Understanding Trauma and Stress-Related Disorders: A Comprehensive Overview

 
Trauma and Stress Related
Disorders
 
Dr.  Alexsandra Urhi
Federal Neuro-Psychiatric Hospital, Benin City
31
st
 August 2022
 
Outline
 
Objectives
Introduction
Classification
Post traumatic stress disorder
Clinical vignette
Other trauma and stress related
disorders
Conclusion
References
 
2
 
Objectives
 
To understand the clinical presentation
and management of trauma and stress
related disorder.
 
3
 
Introduction
 
Trauma and stress related disorders are
maladaptive responses to severe or
continued stress, in that they interfere
with successful coping mechanisms and
thus lead to problems in social
functioning.
 
4
 
Classification (ICD-10)
1
 
Coded at (F43):
1.  Acute stress reaction
2. Post-traumatic stress disorders
3.  Adjustment disorder
.
 
5
 
Classification (ICD-11) 
2
 
Coded at (BlockL1-6B4):
1. Post traumatic stress disorder
2. Complex post traumatic stress disorder
3. Prolonged grief disorder
4.  Adjustment disorder
5. Reactive attachment disorder
6. Disinhibited social engagement disorder
7. Other specified disorders specifically
associated with stress
8. Disorders specifically associated with stress,
unspecified
 
6
 
Post-traumatic stress disorder
(PTSD) - Definition
 
This arises as a delayed and/or protracted
response to a stressful event or situation
(either short-or long-lasting) of an
exceptionally threatening or catastrophic
nature which is likely to cause pervasive
distress in almost anyone
 
7
 
Post-traumatic stress disorder
(PTSD) 
3
 
Essential features:
1.
Re-experiencing of aspects of the
stressful event.
2.
Hyper arousal
3.
Avoidance
 
8
 
Epidemiology 
4
 
General population: 8 out of 100
Women > men
Single, divorced , widowed, socially
withdrawn, or of low socioeconomic level
 
9
 
Etiology
 
Stressor
Risk factors
Psychodynamic factors
Cognitive behavioral factors
Biological factors
 
10
 
Risk factors
 
Childhood trauma
Personality disorder traits
Inadequate family or peer support
Female
Genetic vulnerability to psychiatric illness
Recent stressful life changes
 
11
 
Psychodynamic factors
 
It hypothesized that the trauma has
reactivated a previously quiescent, yet
unresolved psychological conflict.
Revival of the childhood trauma result in
the use of defense mechanisms of
repression, denial, reaction formation and
undoing.
 
12
 
Cognitive-Behavioral factors
 
They attempt to avoid experiencing it by
avoidance techniques
Persons experience alternating periods of
acknowledging and blocking the event
There are 2 phases of its development:
-The trauma (unconditioned stimulus)
-Through instrumental learning
Some people also receive secondary gains
 
13
 
Biological factors
 
Noradrenergic system
Opioid system
Corticotropin-Releasing factor and the
HPA axis
 
14
 
ICD-10 diagnostic criteria for PTSD
 
This disorder should not generally be
diagnosed unless there is evidence that it
arose within 6 months of a traumatic
event of exceptional severity.
In addition to evidence of trauma, there
must be a repetitive, intrusive recollection
or re-enactment of the event in
memories, daytime imagery, or dreams.
 
15
 
PTSD in children and adolescents
 
Symptoms:
Repetitive dreams of the events
Nightmares of monsters
Physical symptoms such as stomach aches
and headaches
Re-experiencing aka traumatic play
Reenactment
 
16
 
Treatment
 
The major approaches are:
1.
Support
2.
Encouragement to discuss the event
3.
Education about coping mechanisms like
relaxation.
4.
Drugs: SSRIs, buspirone (a serotonergic),
MAOIs (phenelzine, trazodone),
anticonvulsants (carbamazepine , sodium
valpraote)
 
17
 
Psychotherapy
 
Behavior therapy
Cognitive therapy
Family/group therapy
Eye movement desensitization and
reprocessing (EMDR)
When PTSD has developed, two major
psychotherapeutic approaches can be taken
 
18
 
Psychotherapy
 
1. Exposure therapy:  it has four main parts:
-
Education about the treatment
-
Breathing retraining for relaxation
-
Imagined exposure through repeated
discussion with therapist
-
Exposure to real world situations related to
the trauma
2. Stress management:  relaxation techniques
and cognitive approaches to coping with
stress.
 
