2. Introduction
• Disorders characterized by exposure to significant stress or trauma
includes:
posttraumatic stress disorder (PTSD),
acute stress disorder, and
adjustment disorders
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3. Contd....
• Persons suffering from one of these disorders develop emotional and
behavioral symptoms in response to a significant stressor or traumatic
event.
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4. PTSD and Acute Stress Disorder
• Persons who have PTSD or acute stress disorder have increased stress
and anxiety following exposure to a traumatic or stressful event.
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5. Contd....
• Traumatic or stressful events may include experiencing
a violent accident or crime, military combat
assault and being kidnapped
being involved in a natural disaster
being diagnosed with a life-threatening illness, or
experiencing systematic physical or sexual abuse.
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6. Contd....
• A PTSD patient typically relives the trauma or tries to avoid reminders
of it.
• They experience negative thoughts and moods about the event and
feel hyperaroused or hyperactive.
• The patient may relive the trauma in their dreams or experience
“flashbacks” or waking thoughts about the ordeal.
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7. Contd....
• The stressors causing both acute stress disorder and PTSD are
sufficiently overwhelming to affect almost everyone.
• They can arise from experiences in war, torture, natural catastrophes,
assault, rape, and serious accidents.
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8. Clinical Features
• Individuals with PTSD relive distressing instances of the traumatic
event, with vivid emotional proximity and high, imperative intensity.
• They organize their lives trying to contain and mitigate the persistent
effects of the traumatic experience.
• For those traumatized in a war zone, they often feel as if the war
never ended.
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9. Contd....
• Victims of rape, assault, or torture describe difficulties engaging and
trusting other humans.
• Constantly reliving the trauma in the present, PTSD patients’ lives
become a series of effortful attempts to avoid reminders of the
traumatic event.
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10. Contd....
• They scan the environment for threat signals, which they fearfully
expect, and remain on guard, tense, restless, and exhausted.
• The persistence of symptoms despite the termination of the threat,
combined with an inability to regain a sense of safety, are core
features of PTSD.
• Another core feature is the involuntary,uncontrollable, and intense
nature of symptoms.
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11. DIAGNOSIS
• The diagnosis includes several categories of symptoms, including
symptoms of intrusion, avoidance, negative mood or cognitions, and
hyperarousal.
• These symptoms cause significant functional impairment and are
present for more than a month.
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12. Contd....
• With acute stress disorder, the primary feature differentiating this
disorder from PTSD is the time course,
with the symptoms of acute stress disorder occurring 3 days to 1
month following a traumatic event.
• Acute stress disorder can have any of the symptoms of PTSD;
however, they do not have to have all the domains.
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13. Contd....
• A person who experiences a minimum of nine symptoms from any of
these domains within 3 days to 1 month of a traumatic event meets
the criteria for acute stress disorder.
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14. Contd....
• DSM-5 parses PTSD symptoms into four subcategories (“diagnostic
criteria”):
reexperiencing
avoidance
negative cognitions, and
hyperarousal
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15. • The directly experienced traumatic events (PTSD criterion A) include,
but are not limited to,
exposure to war as a combatant or civilian
threatened or actual physical assault
threatened or actual sexual violence
being kidnapped
being taken hostage
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16. terrorist attack
torture
incarceration as a prisoner of war
natural or human-made disasters, and
severe motor vehicle accidents.
• Medical incidents that qualify as traumatic events involve sudden,
catastrophic events
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17. Risk Factors for PTSD
• female gender
• age at trauma
• race
• lower education
• childhood abuse
• greater severity of trauma exposure
• lack of social support, and additional life stress
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18. • Seven predictors:
prior trauma
prior psychological adjustment
family history of psychopathology
greater perceived life threat during
the trauma
lower posttrauma social support
greater emotional distress during
exposure, and
greater dissociation during
exposure
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19. PTSD Diagnoses in DSM-5
• Duration is ≥1 month.
• Symptoms
• 1. History of exposure to (directly experiencing,repeated exposure
witnessing in person,learning of occurrence in close acquaintance)
actual threatened death, severe injury, or sexual trauma
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20. Contd....
