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Trauma and Stress Related Disorders

It has long been understood that exposure to a traumatic event, particularly combat, causes some individuals to display abnormal thoughts and behaviors that we today refer to as mental illness. The first medical diagnosis for a trauma-related disorder is attributed to Swiss military physicians who in 1678 identified a pattern of symptoms caused by exposure to combat which they called “nostalgia”. This condition was characterized by melancholy, incessant thinking of home, disturbed sleep, weakness, loss of appetite, anxiety, cardiac palpitations, stupor, and fever. Accounts of trauma-related disorders have historically been linked to warfare.

During World War I “shell shock” was a significant medical and military problem. Symptoms included fatigue, tremor, confusion, nightmares, and impaired sight and hearing. Initially it was believed “shell shock” resulted from physical injury to the nerves due to exposure to heavy artillery bombardment. As medical personnel began recognizing that many soldiers suffered these symptoms without having been on the front lines a greater emphasis was placed on psychological factors as the cause.

The onset of World War II once again resulted in a number of soldiers exposed to combat showing anxiety, intense autonomic arousal, flashbacks, and sensitivity to stimuli that reminded them of the original trauma. The term most commonly used for this condition at that time was “combat exhaustion”. Unfortunately, while this condition was recognized by medical personnel as psychological in nature, those suffering with the condition were often shamed and reprimanded by their superiors because they were thought to be weak and cowardly.

The DSM-I published in 1952 included the diagnosis of gross stress reaction. The criteria for this disorder were intentionally broad and recognized that exposure to traumatic events other than combat (e.g., natural disaster) could also cause significant distress. Without explanation the DSM-II, published in 1968, omitted the diagnosis of gross stress reaction. The publication of the DSM-III in 1980 saw the inclusion of posttraumatic stress disorder (PTSD) as an anxiety disorder for the first time. Subsequent editions of the diagnostics manual (DSM-III-R, DSM-IV, DSM-IV-TR) continued to include PTSD as an anxiety disorder. In the most recent edition of the manual, DSM-5, all trauma- and stressor-related disorders are for the first time grouped together in a single category. The primary trauma- and stressor-related disorders are reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder, acute stress disorder, and the adjustment disorders.




Characteristic Symptoms

The trauma- and stressor-related disorders are serious psychological reactions that develop in some individuals following exposure to a traumatic or stressful event such as childhood neglect, childhood physical / sexual abuse, combat, physical assault, sexual assault, natural disaster, an accident or torture.

The characteristic symptom of psychological distress resulting from childhood emotional neglect is impairment in the child’s ability to relate interpersonally to adults and peers. This symptom is unique to disorders resulting from a pattern of insufficient caregiving that limits an infant’s opportunities to form stable attachments. The characteristic symptoms of all other trauma- and stressor-related disorders can be placed into four broad categories: intrusion symptom, avoidance symptoms, negative alterations in cognition and mood, and hyperarousal symptoms.

Intrusion symptoms include recurrent, involuntary and distressing memories, thoughts, and dreams of the traumatic event. The individual may also experience flashbacks, a dissociative experience in which they feel or act as if the traumatic event is reoccurring. Exposure to stimuli or cues that resemble some aspect of the traumatic event may also result in marked distress for the individual.

Avoidance symptoms are efforts to avoid internal (memories, thoughts, feelings) and/or external (people, places, situations) reminders of the traumatic event. Preoccupation with avoiding trauma related feelings and stimuli can become a central focus of the individual’s life.

Negative alterations in cognition and mood include problems remembering important aspects of the traumatic event, depression, fear, guilt, shame, and feelings of isolation from others.

Hyper-arousal symptoms are often reported to be some of the most troubling symptoms of the trauma- and stressor-related disorders. These symptoms include being jumpy and easily startled, irritability, angry outbursts, self-destructive behavior, problems concentrating, and difficulty sleeping.

