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Module 5: Trauma- and Stressor-Related Disorders

3rd edition as of July 2023


Module Overview

In Module 5, we will discuss matters related to trauma- and stressor-related disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will consist of PTSD, acute stress disorder, adjustment disorder, and prolonged grief disorder. Prior to discussing these clinical disorders, we will explain what stressors are, as well as identify common stressors that may lead to a trauma- or stressor-related disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of models to explain psychopathology (Module 2), and descriptions of various therapies (Module 3).


Module Outline


Module Learning Outcomes

  • Define and identify common stressors.
  • Describe how trauma- and stressor-related disorders present.
  • Describe the epidemiology of trauma- and stressor-related disorders.
  • Describe comorbidity in relation to trauma- and stressor-related disorders.
  • Describe the etiology of trauma- and stressor-related disorders.
  • Describe treatment options for trauma- and stressor-related disorders.


5.1. Stressors


Section Learning Objectives

  • Define stressor.
  • Identify and describe common stressors.


Before we dive into clinical presentations of four of the trauma and stress-related disorders, let’s discuss common events that precipitate a stress-related diagnosis. A stress disorder occurs when an individual has difficulty coping with or adjusting to a recent stressor. Stressors can be any event—either witnessed firsthand, experienced personally, or experienced by a close family member—that increases physical or psychological demands on an individual. These events are significant enough that they pose a threat, whether real or imagined, to the individual. While many people experience similar stressors throughout their lives, only a small percentage of individuals experience significant maladjustment to the event that psychological intervention is warranted.

Among the most studied triggers for trauma-related disorders are combat and physical/sexual assault. Symptoms of combat-related trauma date back to World War I when soldiers would return home with “shell shock” (Figley, 1978). Unfortunately, it was not until after the Vietnam War that significant progress was made in both identifying and treating war-related psychological difficulties (Roy-Byrne et al., 2004). With the more recent wars in Iraq and Afghanistan, attention was again focused on posttraumatic stress disorder  (PTSD) symptoms due to the large number of service members returning from deployments and reporting significant trauma symptoms.

Physical assault, and more specifically sexual assault, is another commonly studied traumatic event. Rape, or forced sexual intercourse or other sexual act committed without an individual’s consent, occurs in one out of every five women and one in every 71 men (Black et al., 2011). Unfortunately, this statistic likely underestimates the actual number of cases that occur due to the reluctance of many individuals to report their sexual assault. Of the reported cases, it is estimated that nearly 81% of female and 35% of male rape victims report both acute stress disorder and posttraumatic stress disorder symptoms (Black et al., 2011).

Now that we have discussed a little about some of the most commonly studied traumatic events, we will now examine the clinical presentation of posttraumatic stress disorder, acute stress disorder, adjustment disorder, and prolonged grief disorder.


Key Takeaways

You should have learned the following in this section:

  • A stressor is any event that increases physical or psychological demands on an individual.
  • It does not have to be personally experienced but can be witnessed or occur to a close family member or friend to have the same effect.
  • Only a small percentage of people experience significant maladjustment due to these events.
  • The most studied triggers for trauma-related disorders include physical/sexual assault and combat.


Section 5.1 Review Questions

  1. Given an example of a stressor you have experienced in your own life.
  2. Why are the triggers of physical/sexual assault and combat more likely to lead to a trauma-related disorder?



5.2. Clinical Presentation


Section Learning Objectives

  • Describe how PTSD presents.
  • Describe how acute stress disorder presents.
  • Describe how adjustment disorder presents.
  • Describe how prolonged grief disorder presents.


5.2.1. Posttraumatic Stress Disorder

Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the development of physiological, psychological, and emotional symptoms following exposure to a traumatic event. Individuals must have been exposed to a situation where actual or threatened death, sexual violence, or serious injury occurred. Examples of these situations include but are not limited to witnessing a traumatic event as it occurred to someone else; learning about a traumatic event that occurred to a family member or close friend; directly experiencing a traumatic event; or being exposed to repeated events where one experiences an aversive event (e.g., victims of child abuse/neglect, ER physicians in trauma centers, etc.).