• 2. Intrusive symptoms
• Involuntary intrusive memories
In children <6 yr,may see reenactment of event through play
• Recurrent nightmares/dreams of the event
In children <6 yr, frightening dreams without identifiable content
may be present
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21. Contd....
• Dissociative responses or reliving of prior experience (i.e., flashbacks)
In children <6 yr, may see reenactment of event through play
• Psychological distress related to exposure to stimuli that are
reminders of prior trauma
• Presence of physiologic response to stimuli that are reminders of
prior trauma
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22. Contd....
• 3. Pattern of avoidance of stimuli associated with prior experience of
trauma
Avoidance of memories related to trauma
Avoidance of external reminders of trauma
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23. Contd....
• 4. Negative mood or cognitions related to trauma
Impairment in memories related to event
Negative perceptions of self and others
Cognitive distortions related to event
Excessive guilt, anger or fear
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24. Contd....
Diminished interest and social withdrawal
Subjective detachment from others
Difficulty experiencing positive feelings in response to previously
pleasurable stimuli
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25. • 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 traumatic
event(s) (typically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
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26. • 2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world, for example:
“I am bad”
“No one can be trusted”
“The world is completely dangerous”
“My whole nervous system is permanently ruined”
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27. • 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 (eg, fear, horror, anger, guilt, or
shame).
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28. • 5. Markedly diminished interest or participation in significant
activities.
• 6. Feelings of detachment or estrangement from others.
• 7. Persistent inability to experience positive emotions (eg, inability to
experience happiness, satisfaction, or loving feelings).
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30. • 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.
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31. 3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (eg, difficulty falling or staying asleep or restless
sleep).
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32. • F. Duration of the disturbance (criteria B, C, D, and E) is more than
one 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 (eg, medication, alcohol) or another medical condition
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33. Contd....
Required number of symptoms
• In addition to history of exposure to trauma,must have
at least one symptom of intrusion
at least one symptom of avoidance
at least two symptoms of negative mood/cognition
at least two symptoms of arousal alterations
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34. Contd....
• Psychosocial consequences of symptoms
Marked distress and impairment in functioning
Exclusions
Exposure through media, electronics, movie, or photo
Related to substance use
Related to another medical condition
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35. Contd....
Symptom specifiers
• With dissociative symptoms:
Depersonalization:perception of feeling outside one’s own body
Derealization:perception of surrounding environment being unreal or
distorted
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36. • Subtypes — Specify whether presentation of disorder is:
• With dissociative symptoms
• With delayed expression
• If the full diagnostic criteria are not met until at least six months after
the event (although the onset and expression of some symptoms may
be immediate).
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37. With dissociative symptoms
• 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 (eg,
feeling as though one were in a dream; feeling a sense of unreality of
self or body or of time moving slowly).
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38. • 2. Derealization – Persistent or recurrent experiences of unreality of
surroundings (eg, the world around the individual is experienced as
unreal, dreamlike, distant, or distorted).
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39. Contd....
Course specifiers
• With delayed expression:
• All diagnostic criteria not met until 6 mo or more after initial
traumatic event
Severity specifiers
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40. Contd....
• Criterion A: Traumatic event
• The trauma experienced by those who present with PTSD is extreme.
• Examples include motor vehicle accidents, exposure to violence in military
operations, home invasions/robberies, rape, and severe physical illness that
threatens death.
• Individuals may be the victim in these events, but may also be observers of an
event, or may hear about a loved one having experienced the event.
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41. • Although some patients present with a single traumatic event as their main
trigger, many patients present with a history of multiple traumatic events.
• These traumatic events may begin in childhood with abuse and neglect.
• In cases of repeated exposure to extreme stimuli, for example, as for first
responders (firefighters, paramedics) or police officers, patients may not be
able to identify a specific traumatic event.
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42. • Criterion B: Intrusion symptoms
• Intrusion symptoms, also known as “re-experiencing” symptoms, are the
hallmark of PTSD.