 

Types of Trauma and Stress Related Disorders

Reactive Attachment Disorder (RAD) 

Reactive Attachment Disorder usually presents before age five and is characterized by serious problems in emotional attachment to others. These children rarely seek comfort when distressed and are minimally emotionally responsive to others. As mentioned above RAD results from a pattern of insufficient caregiving or emotional neglect that limits an infant’s opportunities to form stable attachments. Children who are adopted from foreign orphanages are commonly affected, particularly if they were removed from their birth parents during the first weeks of life.

Disinhibited Social Engagement Disorder

Disinhibited Social Engagement Disorder is characterized by a pattern of behavior that involves culturally inappropriate, overly familiar behavior with unfamiliar adults and strangers. Like RAD, this disorder results from a pattern of insufficient caregiving or emotional neglect that limits an infant’s opportunities to form stable attachments.

Post Traumatic Stress Disorder (PTSD) 

Post Traumatic Stress Disorder is characterized by significant psychological distress lasting more than a month following exposure to a traumatic or stressful event. Symptoms from all of the categories discussed above must be present.

Acute Stress Disorder

Acute Stress Disorder is similar to PTSD but the duration of the psychological distress last only three days to one month following exposure to a traumatic or stressful event.

Adjustment Disorder

Adjustment Disorders are characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor (e.g., problems at work, going off to college). Adjustment disorder symptoms vary from person to person but must occur within three months of the stressful event and once the stressor has ended the symptoms do not persist more than six months.


Prevalence and Age of Onset

Determining the prevalence of the trauma-related disorders is somewhat difficult because unlike other mental disorders they do not spontaneously occur but are triggered by exposure to a specific traumatic or stressful event. RAD and disinhibited social engagement disorder are thought to be rare in the general population affecting less than 1% of children under the age of five. However, the rates of these disorders are thought to be significantly higher in institutionalized populations. For example, it is estimated that half of all U.S. children adopted from orphanages, along with 40% of children in the foster care system meet criteria for these disorders.

The lifetime prevalence of PTSD in the United States is estimated to be 8.7% of the population. PTSD occurs more commonly in women than men and can occur at any age. The prevalence of acute stress disorder varies according to the nature of the traumatic event. For example, significantly higher rates of individuals show acute stress disorder following an assault or rape (20-50%) than following a motor vehicle accident (13-21%). Acute stress disorder can occur at any age and is more common in women than men.

Adjustment disorders are the least severe and the most common of the trauma- and stressor-related disorders. The prevalence of adjustment disorders varies widely as a function of the population and setting studied. Research estimates that 2.9% of primary care patients meet criteria for an adjustment disorder while 5-20% of outpatient mental health clients have been found to meet criteria. Adjustment disorders can occur at any age.

 


Treatment & Support

Successful treatment of the trauma-related disorders usually requires both medication and some form of psychotherapy.

Selective Serotonin Reuptake Inhibitors (SSRI’s) 

As described in the depressive disorders chapter, these antidepressant medications block the neurotransmitter serotonin (5-HT) from being reabsorbed into the brain cells. Currently only the SSRIs Zoloft (sertraline) and Paxil (paroxetine) are approved by the Food and Drug Administration for the treatment of PTSD. There is strong evidence that Prozac (fluoxetine) may also be effective in treating the trauma-related disorders.

Psychotherapy

Two forms of trauma-focused cognitive-behavior therapy (TF-CBT) have been shown to be effective in treating the trauma-related disorders. Prolonged exposure therapy is a variant of CBT that has been shown to be effective in treating both anxiety and trauma-related disorders. In prolonged exposure therapy the therapist creates a safe environment in which to “expose” the individual to the things they fear and avoid. The exposure to the feared objects, activities, or situations in a safe environment helps reduce fear and decrease avoidance.

In cognitive processing therapy (CPT) the therapist seeks to help the client gain an understanding of the traumatic event and take control of distressing thoughts and feelings associated with it. Components of CPT include learning about the symptoms of PTSD, exploring how the traumatic event has affected your life, learning the connection between trauma-related thoughts, feelings, and behaviors, remembering the traumatic event and experiencing the emotions associated with it, and learning skills to challenge maladaptive thoughts related to the trauma.