It is important to understand that while the presentation of these symptoms varies among individuals, to meet the criteria for a diagnosis of PTSD, individuals need to report symptoms among the four different categories of symptoms. Category 1: Recurrent experiences. The first category involves recurrent experiences of the traumatic event, which can occur via dissociative reactions such as flashbacks; recurrent, involuntary, and intrusive distressing memories; or even recurrent distressing dreams (APA, 2022, pgs. 301-2). These recurrent experiences must be specific to the traumatic event or the moments immediately following to meet the criteria for PTSD. Regardless of the method, the recurrent experiences can last several seconds or extend for several days. They are often initiated by physical sensations similar to those experienced during the traumatic events or environmental triggers such as a specific location. Because of these triggers, individuals with PTSD are known to avoid stimuli (i.e., activities, objects, people, etc.) associated with the traumatic event. One or more of the intrusion symptoms must be present. Category 2: Avoidance of stimuli. The second category involves avoidance of stimuli related to the traumatic event and either one or both of the following must be present. First, individuals with PTSD may be observed trying to avoid the distressing thoughts, memories, and/or feelings related to the memories of the traumatic event. Second, they may prevent these memories from occurring by avoiding physical stimuli such as locations, individuals, activities, or even specific situations that trigger the memory of the traumatic event. Category 3: Negative alterations in cognition or mood. The third category experienced by individuals with PTSD is negative alterations in cognition or mood and at least two of the symptoms described below must be present. This is often reported as difficulty remembering an important aspect of the traumatic event. It should be noted that this amnesia is not due to a head injury, loss of consciousness, or substances, but rather, due to the traumatic nature of the event. The impaired memory may also lead individuals to have false beliefs about the causes of the traumatic event, often blaming themselves or others. An overall persistent negative state, including a generalized negative belief about oneself or others is also reported by those with PTSD. Similar to those with depression, individuals with PTSD may report a reduced interest in participating in previously enjoyable activities, as well as the desire to engage with others socially. They also report not being able to experience positive emotions. Category 4: Alterations in arousal and reactivity. The fourth and final category is alterations in arousal and reactivity and at least two of the symptoms described below must be present. Because of the negative mood and increased irritability, individuals with PTSD may be quick-tempered and act out aggressively, both verbally and physically. While these aggressive responses may be provoked, they are also sometimes unprovoked. It is believed these behaviors occur due to the heightened sensitivity to potential threats, especially if the threat is similar to their traumatic event. More specifically, individuals with PTSD have a heightened startle response and easily jump or respond to unexpected noises just as a telephone ringing or a car backfiring. They also experience significant sleep disturbances, with difficulty falling asleep, as well as staying asleep due to nightmares; engage in reckless or self-destructive behavior, and have problems concentrating.

Although somewhat obvious, these symptoms likely cause significant distress in social, occupational, and other (i.e., romantic, personal) areas of functioning. Duration of symptoms is also important, as PTSD cannot be diagnosed unless symptoms have been present for at least one month. If symptoms have not been present for a month, the individual may meet criteria for acute stress disorder (see below).


5.2.2. Acute Stress Disorder

Acute stress disorder is very similar to PTSD except for the fact that symptoms must be present from 3 days to 1 month following exposure to one or more traumatic events. If the symptoms are present after one month, the individual would then meet the criteria for PTSD. Additionally, if symptoms present immediately following the traumatic event but resolve by day 3, an individual would not meet the criteria for acute stress disorder.

Symptoms of acute stress disorder follow that of PTSD with a few exceptions. PTSD requires symptoms within each of the four categories discussed above; however, acute stress disorder requires that the individual experience nine symptoms across five different categories (intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms; note that in total, there are 14 symptoms across these five categories). For example, an individual may experience several arousal and reactivity symptoms such as sleep issues, concentration issues, and hypervigilance, but does not experience issues regarding negative mood. Regardless of the category of the symptoms, so long as nine symptoms are present and the symptoms cause significant distress or impairment in social, occupational, and other functioning, an individual will meet the criteria for acute stress disorder.


Making Sense of the Disorders

In relation to trauma- and stressor-related disorders, note the following:

  • Diagnosis PTSD …… if symptoms have been experienced for at least one month
  • Diagnosis acute stress disorder … if symptoms have been experienced for 3 days to one month


5.2.3. Adjustment Disorder

Adjustment disorder is the least intense of the three disorders discussed so far in this module. An adjustment disorder occurs following an identifiable stressor that happened within the past 3 months. This stressor can be a single event (loss of job, death of a family member) or a series of multiple stressors (cancer treatment, divorce/child custody issues).