19
 
Differential diagnosis
 
Panic disorder
Generalized anxiety disorder
Dissociative disorders
 
20
 
Course and prognosis
 
If untreated:
-30% recover completely
-40% with mild symptoms
-20% with moderate symptoms
-10% remained unchanged or become worst.
PTSD that is comorbid with other disorders
is often more severe and perhaps more
chronic and maybe difficult to treat.
 
21
 
Clinical vignette
 
22
 
Acute stress reaction 
2
 
The disorder is similar to PTSD in many
aspects like the occurrence after
exposure to a traumatic event, with
similar symptoms
The difference is only the duration of the
illness. It typically begins immediately after
the trauma, and persists for at least 3 days
and up to a month.
 
23
 
Adjustment disorder 
2
 
States of subjective distress and emotional
disturbance, usually interfering with
significant life change or to the
consequences of a stressful life event.
Typically, the stressor involves financial
issues, medical illness, or relationship
problem.
Depressed mood, anxiety, worry, a feeling of
inability to cope, plan ahead or continue in
the present situation and some degree of
disability in the performance of daily routine.
 
24
 
Complex post traumatic stress
disorder 
2
 
A disorder that develops following exposure to
an event or series of events of an extremely
threatening or horrific nature, most commonly
prolonged or repetitive events from which
escape is difficult or impossible
Diagnostic criteria for PTSD must be met plus:
1)
Severe and pervasive problems in affect
regulation
2)
Persistent beliefs about oneself
3)
Persistent difficulties in sustaining relationships
and in feeling close to others.
 
25
 
Prolonged grief disorder 
2
 
A disturbance, in which following the death
of a partner , parent, child or other person
close to the bereaved, there is persistent and
pervasive grief response characterized by
longing for the deceased or persistent
preoccupation with the deceased
accompanied by intense emotional pain.
The grief response occurs for an atypically
long period of time
It clearly exceeds expected social, cultural or
religious norms for the individual’s culture
and context.
 
26
 
Reactive attachment disorder 
2
 
Characterized by grossly abnormal attachment
behaviors in early childhood, occurring in the
context of a history of grossly inadequate child
care (e.g. severe neglect, maltreatment).
Even when an adequate primary care giver is
available, the child does not turn to the primary
caregiver for comfort , support and nurture
Rarely displays security-seeking behavior towards
any adult, and does not respond when comfort is
offered.
Diagnosed in children, however, cannot be
diagnosed below the age of 1
 
27
 
Disinhibited social engagement
disorder 
2
 
Characterized by grossly abnormal social
behavior, occurring in the context of a
grossly inadequate child care (e.g. severe
neglect institutional deprivation)
The child approaches adults indiscriminately,
lacks reticence to approach.
will go away with unfamiliar adults.
Exhibits overfamiliar behavior towards
strangers.
Diagnosed in children, however, cannot be
diagnosed below the age of 1
 
