Theme 2 Trauma and Stressor Related Disorders: Acute and Posttraumatic
Stress Disorders
Introduction to the theme
The relationship between illness and stress is embedded in complex mutual interactions between biological,
psychological, social, and socio-cultural factors, and although stressor-related effects have always been present, there
was no stressor-related category name in the DSM until now. In the past, Acute and Posttraumatic Stress Disorders
were categorized as Anxiety Disorders in the DSM-IV-TR until the end of 2012. However, since the inception of the
DSM-5 in May 2013, a new DSM-5 category, Trauma- and Stressor-Related Disorders, has become the officially
recognized diagnostic category for the following two childhood disorders - Reactive Attachment Disorder and
Disinhibited Social Engagement Disorder - and three childhood/adulthood disorders - Acute Stress Disorder,
Posttraumatic Stress Disorder and Adjustment Disorders.
The presence of psychological distress which usually follows the exposure to such a traumatic or stressful event
typically manifests as symptoms of anhedonia (loss of experiencing pleasure), dysphoria (a state of feeling sad,
unwell or unhappy), externalising angry and aggressive symptoms, or dissociative symptoms, in addition to the
typical presence of anxiety- and fear-based symptoms. This combination of anxiety, dissociative, depressive,
aggressive, angry, and fear based symptoms has therefore baffled clinicians for many years, and stress and trauma
related disorders were thus relegated to a wide spectrum of different DSM categories. This heterogeneous group of
symptoms has also been recognised in the Adjustment Disorders, Reactive Attachment Disorder and Disinhibited
Social Engagement Disorder. In the case of Reactive Attachment Disorder and Disinhibited Social Engagement
Disorder, social neglect was found to be the common etiological foundation for traumatic experiences in children
below the age of 5. Social neglect of children can lead to either internalising, depressive, withdrawn behaviour, as
depicted in Reactive Attachment Disorder, or Disinhibiting and Externalising behaviour, as depicted in Disinhibited
Social Engagement Disorder.
DSM-5 diagnostic criteria for Acute Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing in person the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member
or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must
have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion,
negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s)
occurred: Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events.
Note: In children repetitive play may occur in which themes or aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)
were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
, 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or
external cues that symbolize or esemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction,
or loving feelings).
Dissociative Symptoms
6. An altered sense of reality of one’s surroundings or oneself (e.g., seeing oneself from another’s
perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) typically due to dissociative
amnesia and not to other factors such as head injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic
event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, or restless sleep.
11. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or
physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least three days and
up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social occupational, or other
important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol)
or another medical condition
(e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.
DSM-5 diagnostic criteria for Posttraumatic Stress Disorder
Note: The following criteria apply to adults, adolescents, and children older than 6 years.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing in person the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events.
Note: In children older than 6 years repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
Stress Disorders
Introduction to the theme
The relationship between illness and stress is embedded in complex mutual interactions between biological,
psychological, social, and socio-cultural factors, and although stressor-related effects have always been present, there
was no stressor-related category name in the DSM until now. In the past, Acute and Posttraumatic Stress Disorders
were categorized as Anxiety Disorders in the DSM-IV-TR until the end of 2012. However, since the inception of the
DSM-5 in May 2013, a new DSM-5 category, Trauma- and Stressor-Related Disorders, has become the officially
recognized diagnostic category for the following two childhood disorders - Reactive Attachment Disorder and
Disinhibited Social Engagement Disorder - and three childhood/adulthood disorders - Acute Stress Disorder,
Posttraumatic Stress Disorder and Adjustment Disorders.
The presence of psychological distress which usually follows the exposure to such a traumatic or stressful event
typically manifests as symptoms of anhedonia (loss of experiencing pleasure), dysphoria (a state of feeling sad,
unwell or unhappy), externalising angry and aggressive symptoms, or dissociative symptoms, in addition to the
typical presence of anxiety- and fear-based symptoms. This combination of anxiety, dissociative, depressive,
aggressive, angry, and fear based symptoms has therefore baffled clinicians for many years, and stress and trauma
related disorders were thus relegated to a wide spectrum of different DSM categories. This heterogeneous group of
symptoms has also been recognised in the Adjustment Disorders, Reactive Attachment Disorder and Disinhibited
Social Engagement Disorder. In the case of Reactive Attachment Disorder and Disinhibited Social Engagement
Disorder, social neglect was found to be the common etiological foundation for traumatic experiences in children
below the age of 5. Social neglect of children can lead to either internalising, depressive, withdrawn behaviour, as
depicted in Reactive Attachment Disorder, or Disinhibiting and Externalising behaviour, as depicted in Disinhibited
Social Engagement Disorder.
DSM-5 diagnostic criteria for Acute Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing in person the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member
or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must
have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion,
negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s)
occurred: Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events.
Note: In children repetitive play may occur in which themes or aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)
were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
, 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or
external cues that symbolize or esemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction,
or loving feelings).
Dissociative Symptoms
6. An altered sense of reality of one’s surroundings or oneself (e.g., seeing oneself from another’s
perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) typically due to dissociative
amnesia and not to other factors such as head injury, alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that
arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic
event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, or restless sleep.
11. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or
physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least three days and
up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social occupational, or other
important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol)
or another medical condition
(e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.
DSM-5 diagnostic criteria for Posttraumatic Stress Disorder
Note: The following criteria apply to adults, adolescents, and children older than 6 years.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the
following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing in person the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or
threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events.
Note: In children older than 6 years repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