Unlike PTSD and acute stress disorder, adjustment disorder does not have a set of specific symptoms an individual must meet for diagnosis. Rather, whatever symptoms the individual is experiencing must be related to the stressor and must be significant enough to impair social, occupational, or other important areas of functioning and causes marked distress “…that is out of proportion to the severity or intensity of the stressor” (APA, 2022, pg. 319).

It should be noted that there are modifiers associated with adjustment disorder. Due to the variety of behavioral and emotional symptoms that can be present with an adjustment disorder, clinicians are expected to classify a patient’s adjustment disorder as one of the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, or unspecified if the behaviors do not meet criteria for one of the aforementioned categories. Based on the individual’s presenting symptoms, the clinician will determine which category best classifies the patient’s condition. These modifiers are also important when choosing treatment options for patients.


5.2.4. Prolonged Grief Disorder

The DSM-5 included a condition for further study called persistent complex bereavement disorder. In 2018, a proposal was submitted to include this category in the main text of the manual and after careful review of the literature and approval of the criteria, it was accepted in the second half of 2019 and added as a new diagnostic entity called prolonged grief disorder. Prolonged grief disorder is defined as an intense yearning/longing and/or preoccupation with thoughts or memories of the deceased who died at least 12 months ago. The individual will present with at least three symptoms to include feeling as though part of oneself has died, disbelief about the death, emotional numbness, feeling that life is meaningless, intense loneliness, problems engaging with friends or pursuing interests, intense emotional pain, and avoiding reminders that the person has died.

Individuals with prolonged grief disorder often hold maladaptive cognitions about the self, feel guilt about the death, and hold negative views about life goals and expectancy. Harmful health behaviors due to decreased self-care and concern are also reported. They may also experience hallucinations about the deceased, feel bitter an angry be restless, blame others for the death, and see a reduction in the quantity and quality of sleep (APA, 2022).


Key Takeaways

You should have learned the following in this section:

  • In terms of stress disorders, symptoms lasting over 3 days but not exceeding one month, would be classified as acute stress disorder while those lasting over a month are typical of PTSD.
  • If symptoms begin after a traumatic event but resolve themselves within three days, the individual does not meet the criteria for a stress disorder.
  • Symptoms of PTSD fall into four different categories for which an individual must have at least one symptom in each category to receive a diagnosis. These categories include recurrent experiences, avoidance of stimuli, negative alterations in cognition or mood, and alterations in arousal and reactivity.
  • To receive a diagnosis of acute stress disorder an individual must experience nine symptoms across five different categories (intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms).
  • Adjustment disorder is the last intense of the three disorders and does not have a specific set of symptoms of which an individual has to have some number. Whatever symptoms the person presents with, they must cause significant impairment in areas of functioning such as social or occupational, and several modifiers are associated with the disorder.
  • Prolonged grief disorder is a new diagnostic entity in the DSM-5-TR and is defined as an intense yearning/longing and/or preoccupation with thoughts or memories of the deceased who died at least 12 months ago.


Section 5.2 Review Questions

  1. What is the difference in diagnostic criteria for PTSD, Acute Stress Disorder, and Adjustment Disorder?
  2. What are the four categories of symptoms for PTSD? How do these symptoms present in Acute Stress Disorder and Adjustment Disorder?
  3. What is prolonged grief disorder?


5.3. Epidemiology


Section Learning Objectives

  • Describe the epidemiology of PTSD.
  • Describe the epidemiology of acute stress disorder.
  • Describe the epidemiology of adjustment disorders.
  • Describe the epidemiology of prolonged grief disorder.


5.3.1. PTSD

The national lifetime prevalence rate for PTSD using DSM-IV criteria is 6.8% for U.S. adults and 5.0% to 8.1% for U.S. adolescents. There are currently no definitive, comprehensive population-based data using DSM-5 though studies are beginning to emerge (APA, 2022). It should not come as a surprise that the rates of PTSD are higher among veterans and others who work in fields with high traumatic experiences (i.e., firefighters, police, EMTs, emergency room providers). In fact, PTSD rates for combat veterans are estimated to be as high as 30% (NcNally, 2012). Between one-third and one-half of all PTSD cases consist of rape survivors, military combat and captivity, and ethnically or politically motivated genocide (APA, 2022).