28
 
Conclusion
 
Thank you
 
29
 
References
 
1.
ICD-10 Version:2019 [Internet]. icd.who.int. Available from:
https://icd.who.int/browse10/2019/en#/F43.1
2.
ICD-11 for Mortality and Morbidity Statistics [Internet].
icd.who.int. Available from: 
https://icd.who.int/browse11/l-
m/en#/http%253a%252f%252fid.who.int%252ficd%252fentit
y%252f2070699808
3.
Shorter Oxford Textbook Of Psychiatry 7th Edition
[Internet]. Internet Archive. Available from:
https://archive.org/details/shorter-oxford-textbook-of-
psychiatry-7th-edition_202008
4.
Kaplan & Sadock’s Synopsis of Psychiatry [Internet].
shop.lww.com. [cited 2022 Aug 28]. Available from:
https://shop.lww.com/Kaplan---Sadock-s-Synopsis-of-
Psychiatry/p/9781975145569
 
30
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Trauma and stress-related disorders encompass maladaptive responses to severe stress, affecting social functioning. This article delves into classifications, specifically PTSD, emphasizing clinical presentation and management. It explores ICD-10 and ICD-11 coding, defining PTSD and its essential features. Additionally, it touches on the epidemiology of these disorders in the general population, particularly among women and those of low socioeconomic status.


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  1. Trauma and Stress Related Disorders Dr. Alexsandra Urhi Federal Neuro-Psychiatric Hospital, Benin City 31stAugust 2022

  2. Outline Objectives Introduction Classification Post traumatic stress disorder Clinical vignette Other trauma and stress related disorders Conclusion References 2

  3. Objectives To understand the clinical presentation and management of trauma and stress related disorder. 3

  4. Introduction Trauma and stress related disorders are maladaptive responses to severe or continued stress, in that they interfere with successful coping mechanisms and thus lead to problems in social functioning. 4

  5. Classification (ICD-10)1 Coded at (F43): 1. Acute stress reaction 2. Post-traumatic stress disorders 3. Adjustment disorder . 5

  6. Classification (ICD-11) 2 Coded at (BlockL1-6B4): 1. Post traumatic stress disorder 2. Complex post traumatic stress disorder 3. Prolonged grief disorder 4. Adjustment disorder 5. Reactive attachment disorder 6. Disinhibited social engagement disorder 7. Other specified disorders specifically associated with stress 8. Disorders specifically associated with stress, unspecified 6

  7. Post-traumatic stress disorder (PTSD) - Definition This arises as a delayed and/or protracted response to a stressful event or situation (either short-or long-lasting) of an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in almost anyone 7

  8. Post-traumatic stress disorder (PTSD) 3 Essential features: 1. Re-experiencing of aspects of the stressful event. 2. Hyper arousal 3. Avoidance 8

  9. Epidemiology 4 General population: 8 out of 100 Women > men Single, divorced , widowed, socially withdrawn, or of low socioeconomic level 9

  10. Etiology Stressor Risk factors Psychodynamic factors Cognitive behavioral factors Biological factors 10

  11. Risk factors Childhood trauma Personality disorder traits Inadequate family or peer support Female Genetic vulnerability to psychiatric illness Recent stressful life changes 11

  12. Psychodynamic factors It hypothesized that the trauma has reactivated a previously quiescent, yet unresolved psychological conflict. Revival of the childhood trauma result in the use of defense mechanisms of repression, denial, reaction formation and undoing. 12

  13. Cognitive-Behavioral factors They attempt to avoid experiencing it by avoidance techniques Persons experience alternating periods of acknowledging and blocking the event There are 2 phases of its development: -The trauma (unconditioned stimulus) -Through instrumental learning Some people also receive secondary gains 13

  14. Biological factors Noradrenergic system Opioid system Corticotropin-Releasing factor and the HPA axis 14

  15. ICD-10 diagnostic criteria for PTSD This disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. 15

  16. PTSD in children and adolescents Symptoms: Repetitive dreams of the events Nightmares of monsters Physical symptoms such as stomach aches and headaches Re-experiencing aka traumatic play Reenactment 16

  17. Treatment The major approaches are: 1. Support 2. Encouragement to discuss the event 3. Education about coping mechanisms like relaxation. 4. Drugs: SSRIs, buspirone (a serotonergic), MAOIs (phenelzine, trazodone), anticonvulsants (carbamazepine , sodium valpraote) 17

