/

NAME: Sohaila
________AlFaisal._________________

LECTURE: Trauma and Stressor-Related

________ _______________Disorders.

Doctor’s Name: Abdulaziz

________ ____________
Al-Garni.
Trauma and Stressor-Related
Disorders

Abdulaziz Al-Garni MD
Assistant Professor Of Psychiatry
King Khalid University
Objectives:

• Explain Trauma- and Stressor-Related Disorders

given in DSM V classification.

• Describe prevalence; etiology; risk factors and D/D of Trauma- and

Stressor-Related Disorders

• Formulate a management plan Trauma- and Stressor-Related

Disorders
on BIOPSYCHOSOCIAL MODEL.
 DSM 5 classification:

‫في‬
• Reactive Attachment Disorder
‫األطفال‬
• Disinhibited Social Engagement Disorder
‫بنتكلم‬
• Posttraumatic Stress Disorder
‫عنها في‬
‫ذي‬
‫املحاضرة‬
• Acute Stress Disorder
• Adjustment Disorders
• Other Specified Trauma- and Stressor-Related Disorder
• Unspecified Trauma- and Stressor-Related Disorder
Posttraumatic Stress Disorder and Acute
Stress Disorder
 • Both Posttraumatic Stress Disorder and Acute Stress Disorder are marked by ‫الشرط األساسي فيهم‬
increased stress and anxiety following exposure to a traumatic or stressful event . Trauma ‫وجود‬

Examples • Traumatic or stressful event may include being a witness to or being involved in a
of
traumatic violent accident or crime , military combat , or being involved in a natural disaster or
illnesses
experiencing physical or sexual abuse. .
Epidemiology : ‫قراءة‬

• The lifetime prevalence is estimated to be :

- 8% of general population .
- 10% in women and 4% in men .
- Up to 75 % in high-risk groups whose experienced traumatic events.
- 5 to 15 % may experience subclinical forms of the disorder
 • A: Exposure > 1 or more.
• B: Intrusion > 1 or more.

DSM 5 Criteria : • Only Understand them do NOT remember.

• The words highlighted in blue capture the main idea.
•
•
C: Avoidance > 1 or more.
D: Alteration in cognition & mood > 2 or more.
• E: Arousal > 2 or more.

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6
years and younger, see corresponding criteria below.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others. "‫"كان في حرب ومات زميله جنبه‬
‫ما حضر‬
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of ‫الحدث فقط‬
actual or threatened death of a family member or friend, the event(s) must have been violent or ‫سمعه لكن‬
.‫بشكل صادم‬
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first Also
Fire ghters
responders collecting human remains: police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.
 B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic
event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In
children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).Note: In children, there may be frightening dreams without recognizable content.
‫ يتكرر معه‬3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
‫الحدث وهو‬
.‫مستيقظ‬
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme
“Not expression being a complete loss of awareness of present surroundings.)Note: In children, trauma-
Nightmare”
specific reenactment may occur in play. "‫ أو حتى لو راح نفس املدينة يبدأ يتذكر الحدث‬،‫"مثال صار املوقف في الحرب وفقد العسكري زمالءه؛ فيصير أول ما يشوف بدله عسكرية يبدأ يقلق‬
ً

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s). ".‫مثال مواقفه مع الشخص أو حتى يتذكر الحادثة نفسها‬ ً ‫"هو يتذكر بنفسه‬

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
As palpitation, sweating,
tremor etc…
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).
 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 ‫"مثال العسكري يتذكر املقذوف‬
‫ وبعدها ما عاد‬،‫وقت ما جاء‬
‫يقدر يتذكر وش صار ووش‬

amnesia and not to other factors such as head injury, alcohol, or drugs). Inability to remember Details of trauma. ‫صلح مع إنه كان صاحي‬
"‫ويشعر بالناس حوله‬

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g.,
“I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system
is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead
the individual to blame himself/herself or others. "‫“كان بإمكاني أصلح أكثر وأنقذهم‬

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities. As anhedonia in depression.
6. Feelings of detachment or estrangement from others. Dissociation.
‫" ما يتفاعل مع‬
‫األحداث اللي‬
"‫حوله‬
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, Satisfaction or loving feelings)
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. "‫ ما كان يستدعي كل ردة الفعل هذه‬trigger ‫"رغم إن‬
2. Reckless or self-destructive behavior.
3. Hyper-vigilance. "‫"تي ّقظ‬
4. Exaggerated startle response. "‫"يكون في الغرفة وأول ما يدق الباب يفز‬
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 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 (e.g., medication,
alcohol) or another medical condition.
 ASD vs PTSD
‫الزم وجود‬
Trauma
.‫فيهم كلهم‬
…‫ إلخ‬A, B ‫ بدون تصنيفها إلى‬،‫عبارة عن تجميع لبعض من األعراض املذكورة فوق بشكل عام‬
A: Exposure > 1 or more.
B: Intrusion > 1 or more.
C: Avoidance > 1 or more.
D: Alteration in cognition & mood > 2 or more.
E: Arousal > 2 or more.

