Trauma And Stressor-Related Disorder Research Paper
Trauma- and Stressor-Related Disorders
Samantha Farmer
Liberty University
Abstract
Trauma- and stressor-related disorders are psychological illnesses that are triggered by traumatic events experienced by an individual. These debilitating disorders include reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, posttraumatic stress disorder, and adjustment disorders. Traumas that can trigger one of these disorders include sexual victimization, involvement in battle or war, or any other traumatic event especially those which are interpersonal. Assessing those who may suffer with a trauma- or stressor-related disorder can prove to be difficult. A practitioner must be culturally sensitive. One …show more content…
way of understanding trauma within a culture is to learn and understand the idioms of distress of different cultures that could indicate an individual is suffering from a trauma- or stressor-related disorder. Practitioners must also be culturally aware of subgroups such as the deaf population and socioeconomic differences such as in families receiving child welfare preventive services. Fortunately, research has shown these disorders can be treated using a variety of treatments such as patient-centered and trauma-cognizant management, responsive integrative treatment, cognitive behavioral therapy, and psychotherapy. Christian-based spiritual practices also show promising healing in cases of trauma- and stressor-related disorders.
Trauma- and Stressor-Related Disorders Trauma- and stressor-related disorders can be debilitating, disrupting, and at times terrifying. Included in the category of trauma- and stressor-related disorders are reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder (ASD), adjustment disorders, and other specified trauma- and stressor-related disorders. Trauma can happen to any person unexpectedly without discrimination but not everyone who experiences a trauma will develop a trauma- or stressor-related disorder. Not only is there a differentiation in who will actually develop a disorder but different people will also exhibit different symptoms. This paper will provide an overview of these disorders, a discussion of the potential causes, and a summary of treatment options. Although these disorders are devastating there is hope for healing with a holistic approach combining an individual 's biological, psychological, social, and spiritual needs.
An Overview of Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder Reactive attachment disorder (RAD) manifests in children under 5 years of age with a developmental age of at least 9 months who have been deprived of basic emotional and physical needs.
Children who develop this disorder experience neglect and are denied stimulation and affection by their adult caregivers. This disorder is also often seen in children who have been moved from caregiver to caregiver such as in the foster care system. This happens because the child has not been able to spend enough time with any caregiver in order to develop a healthy attachment. Children who are reared in institutions such as orphanages are also at risk for RAD as the children are never able to develop an attachment to any one selected caregiver due to the high child-to caregiver ratio. A persistent type is diagnosed if the child has shown symptoms for over 12 months. Symptoms include emotionally withdrawn behavior in which the child rarely seeks comfort or responds to comfort when distressed on a consistent level. He or she also may have trouble emotionally responding to others, have limited positive affect, and may experience episodes of unexplained irritability, sadness, or fearfulness (American Psychiatric Association (APA), …show more content…
2013).
Disinhibited Social Engagement Disorder In previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), RAD had two subtypes. An Inhibited Type where the child has trouble initiating and responding to social interactions and a Disinhibited Type where the child shows indiscriminate sociability. However, the DSM-5 Disinhibited social engagement disorder (DSED) took the place of the Disinhibited Type. DSED also should only be diagnosed when the child is over the developmental age of 9 months. Children who fit the criteria for DSED have also experienced extreme neglect and deprivation, repeated changes in primary caregivers, and/or high child-to caregiver ratios. These children will display indiscriminate social or physical behavior in front of unfamiliar adults and will show overly familiar verbal and physical behavior. They also may go off with strangers and not check back in with their caregivers, even when they find themselves in unfamiliar surroundings (APA, 2013). Symptoms will cross culturally acceptable boundaries (Velotti, Di Folco, Cesare Zavattini, 2013).
Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) is a disorder in which a person experiences an extreme response to a severe stressor. The stressor could include exposure to an actual or threatened death, serious injury, or sexual injury. These traumas could be experienced personally, witnessed in person, experienced by someone close, or through repeated or extreme exposure except for media reports. In order to receive a diagnosis of PTSD, one must experience at least one avoidance symptom which includes avoiding internal reminders and avoiding external reminders. They also must experience at least two symptoms of negative alterations in cognitions and mood. These include the inability to remember important aspects of the trauma, persistent and exaggerated negative beliefs or expectations about one 's self, others, or the world, persistent excessive blame of self or others about the traumas, persistent negative emotional state, diminished interest or participation in significant activities, feeling of detachment or estrangement from others, and the persistent inability to experience positive emotions. The individual also must experience two symptoms of alterations in arousal and reactivity including irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. All symptoms must began or worsen after the trauma was experienced and must continue for at least one month (Kring, Johnson, Davison & Neale, 2014). Individuals may experience dissociative symptoms such as depersonalization or derealization where one either feels detached from his body or experienced the world in a dream-like state (APA, 2013).
Acute Stress Disorder Acute stress disorder (ASD) is experienced after either exposure to actual or threatened death, serious injury, or sexual violation similar to PTSD. ASD is actually very similar to PTSD with the exception of the duration time as the duration of ASD is shorter compared to PTSD. Symptoms must present between 3 days and 1 month after a trauma occurs (Kring et al., 2014). Symptoms that individuals may experience include intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms (APA, 2014).
Adjustment Disorders Adjustment disorders present within 3 months of the onset of a stressor which can include a single event like the loss of a relationship or multiple stressors such as marital problems. Symptoms of adjustment disorders are more intense and greater in severity than in the normal bereavement process. It is also important to note that symptoms do not continue for more than 6 months after the stressor has ended (APA, 2013).
