Trauma related psychiatric illness

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Trauma-Related Psychiatric Illness

Trauma-related psychiatric illnesses are a group of disorders in which exposure to a traumatic or stressful event is explicitly listed as a diagnostic criterion. The major conditions are covered below.

1. Posttraumatic Stress Disorder (PTSD)

Definition & Epidemiology

PTSD develops after exposure to actual or threatened death, serious injury, or sexual violence — either directly experienced, witnessed, or learned about. Key epidemiological figures:

Lifetime prevalence: ~6.8% in the general population; current (past-year) prevalence ~3.5%
Gender disparity: Lifetime prevalence 9.7% in women vs. 3.6% in men
Combat exposure: Among Vietnam veterans, 30.9% of men and 26.9% of women developed PTSD
Most prevalent in young adults due to higher trauma exposure; children can also be affected
Higher rates in those who are single, divorced, widowed, socially withdrawn, or of low socioeconomic status

— Kaplan and Sadock's Synopsis of Psychiatry

DSM-5 Diagnostic Criteria (4 Symptom Clusters)

Cluster	Core Symptoms
1. Intrusion	Recurrent involuntary memories; nightmares; flashbacks (dissociative reactions reliving the event); marked psychological distress to trauma cues; physiologic reactivity to trauma reminders. In children <6 yr, may see reenactment through play.
2. Avoidance	Avoidance of distressing memories/thoughts/feelings; avoidance of external reminders (people, places, activities, situations)
3. Negative alterations in cognition/mood	Impaired recall of trauma details; persistent negative beliefs about self/world; cognitive distortions; persistent negative emotional states (fear, horror, anger, guilt, shame); diminished interest in activities; estrangement from others; inability to experience positive emotions
4. Altered arousal & reactivity	Irritability/angry outbursts; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; concentration difficulties; sleep disturbances

Required: At least 1 intrusion symptom + 1 avoidance symptom + 2 negative cognition/mood symptoms + 2 arousal symptoms, persisting >1 month with functional impairment.

Specifiers:

With dissociative symptoms: Depersonalization (feeling outside one's own body) or Derealization (surroundings feel unreal/distorted)
With delayed expression: Full criteria not met until ≥6 months after the trauma

— Kaplan and Sadock's Synopsis of Psychiatry

Risk Factors for PTSD

Pre-trauma factors:

Female gender
Prior trauma exposure, history of childhood abuse
Lower education level
Family history of psychopathology
Pre-existing personality disorder traits (borderline, paranoid, dependent, antisocial)
Inadequate social support
Recent life stressors, excessive alcohol use

Peri-trauma factors:

Higher severity, duration, and proximity to the traumatic event
Perceived life threat
High dissociation during exposure
Witnessing injury or death; discharging a weapon in combat

Post-trauma factors:

Lower social support after the event
Greater emotional distress immediately after exposure

Genetics: Genes account for ~30% of variance in PTSD risk. Relevant polymorphisms include FKBP5, PACAP1, COMT, DRD2, GABA alpha-2 receptor, RSG2, and the serotonin transporter gene (s/s genotype interacting with childhood adversity).

— Kaplan and Sadock's Synopsis of Psychiatry

Predisposing Vulnerability Factors (DSM Table)

Vulnerability Factor
Presence of childhood trauma
Borderline, paranoid, dependent, or antisocial personality traits
Inadequate family or peer support system
Female gender
Genetic vulnerability to psychiatric illness
Recent stressful life changes
External locus of control (natural vs. human cause)
Recent excessive alcohol intake

2. Acute Stress Disorder (ASD)

Acute Stress Disorder shares many features with PTSD but is distinguished by its time course: symptoms occur within 3 days to 1 month after trauma exposure. It can include intrusion, avoidance, negative mood, dissociative, and arousal symptoms. If symptoms persist beyond 1 month and full PTSD criteria are met, the diagnosis converts to PTSD.

ASD is important because it identifies individuals at high risk for developing PTSD, and early intervention may reduce progression.

3. Adjustment Disorder

Core Features

An adjustment disorder is an emotional or behavioral response to an identifiable stressor that is out of proportion to the stressor's severity or causes significant functional impairment. The stressor need not be extreme or life-threatening — it can be loss of a job, divorce, medical illness, or a developmental life transition.

