Trauma- & Stressor-Related Disorders

Treatment for both types of disorders typically requires the use of medications and behavioral interventions like therapy. When someone has a co-occurring substance use disorder and a trauma- and stressor-related disorder, the disorders are treated concurrently.

Defining Trauma

Trauma refers to the experience of a highly disturbing or distressing event. These experiences are considered to be significantly disturbing. They include being a victim of abuse, being a victim of a violent crime, or being a combatant in a warzone.

Not everyone who experiences a traumatic event will develop a type of psychiatric disorder. In fact, most people who experience these events do not. But some people suffer such damage to their sense of self that they need professional help to cope with their experience. The sense of self is often referred to as the “psyche.”

Before 2013, the American Psychiatric Association (APA) listed all the different types of trauma-related disorders under the anxiety disorders because it was believed that anxiety was the primary symptom that people with these disorders expressed.

After years of research studies, APA placed these disorders in their own category: trauma- and stressor-related disorders. These disorders were found to be separate from anxiety disorders, like panic disorder or phobias, even though anxiety is a component of them.

All of these disorders have one commonality: The person has had an experience of significant stress or trauma that is believed to have triggered many of the symptoms they express.

Again, simply experiencing trauma or stress does not guarantee that one will develop one of these disorders. Instead, these disorders are the result of numerous interacting factors. Their actual triggers are not known.

Types of Trauma- & Stressor-Related Disorders

According to APA, the following major disorders are now placed in the category of trauma- and stressor-related disorders:

• Post-traumatic stress disorder (PTSD): This is the development of characteristic symptoms after one has been exposed to one or more traumatic events. The prevalence of PTSD varies depending on the type of trauma, but the lifetime risk for PTSD is about 8.7 percent, according to APA. However, as many as a third or slightly more of people who are exposed to severe trauma like combat or rape may develop PTSD.
• Acute stress disorder: This is the acute expression of PTSD-like symptoms (not as severe), but symptoms only last for three days to one month. Prevalence varies depending on the type of stressful event.
• Reactive attachment disorder: This occurs in children. It is a pattern of inhibited and emotionally withdrawn behavior directed toward adult caregivers. Its prevalence is unknown, but it is typically found in very young children who have been exposed to severe neglect.
• Disinhibited social engagement disorder: This also occurs in children. Affected children approach and interact with unfamiliar adults in a manner that is potentially dangerous. The prevalence of this disorder is also unknown, and it may be associated with severe neglect.
• Adjustment disorder: This is the development of symptoms in response to a stressor, but it is a time-limited and less severe disorder than PTSD or acute stress disorder. Prevalence rates range from 5 to 20 percent.

General Signs of Trauma- & Stressor-Related Disorders

All of the trauma- and stressor-related disorders have symptom profiles that vary according to the particular disorder in question. However, some of the general signs of trauma- and stressor-related disorders include:

• Having intrusive memories of the traumatic or stressful event that can include flashbacks (feeling as if you are reexperiencing the event) or very vivid dreams.
• Avoidance of places, people, or activities that serve as reminders of the event.
• Negative changes in mood and thinking that can include significant depression, feelings of hopelessness, feeling detached, a loss of interest in things, negative thoughts, suspiciousness, feeling emotionally numb, or not being able to experience pleasure.
• Changes in emotional reactions that can include becoming easily frightened or startled, trouble sleeping, always feeling on guard or in danger, irritability, significant guilt or shame, or self-destructive behavior, such as substance abuse.

Causes of These Disorders

According to APA, all of the trauma- and stressor-related disorders must occur following some identifiable traumatic or stressful event. However, the event itself cannot be designated as the cause of the syndrome because most people who experience severe trauma are not diagnosed with these disorders (as can be seen by the prevalence rates).

Other interacting risk factors can predispose someone to a higher chance of developing a trauma- and stressor-related disorder. These include:

• Being diagnosed with another psychiatric disorder.
• Having a history of substance abuse.
• Lack of a solid support system.
• Being a victim of neglect or abuse as a child.

APA reports that there are some aspects of the traumatic or stressful event that may increase the risk that one could develop a trauma- and stressor-related disorder.

• The traumatic or stressful event was unexpected.
• The person was not prepared for the event.
• When the event was occurring, they felt they had no control over what was happening.
• They experienced severe emotional distress or emotional detachment during or after the event.