Other Specified Trauma- and Stressor-Related Disorders The category of other specified trauma- and stressor-related disorders refers to situations in which a patient may not fulfill all diagnostic criteria for a trauma- or stressor-related disorder but his symptoms are causing clinically significant pain. Some examples include the following: the delay of symptoms longer than 3 months after the stressor has occurred; the duration of symptoms longer than 6 months even though the stressor has ceased; Ataque de nervios, a Latino-specific disorder; other cultural syndromes; or persistent complex bereavement disorder in which the individual experiences severe and persistent grief (APA, 2013).
Unspecified Trauma- and Stressor-Related Disorders This category includes any cases where the symptoms are causing the client distress but the symptoms do not fulfill the diagnostic criteria. This category differs from the category of other specified trauma-and stressor-related disorders in that the diagnosing clinician chooses not to specify a disorder due to insufficient information (APA, 2013).
Potential Causes of Trauma- and Stressor-Related Disorders There are many causes related to trauma- and stressor-related disorders. A trauma or extreme stressor must be experienced in order for a diagnosis to be made in one of these disorders. However, not everyone who experiences a trauma or stressor will develop a disorder. There are many causes and factors that can lead to the development of a trauma- or stress-related disorder. However, it is believed that it is the combination and culmination of both biological factors and environmental factors that affect the vulnerability and resilience of whether or not a person will indeed develop a disorder (Jovanovic & Ressler, 2010).This section will focus on these traits that make some individuals more apt to develop a trauma- or stressor-related disorder.
Biological Causes Dissociative symptoms may be present in PTSD and ASD. It is thought that dysfunctional brain development may be at fault and can cause the inhibition of the creation of integrative connections in a child 's developing mind (Weber, 2008). Another genetic predisposition is gender as women are more likely develop both PTSD and ASD. This is due to the sex-linked neurobiological differences in the stress response of males and females. It is also possible that the gender difference is due to the likelihood that women are more prone to traumas such as rape and other interpersonal violence such as domestic violence which is most often linked to ASD (APA, 2013). The neurocircuitry and genetics that control the inhibition of fear is also implicated in the development of PTSD, implicating the areas the amygdala and the prefrontal cortex of the brain. If a person is born with the heredity that allows them the ability to remain resilient in times of extreme trauma such as severe child abuse, they may avoid the psychopathology that many individuals may experience (Jovanovic & Ressler, 2010).
Personality
The personality traits of a person can actually impact the formation of a disorder. For instance, it was found that traits such as disagreeableness, emotional instability, introversion, and compulsivity could positively predict both internalizing and externalizing problem behavior (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). Elevated reactivity is also implicated in predicting ASD (APA, 2013).
Environment
A person 's environment is thought to be an immense factor in the development of a trauma- or stressor-related disorder.
The diagnoses of both RAD and DSED depend on the environmental trauma of extreme neglect (APA, 2013). Infants and small children need to form secure attachments in order to feel safe. When secure and consistent attachments are not formed, children learn they cannot depend on their caregivers. Therefore, they never learn the appropriate approach to obtain comfort from their caregivers (Velotti, Di Folco, & Cesare Zavattini, 2013). Even inconsistent, harsh discipline strategies, limited warmth, and lack of responsiveness or rejection can influence the development of psychopathological behavior in children (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). Another environmental risk factor is the exposure to trauma by one 's parent. One study examining the trauma exposure of mothers whose children were involved in the child welfare (CW) system showed that 91.6% of the mothers had experienced at least one traumatic event and 92.2% reported that their children had experienced at least one traumatic event. This shows that children whose are raised in an environment with parents who have experienced trauma are themselves prone to experience trauma (Chemtob, Griffing, Tullberg, Roberts, & Ellis, 2011). Other environmental factors that may influence the development of a trauma- or stressor-related disorder include lower socio-economic status, lower
education, and other disadvantaged life circumstances (APA, 2013).
Type of Trauma The highest rates of disorders tend to occur when the trauma was interpersonal such as in cases of assault, rape, or witnessing a mass shooting. Lower rates of trauma- and stressor-related disorders are reported when the trauma was not interpersonal such as car accidents, industrial incidents, burns, or mild brain injuries. The severity of the trauma also effects the development of PTSD (APA, 2014).
Past History It is thought that childhood-onset psychopathology may progress in a more maladaptive course as opposed to psychopathology that is brought on as an adolescent (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). It is also believed that experiencing an episode of ASD seems to make it more likely that one will develop PTSD within 2 years and treating ASD may help prevent the development of PTSD (Kring, 2014). It is also shown that repeated trauma such as emotional, physical, and sexual abuse can lead to PTSD, complex PTSD, or dissociative disorders (Mauritz, Goossens, Draijer & van Achterberg, 2013).
Evaluating and Treating Trauma- and Stressor-Related Disorders The evaluation and treatment of trauma and stressor-related disorders should be handled with care and much consideration. Due to the overlap of symptoms with other disorders in the DSM-5 such as anxiety disorders, OCD and related disorders, and dissociative disorders, trauma- and stressor-related disorders are often under diagnosed. Without the proper assessment, the client will not receive the proper diagnosis and therefore will not receive the best treatment.
