2.2 Trauma- and Stressor-Related Disorders

Trauma- and stressor-related disorders are a category in the DSM-5-TR that share a common diagnostic requirement: exposure to a traumatic or stressful event. Social workers must understand the precise diagnostic boundaries and duration differences among Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder (ASD), and Adjustment Disorders to make accurate assessments.

Posttraumatic Stress Disorder (PTSD)

PTSD occurs in individuals who have been exposed to actual or threatened death, serious injury, or sexual violence. This exposure can occur through direct experience, witnessing the event in person, learning that the event occurred to a close family member or friend, or experiencing repeated exposure to aversive details of the event (common in first responders).

A diagnosis of PTSD in adults requires the presence of symptoms across four distinct symptom clusters:

1. Intrusion symptoms (at least one required): This includes recurrent, involuntary, and intrusive distressing memories of the event; distressing dreams; dissociative reactions (such as flashbacks where the client feels or acts as if the traumatic event is recurring); and intense physiological reactivity when exposed to cues that symbolize the event.
2. Avoidance symptoms (at least one required): The client must show persistent avoidance of stimuli associated with the traumatic event. This includes avoiding internal reminders (distressing thoughts, feelings) and external reminders (people, places, conversations, activities) that arouse distressing memories.
3. Negative alterations in cognitions and mood (at least two required): This represents a negative shift in the client’s internal state. Symptoms include an inability to remember an important aspect of the event; persistent negative beliefs about oneself, others, or the world; distorted cognitions about the cause of the event that lead the client to blame themselves or others; a persistent negative emotional state; diminished interest in significant activities; feelings of detachment from others; or a persistent inability to experience positive emotions.
4. Alterations in arousal and reactivity (at least two required): This includes irritable behavior and angry outbursts; reckless or self-destructive behavior; hypervigilance; an exaggerated startle response; problems with concentration; and sleep disturbances.

For a diagnosis of PTSD, the symptoms must persist for more than one month (>1 month) and must cause clinically significant impairment.

Acute Stress Disorder (ASD)

Acute Stress Disorder (ASD) shares the same traumatic exposure criteria as PTSD but differs in duration and symptom structure.

While PTSD requires a specific number of symptoms from each of the four clusters, ASD utilizes a single list of 14 symptoms spanning five categories (intrusion, negative mood, dissociation, avoidance, and arousal). To be diagnosed with ASD, a client must exhibit at least nine symptoms from any of these categories.

The primary distinction is the duration threshold:

• ASD symptoms must occur and resolve within three days to one month following exposure to the traumatic event.
• If symptoms begin immediately but resolve within two days, the threshold for ASD is not met.
• If symptoms persist beyond one month, the social worker must reevaluate the client for PTSD.

Adjustment Disorders

Adjustment Disorders are diagnosed when a client develops emotional or behavioral symptoms in response to an identifiable stressor (such as divorce, job loss, moving, or chronic illness). The stressor does not need to meet the extreme, life-threatening threshold required for PTSD or ASD.

The diagnostic criteria dictate that:

• The emotional or behavioral symptoms must develop within three months of the onset of the stressor.
• The symptoms must be clinically significant, as evidenced by distress that is out of proportion to the severity of the stressor, and/or significant impairment in social or occupational functioning.
• The symptoms do not meet the criteria for another mental disorder.
• Once the stressor or its consequences have terminated, the symptoms must not persist for more than six months.

Adjustment disorders are subtyped based on the predominant symptoms: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, or unspecified.

Clinical Vignette

A 35-year-old construction worker is referred to a clinical social worker by his physician. Six weeks ago, the client witnessed a coworker fall from a high scaffolding and suffer fatal injuries. The client reports that since the accident, he has experienced vivid nightmares of the fall, avoids driving past the construction site, and feels constantly on guard. He is highly irritable with his children and describes feeling "emotionally numb."

Clinical Analysis: The client was exposed to a traumatic event. His symptoms span all four PTSD clusters: intrusion (nightmares), avoidance (avoiding the construction site), negative alterations in cognitions/mood (emotional numbness), and arousal (hypervigilance, irritability). Because his symptoms have persisted for six weeks (longer than the one-month threshold), the most appropriate diagnosis is Posttraumatic Stress Disorder (PTSD).