Learning Objectives
- Describe how PTSD presents.
- Describe how acute stress disorder presents.
- Describe how adjustment disorder presents.
- Describe how prolonged grief disorder presents.
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.
5.2.1.1. 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.
5.2.1.2. 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.
5.2.1.3. Category 3: Negative alterations in cognition or mood. The third category experienced by individuals with PTSD is negativealterations 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.
5.2.1.4. 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).
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.
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.
Review Questions
- What is the difference in diagnostic criteria for PTSD, Acute Stress Disorder, and Adjustment Disorder?
- What are the four categories of symptoms for PTSD? How do these symptoms present in Acute Stress Disorder and Adjustment Disorder?
- What is prolonged grief disorder?