Assessment
Differential diagnoses and comorbidity. When diagnosing any disorder, care should be taken to differentiate between disorders as many symptoms are present in more than one disorder. When assessing children presenting with RAD, clinicians should be sure to differentiate that the diagnosis is actually RAD and not autism spectrum disorder, an intellectual developmental disorder, or a depressive disorder (APA, 2013). DSED should be differentiated from attention-deficit/hyperactivity disorder (ADHD) as both disorders are characterized by impulsivity (Velotti, Di Folco, Cesare Zavattini, 2013). However, children with DSED do not have problems with attention or hyperactivity. PTSD can be confused with diagnoses of an adjustment disorder, other posttraumatic disorders and condition, ASD, anxiety disorders and obsessive-compulsive disorder (OCD), major depressive disorder, personality disorders, dissociative disorders, conversion disorder, psychotic disorders, or traumatic brain injury. ASD can be misdiagnosed with an adjustment disorder, panic disorder dissociative disorders, PTSD, OCD, psychotic disorders, or traumatic brain injury. A diagnosis of adjustment disorder should be differentiated from major depressive disorder, PTSD, ASD, personality disorders, (APA, 2013). It is also important to take care assessing those who have severe mental illness (SMI) as the diagnosis of trauma- and stressor-related disorders is often overlooked due to a number of factors (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Comorbidity is another issue that may hinder the diagnosis of those with trauma- and stressor-related disorders. Children with RAD may be diagnosed with cognitive or language delays, stereotypies as well as depressive symptoms. As RAD is a disorder diagnosed following severe neglect, children also may suffer with malnutrition. Children with DSED also may be diagnosed with cognitive and language delays and stereotypies as well as ADHD. Those with PTSD are about 80% more likely to develop another disorder such as depressive, bipolar, anxiety, or substance use disorders (APA, 2013). Cultural implications. Cultural differences can often lead to the misdiagnosis of any mental disorder. However, it is reported that attachment behaviors are relatively the same throughout cultures. PTSD may have some cultural implications however. First, the onset and severity may differ which can be attributable to different types of traumatic experiences such as genocide, funerary rites issues, living in post-conflict settings, immigration stress, or even religious persecution. Symptoms may also vary according to culture (APA, 2013). Idioms of distress are defined as the mode to express distress and they are shaped by a culture 's values, norms, themes, and health concerns. This is another cultural implication that may indicate trauma exposure, various types of psychopathology and levels of distress, as well as risk and functioning. Idioms of distress also may influence the way an individual understands his trauma- or stressor-related disorder as well as help-seeking and self-treatment patterns. These are metaphorical expressions that are linked to conflicts of the culture and based on how the body and mind functions. One example is the American epidemic of lower back pain which is associated with overwork, stress, and moral failure (Hilton & Lewis-Fernandez, 2010). The deaf population is a subculture in which clinicians need to understand in order to not misdiagnose a trauma- or stressor-related disorder. Unfortunately, deaf children experience trauma at much higher rates than hearing children which often leads to behavioral and emotional problems including PTSD, anxiety, and depression. Deaf individuals may experience symptoms differently than hearing individuals. Symptoms such as hypervigilance and hyperactivity are connected with ADHD but could also be an arousal symptom of trauma and clinicians should be aware of the differentiation of symptom prevalence (Schwenke, 2011).
Treatment
When treating trauma- and stressor-related disorders in those with SMI, it has been thought by many clinicians that treating the trauma would lead to more distress in the patient but there is no evidence for this claim (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Though trauma- and stressor-related disorders can be quite distressing, there are many treatments available and many other treatments continually being studied to help bring support and healing to those suffering with these disorders. Attachment therapy. In the cases of RAD and DSED, there is thought to be a reasonable correlation between prognosis of these disorders and the quality of the care giving that is received after the neglect has taken place. This means that simply a change in environment where the child can begin to make secure attachments could aid in the child 's recovery (APA, 2013). Also aiding in the healing of children who have been severely mistreated is dyadic developmental therapy. This therapy does not use intrusive or dangerous treatment interventions but instead consists of treatment based on attachment theory provided by one therapist in an outpatient setting. One study showed that children receiving this treatment experience significant decreases in symptoms of attachment disorder, withdrawn behaviors, anxiety and depression, social problems, thought problems, attention problems, rule-breaking behaviors, and aggressive behaviors (Becker-Weidman, 2006). The attachment theory is also shown to be effective in a case study of a little boy named Tom who suffered from a severe case of RAD. He was also treated in an outpatient setting where human connection was promoted first and foremost (Shi, 2014). Cognitive behavior therapy. One study examining the treatment for ASD in an adolescent girl found that the combination of trauma-focused cognitive behaviour therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) was an effective treatment. Before receiving this treatment, the girl experienced distressing memories, anxiety, and flashbacks. After receiving this treatment, the girl reported she experienced no more flashbacks of her injury, no problems sleeping, and no more recurrent and distressing memories. This treatment is especially promising for helping to prevent the development of PTSD and for helping children and adolescents who have had a life-threatening medical event take place (Bronner, Beer, van Zelm van Eldik, Grootenhuis, & Last, 2009). Responsive integrative treatment. This treatment model integrates cognitive-behavioral, psychodynamic, and process/experiential psychotherapy in order to help those with straightforward cases of PTSD. There are many empirically supported treatments (ESTs) showing efficiency in treating PTSD but these treatments can lead to rigidity in treatment. Clinicians oftentimes feel as though they must strictly follow a set treatment plan. However, it may be best to teach clinicians how to let the client 's values and circumstances guide the treatment course. This