It should be understood that risk factors are not guarantees. They only increase the probability, often very slightly, that a person may develop a disorder or disease. However, if someone has multiple risk factors, their chances of developing the disorder increase.

Co-Occurring Substance Abuse

Research studies have indicated that there is a high rate of substance abuse among people who suffer from trauma- and stressor-related disorders. The rate has been estimated to be between 40 percent and 60 percent.

Obviously, for the childhood disorders listed above, the rate would be significantly lower (near 0). For adolescents and adults who develop PTSD, acute stress disorder, or adjustment disorders, the rate is higher.

Being predisposed to develop any form of mental illness also makes a person at greater risk to develop other forms of mental illness, including substance use disorders. Simply having a mental health disorder, such as a trauma- and stressor-related disorder, makes it more likely that someone will also struggle with substance abuse. And again, a history of substance abuse makes it more likely that someone will develop a trauma- and stressor-related disorder in response to trauma.

The major drugs of abuse among those with trauma- and stressor-related disorders are alcohol abuse and prescription medications. Pain medications and benzodiazepines or other types of drugs to control anxiety are often abused.

Treatment Approaches for Co-Occurring Disorders

Currently, there are certain drugs being investigated to treat disorders like PTSD, but there is no specific drug that can treat any of the trauma- and stressor-related disorders. Medications are often used to address specific symptoms, such as depression, anxiety, or even psychosis.

Medications will typically be used in conjunction with behavioral interventions like different types of psychotherapy. For example, a person may be prescribed antidepressants for depression or anxiety, anxiolytic medications for severe anxiety (with discretion as these medications can be addictive), sleep aids, and medications to treat withdrawal symptoms and cravings related to use of alcohol or drugs. Medications are not sufficient on their own; they must be combined with therapy.

If someone has a co-occurring trauma- and stressor-related disorder and a substance use disorder, the two must be treated at the same time. It is essentially impossible to achieve success by addressing one disorder first, even if the clinician thinks that the trauma- and stressor-related disorder is triggering abuse of alcohol or drugs.

People with dual diagnoses are most often treated by a team of specialists. Each professional addresses the client’s issues separately. They then work together to ensure that the client is treated consistently and in a comprehensive manner.

Types of Behavioral Treatments for Trauma- & Stressor-Related Disorders

Psychotherapy for trauma helps the person adjust to their experience of the traumatic or stressful event and to slowly alleviate the effects of the event. The treatment protocols are often very complicated and require significant training. Most of these apply a cognitive-behavioral approach (CBT) where dysfunctional thoughts and beliefs are identified and restructured.

The following are other types of approaches that might be used:

• Eye movement desensitization and reprocessing (EMDR) is a useful  type of psychotherapy that aims to provide relief from the symptom and emotional distress related to traumatic experiences.
• The self-trauma model uses a mixture of CBT and psychodynamic therapy (Freudian-based principles) to understand the reaction to trauma and help the person adjust it.
• Brief psychodynamic therapy is a shortened version of the Freudian type of therapy that investigates motivations and the reaction to trauma. This therapy provides some insight into why the person thinks, acts, and behaves the way they do.
• Exposure therapies and systematic desensitization are cognitive-behavioral techniques that help the person revisit the traumatic or stressful event and experience it repeatedly to slowly reprogram their reaction to it. These techniques require extreme expertise to deliver.
• Support group participation can also be useful. These are not forms of therapy, but they are run by people with similar problems. They don’t replace therapy, but they offer a good form of long-term support.

All psychotherapeutic techniques for trauma- and stressor-related disorders attempt to work on the relationship between the client and therapist as the mechanism of change. This relationship (often referred to as the therapeutic alliance) is one of mutual respect, trust, and sharing.

Treatment for Substance Abuse

Treatment for the substance use disorder should be delivered along with the treatment for the trauma- and stressor-related disorder.

Addiction treatment is delivered in its standard format, but with the addition of other interventions to address the dual diagnosis. Overall, addiction treatment will include the following, as appropriate for the particular situation:

• Medical detox
• Medication management
• Traditional therapy
• Complementary therapies
• Peer support groups
• Family involvement

Length of Treatment

The time someone spends in treatment for a trauma- and stressor-related disorder depends on the severity of the disorder. A disorder like PTSD typically requires extensive and lengthy treatment.

Treatment for a substance use disorder is considered a long-term endeavor, and the person should be involved in treatment for years. Many people will remain in some form of care, like support groups or therapy, for several years.