensity of the stressor external context cultural factors
• Significant impairment in social, occupational, or other important areas of functioning.
• Criterion 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.
• Criterion D – The symptoms do not represent normal bereavement.
• Conditions for Further Study - Persistent complex bereavement disorder Criterion
• E – Once the stressor or its consequences have terminated, the symptoms do not persist for more than an
additional 6 months.
Specify:
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.
• Adjustment Disorders Fact Sheet
Common 5-20% outpatient 50% in inpatient Risk factors High rate of stressors Culture matters Comorbidity
Commonly accompany medical illnesses or disorders Comorbid with any disorder as long as criteria are met
Associated with increased risk of suicide attempts and completion
 Reactive Attachment Disorder in DSM-5
Criterion A – Consistent pattern of inhibited, emotionally withdrawn behavior toward adult
caregivers, manifested by both of the following: The child rarely or minimally seeks comfort when
distressed. The child rarely or minimally responds to comfort when distressed. Criterion B –
Persistent social and emotional disturbance characterized by 2 or more of the following: Minimal
social and emotional responsiveness to others. Limited positive affect. Episodes of unexplained
irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with
adult caregivers.
• Criterion C – Child has experienced pattern of extremes of insufficient care as evidenced by 1 or
more 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 care-giving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments.
3. Rearing in unusual settings that severely limit opportunities to form selective attachments.
• Criterion D –Care in Criterion C is presumed to be responsible for the disturbed behavior in
Criterion A.
• Criterion E – The criteria are not met for autism spectrum disorder.
• Criterion F – The disturbance is evident before age 5 years. Criterion G – The child has a
developmental age of at least months Specify : Persistent (more than 12 months) Current
Severity (ex: severe)
• Reactive Attachment Disorder Fact Sheet
Capacity for attachment is present, but opportunities in early life were scarce Comorbidity
Developmental delays due to neglect (cognitive & language) Depressive symptoms “Relatively
rare” even in populations of severely neglected children <10%
 ‫اضطراب التعلق التفاعلي‬
‫)‪Reactive Attachment Disorder (F94.1‬‬
‫‪ A‬نمط ثابت من السلوك المنسحب عاطفيًا المكبوت تجاه مقدمي الرعاية البالغين والذي يتظاهر بكٍل مما يلي‪- :‬‬
‫( ‪ ( 1‬نادرًا أو في الحدود الدنيا ما يسعى الطفل للبحث عن السلوان عندما يعاني‪.‬‬
‫( ‪ ( 2‬نادرًا أو في الحدود الدنيا ما يستجيب الطفل للسلوان عندما يعاني‪.‬‬
‫‪ B‬اضطراب اجتماعي وعاطفي ثابت يتميز باثنين على األقل مما يلي‪- :‬‬
‫( ‪ ( 1‬استجابة عاطفية واجتماعية في الحد األدنى لألخرين‪- .‬‬
‫( ‪ ( 2‬وجدان إيجابي محدود‪- .‬‬
‫( ‪ ( 3‬نوب غير مفسرة من الهياج‪ ،‬الحزن‪ ،‬أو الخوف‪ ،‬حيث تكون هذه النوب مثبتة حتى في ‪-‬‬
‫حالة عدم التفاعل مع مقدمي الرعاية البالغين‪.‬‬
‫‪ C‬اختبر الطفل نمطًا متطرفًا من الرعاية الغير كافية كما ثبت بواحد من التالي على األقل‪- :‬‬
‫( ‪ ( 1‬اإلهمال االجتماعي أو الحرمان على شكل الفقد المستمر للحاجات العاطفية األساسية من‬
‫الراحة‪ ،‬والتحفيز‪ ،‬والمودة المقدمة من قبل مقدمي الرعاية البالغين‪.‬‬
‫( ‪ ( 2‬التغيير المتكرر لمقدمي الرعاية األساسيين والتي تحد من فرص تشكيل ارتباطات مستقرة‬
‫)على سبيل المثال‪ ،‬التغيير المتكرر في دور الرعاية(‪.‬‬
‫( ‪ ( 3‬التنشئة في مواضع غير عادية والتي تحد بشدة من فرص تشكيل ارتباطات انتقائية )مثل‬
‫المؤسسات ذات النسب العالية من طفل مقدم الرعاية(‪- .‬‬
‫‪ D‬يفترض أن الرعاية في المعيار ‪ C -‬هي المسؤولة عن السلوك المضطرب في المعيار ‪) A‬على سبيل المثال‪،‬‬
‫بدأت االضطرابات في المعيار ‪ A‬تاليًة لعدم وجود الرعاية الكافية في المعيار ‪). C‬‬
‫‪ E‬لم يتم الوفاء بمعايير اضطراب طيف التوحد‪- .‬‬
‫‪ F‬االضطراب مثبت قبل سن ‪ 5 -‬سنوات‪.‬‬
‫‪ G‬السن التطوري للطفل هو ‪ 9 -‬أشهر على األقل‪.‬‬
‫تحديد ما إذا كان‪:‬‬
‫المستمر‪ :‬كان االضطراب الحالي حاضرًا ألكثر من ‪ 12‬شهرًا‪.‬‬
‫تحديد الشدة الحالية‪:‬‬
‫يتم تحديد اضطراب التعلق التفاعلي كشديد عندما يظهر الطفل كل أعراض هذا االضطراب‪ ،‬وكل عرض يظهر‬
‫عند مستويات مرتفعة نسبيًا‪.‬‬
 Disinhibited Social Engagement Disorder in DSM-5
Criterion 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 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.
• Criterion B – The behaviors in Criterion A are not limited to impulsivity (as in
ADHD) but include socially disinhibited behavior.
• Criterion 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.
3. Rearing in unusual settings that severely limit opportunities to form selective attachments .

• Criterion D – The care in Criterion C presumed to be responsible for disturbed

behavior in Criterion A. Criterion
• E – The child has a developmental age of at least 9 months. Specify: Persistent
(more than 12 months) Current severity (ex: severe)