Key Points

The stressor's severity does not reliably predict disorder severity — it depends on its psychological meaning, the patient's vulnerability, and available support
Stressors can be single, recurrent, or continuous; they can affect individuals, families, or entire communities
Prevalence: <1% in community samples; ~3% in primary care; higher in medical settings (especially oncology/palliative care, ~11%)
Subtypes (DSM-5): with depressed mood, with anxious mood, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, unspecified

Psychodynamic Factors

Understanding adjustment disorders requires exploring the nature of the stressor, its conscious and unconscious meaning, and the patient's pre-existing vulnerability. Current stressors may reawaken past traumas. Defense mechanisms developed during childhood play a significant role in how individuals respond to adult stressors.

— Kaplan and Sadock's Synopsis of Psychiatry

4. Dissociative Disorders Related to Trauma

Trauma is a major precipitant of dissociative disorders, including:

Dissociative Amnesia: Inability to recall important autobiographical information, usually traumatic in nature — distinct from organic amnesia (no neurological cause, memory loss is specific to trauma-related material)
Dissociative Identity Disorder (DID): Disruption of identity with two or more distinct personality states, strongly associated with severe early childhood trauma, especially abuse
Depersonalization/Derealization Disorder: May co-occur with PTSD as a specifier or as a separate disorder

Differential diagnosis of dissociative amnesia must exclude: ordinary forgetfulness, dementia, delirium, posttraumatic amnesia (brain injury), seizure disorders, substance effects, and factitious disorder/malingering.

5. Other Trauma-Related Conditions

Condition	Key Feature
Reactive Attachment Disorder	Childhood; inhibited emotionally withdrawn behavior from adult caregivers; result of social neglect/deprivation
Disinhibited Social Engagement Disorder	Childhood; disinhibited, overly familiar behavior with strangers; result of social neglect/deprivation
Complex PTSD (ICD-11)	Prolonged, repeated trauma (e.g., childhood abuse, captivity); adds disturbances in self-organization (affect dysregulation, negative self-concept, relationship difficulties) to core PTSD features

6. Comorbidities

PTSD and trauma-related disorders have high rates of comorbidity with:

Major depressive disorder
Substance use disorders (self-medication)
Anxiety disorders (panic disorder, generalized anxiety)
Personality disorders (borderline, antisocial)
Somatic symptoms and chronic pain
Cardiovascular disease (PTSD is an independent risk factor)

7. Treatment Overview

Psychotherapy (First-Line)

Trauma-focused CBT (TF-CBT) — especially for children and adolescents
Prolonged Exposure (PE) — systematic confrontation of trauma memories and cues
Cognitive Processing Therapy (CPT) — targets maladaptive trauma-related cognitions
EMDR (Eye Movement Desensitization and Reprocessing)

Pharmacotherapy

SSRIs (sertraline, paroxetine) — FDA-approved for PTSD; first-line pharmacological treatment
SNRIs (venlafaxine) — effective for PTSD symptoms
Prazosin — alpha-1 blocker; used specifically for trauma-related nightmares
Atypical antipsychotics (e.g., risperidone, quetiapine) — adjunctive use for severe hyperarousal, dissociation, or psychotic features
Benzodiazepines: generally not recommended in PTSD due to risk of dependence and limited efficacy

Special Populations

Children: School-based interventions (e.g., La Greca's post-Hurricane Andrew protocol, HATS program), parent involvement critical; validated assessment tools include the Child PTSD Symptom Scale (CPSS) and UCLA PTSD Reaction Index
Communities post-disaster: Community resilience frameworks (e.g., CART toolkit), psychoeducational group interventions

— Kaplan and Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Summary Table

Disorder	Stressor Required	Onset	Duration
Acute Stress Disorder	Yes (trauma criterion)	Within 1 month	3 days – 1 month
PTSD	Yes (trauma criterion)	Any time (may be delayed ≥6 months)	>1 month
Adjustment Disorder	Yes (any identifiable stressor)	Within 3 months	Resolves within 6 months of stressor ending
Dissociative Amnesia	Often trauma-related	Variable	Variable
Complex PTSD (ICD-11)	Yes (prolonged/repeated)	Variable	Chronic

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