Hello everyone and welcome back to our Licensure Exam podcast . I'm Dr Linton Hutchinson and I'm here with my co-host , stacey Frost . In this episode on our Demystifying Disorders series , we'll be talking about some common trauma and stress-related disorders . Demystifying is a disorder that is associated with PTSD , acute stress disorder and adjustment disorder .
But before we begin , I'd like to give a shout out to our therapists , who are listening from New Zealand . I used to teach at the University of the South Pacific in the Fiji Islands , which is , you know , just a hop , skip and jump to the north , and I always enjoyed teaching students from New Zealand .
I know why the country is known as the friendliest place on the planet .
All that was true with all the tragedy that they've experienced from the never-ending earthquakes they've got going on there .
Well , earthquakes are a problem Stacey as New Zealand straddles the Pacific and Australian tectonic plates , and that's not going to change anytime soon . It's not uncommon for them to have at least 45 earthquakes a day .
Oh my gosh . Well , I'm sure that our therapists out there in New Zealand work with clients who are experiencing trauma and significant life stressors on a daily basis .
On the surface , working with clients who have PTSD , acute stress disorder or adjustment disorder may seem pretty similar , and there are some critical differences in their diagnostic criteria that we're actually going to break down today , and we'll also be talking about some common misconceptions associated with these disorders .
That's right . Let's start with PTSD , or post-traumatic stress disorder . According to the DSM , the diagnostic criteria for PTSD include exposure to actual or threatened death , serious injury or sexual violence . The exposure can happen directly , by witnessing the event , or indirectly , like learning about a traumatic event occurring to a close friend or family member .
And therein lies our first myth to debunk that everyone who experiences trauma develops PTSD . Well , exposure to a traumatic event is just part of the criteria needed to diagnose PTSD . And what are the other criteria for this disorder , Linton ?
Well , after the trauma , the person experiences a variety of symptoms that are grounded in four main clusters Intrusion symptoms avoidance .
Wait a minute , Linton . Can you define intrusion symptoms ?
Sure . Intrusion thoughts are unwanted , involuntary thoughts , images or urges that repeatedly enter a person's mind . They are often disturbing or really distressing in nature . These thoughts are ego-distanic , which is another good word you need to know for the exam , meaning that they are inconsistent with the client's values and cause them great anxiety .
The client usually recognizes that the intrusive thoughts are unreasonable and tries to suppress or ignore them . In response to the intrusive thoughts , the client may develop compulsive behaviors or mental rituals to reduce anxiety and prevent the feared consequences , For example repetitive praying , counting , cleaning or checking behaviors .
So we have intrusive symptoms , avoidance , negative changes in thinking and mode and changes in arousal and reactivity .
All right , and let me give a few examples of these . So intrusive symptoms include things like distressing memories , dreams and flashbacks . Avoidance symptoms include behaviors like not wanting to be around other people or places that remind the person of the traumatic event .
Cognitive and mood changes include negative beliefs , feelings of guilt , shame or anger and withdrawal from others , and prolonged psychological distress or physical reactions to reminders of the trauma . This could include things like angry outburst , hypervigilance and having trouble concentrating .
Got it . So the symptomology for PTSD is almost the same as acute stress disorder . There is a difference in the total number of symptoms required to make each diagnosis . Acute stress requires nine symptoms from a long list of symptoms , while PTSD requires at least six symptoms , with a certain number of symptoms coming from specific categories .
But the most significant difference between the two disorders that you must remember for the exam is duration , or how long the symptoms last . With acute stress disorder the symptoms last between three days and one month .
What happens if you're working with a client in New Zealand who has just been through an earthquake and has been diagnosed with acute stress disorder and their symptoms go on for longer than a month ?
Well , I'd say , in that case you're looking at potentially changing the diagnosis to PTSD . And now you've actually got me curious about something , linton .
Yes , you want .
So say , you've got a client who's diagnosed with acute stress disorder , do they always go on to develop PTSD ?
No , some cases of acute stress disorder will resolve within that first month . So there are several reasons for this . The first is that early clinical intervention after a trauma can help prevent acute stress reactions from developing into PTSD .
Also , resilient factors like social support , healthy coping strategies and a positive outlook can help some clients recover from acute trauma without chronic impairment . Plus , the trauma event itself matters . Sexual trauma , for example , has a higher risk of PTSD versus physical trauma sustained from a car accident or an earthquake .
The severity and nature of the trauma affects the probability of developing PTSD .
Okay , thanks for explaining that . Now . There are a lot of misconceptions about PTSD . One of those is that PTSD always develops immediately . But in reality , while symptoms usually begin within the first three months following the trauma , I could actually take several more months or even years before full criteria for PTSD is met .
There's even a specifier for for that in the diagnosis PTSD with delayed expression and this is noted when full diagnostic criteria aren't met until at least six months following the traumatic event . And that's not the most common course , but it is still possible . So we want to make sure that you know about it .
Then there's that diagnostic specifier , as you love so much , stacy . Are they really that important for test takers to know about ?
Yes , this is not the time to start skimping in your studies , linton . Not only do you need to have a good foundational knowledge of diagnostic criteria , but you also need to familiarize yourself with the different specifiers that are used to provide that extra clinical detail about the client's presentation and features of a diagnosed medical disorder .