Concerning gender, PTSD is more prevalent among females (8% to 11%) than males (4.1% to 5.4%), likely due to their higher occurrence of exposure to traumatic experiences such as childhood sexual abuse, rape, domestic abuse, and other forms of interpersonal violence. Women also experience PTSD for a longer duration. (APA, 2022). Gender differences are not found in populations where both males and females are exposed to significant stressors suggesting that both genders are equally predisposed to developing PTSD. Prevalence rates vary slightly across cultural groups, which may reflect differences in exposure to traumatic events. More specifically, prevalence rates of PTSD are highest for African Americans, followed by Latinx Americans and European Americans, and lowest for Asian Americans (Hinton & Lewis-Fernandez, 2011). According to the DSM-5-TR, there are higher rates of PTSD among Latinx, African-Americans, and American Indians compared to whites, and likely due to exposure to past adversity and racism and discrimination (APA, 2022).


5.3.2. Acute Stress Disorder

The prevalence rate for acute stress disorder varies across the country and by traumatic event. Accurate prevalence rates for acute stress disorder are difficult to determine as patients must seek treatment within 30 days of the traumatic event. Despite that, it is estimated that anywhere between 7-30% of individuals experiencing a traumatic event will develop acute stress disorder (National Center for PTSD). While acute stress disorder is not a good predictor of who will develop PTSD, approximately 50% of those with acute stress disorder do eventually develop PTSD (Bryant, 2010; Bryant, Friedman, Speigel, Ursano, & Strain, 2010).

As with PTSD, acute stress disorder is more common in females than males; however, unlike PTSD, there may be some neurobiological differences in the stress response, gender differences in the emotional and cognitive processing of trauma, and sociocultural factors that contribute to females developing acute stress disorder more often than males (APA, 2022). With that said, the increased exposure to traumatic events among females may also be a strong reason why women are more likely to develop acute stress disorder.


5.3.3. Adjustment Disorder

Adjustment disorders are relatively common as they describe individuals who are having difficulty adjusting to life after a significant stressor. In psychiatric hospitals in the U.S., Australia, Canada, and Israel, adjustment disorders accounted for roughly 50% of the admissions in the 1990s. It is estimated that anywhere from 5-20% of individuals in outpatient mental health treatment facilities have an adjustment disorder as their principal diagnosis. Adjustment disorder has been found to be higher in women than men (APA, 2022).


5.3.4. Prolonged Grief Disorder

As this is a new disorder, the prevalence of DSM-5 prolonged grief disorder is currently unknown. Using a different definition of the disorder a meta-analysis of studies across four continents suggests a pooled prevalence of 9.8%. It should be noted that these studies could only be loosely compared with one another making the reported prevalence rate questionable.


Key Takeaways

You should have learned the following in this section:

  • Regarding PTSD, rates are highest among people who are likely to be exposed to high traumatic events, women, and minorities.
  • As for acute stress disorder, prevalence rates are hard to determine since patients must seek medical treatment within 30 days, but females are more likely to develop the disorder.
  • Adjustment disorders are relatively common since they occur in individuals having trouble adjusting to a significant stressor, though women tend to receive a diagnosis more than men.


Section 5.3 Review Questions

  1. Compare and contrast the prevalence rates among the trauma and stress-related disorders.
  2. What do we know about the prevalence rate for prolonged grief disorder and why?


5.4. Comorbidity


Section Learning Objectives

  • Describe the comorbidity of PTSD.
  • Describe the comorbidity of acute stress disorder.
  • Describe the comorbidity of adjustment disorder.
  • Describe the comorbidity of prolonged grief disorder.


5.4.1. PTSD

Given the traumatic nature of the disorder, it should not be surprising that there is a high comorbidity rate between PTSD and other psychological disorders. Individuals with PTSD are more likely than those without PTSD to report clinically significant levels of depressive, bipolar, anxiety, or substance abuse-related symptoms (APA, 2022). There is also a strong relationship between PTSD and major neurocognitive disorders, which may be due to the overlapping symptoms between these disorders (Neurocognitive Disorders will be covered in Module 14).


5.4.2. Acute Stress Disorder

Because 30 days after the traumatic event, acute stress disorder becomes PTSD (or the symptoms remit), the comorbidity of acute stress disorder with other psychological disorders has not been studied. While acute stress disorder and PTSD cannot be comorbid disorders, several studies have explored the relationship between the disorders to identify individuals most at risk for developing PTSD. The literature indicates roughly 80% of motor vehicle accident survivors, as well as assault victims, who met the criteria for acute stress disorder went on to develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Bryant & Harvey, 1998; Harvey & Bryant, 1998). While some researchers indicated acute stress disorder is a good predictor of PTSD, others argue further research between the two and confounding variables should be explored to establish more consistent findings.