treatment encourages the idea of responsiveness where the clinician remains open to changing the formulation of the treatment plan from moment to moment. In order to achieve this level of responsiveness, the clinician must remain checked in with the client constantly (Edwards, 2013). Holistic therapy. A holistic approach to treating trauma- and stressor-related disorders includes treating mind, body, and spirit in order to achieve healing. The most neglected part of using a holistic approach in PTSD is the spiritual factor (Weis, 2010). However, it is known that the experience of trauma can have a profound effect on one 's spirituality. This effect can either be negative or positive, leading an individual closer to his spirituality or farther away. In order to treat patients suffering with a trauma- or stressor-related disorder that have been pushed away from God due to their traumatic experience, it is important to help the client first come to see themselves the way God sees them. This is called a truthful self-image. Oftentimes, people who experience a trauma, lose their spiritual identity and can only see themselves as a victim. It is important to remind patients of their truthful self-image as this can help the patient heal quickly and wholly and help them make healthy, responsible life choices. Trauma victims also need to have a truthful God image. Individuals often develop an image of God that encompasses the attributes of one 's parents, one 's own negative self-images, or even the attributes of one 's perpetrator. Thirdly, clinicians can help their clients overcome trauma by helping them to learn how to let love into their lives. Those who experience trauma usually have trouble with trust and see themselves as unworthy of love and support. Clinicians can help clients struggling with this by modeling love, support, and acceptance. Group therapy is also beneficial in this area (Berrett, Hardman, O 'Grady, & Richards, 2007). Future Research There has been expansive research in the areas of trauma- and stressor-related disorders. However, there is still much to be known. In the area of RAD, little is known about the evolution and behavioral phenotype throughout the lifespan of the child. This could be helped with the completion of longitudinal studies between the ages of 4 and 8 of the child (Velotti, Di Folco, & Cesare Zavattini, 2013). Future research is also needed in the area of working with the deaf population. Because of the communication differences between hearing and deaf clients, it requires some creativity in the treatment process. Some early work has been done using certain types of play therapy with good results but more empirical studies are needed (Schwenke, 2011). There is also future research needed in the area of PTSD and SMI. Physical neglect, emotional neglect, and emotional abuse are all thought to increase the risk of developing PTSD and therefore should receive greater attention in future research (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Eye movement desensitization and reprocessing (EMDR) is also in need of future research as the literature is lacking in this area. Although it seems to have benefits when treating those with trauma- and stressor-related disorders, it is unknown how EDMR is related to the beneficial results seen with those who receive this treatment.
Conclusion
In conclusion, trauma- and stressor-related disorders are extremely complex in symptomology, causes, assessment techniques and treatment. Study in this area is very important as living with these disorders can have a terribly distressing impact in the life of an individual suffering with one of these disorders. Research is abundant in many areas and it is seen that hope and healing are within reach for those in pain. Combining treatments such as cognitive-behavioral therapy with a compassionate and nurturing environment along with the healing powers of God can provide the greatest amount of help.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Berrett, M., Hardman, R., O 'Grady, K., & Richards, S. (2007). The role of spirituality in the treatment of trauma and eating disorders: Recommendations for clinical practice. Eating Disorders, 15, 373-389. doi: 10.1080/10640260701454394
Becker-Weidman, A. (2006). Treatment for children with trauma-attachment disorders: Dyadic developmental psychotherapy. Child& Adolescent Social Work Journal, 23(2), 147-171. doi:10.1007/s10560-005-0039-0
Bronner, M., Beer, R., Jozine van Zelm van Eldik, M., Grootenhuis, M., & Last, B. (2009). Reducing acute stress in a 16-year old using trauma-focused cognitive behaviour therapy and eye movement desensitization and reprocessing. Developmental Neurorehabilitation, 12(3), 170-174. doi: 10.1080/17518420902858975
Chemtob, C.M., Griffing, S., Tullberg, E., Roberts, E., & Ellis, P. (2011). Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services. Child Welfare, 90(6), 109-127.
De Clercq, B., Van Leeuwen, K., De Fruyt, F., Van Hiel, A., & Mervielde, I. (2008). Maladaptive personality traits and psychopathology in childhood and adolescence: The moderating effect of parenting. Journal of Personality, 76(2), 357-383. doi:10.1111/j.1467- 6494.2007.00489.x
Edwards, D. (2013). Responsive integrative treatment of clients with PTSD and trauma-related disorders: An expanded evidence-based model. Journal of Psychology in Africa, 23(1), 7- 19.
Hinton, D., & Lewis-Fernandex, R. (2010). Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine And Psychiatry, 34(2), 209-218. doi:10.1007/s11013- 101-9175-x
Jovanovic, T., & Ressler, K. How the neurocircuitry and genetics of fear inhibition may inform our understanding of PTSD. American Journal of Psychiatry,167, 648-662. doi:10.1176/appi.ajp.2009.09071074
Kring, A., Johnson, S., Davison, G., & Neale, J. (2014).Abnormal psychology . (12 ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Mauritz, M.W., Goossens, P.J., Draijer, N., & van Achterberg, T. (2013). Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness. European Journal of Psychotraumatology, 4, 1-15. doi:10.3402/ejpt.v4i019985
Schwenke, T. (2011). Childhood trauma: Considering diagnostic and culturally sensitive treatment approaches for deaf clients. Journal of the American Deafness & Rehabilitation Association (JADARA), 45(1), 158-173.
Shi, L. (2014). Treatment of reactive attachment disorder in young children: Importance of understanding emotional dynamics. American Journal of Family Therapy, 42(1), 1-13. doi:10.1080/01926187.2013.763513
Velotti, P., Di Folco, S., & Cesare Zavattini, G. (2013). What we know about 'attachment disorders ' in childhood. Journal of Special Education & Rehabilitation, 14(3/4), 61-77. doi:10.2478/jser-2013-001110.2478
Weber, S. (2008). Diagnosis of trauma and abuse-related dissociative symptom disorders in children and adolescents. Journal of Child & Adolescent Psychiatric Nursing, 21(4), 205- 212.
Weis, M. (2010). Integrated and Holistic Treatment Approach to PTSD and SUD: A Synergy. Journal Of Addictions & Offender Counseling, 31(1), 25-37.