• Unwanted intrusive memories of the traumatic event vary widely from occasional
unwanted thoughts about the trauma to frequent nightmares to “flashbacks.”
• Intrusion symptoms are typically associated with substantial psychological
distress such as fear or panic.
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43. • Physiological reactions such as autonomic arousal may also be
present.
• Intrusion symptoms can occur spontaneously or be triggered by
events that resemble or symbolize an aspect of the trauma.
• Intrusion symptoms can help differentiate PTSD from other mental
health disorders associated with trauma.
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44. • Criterion C: Avoidance symptoms
• Avoidance of stimuli associated with the traumatic event can lead to
changes in behavior that affect personal and work life.
• Patients may try to avoid internal thoughts or feelings related to the
trauma but may also avoid activities, people, or situations that
remind them of the trauma.
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45. • This avoidance may lead to impairment in daily life functioning, for
example, if it leads to avoidance of driving in a vehicle or being in a
crowded location.
• Victims of trauma will often avoid specific places where the trauma
occurred.
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46. • Criterion D: Negative cognitions and mood
• Depression and negative mood alterations may be initial presentation
of PTSD.
• Patients may have difficulty experiencing positive emotions, have
decreased interest in activities such as work, leisure, or social
engagements.
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47. • They may describe being unable to connect to others.
• Many patients experience excessive guilt about the event and blame
themselves for the occurrence.
• This may lead to negative beliefs about themselves and may
ultimately change their worldview.
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48. • They may begin to see the world as a dangerous, malevolent place.
• Recognition of these symptoms as part of a response to a traumatic
experience is essential for diagnosis of PTSD.
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49. • Criterion E: Arousal and reactivity changes
• Patients may initially present with symptoms of irritability or aggressive physical or
verbal behaviors.
• Other symptoms may include reckless or self-destructive behaviors (eg, substance
use), feeling on edge, being easily startled, decreased concentration, and sleep
disturbances.
• For accurate diagnosis, it is important to recognize these symptoms as having started
after the traumatic event.
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50. Contd....
Dissociative subtype
• Some patients may be classified as having a dissociative subtype of
PTSD.
• These patients have prominent dissociative symptoms, which are
common in PTSD.
• They are associated with higher levels of impairment, comorbidity, and
suicide risk than in PTSD without dissociative symptoms.
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51. Contd....
• Dissociative symptoms include:
• Depersonalization – The person feels disconnected from one’s body.
• For example, they feel as if their body is not their own or they feel “lost” or “in
a daze.”
• Derealization – The person feels as if the world around them is not real.
• For example, they feel as if they are watching the world or experiencing the
world in a dreamlike state.
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52. Contd....
• Amnestic symptoms may also be present in PTSD.
• This may include an inability to remember aspects of the traumatic
event or loss of awareness of situations.
• Typically, this is due to a dissociative amnesia.
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53. COMORBIDITY
• Comorbidity rates are high among patients with PTSD, with about
two-thirds having at least two other disorders.
• Common comorbid conditions include depressive disorders,
substance-related disorders, anxiety disorders, and bipolar disorders.
• Comorbid disorders make persons more vulnerable to develop PTSD.
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54. Psychiatric comorbidities
• Personality disorders
• Patients with PTSD have been found to have increased rates of co-
occurring borderline personality disorder and antisocial personality
disorder compared with the general population.
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55. • Somatic symptoms
• Studies suggest that somatic symptoms are as much as 90 times more
likely in patients with PTSD than in patients without the disorder.
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56. Medical comorbidities
• As examples, large, prospective epidemiologic studies and
retrospective data analyses, have found patients with PTSD to have
• Diseases of bones and joints or of the neurologic, cardiovascular,
respiratory, or metabolic systems between 1.5 and 3 times more
commonly compared with individuals without PTSD.
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57. CNS Mediation of PTSD Clinical Manifestations
• Several brain circuits have been implied in the mediation of PTSD
clinical manifestations.
• Those include fear learning, emotion regulation, executive control,
and contextual learning.