5.4.3. Adjustment Disorder

Unlike most of the disorders we have reviewed thus far, adjustment disorders have a high comorbidity rate with various other medical conditions (APA, 2022). Often following a critical or terminal medical diagnosis, an individual will meet the criteria for adjustment disorder as they process the news about their health and the impact their new medical diagnosis will have on their life. Other psychological disorders are also diagnosed with adjustment disorder; however, symptoms of adjustment disorder must be met independently of the other psychological condition. For example, an individual with adjustment disorder with depressive mood must not meet the criteria for a major depressive episode; otherwise, the diagnosis of MDD should be made over adjustment disorder. As the DSM-5-TR says, “adjustment disorders are common accompaniments of medical illness and may be the major psychological response to a medical condition” (APA, 2022).


5.4.4. Prolonged Grief Disorder

Prolonged grief disorder is commonly comorbid with MDD, PTSD if the death occurred in violent or accidental circumstances, substance use disorders, and separation anxiety disorder.


Key Takeaways

You should have learned the following in this section:

  • PTSD has a high comorbidity rate with psychological and neurocognitive disorders while this rate is hard to establish with acute stress disorder since it becomes PTSD after 30 days.
  • Adjustment disorder has a high comorbidity rate with other medical conditions as people process news about their health and what the impact of a new medical diagnosis will be on their life.
  • Prolonged grief disorder has a high comorbidity with PTSD, MDD, separation anxiety disorder, and substance use disorders.


Section 5.4 Review Questions

  1. What are the most common comorbidities among trauma and stress-related disorders?
  2. Why is it hard to establish comorbidities for acute stress disorder?


5.5. Etiology


Section Learning Objectives

  • Describe the biological causes of trauma- and stressor-related disorders.
  • Describe the cognitive causes of trauma- and stressor-related disorders.
  • Describe the social causes of trauma- and stressor-related disorders.
  • Describe the sociocultural causes of trauma- and stressor-related disorders.


5.5.1. Biological

HPA axis. One theory for the development of trauma and stress-related disorders is the over-involvement of the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is involved in the fear-producing response, and some speculate that dysfunction within this axis is to blame for the development of trauma symptoms. Within the brain, the amygdala serves as the integrative system that inherently elicits the physiological response to a traumatic/stressful environmental situation. The amygdala sends this response to the HPA axis to prepare the body for “fight or flight.” The HPA axis then releases hormones—epinephrine and cortisol—to help the body to prepare to respond to a dangerous situation (Stahl & Wise, 2008). While epinephrine is known to cause physiological symptoms such as increased blood pressure, increased heart rate, increased alertness, and increased muscle tension, to name a few, cortisol is responsible for returning the body to homeostasis once the dangerous situation is resolved.

Researchers have studied the amygdala and HPA axis in individuals with PTSD, and have identified heightened amygdala reactivity in stressful situations, as well as excessive responsiveness to stimuli that is related to one’s specific traumatic event (Sherin & Nemeroff, 2011). Additionally, studies have indicated that individuals with PTSD also show a diminished fear extinction, suggesting an overall higher level of stress during non-stressful times. These findings may explain why individuals with PTSD experience an increased startle response and exaggerated sensitivity to stimuli associated with their trauma (Schmidt, Kaltwasser, & Wotjak, 2013).


5.5.2. Cognitive

Preexisting conditions of depression or anxiety may predispose an individual to develop PTSD or other stress disorders. One theory is that these individuals may ruminate or over-analyze the traumatic event, thus bringing more attention to the traumatic event and leading to the development of stress-related symptoms. Furthermore, negative cognitive styles or maladjusted thoughts about themselves and the environment may also contribute to PTSD symptoms. For example, individuals who identify life events as “out of their control” report more severe stress symptoms than those who feel as though they have some control over their lives (Catanesi et al., 2013).


5.5.3. Social

While this may hold for many psychological disorders, social and family support have been identified as protective factors for individuals prone to develop PTSD. More specifically, rape victims who are loved and cared for by their friends and family members as opposed to being judged for their actions before the rape, report fewer trauma symptoms and faster psychological improvement (Street et al., 2011).