Samantha Farmer
Liberty University
Abstract
Trauma- and stressor-related disorders are psychological illnesses that are triggered by traumatic events experienced by an individual. These debilitating disorders include reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, posttraumatic stress disorder, and adjustment disorders. Traumas that can trigger one of these disorders include sexual victimization, involvement in battle or war, or any other traumatic event especially those which are interpersonal. Assessing those who may suffer with a trauma- or stressor-related disorder can prove to be difficult. A practitioner must be culturally sensitive. One …show more content…
way of understanding trauma within a culture is to learn and understand the idioms of distress of different cultures that could indicate an individual is suffering from a trauma- or stressor-related disorder. Practitioners must also be culturally aware of subgroups such as the deaf population and socioeconomic differences such as in families receiving child welfare preventive services. Fortunately, research has shown these disorders can be treated using a variety of treatments such as patient-centered and trauma-cognizant management, responsive integrative treatment, cognitive behavioral therapy, and psychotherapy. Christian-based spiritual practices also show promising healing in cases of trauma- and stressor-related disorders.
Trauma- and Stressor-Related Disorders Trauma- and stressor-related disorders can be debilitating, disrupting, and at times terrifying. Included in the category of trauma- and stressor-related disorders are reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder (ASD), adjustment disorders, and other specified trauma- and stressor-related disorders. Trauma can happen to any person unexpectedly without discrimination but not everyone who experiences a trauma will develop a trauma- or stressor-related disorder. Not only is there a differentiation in who will actually develop a disorder but different people will also exhibit different symptoms. This paper will provide an overview of these disorders, a discussion of the potential causes, and a summary of treatment options. Although these disorders are devastating there is hope for healing with a holistic approach combining an individual 's biological, psychological, social, and spiritual needs.
An Overview of Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder Reactive attachment disorder (RAD) manifests in children under 5 years of age with a developmental age of at least 9 months who have been deprived of basic emotional and physical needs.
Children who develop this disorder experience neglect and are denied stimulation and affection by their adult caregivers. This disorder is also often seen in children who have been moved from caregiver to caregiver such as in the foster care system. This happens because the child has not been able to spend enough time with any caregiver in order to develop a healthy attachment. Children who are reared in institutions such as orphanages are also at risk for RAD as the children are never able to develop an attachment to any one selected caregiver due to the high child-to caregiver ratio. A persistent type is diagnosed if the child has shown symptoms for over 12 months. Symptoms include emotionally withdrawn behavior in which the child rarely seeks comfort or responds to comfort when distressed on a consistent level. He or she also may have trouble emotionally responding to others, have limited positive affect, and may experience episodes of unexplained irritability, sadness, or fearfulness (American Psychiatric Association (APA), …show more content…
2013).
Disinhibited Social Engagement Disorder In previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), RAD had two subtypes. An Inhibited Type where the child has trouble initiating and responding to social interactions and a Disinhibited Type where the child shows indiscriminate sociability. However, the DSM-5 Disinhibited social engagement disorder (DSED) took the place of the Disinhibited Type. DSED also should only be diagnosed when the child is over the developmental age of 9 months. Children who fit the criteria for DSED have also experienced extreme neglect and deprivation, repeated changes in primary caregivers, and/or high child-to caregiver ratios. These children will display indiscriminate social or physical behavior in front of unfamiliar adults and will show overly familiar verbal and physical behavior. They also may go off with strangers and not check back in with their caregivers, even when they find themselves in unfamiliar surroundings (APA, 2013). Symptoms will cross culturally acceptable boundaries (Velotti, Di Folco, Cesare Zavattini, 2013).
Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) is a disorder in which a person experiences an extreme response to a severe stressor. The stressor could include exposure to an actual or threatened death, serious injury, or sexual injury. These traumas could be experienced personally, witnessed in person, experienced by someone close, or through repeated or extreme exposure except for media reports. In order to receive a diagnosis of PTSD, one must experience at least one avoidance symptom which includes avoiding internal reminders and avoiding external reminders. They also must experience at least two symptoms of negative alterations in cognitions and mood. These include the inability to remember important aspects of the trauma, persistent and exaggerated negative beliefs or expectations about one 's self, others, or the world, persistent excessive blame of self or others about the traumas, persistent negative emotional state, diminished interest or participation in significant activities, feeling of detachment or estrangement from others, and the persistent inability to experience positive emotions. The individual also must experience two symptoms of alterations in arousal and reactivity including irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. All symptoms must began or worsen after the trauma was experienced and must continue for at least one month (Kring, Johnson, Davison & Neale, 2014). Individuals may experience dissociative symptoms such as depersonalization or derealization where one either feels detached from his body or experienced the world in a dream-like state (APA, 2013).
Acute Stress Disorder Acute stress disorder (ASD) is experienced after either exposure to actual or threatened death, serious injury, or sexual violation similar to PTSD. ASD is actually very similar to PTSD with the exception of the duration time as the duration of ASD is shorter compared to PTSD. Symptoms must present between 3 days and 1 month after a trauma occurs (Kring et al., 2014). Symptoms that individuals may experience include intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms (APA, 2014).
Adjustment Disorders Adjustment disorders present within 3 months of the onset of a stressor which can include a single event like the loss of a relationship or multiple stressors such as marital problems. Symptoms of adjustment disorders are more intense and greater in severity than in the normal bereavement process. It is also important to note that symptoms do not continue for more than 6 months after the stressor has ended (APA, 2013).