• Experimental methods used to explore these circuits encompass
psychophysiology, neurocognitive assessments, and brain imaging.
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58. Fear Conditioning Theory of PTSD
• This model equates the acquisition and the maintenance of PTSD symptoms
with the consolidation and extinction of conditioned fear responses.
• Within this model, the traumatic event is the conditioning stimulus (CS),
• the immediate responses to trauma are unconditioned responses (UCRs), and
• stimuli (sights, sounds) present during the traumatic event acquire the ability
to elicit conditioned responses (CRs) resembling the CR in the absence of real
threat.
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59. CNS Circuits Involved in Fear Conditioning.
• Fear conditioning and extinction are adaptive learning processes.
• The neural circuitry that mediates these processes is essential to
survival and conserved across species.
• It commands the body’s hard-wired, involuntary, instantaneous
defensive responses to imminent threat (a “species-specific defense
response”).
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60. • This highly conserved stress response system includes
sympathetic and parasympathetic system activation
cardiovascular and respiratory reactions
activation of the hypothalamic–pituitary–adrenal (HPA) axis,
defensive fight, flight, and freezing behaviors, and
changes in information processing.
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61. • It is orchestrated by the central nucleus of the amygdala, a brain
structure that simultaneously connects to critical brain areas
responsible for response execution.
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62. • The activity of the central nucleus is modulated by
layers of midbrain nuclei capable of filtering and evaluating threat
stimuli (such as the basolateral amygdala [BLA]) and further by
cortical and subcortical structures, such as the hippocampus, insula,
and prefrontal structures.
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63. • Each of these modulatory layers is highly plastic and therefore subject
to new learning throughout life.
• PTSD is thought to involve new learning in these modulatory systems
as follows.
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64. • During exposure to extreme threat, previously neutral stimuli
overlapping in time with threat stimuli pass through the thalamus to
the basolateral nucleus of the amygdala, which activates the central
nucleus of the amygdala to enable defensive responding.
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65. • The association between threat or “unconditioned” stimuli (US) and
the previously neutral but currently conditioned stimuli (CS) is made
in the basolateral nucleus of the amygdala.
• Once formed this association enables an exposure to the CS to trigger
a defensive response.
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66. • The magnitude of the defense response is modulated by brainstem
serotonergic, noradrenergic, and dopaminergic neurons in the ventral
tegmental area, dorsal and median raphe nuclei, and locus coeruleus.
• These monoamines affect both the magnitude of UCRs and the
consolidation of US–CS associations.
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67. • The balance of neurotransmitters and neuromodulators activated
during unconditioned response also influences the extent to which
contextual stimuli, more loosely associated in time with the US, may
contribute to later overgeneralization of threat stimuli.
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68. • Activity within the amygdala is under inhibitory control of the prefrontal
cortex (PFC).
• Specifically, glutamatergic neurons from the PFC activate inhibitory
interneurons within the BLA, which in turn suppress BLA outputs to the CE.
• The monoaminergic effects are further modulated by neuroactive steroids and
neuropeptides released by the adrenal gland during stress.
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70. Adjustment Disorders
• People with adjustment disorders have an emotional response to a
stressful event.
• It is one of the few diagnostic entities that directly links an external
stressor to the development of symptoms.
• Typically, the stressor involves financial issues, a medical illness, or a
relationship problem.
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71. Contd....
• The symptom complex that develops may involve anxious or
depressive affect or may present with a disturbance of conduct.
• The symptoms must begin within 3 months of the stressor.
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72. Contd....
• The DSM-5 includes a variety of subtypes of the disorder, including
adjustment disorder with depressed mood
mixed anxiety and depressed mood
disturbance of conduct
mixed disturbance of emotions and conduct, and
unspecified type
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73. Clinical Features
• Patients with adjustment disorders develop intense emotional or
behavioral symptoms in response to one or more external stressors.
• The intensity of the symptoms is subjectively considered beyond what
one would expect in the given situation and impairs the patient’s
ability to function
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