5.5.4. Sociocultural

As was mentioned previously, different ethnicities report different prevalence rates of PTSD. While this may be due to increased exposure to traumatic events, there is some evidence to suggest that cultural groups also interpret traumatic events differently, and therefore, may be more vulnerable to the disorder. Hispanic Americans have routinely been identified as a cultural group that experiences a higher rate of PTSD. Studies ranging from combat-related PTSD to on-duty police officer stress, as well as stress from a natural disaster, all identify Hispanic Americans as the cultural group experiencing the most traumatic symptoms (Kaczkurkin et al., 2016; Perilla et al., 2002; Pole et al., 2001).

Women also report a higher incidence of PTSD symptoms than men. Some possible explanations for this discrepancy are stigmas related to seeking psychological treatment, as well as a greater risk of exposure to traumatic events that are associated with PTSD (Kubiak, 2006).  Studies exploring rates of PTSD symptoms for military and police veterans have failed to report a significant gender difference in the diagnosis rate of PTSD suggesting that there is not a difference in the rate of occurrence of PTSD in males and females in these settings (Maguen, Luxton, Skopp, & Madden, 2012).


Key Takeaways

You should have learned the following in this section:

  • In terms of causes for trauma- and stressor-related disorders, an over-involvement of the hypothalamic-pituitary-adrenal (HPA) axis has been cited as a biological cause, with rumination and negative coping styles or maladjusted thoughts emerging as cognitive causes.
  • Culture may lead to different interpretations of traumatic events thus causing higher rates among Hispanic Americans.
  • Social and family support have been found to be protective factors for individuals most likely to develop PTSD.


Section 5.5 Review Questions

  1. Discuss the four etiological models of the trauma- and stressor-related disorders. Which model best explains the maintenance of trauma/stress symptoms? Which identifies protective factors for the individual?


5.6. Treatment


Section Learning Objectives

  • Describe the treatment approach of the psychological debriefing.
  • Describe the treatment approach of exposure therapy.
  • Describe the treatment approach of CBT.
  • Describe the treatment approach of Eye Movement Desensitization and Reprocessing (EMDR).
  • Describe the use of psychopharmacological treatment.


5.6.1. Psychological Debriefing

One way to negate the potential development of PTSD symptoms is thorough psychological debriefing. Psychological debriefing is considered a type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event (Kinchin, 2007). While there are a few different methods to a psychological debriefing, they all follow the same general format:

  1. Identifying the facts (what happened?)
  2. Evaluating the individual’s thoughts and emotional reaction to the events leading up to the event, during the event, and then immediately following
  3. Normalizing the individual’s reaction to the event
  4. Discussing how to cope with these thoughts and feelings, as well as creating a designated social support system (Kinchin, 2007).

Throughout the last few decades, there has been a debate on the effectiveness of psychological debriefing. Those within the field argue that psychological debriefing is not a means to cure or prevent PTSD, but rather, psychological debriefing is a means to assist individuals with a faster recovery time posttraumatic event (Kinchin, 2007). Research across a variety of traumatic events (i.e., natural disasters, burns, war) routinely suggests that psychological debriefing is not helpful in either the reduction of posttraumatic symptoms nor the recovery time of those with PTSD (Tuckey & Scott, 2014).  One theory is these early interventions may encourage patients to ruminate on their symptoms or the event itself, thus maintaining PTSD symptoms (McNally, 2004). In efforts to combat these negative findings of psychological debriefing, there has been a large movement to provide more structure and training for professionals employing psychological debriefing, thus ensuring that those who are providing treatment are properly trained to do so.


5.6.2. Exposure Therapy

While exposure therapy is predominately used in anxiety disorders, it has also shown great success in treating PTSD-related symptoms as it helps individuals extinguish fears associated with the traumatic event. There are several different types of exposure techniques—imaginal, in vivo, and flooding are among the most common types (Cahill, Rothbaum, Resick, & Follette, 2009).

In imaginal exposure, the individual mentally re-creates specific details of the traumatic event. The patient is then asked to repeatedly discuss the event in increasing detail, providing more information regarding their thoughts and feelings at each step of the event. During in vivo exposure, the individual is reminded of the traumatic event through the use of videos, images, or other tangible objects related to the traumatic event that induces a heightened arousal response. While the patient is re-experiencing cognitions, emotions, and physiological symptoms related to the traumatic experience, they are encouraged to utilize positive coping strategies, such as relaxation techniques, to reduce their overall level of anxiety.