Other Specified Trauma- and Stressor-Related Disorders The category of other specified trauma- and stressor-related disorders refers to situations in which a patient may not fulfill all diagnostic criteria for a trauma- or stressor-related disorder but his symptoms are causing clinically significant pain. Some examples include the following: the delay of symptoms longer than 3 months after the stressor has occurred; the duration of symptoms longer than 6 months even though the stressor has ceased; Ataque de nervios, a Latino-specific disorder; other cultural syndromes; or persistent complex bereavement disorder in which the individual experiences severe and persistent grief (APA, 2013).
Unspecified Trauma- and Stressor-Related Disorders This category includes any cases where the symptoms are causing the client distress but the symptoms do not fulfill the diagnostic criteria. This category differs from the category of other specified trauma-and stressor-related disorders in that the diagnosing clinician chooses not to specify a disorder due to insufficient information (APA, 2013).
Potential Causes of Trauma- and Stressor-Related Disorders There are many causes related to trauma- and stressor-related disorders. A trauma or extreme stressor must be experienced in order for a diagnosis to be made in one of these disorders. However, not everyone who experiences a trauma or stressor will develop a disorder. There are many causes and factors that can lead to the development of a trauma- or stress-related disorder. However, it is believed that it is the combination and culmination of both biological factors and environmental factors that affect the vulnerability and resilience of whether or not a person will indeed develop a disorder (Jovanovic & Ressler, 2010).This section will focus on these traits that make some individuals more apt to develop a trauma- or stressor-related disorder.
Biological Causes Dissociative symptoms may be present in PTSD and ASD. It is thought that dysfunctional brain development may be at fault and can cause the inhibition of the creation of integrative connections in a child 's developing mind (Weber, 2008). Another genetic predisposition is gender as women are more likely develop both PTSD and ASD. This is due to the sex-linked neurobiological differences in the stress response of males and females. It is also possible that the gender difference is due to the likelihood that women are more prone to traumas such as rape and other interpersonal violence such as domestic violence which is most often linked to ASD (APA, 2013). The neurocircuitry and genetics that control the inhibition of fear is also implicated in the development of PTSD, implicating the areas the amygdala and the prefrontal cortex of the brain. If a person is born with the heredity that allows them the ability to remain resilient in times of extreme trauma such as severe child abuse, they may avoid the psychopathology that many individuals may experience (Jovanovic & Ressler, 2010).
Personality
The personality traits of a person can actually impact the formation of a disorder. For instance, it was found that traits such as disagreeableness, emotional instability, introversion, and compulsivity could positively predict both internalizing and externalizing problem behavior (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). Elevated reactivity is also implicated in predicting ASD (APA, 2013).
Environment
A person 's environment is thought to be an immense factor in the development of a trauma- or stressor-related disorder.
The diagnoses of both RAD and DSED depend on the environmental trauma of extreme neglect (APA, 2013). Infants and small children need to form secure attachments in order to feel safe. When secure and consistent attachments are not formed, children learn they cannot depend on their caregivers. Therefore, they never learn the appropriate approach to obtain comfort from their caregivers (Velotti, Di Folco, & Cesare Zavattini, 2013). Even inconsistent, harsh discipline strategies, limited warmth, and lack of responsiveness or rejection can influence the development of psychopathological behavior in children (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). Another environmental risk factor is the exposure to trauma by one 's parent. One study examining the trauma exposure of mothers whose children were involved in the child welfare (CW) system showed that 91.6% of the mothers had experienced at least one traumatic event and 92.2% reported that their children had experienced at least one traumatic event. This shows that children whose are raised in an environment with parents who have experienced trauma are themselves prone to experience trauma (Chemtob, Griffing, Tullberg, Roberts, & Ellis, 2011). Other environmental factors that may influence the development of a trauma- or stressor-related disorder include lower socio-economic status, lower
education, and other disadvantaged life circumstances (APA, 2013).
Type of Trauma The highest rates of disorders tend to occur when the trauma was interpersonal such as in cases of assault, rape, or witnessing a mass shooting. Lower rates of trauma- and stressor-related disorders are reported when the trauma was not interpersonal such as car accidents, industrial incidents, burns, or mild brain injuries. The severity of the trauma also effects the development of PTSD (APA, 2014).
Past History It is thought that childhood-onset psychopathology may progress in a more maladaptive course as opposed to psychopathology that is brought on as an adolescent (De Clercq, Van Leeuwen, De Fruyt, Van Hiel, & Mervielde, 2008). It is also believed that experiencing an episode of ASD seems to make it more likely that one will develop PTSD within 2 years and treating ASD may help prevent the development of PTSD (Kring, 2014). It is also shown that repeated trauma such as emotional, physical, and sexual abuse can lead to PTSD, complex PTSD, or dissociative disorders (Mauritz, Goossens, Draijer & van Achterberg, 2013).
Evaluating and Treating Trauma- and Stressor-Related Disorders The evaluation and treatment of trauma and stressor-related disorders should be handled with care and much consideration. Due to the overlap of symptoms with other disorders in the DSM-5 such as anxiety disorders, OCD and related disorders, and dissociative disorders, trauma- and stressor-related disorders are often under diagnosed. Without the proper assessment, the client will not receive the proper diagnosis and therefore will not receive the best treatment.