 

A Spiritual Perspective

The Scriptures teach five significant principles about trauma and suffering: (1) God is present and in control of our suffering; (2) God is good and cares for us; (3) suffering is an opportunity to grow closer to God; (4) Jesus understands our suffering; and (5) our identity—who we are—is not defined by traumatic events or suffering but is grounded in Christ. Let’s briefly look at each of these points.

First, God is present and in control of our suffering. We often feel the furthest from God in times of great suffering and pain. Where is He? Has He forgotten me? How could He let this happen? This was also the case in the lives of great heroes of faith in the Bible. Look at David (Psalm 13:1), Jeremiah (Lamentations 3:8), and Job (Job 9:16). Even Jesus, at the height of His pain, cries out, “My God, My God, why have You forsaken Me?” (Matthew 27:46). From our limited human perspective, pain and suffering seem contrary to our idea of a sovereign God who is good and loving. We think that God blinked and wasn’t able to stop this traumatic event or that He isn’t really a loving God. We forget that Adam and Eve chose to sin and that we live in a fallen world full of suffering. Suffering should not cause us to question God’s sovereignty, as Job so clearly understood (Job 2:10). God is sovereign, despite our circumstances. He created all things, and He controls all things (Deuteronomy 4:39; 1 Chronicles 29:11; Psalm 103:19; Daniel 4:34–35; Colossians 1:16–17). He allows us to experience the consequences of sin, while remaining fully in control of all things—including Satan, who can bring suffering into our lives only if God allows it (Job 1:12; 2:6; Luke 22:31). God is in control of our circumstances, and He wants to transform us into the very image of His Son.

Second, we learn from the Scriptures that God is good and that He cares for us. We have all heard this question: “How could a loving God allow __________?” Fill in the blank with any horribly traumatic event that occurs here on planet Earth. People often use this dilemma to argue against not only the love of God but also the very existence of God. But God does love us, and that love is evident in our redemptive history. The Creator of the world made a way for disobedient, powerless creatures to come into an eternal relationship with Him. He is patient and gracious. He became one of us (John 1:14; 3:16) and then sacrificed Himself for us (1 John 3:16). Self-sacrifice is the ultimate act of love (John 15:13). God is indeed good, and He longs to be in an ever-deepening relationship with us.
In James 1:2, we are told to “consider it all joy” when we go through difficult times. What kind of strange mental gymnastics does God want us to do? We’re supposed to be happy when we’re in pain? No, not at all. Even Jesus was overcome with grief when He went through difficult times—at the grave of His friend Lazarus, in the Garden of Gethsemane, and on the cross. We must understand that trials or difficult times in our lives are opportunities God allows so we will recognize our need for complete dependence on Him (John 15:5).

The third truth we are called to recognize is that through our trials and suffering we have an opportunity to draw closer to God. During the easy times we often become self-reliant, forgetting our need for God. It is in the hard times, when our faith is tested, that we recognize our need for complete dependency on Him. James tells us that persevering through the difficult times develops a mature and complete faith (James 1:4). We are ever being conformed into the image of Christ, and suffering is a necessary part of that transformation (Romans 8:17, 29; Philippians 1:29; 1 Peter 2:21). As we draw near to Him during difficult times and submit to the Holy Spirit within us, He draws near to us, and the intimacy of our relationship grows (Galatians 4:6).