Imaginal exposure and in vivo exposure are generally done in a gradual process, with imaginal exposure beginning with fewer details of the event, and slowly gaining information over time. In vivo starts with images or videos that elicit lower levels of anxiety, and then the patient slowly works their way up a fear hierarchy, until they are able to be exposed to the most distressing images. Another type of exposure therapy, flooding, involves disregard for the fear hierarchy, presenting the most distressing memories or images at the beginning of treatment. While some argue that this is a more effective method, it is also the most distressing and places patients at risk for dropping out of treatment (Resick, Monson, & Rizvi, 2008).


5.6.3. Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy, as discussed in the mood disorders chapter, has been proven to be an effective form of treatment for trauma/stress-related disorders. It is believed that this type of treatment is effective in reducing trauma-related symptoms due to its ability to identify and challenge the negative cognitions surrounding the traumatic event, and replace them with positive, more adaptive cognitions (Foa et al., 2005).

Trauma-focused cognitive-behavioral therapy (TF-CBT) is an adaptation of CBT that utilizes both CBT techniques and trauma-sensitive principles to address the trauma-related symptoms. According to the Child Welfare Information Gateway (CWIG; 2012), TF-CBT can be summarized via the acronym PRACTICE:

  • P: Psycho-education about the traumatic event. This includes discussion about the event itself, as well as typical emotional and/or behavioral responses to the event.
  • R: Relaxation Training. Teaching the patient how to engage in various types of relaxation techniques such as deep breathing and progressive muscle relaxation.
  • A: Affect. Discussing ways for the patient to effectively express their emotions/fearsrelated to the traumatic event.
  • C: Correcting negative or maladaptive thoughts.
  • T: Trauma Narrative. This involves having the patient relive the traumatic event (verbally or written), including as many specific details as possible.
  • I: In vivo exposure (see above).
  • C: Co-joint family session. This provides the patient with strong social support and a sense of security. It also allows family members to learn about the treatment so that they are able to assist the patient if necessary.
  • E: Enhancing Security. Patients are encouraged to practice the coping strategies they learn in TF-CBT to prepare for when they experience these triggers out in the real world, as well as any future challenges that may come their way.


5.6.4. Eye Movement Desensitization and Reprocessing (EMDR)

In the late 1980s, psychologist Francine Shapiro found that by focusing her eyes on the waving leaves during her daily walk, her troubling thoughts resolved on their own. From this observation, she concluded that lateral eye movements facilitate the cognitive processing of traumatic thoughts (Shapiro, 1989).

While EMDR has evolved somewhat since Shapiro’s first claims, the basic components of EMDR consist of lateral eye movement induced by the therapist moving their index finger back and forth, approximately 35 cm from the client’s face, as well as components of cognitive-behavioral therapy and exposure therapy. The following 8-step approach is the standard treatment approach of EMDR (Shapiro & Maxfield, 2002):

  1. Patient History and Treatment Planning – Identify trauma symptoms and potential barriers to treatment.
  2. Preparation – Psychoeducation of trauma and treatment.
  3. Assessment – Careful and detailed evaluation of the traumatic event. Patient identifies images, cognitions, and emotions related to the traumatic event, as well as trauma-related physiological symptoms.
  4. Desensitization and Reprocessing – Holding the trauma image, cognition, and emotion in mind, while simultaneously assessing their physiological symptoms, the patient must track the clinician’s finger movement for approximately 20 seconds. At this time, the patient must “blank it out” and let go of the memory.
  5. Installation of Positive Cognitions – Once the negative image, cognition, and emotions are reduced, the patient must hold onto a positive image or thought while again tracking the clinician’s finger movement for approximately 20 seconds.
  6. Body Scan – Patient must identify any lingering bodily sensations while again tracking the clinician’s fingers for a third time to discard any remaining trauma symptoms.
  7. Closure – Patient is provided with positive coping strategies and relaxation techniques to assist with any recurrent cognitions or emotions related to the traumatic experience.
  8. Reevaluation – Clinician assesses if treatment goals were met. If not, schedules another treatment session and identifies remaining symptoms.

