Outlines

• The stress
• Adjustment disorder
• Case demonstration 1
• Posttraumatic stress disorder and Acute stress disorder
• Case demonstration 2
• Q&A
Fight or Flight response
What is stress?
• Stress; the non-specific response (mind/body) of the
organism to any pressure or demand.

• Stressor; stimulus or event (internal/external) that

produce the stress response.
The stress reaction cycle
“It is not the potential stressor itself by how you perceive
it and then how you handle it that will determine whether
or not it will lead to stress”. Martin Saligman
Adjustment disorder (DSM 5)
A. Emotional or behavioral symptoms develop in response to an identifiable
stressor or stressors within 3 months of the onset of the stressor(s)
B. either or both of;
(1) marked distress that is out of proportion to the severity or intensity of the
stressor, even when external context and cultural factors that might influence
symptom severity and presentation are taken into account and/or
(2) significant impairment in social, occupational, or other areas of functioning.
C. The stress-related disturbance does not meet criteria for another mental
disorder and is not merely an exacerbation of a preexisting mental disorder
D. The symptoms do not represent normal bereavement
E. After the termination of the stressor (or its consequences), the symptoms
persist for no longer than an additional 6 months
 Adjustment disorder (DSM 5)
• The following 6 specifiers are used to identify subtypes:

• With depressed mood (dysphoria, tearfulness, hopelessness, suicidality)

• With anxious mood (psychic anxiety, palpitation, jitteriness, hyperventilation)
• With disturbance of conduct (vandalism, reckless driving, fighting)

• With mixed anxiety and depressed mood

• With mixed disturbance of emotions and conduct
• Unspecified
Stressors occurring in adjustment disorders
Adolescents Adults
Stressors % Stressors %
School problems 60 Marital problems 25
Parental rejection 27 Separation or divorce 23
Alcohol and/or drug problems 26 Move 17
Parental separation or divorce 25 Financial problems 14
Girlfriend or boyfriend problems 20 School problems 14
Marital problems in parents 18 Work problems 9
Move 16 Alcohol and/or drug problems 8
Legal problems 12 Illness 6
Work problems 8 Legal problems 6
Other 60 Other 81
Adjustment disorders
• 5-10% in psychiatric clinics.
• Women, unmarried, younger people.
• Can occur in any age range, but the mean age is in the mid 20s to
early 30s.
• Generally transient, typically lasting only days or weeks (last no longer
than 6 months after the stressors end).
• Some adjustment patients are more chronic with ongoing stressorsใ
• Usually have a good outcome.
 “What is the patient having trouble adjusting
to?”
• For diagnosing adjustment disorder, the psychosocial stressors must be identified.

• Cause (stressor) and effect (psychiatric symptoms) relationship is presumed.

• Most people are remarkably resilient and do not develop adjustment disorder or
other psychiatric syndromes in response to the stressful situations.
Each person has his or her own breaking point
Management of adjustment disorder
• Supportive counseling/psychotherapy
-review the meaning and significance of the psychosocial stressor
that led to the disturbance.
-cope/adapt to the stressor

• Medications target predominant symptoms

-hypnotic for insomnia
-benzodiazepine for anxiety
Posttraumatic Stress Disorder; Criterion A (stressor)

• The person was exposed to: death, threatened death, actual or threatened
serious injury, or actual or threatened sexual violence, as follows: (one required)

• Direct exposure.
• Witnessing the trauma, in person.
• Indirectly, by learning that a close relative or close friend was exposed
to trauma.
• Indirect exposure to aversive details of the event(s), usually in the
course of professional duties (e.g., first responders, collecting body
parts; professionals repeatedly exposed to details of child abuse).
Criterion B: intrusion symptoms

• The traumatic event is persistently re-experienced in the following way(s): (one

required)

• Intrusive thoughts: Recurrent, involuntary, and intrusive memories. Note: Children

older than six may express this symptom in repetitive play.
• Nightmares. Note: Children may have frightening dreams without content related to
the trauma(s).
• Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief
episodes to complete loss of consciousness. Note: Children may reenact the event in
play.
• Intense or prolonged distress after exposure to traumatic reminders.
• Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance

• Avoidance of trauma-related stimuli after the trauma, in the following

way(s): (one required)

• Trauma-related thoughts or feelings.