Assessment
Differential diagnoses and comorbidity. When diagnosing any disorder, care should be taken to differentiate between disorders as many symptoms are present in more than one disorder. When assessing children presenting with RAD, clinicians should be sure to differentiate that the diagnosis is actually RAD and not autism spectrum disorder, an intellectual developmental disorder, or a depressive disorder (APA, 2013). DSED should be differentiated from attention-deficit/hyperactivity disorder (ADHD) as both disorders are characterized by impulsivity (Velotti, Di Folco, Cesare Zavattini, 2013). However, children with DSED do not have problems with attention or hyperactivity. PTSD can be confused with diagnoses of an adjustment disorder, other posttraumatic disorders and condition, ASD, anxiety disorders and obsessive-compulsive disorder (OCD), major depressive disorder, personality disorders, dissociative disorders, conversion disorder, psychotic disorders, or traumatic brain injury. ASD can be misdiagnosed with an adjustment disorder, panic disorder dissociative disorders, PTSD, OCD, psychotic disorders, or traumatic brain injury. A diagnosis of adjustment disorder should be differentiated from major depressive disorder, PTSD, ASD, personality disorders, (APA, 2013). It is also important to take care assessing those who have severe mental illness (SMI) as the diagnosis of trauma- and stressor-related disorders is often overlooked due to a number of factors (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Comorbidity is another issue that may hinder the diagnosis of those with trauma- and stressor-related disorders. Children with RAD may be diagnosed with cognitive or language delays, stereotypies as well as depressive symptoms. As RAD is a disorder diagnosed following severe neglect, children also may suffer with malnutrition. Children with DSED also may be diagnosed with cognitive and language delays and stereotypies as well as ADHD. Those with PTSD are about 80% more likely to develop another disorder such as depressive, bipolar, anxiety, or substance use disorders (APA, 2013). Cultural implications. Cultural differences can often lead to the misdiagnosis of any mental disorder. However, it is reported that attachment behaviors are relatively the same throughout cultures. PTSD may have some cultural implications however. First, the onset and severity may differ which can be attributable to different types of traumatic experiences such as genocide, funerary rites issues, living in post-conflict settings, immigration stress, or even religious persecution. Symptoms may also vary according to culture (APA, 2013). Idioms of distress are defined as the mode to express distress and they are shaped by a culture 's values, norms, themes, and health concerns. This is another cultural implication that may indicate trauma exposure, various types of psychopathology and levels of distress, as well as risk and functioning. Idioms of distress also may influence the way an individual understands his trauma- or stressor-related disorder as well as help-seeking and self-treatment patterns. These are metaphorical expressions that are linked to conflicts of the culture and based on how the body and mind functions. One example is the American epidemic of lower back pain which is associated with overwork, stress, and moral failure (Hilton & Lewis-Fernandez, 2010). The deaf population is a subculture in which clinicians need to understand in order to not misdiagnose a trauma- or stressor-related disorder. Unfortunately, deaf children experience trauma at much higher rates than hearing children which often leads to behavioral and emotional problems including PTSD, anxiety, and depression. Deaf individuals may experience symptoms differently than hearing individuals. Symptoms such as hypervigilance and hyperactivity are connected with ADHD but could also be an arousal symptom of trauma and clinicians should be aware of the differentiation of symptom prevalence (Schwenke, 2011).
Treatment
When treating trauma- and stressor-related disorders in those with SMI, it has been thought by many clinicians that treating the trauma would lead to more distress in the patient but there is no evidence for this claim (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Though trauma- and stressor-related disorders can be quite distressing, there are many treatments available and many other treatments continually being studied to help bring support and healing to those suffering with these disorders. Attachment therapy. In the cases of RAD and DSED, there is thought to be a reasonable correlation between prognosis of these disorders and the quality of the care giving that is received after the neglect has taken place. This means that simply a change in environment where the child can begin to make secure attachments could aid in the child 's recovery (APA, 2013). Also aiding in the healing of children who have been severely mistreated is dyadic developmental therapy. This therapy does not use intrusive or dangerous treatment interventions but instead consists of treatment based on attachment theory provided by one therapist in an outpatient setting. One study showed that children receiving this treatment experience significant decreases in symptoms of attachment disorder, withdrawn behaviors, anxiety and depression, social problems, thought problems, attention problems, rule-breaking behaviors, and aggressive behaviors (Becker-Weidman, 2006). The attachment theory is also shown to be effective in a case study of a little boy named Tom who suffered from a severe case of RAD. He was also treated in an outpatient setting where human connection was promoted first and foremost (Shi, 2014). Cognitive behavior therapy. One study examining the treatment for ASD in an adolescent girl found that the combination of trauma-focused cognitive behaviour therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) was an effective treatment. Before receiving this treatment, the girl experienced distressing memories, anxiety, and flashbacks. After receiving this treatment, the girl reported she experienced no more flashbacks of her injury, no problems sleeping, and no more recurrent and distressing memories. This treatment is especially promising for helping to prevent the development of PTSD and for helping children and adolescents who have had a life-threatening medical event take place (Bronner, Beer, van Zelm van Eldik, Grootenhuis, & Last, 2009). Responsive integrative treatment. This treatment model integrates cognitive-behavioral, psychodynamic, and process/experiential psychotherapy in order to help those with straightforward cases of PTSD. There are many empirically supported treatments (ESTs) showing efficiency in treating PTSD but these treatments can lead to rigidity in treatment. Clinicians oftentimes feel as though they must strictly follow a set treatment plan. However, it may be best to teach clinicians how to let the client 's values and circumstances guide the treatment course. This