  18. Psychotherapy Behavior therapy Cognitive therapy Family/group therapy Eye movement desensitization and reprocessing (EMDR) When PTSD has developed, two major psychotherapeutic approaches can be taken 18

  19. Psychotherapy 1. Exposure therapy: it has four main parts: - Education about the treatment - Breathing retraining for relaxation - Imagined exposure through repeated discussion with therapist - Exposure to real world situations related to the trauma 2. Stress management: relaxation techniques and cognitive approaches to coping with stress. 19

  20. Differential diagnosis Panic disorder Generalized anxiety disorder Dissociative disorders 20

  21. Course and prognosis If untreated: -30% recover completely -40% with mild symptoms -20% with moderate symptoms -10% remained unchanged or become worst. PTSD that is comorbid with other disorders is often more severe and perhaps more chronic and maybe difficult to treat. 21

  22. Clinical vignette 22

  23. Acute stress reaction 2 The disorder is similar to PTSD in many aspects like the occurrence after exposure to a traumatic event, with similar symptoms The difference is only the duration of the illness. It typically begins immediately after the trauma, and persists for at least 3 days and up to a month. 23

  24. Adjustment disorder 2 States of subjective distress and emotional disturbance, usually interfering with significant life change or to the consequences of a stressful life event. Typically, the stressor involves financial issues, medical illness, or relationship problem. Depressed mood, anxiety, worry, a feeling of inability to cope, plan ahead or continue in the present situation and some degree of disability in the performance of daily routine. 24

  25. Complex post traumatic stress disorder 2 A disorder that develops following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible Diagnostic criteria for PTSD must be met plus: 1) Severe and pervasive problems in affect regulation 2) Persistent beliefs about oneself 3) Persistent difficulties in sustaining relationships and in feeling close to others. 25

  26. Prolonged grief disorder 2 A disturbance, in which following the death of a partner , parent, child or other person close to the bereaved, there is persistent and pervasive grief response characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain. The grief response occurs for an atypically long period of time It clearly exceeds expected social, cultural or religious norms for the individual s culture and context. 26

  27. Reactive attachment disorder 2 Characterized by grossly abnormal attachment behaviors in early childhood, occurring in the context of a history of grossly inadequate child care (e.g. severe neglect, maltreatment). Even when an adequate primary care giver is available, the child does not turn to the primary caregiver for comfort , support and nurture Rarely displays security-seeking behavior towards any adult, and does not respond when comfort is offered. Diagnosed in children, however, cannot be diagnosed below the age of 1 27

  28. Disinhibited social engagement disorder 2 Characterized by grossly abnormal social behavior, occurring in the context of a grossly inadequate child care (e.g. severe neglect institutional deprivation) The child approaches adults indiscriminately, lacks reticence to approach. will go away with unfamiliar adults. Exhibits overfamiliar behavior towards strangers. Diagnosed in children, however, cannot be diagnosed below the age of 1 28

  29. Conclusion Thank you 29

  30. References ICD-10 Version:2019 [Internet]. icd.who.int. Available from: https://icd.who.int/browse10/2019/en#/F43.1 ICD-11 for Mortality and Morbidity Statistics [Internet]. icd.who.int. Available from: https://icd.who.int/browse11/l- m/en#/http%253a%252f%252fid.who.int%252ficd%252fentit y%252f2070699808 Shorter Oxford Textbook Of Psychiatry 7th Edition [Internet]. Internet Archive. Available from: https://archive.org/details/shorter-oxford-textbook-of- psychiatry-7th-edition_202008 Kaplan & Sadock s Synopsis of Psychiatry [Internet]. shop.lww.com. [cited 2022 Aug 28]. Available from: https://shop.lww.com/Kaplan---Sadock-s-Synopsis-of- Psychiatry/p/9781975145569 1. 2. 3. 4. 30

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