As you can see from above, only steps 4-6 are specific to EMDR; the remaining treatment is essentially a combination of exposure therapy and cognitive-behavioral techniques. Because of the high overlap between treatment techniques, there have been quite a few studies comparing the treatment efficacy of EMDR to TF-CBT and exposure therapy. While research initially failed to identify a superior treatment, often citing EMDR and TF-CBT as equally efficacious in treating PTSD symptoms (Seidler & Wagner, 2006), more recent studies have found that EMDR may be superior to that of TF-CBT, particularly in psycho-oncology patients (Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While meta-analytic studies continue to debate which treatment is the most effective in treating PTSD symptoms, the World Health Organization’s (2013) publication on the Guidelines for the Management of Conditions Specifically Related to Stress, identified TF-CBT and EMDR as the only recommended treatment for individuals with PTSD.

The National Institute for Health and Care Excellence (NICE) says to consider EMDR for adults with a diagnosis of PTSD and who presented between 1 and 3 months after a non-combat related trauma if the person shows a preference for EMDR and to offer it to adults with a diagnosis of PTSD who have presented more than three months after a non-combat related trauma. They state that EMDR for adults should (cited directly from their website):

  • be based on a validated manual
  • typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas
  • be delivered by trained practitioners with ongoing supervision
  • be delivered in a phased manner and include psychoeducation about reactions to trauma; managing distressing memories and situations; identifying and treating target memories (often visual images); and promoting alternative positive beliefs about the self
  • use repeated in-session bilateral stimulation (normally with eye movements but use other methods, including taps and tones, if preferred or more appropriate, such as for people who are visually impaired) for specific target memories until the memories are no longer distressing
  • include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.

For more on NICE’s PTSD guidance (2018) as it relates to EMDR, please see Sections 1.6.18 to 1.6.20: https://www.nice.org.uk/guidance/ng116/chapter/Recommendations


5.6.5. Psychopharmacological Treatment

While psychopharmacological interventions have been shown to provide some relief, particularly to veterans with PTSD, most clinicians agree that resolution of symptoms cannot be accomplished without implementing exposure and/or cognitive techniques that target the physiological and maladjusted thoughts maintaining the trauma symptoms. With that said, clinicians agree that psychopharmacology interventions are an effective second line of treatment, particularly when psychotherapy alone does not produce relief from symptoms.

Among the most common types of medications used to treat PTSD symptoms are selective serotonin reuptake inhibitors (SSRIs; Bernardy & Friedman, 2015). As previously discussed in the depression chapter, SSRIs work by increasing the amount of serotonin available to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are also recommended as second-line treatments. Their effectiveness is most often observed in individuals who report co-occurring major depressive disorder symptoms, as well as those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately, due to the effective CBT and EMDR treatment options, research on psychopharmacological interventions has been limited. Future studies exploring other medication options are needed to determine if there are alternative medication options for stress/trauma disorder patients.


Key Takeaways

You should have learned the following in this section:

  • Several treatment approaches are available to clinicians to alleviate the symptoms of trauma- and stressor-related disorders.
  • The first approach, psychological debriefing, has individuals who have recently experienced a traumatic event discuss or process their thoughts related to the event and within 72 hours.
  • Another approach is to expose the individual to a fear hierarchy and then have them use positive coping strategies such as relaxation techniques to reduce their anxiety or to toss the fear hierarchy out and have the person experience the most distressing memories or images at the beginning of treatment.
  • The third approach is Cognitive Behavioral Therapy (CBT) and attempts to identify and challenge the negative cognitions surrounding the traumatic event and replace them with positive, more adaptive cognitions.
  • The fourth approach, called EMDR, involves an 8-step approach and the tracking of a clinician’s fingers which induces lateral eye movements and aids with the cognitive processing of traumatic thoughts.
  • Finally, when psychotherapy does not produce relief from symptoms, psychopharmacology interventions are an effective second line of treatment and may include SSRIs, TCAs, and MAOIs.


Section 5.6 Review Questions

  1. Identify the different treatment options for trauma and stress-related disorders. Which treatment options are most effective? Which are least effective?


Module Recap

In Module 5, we discussed trauma- and stressor-related disorders to include PTSD, acute stress disorder, adjustment disorder, and prolonged stress disorder. We defined what stressors were and then explained how these disorders present. In addition, we clarified the epidemiology, comorbidity, and etiology of each disorder. Finally, we discussed potential treatment options for trauma- and stressor-related disorders. Our discussion in Module 6 moves to dissociative disorders.

3rd edition


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