treatment encourages the idea of responsiveness where the clinician remains open to changing the formulation of the treatment plan from moment to moment. In order to achieve this level of responsiveness, the clinician must remain checked in with the client constantly (Edwards, 2013). Holistic therapy. A holistic approach to treating trauma- and stressor-related disorders includes treating mind, body, and spirit in order to achieve healing. The most neglected part of using a holistic approach in PTSD is the spiritual factor (Weis, 2010). However, it is known that the experience of trauma can have a profound effect on one 's spirituality. This effect can either be negative or positive, leading an individual closer to his spirituality or farther away. In order to treat patients suffering with a trauma- or stressor-related disorder that have been pushed away from God due to their traumatic experience, it is important to help the client first come to see themselves the way God sees them. This is called a truthful self-image. Oftentimes, people who experience a trauma, lose their spiritual identity and can only see themselves as a victim. It is important to remind patients of their truthful self-image as this can help the patient heal quickly and wholly and help them make healthy, responsible life choices. Trauma victims also need to have a truthful God image. Individuals often develop an image of God that encompasses the attributes of one 's parents, one 's own negative self-images, or even the attributes of one 's perpetrator. Thirdly, clinicians can help their clients overcome trauma by helping them to learn how to let love into their lives. Those who experience trauma usually have trouble with trust and see themselves as unworthy of love and support. Clinicians can help clients struggling with this by modeling love, support, and acceptance. Group therapy is also beneficial in this area (Berrett, Hardman, O 'Grady, & Richards, 2007). Future Research There has been expansive research in the areas of trauma- and stressor-related disorders. However, there is still much to be known. In the area of RAD, little is known about the evolution and behavioral phenotype throughout the lifespan of the child. This could be helped with the completion of longitudinal studies between the ages of 4 and 8 of the child (Velotti, Di Folco, & Cesare Zavattini, 2013). Future research is also needed in the area of working with the deaf population. Because of the communication differences between hearing and deaf clients, it requires some creativity in the treatment process. Some early work has been done using certain types of play therapy with good results but more empirical studies are needed (Schwenke, 2011). There is also future research needed in the area of PTSD and SMI. Physical neglect, emotional neglect, and emotional abuse are all thought to increase the risk of developing PTSD and therefore should receive greater attention in future research (Mauritz, Goossens, Draijer, & van Achterberg, 2013). Eye movement desensitization and reprocessing (EMDR) is also in need of future research as the literature is lacking in this area. Although it seems to have benefits when treating those with trauma- and stressor-related disorders, it is unknown how EDMR is related to the beneficial results seen with those who receive this treatment.
Conclusion
In conclusion, trauma- and stressor-related disorders are extremely complex in symptomology, causes, assessment techniques and treatment. Study in this area is very important as living with these disorders can have a terribly distressing impact in the life of an individual suffering with one of these disorders. Research is abundant in many areas and it is seen that hope and healing are within reach for those in pain. Combining treatments such as cognitive-behavioral therapy with a compassionate and nurturing environment along with the healing powers of God can provide the greatest amount of help.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Berrett, M., Hardman, R., O 'Grady, K., & Richards, S. (2007). The role of spirituality in the treatment of trauma and eating disorders: Recommendations for clinical practice. Eating Disorders, 15, 373-389. doi: 10.1080/10640260701454394
Becker-Weidman, A. (2006). Treatment for children with trauma-attachment disorders: Dyadic developmental psychotherapy. Child& Adolescent Social Work Journal, 23(2), 147-171. doi:10.1007/s10560-005-0039-0
Bronner, M., Beer, R., Jozine van Zelm van Eldik, M., Grootenhuis, M., & Last, B. (2009). Reducing acute stress in a 16-year old using trauma-focused cognitive behaviour therapy and eye movement desensitization and reprocessing. Developmental Neurorehabilitation, 12(3), 170-174. doi: 10.1080/17518420902858975
Chemtob, C.M., Griffing, S., Tullberg, E., Roberts, E., & Ellis, P. (2011). Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services. Child Welfare, 90(6), 109-127.
De Clercq, B., Van Leeuwen, K., De Fruyt, F., Van Hiel, A., & Mervielde, I. (2008). Maladaptive personality traits and psychopathology in childhood and adolescence: The moderating effect of parenting. Journal of Personality, 76(2), 357-383. doi:10.1111/j.1467- 6494.2007.00489.x
Edwards, D. (2013). Responsive integrative treatment of clients with PTSD and trauma-related disorders: An expanded evidence-based model. Journal of Psychology in Africa, 23(1), 7- 19.
Hinton, D., & Lewis-Fernandex, R. (2010). Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine And Psychiatry, 34(2), 209-218. doi:10.1007/s11013- 101-9175-x
Jovanovic, T., & Ressler, K. How the neurocircuitry and genetics of fear inhibition may inform our understanding of PTSD. American Journal of Psychiatry,167, 648-662. doi:10.1176/appi.ajp.2009.09071074
Kring, A., Johnson, S., Davison, G., & Neale, J. (2014).Abnormal psychology . (12 ed.). Hoboken, NJ: John Wiley & Sons, Inc.
Mauritz, M.W., Goossens, P.J., Draijer, N., & van Achterberg, T. (2013). Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness. European Journal of Psychotraumatology, 4, 1-15. doi:10.3402/ejpt.v4i019985
Schwenke, T. (2011). Childhood trauma: Considering diagnostic and culturally sensitive treatment approaches for deaf clients. Journal of the American Deafness & Rehabilitation Association (JADARA), 45(1), 158-173.
Shi, L. (2014). Treatment of reactive attachment disorder in young children: Importance of understanding emotional dynamics. American Journal of Family Therapy, 42(1), 1-13. doi:10.1080/01926187.2013.763513
Velotti, P., Di Folco, S., & Cesare Zavattini, G. (2013). What we know about 'attachment disorders ' in childhood. Journal of Special Education & Rehabilitation, 14(3/4), 61-77. doi:10.2478/jser-2013-001110.2478
Weber, S. (2008). Diagnosis of trauma and abuse-related dissociative symptom disorders in children and adolescents. Journal of Child & Adolescent Psychiatric Nursing, 21(4), 205- 212.
Weis, M. (2010). Integrated and Holistic Treatment Approach to PTSD and SUD: A Synergy. Journal Of Addictions & Offender Counseling, 31(1), 25-37.