Most
• One day or two days considered as normal reaction. By:
important
• If the patient comes after two days and can’t sleep, you can start Alhanouf
difference
medication to help them sleep. However, such cases are rare, and Awad.
most patients consider them normal.
Comorbidity: ‫قراءة‬

• Two thirds (66%) having at least two other disorders.

• Common:
• depressive disorders
• substance-related disorders
• other anxiety disorders
• bipolar disorders.
Course and Prognosis : ‫قراءة‬

• Fluctuate over time and may be most intense during periods of stress.
• Untreated:
• about 30 percent of patients recover completely,
• 40 percent continue to have mild symptoms,
• 20 percent continue to have moderate symptoms,
• 10 percent remain unchanged or become worse.
• After 1 year, about 50 percent of patients will recover.

• A good prognosis :
• rapid onset of the symptoms,
• short duration of the symptoms (less than 6 months),
• good pre-morbid functioning,
• strong social supports
• absence of other psychiatric, medical, or substance-related disorders or other risk factors.
Treatment : ‫قراءة‬

• Pharmacotherapy :
• First line :
• SSRI Such as ( sertraline and paroxetine )
• SNRI Such as ( Venlafaxine )
• Second line :
• Antipsychotics Such as (Olanzapine , Risperidone )
• TCA Such as (Amitriptyline )
• MAOI Such as ( phenelzine)
• Clonidine and Propranolol .
Psychotherapy : ‫مهم ج ًدا في‬
PSTD

• Support – reassurance – explanation – education.

• Encourage discussing stressful events and overcome patient’s denial.
• In vivo (imaginary) exposure with relaxation and cognitive techniques. "‫ لكن بشكل غير حقيقي‬Trauma ‫"يعرضونه لنفس‬
ّ

• Eye movement desensitization and reprocessing (EMDR): while maintaining a mental image of the
trauma the patient focuses on, and follow the rapid lateral movement of the therapist's finger so
that the traumatic mental experience is distorted and the associated intense emotions are
eliminated. Speci cly for PSTD
Especially if the group has the
• Group therapy (for group of people who were involved in a disaster e.g. flooding, fire). same traumatic experience.
Adjustment Disorders
• Adjustment disorders are characterized by an emotional response to a stressful
‫الحدث ما يوصل ملرحلة تهديد الحياة‬
event. Unlike Trauma in PTTD & ATD

• The stressor involves financial issues, a medical illness, or a relationship problem.

• The symptoms must begin within 3 months of the stressor and must remit within 6
months of removal of the stressor. ‫ ؛ الزم إن األعراض تبدأ خالل‬Adjustment Symptoms ‫"مثال نقلت الرياض ومع البيئة الجديدة صار عندك‬
ً
ً
‫ لكن اللي صار اآلن‬،‫وافتراضا ما قدرت تتأقلم على األعراض وتقرر ترجع ألبها‬ ،‫ شهور من انتقالك للرياض‬٣
"‫ شهور في أبها والزلت تحس باألعراض‬٦ ‫إن لك‬

• The prevalence 8-10% .

• Women are diagnosed twice as often as men .
 DSM 5 Criteria :

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).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into
account the external context and the cultural factors that might influence symptom severity and
presentation. .‫ تكون طبيعية في ثقافة ثانية؛ فالزم تؤخد العوامل املؤثرة في االعتبار‬،‫ممكن ردة فعل غير طبيعية في ثقافتنا‬
2. Significant impairment in social, occupational, or other important areas of functioning.

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.
 ‫ امل ّدة الطبيعية تعتمد‬،‫ محدد وثابت‬duration ‫( ما له‬Grief) ‫مهم أعرف إن حزن الفقد‬

D. The symptoms do not represent normal bereavement. .‫ فالطبيعي في منطقة ممكن غير طبيعي في منطقة ثانية وهكذا‬،culture ‫على الـ‬
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than
an additional 6 months.
Specify whether:
With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
‫"وجود سلوكيات‬
With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. ‫مصاحبة كنوع من‬
Adjustment ‫الـ‬
With disturbance of conduct: Disturbance of conduct is predominant. ‫لكن بطريقة غير‬

With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, ،‫صحية أو صحيحة‬
ً
‫مثال يروح يدخن‬
anxiety) and a disturbance of conduct are predominant. ‫ويدخل في‬
Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of " substance
adjustment disorder.
Acute: if the disturbance lasts less than 6 months. Or Chronic: if the disturbance lasts for 6 months or
longer (when the stressors or consequences continue).
Course and Prognosis ‫قراءة‬

• With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable.

• Most patients return to their previous level of functioning within 3 months.

• Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later
have mood disorders or substance-related disorders.

• Adolescents usually require a longer time to recover than adults.

Treatment : ‫قراءة‬

Psychotherapy :
The treatment of choice .
Group therapy , Individual therapy .
Empathy, understanding, support,& ventilation , explore the meaning of the stressor
to the patient.

Crisis intervention :
Daily sessions may be necessary , sometimes tow or 3 per day .
• Pharmacotherapy : ‫"ما نستخدمه إال في حاالت‬
"‫قليلة ج ًدا‬

Sever

• Short course of benzodiazepines in case of adjustment disorder with anxiety.

• Small doses of antidepressants might be beneficial for adjustment disorder with
depressed mood.
Thanks ..