• Trauma-related external reminders (e.g., people, places,
conversations, activities, objects, or situations).
 Criterion D: negative alterations in cognitions and mood

• Negative thoughts or feelings that began or worsened after the trauma, in the following
way(s): (two required)

• Inability to recall key features of the trauma (usually dissociative amnesia; not due to head
injury, alcohol, or drugs).
• Overly (and often distorted) negative thoughts and assumptions about oneself or the world
(e.g., "I am bad," "The world is completely dangerous").
• Exaggerated blame of self or others for causing the trauma event or for resulting
consequences.
• Negative affect / negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
• Decreased interest in (pre-traumatic) activities.
• Feeling isolated (e.g., detachment or estrangement).
• Difficulty experiencing positive affect / persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity

• Trauma-related alterations in arousal and reactivity that began or

worsened after the trauma, in the following way(s): (two required)

• Irritability or aggression
• Risky or destructive behavior
• Hypervigilance
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping
• Criterion F: duration
-Symptoms last for more than 1 month.

• Criterion G: functional significance

-Symptoms create distress or functional impairment (e.g., social, occupational)

• Criterion H: exclusion
-Symptoms are not due to medication, substance use, or other illness.

• Specify if: With dissociative symptoms.

-In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in
reaction to trauma-related stimuli:
-Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if
"this is not happening to me" or one were in a dream).
-Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").
• Specify if: With delayed expression.
-Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur
immediately.
Acute stress disorder ( persist 3 days-1 months after
trauma)
Exposure to trauma and Presenting
with 9/14 of ;

1. Recurrent, intrusive memories 7. Dissociative amnesia

2. Recurrent, intrusive dreams 8. Avoid distressing memories, thoughts,
feelings
3. Dissociative reactions (flashbacks) 9. Avoid external reminders
4. Psychological or physiologic 10. Sleep disturbance
reactions to cues/symbols of trauma 11. Irritable behavior and angry outbursts
5. Inability of experience positive 12. Hypervigilance
emotions
13. Problems with concentration
6. Depersonalization, derealization 14. Exaggerated startle response
PTSD
• Life time prevalence 8% (10% in women, 4 % in men).
• Most prevalent in young adults (exposed to precipitating events).
• Men; combat experience, women; assault or rape.

• No one is immune for PTSD as the risk depends on the severity,

duration, and proximity of a persons’ exposure to trauma.

• Comorbid with depression, substance use, anxiety, bipolar disorders.

Predisposing vulnerability factors in PTSD

• Genetic to psychiatric illnesses

Remote • Female
• Childhood trauma, previous trauma

• Borderline, paranoid, dependent, antisocial personality

Recent •
•
•
Excessive alcohol intake
Inadequate family or peer support system
Recent stressful life changes
 Etiological factors
• Cognitive-behavioral factors; can not process or rationalize the trauma 🡪
ongoing stress 🡪 blocking/avoidance
; Classical conditioning theory
1) Trauma (unconditioned stimulus) 🡪 Stress (unconditioned response)
2) Trauma (unconditioned s.) + Reminders of the trauma (conditioned r.) 🡪 fear response (conditioned r.)
3) Reminders of the trauma (conditioned r.) 🡪 fear response (conditioned r.) + avoidance pattern

• Biological factors; Noradrenergic, opioid, ANS, HPA hyperactivity

; structural change in amygdala, lower volume in hippocampus
Onset (any times after the trauma)
& Course (can be recovered, can be chronic)

Traumatic event🡪 3-30 d. = ASD

>1 mo.-6mo. = PTSD

>6 mo. = PTSD, with delayed expression

Treatments
• Acute; removal from the stressor, medical care, safety, support, group,
relaxation, education,, monitoring.

• SSRIs (Sertraline, Paroxetine), Alpha adrenergic blocker (Prazosin).

• Cognitive behavioral therapy (CBT), Eye movement desensitization

and reprocessing (EMDR).