A fourth truth is that we do not worship a distant, unapproachable God. We worship a God who knows what it is to be human (Hebrews 4:15). Jesus knows what it is to suffer (Hebrews 2:17–18). Just think about Jesus’ life for a moment. He didn’t experience just one traumatic event during His time on earth—His whole life was full of suffering (Isaiah 53:3–5). He was born into unimaginable poverty in a country occupied by a cruel army (Luke 2:1–7). He narrowly escaped a mass slaughtering of children that was ordered because of His birth (Matthew 2:13–16). He was physically confronted by Satan (Matthew 4:1–11), persecuted because of His teachings (Luke 4:28–29), thought insane by His family (Mark 3:21), betrayed by His own disciple (Mark 14:43–45), deserted by His friends (Mark 14:50), falsely charged (Mark 14:55–59), publicly humiliated (Mark 15:16–20; Luke 23:8–11), whipped mercilessly (Matthew 27:26), and then slowly and painfully executed by public crucifixion as a common criminal (Matthew 27:33–44). We can take great comfort in the fact that God can relate to us on our level; He understands what it is to suffer.

Finally, our identity is not defined by traumatic events or suffering. Our identity is grounded in Christ. God does not see you as a victim. He sees you as His child. The Scriptures tell us that, as children of God, we were chosen before the creation of the world to be holy and blameless adopted sons and daughters, lavished with grace, redeemed, forgiven, given spiritual wisdom and understanding, and marked with the Holy Spirit (Ephesians 1:3–14). We are in Christ! We sit at the right hand of the Father! We have His righteousness! We must not allow tragedy or circumstances to define who we are or how we live. We have His very life within us, and we must choose to live out of that truth.

  

Finding Care

The links and information below will provide you with a starting point in terms of finding mental health care providers, treatment facilities and support groups for those struggling with a trauma related disorder.

Mental Health Care Providers

When assisting an individual it is important to help them find the right type of mental health care provider. These links will assist you in beginning your provider search. Knowing and building relationships with providers in your area can prove invaluable. Both in aiding the individual in getting an appointment, as well as, being able to better support them once they begin receiving professional treatment.

An individual struggling with a trauma related disorder will most likely need to see both a clinical psychologist / therapist for psychotherapy (talk therapy) and a psychiatrist for medication.

By providing your zip code the following search engine will give you information about mental health treatment facilities in your area.

Clinical Psychologist Psychiatrists

 

Treatment Facilities

In some people, trauma related disorders can become so severe that a hospital stay is needed. This may be necessary if the individuals seeking your care can’t take care of themselves properly or are in immediate danger of harming themselves or someone else. Psychiatric treatment at a hospital can help keep them calm and safe until their mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

By providing your zip code the following search engine will give you information about mental health treatment facilities in your area.

Substance Abuse and Mental Health Services Administration American Residential Treatment Association

 

Support Groups

Recognizing that community is one of the factors necessary for successful recovery, attending support groups can be a powerful and meaningful way to connect with others facing similar challenges. Support group experiences allow people affected by mental health difficulties and disorders to connect in a safe and supportive environment. Support groups are led by trained facilitators and teach coping skills, help reduce anxiety, build resiliency and provide a place for people to share common concerns and receive emotional support.

These links will give you information on support groups in your area.

PTSD Foundation of America (Warrior Groups) National Alliance for Mentally Ill Grace Alliance  Anxiety and Depression Association of America


Supporting the Family

Many times the family caring for an individual with a mental illness is overlooked. They are often the front line support for the individual. The responsibility of care can take a physical and psychological toll on caregivers. Many times the caregiver needs as much support as the individual that has the illness. Caregiver support groups are available for the families of those struggling with trauma.

These links will give you information on caregiver (family) support groups in your area.

Anxiety and Depression Association of America – Family Support Group National Alliance on Mental Illness – Family Support Group National Alliance on Mental Illness – Family to Family Support GroupGrace Alliance  Fresh Hope for Mental Health




Educational Resources

Here are some links to aid you in learning more about PTSD and other trauma related disorders. The more information you have, the better you will be able to help those seeking your guidance.

National Institute of Mental Health Mental Health America


Downloadable Resources 

First Step – What to do once a diagnosis has been made.

Daily Steps – Developing a holistic mental health care plan.

Difficult Steps – Navigating destructive behavior and legal issues.

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