Certain specifiers , like those for severity , may indicate the need for more aggressive treatment . Specifiers noting remission suggests that treatment has been effective so far , and and specifiers really allow clinicians to provide more nuance and detail in the diagnosis , which can really help guide treatment planning .
And I've got more reasons if you want to just tell okay , okay , I get the picture back to PTSD .
Some people think it only affects veterans , but the truth is that they can develop following any traumatic event , like sexual assault , robbery , accidents or like earthquakes that they have so frequently in New Zealand .
Exactly . And another misconception is that people with PTSD are prone to violence . Many people with PTSD , most people with PTSD , actually are not violent . Irritability can be a symptom , but PTSD treatment usually aids by improving emotional regulation .
Mm-hmm . Well , that's a good point . So let's now move on to adjustment disorder . This diagnosis requires the development of emotional or behavioral symptoms in response to a Identifiable stressor .
Yes , and the distress has to incur within three months of the onset of the stressor . And what do we mean by stressor ? Well , common stressors can be things like divorce , job loss , a new life phase , maybe you're leaving home for the first time or are gonna be living on your own .
Or moving up north .
Yes , moving up north from the south .
Right now . Part of the nature of being human and alive on the planet is that we're constantly Exposed to stressors and sometimes we don't deal with those stressors very well . So if I go to the public's or countdown or New World and they're out of sushi and I'm stressed , could I be diagnosed with adjustment disorder ?
Uh , probably not , Linton , because your symptoms have to cause significant impairment and functioning or be way out of proportion to the severity or intensity of the stressor .
Okay , I get it . So now , one thing that we hear a lot of confusion about is the duration Requirements to diagnose adjustment disorder . Can you explain that for us ?
Sure , yes . So one of the big misconceptions is that adjustment disorder can only last six months . All right , this is incorrect . If you learned this , please , please , please , listen closely . The duration of an adjustment disorder can vary . There's an acute form and a chronic or persistent form , and To explain this , I'm gonna take it from the top .
Okay .
All right . So adjustment disorder is diagnosed when emotional or behavioral symptoms develop in response to an identifiable stressor . The symptoms must develop within three months of the onset of the stressor . Once the stressor or the consequences of the stressor are gone , the symptoms cannot persist for more than six more months .
Okay , that sounds a bit complicated there . Care to give an example ?
Yes , okay . So let's say we've got a client , olivia , who works in Wellington and lost her job in January . Well , over the next month she works her butt off going to one interview after the next . By March she hasn't been able to get a new job and she's having a really rough time of it . She alternates between feeling anxious and depressed .
She can't sleep and she's really getting behind on her bills . You see her for therapy and diagnose adjustment disorder . Now let's fast forward to Uh , august , about eight months after she initially lost her job right . The economy took a downturn and she's been unable to find a job . She's been living off her credit card .
She was booted out of her flat , she had to move back home with her parents and her symptoms have not significantly improved .
Okay , the job loss sounds like a significant stressor , but it's been eight months since she lost her job . Can you still diagnose her with an adjustment disorder ?
Yes , and this is where those specifiers come in handy .
Your favorite things . Of course , there are specifiers .
Yes , and there are two specifiers for adjustment disorder acute and persistent . Acute is used when the symptoms resolve in less than six months . Persistent is used when the symptoms continue for more than six months . Now it's been over six months since Olivia lost her job .
She's still having a tough time dealing with her job loss and we can really say that unemployment has become a chronic stressor for her . So we'd attach the persistent specifier to her adjustment disorder diagnosis .
Hmm , okay Now . Can you give us a recap of all of that ?
Sure , okay . So adjustment disorder is a diagnosed when emotional or behavioral symptoms develop in response to an identifiable stressor , like we talked about a job loss or divorce , something that is causing significant stress . The symptoms must develop within three months of the onset of the stressor .
Once the stressor or the consequences of the stressor are gone , the symptoms cannot persist for more than six months . If the symptoms resolve in six months after the stressor or its consequences terminate , you will use the specifier acute .
If the symptoms persist for six months or longer in response to this chronic stressor or a stressor that has persistent consequences , then you can tack on a persistent or chronic specifier to the adjustment disorder .
Let's just move along to the critical difference between adjustment disorder , acute stress disorder and PTSD . A key difference is that with adjustment disorder , the stressor does not have to be traumatic . Any significant life stressor can lead to adjustment difficulties . Except the public's being out of sushi , I get it .
So , going back to the case we just talked about , why would you diagnose Olivia with adjustment disorder and not PTSD ?
Okay , that's a good question and there are a few reasons why so . The main diagnostic criteria for PTSD is exposure to actual or threatened death , serious injury or sexual violence . Now , losing a job and having financial and housing struggles while really stressful doesn't meet the threshold for a traumatic event that you would diagnose PTSD .
For Another reason , adjustment disorder is commonly diagnosed when someone has difficulty coping with unemployment . Now the job loss is an identifiable stressor and Olivia's prolonged inability to find work is understandably causing distress . Ptsd would only be considered if the job loss itself was dramatically experienced .
Right , and although you can diagnose adjustment disorder for someone who has experienced a trauma and is having subsequent issues related to that trauma , you have to consider the entire clinical presentation of that client . For example , are they having flashbacks ? Are they easily startled ? Are they unable to experience positive emotions ?
If so , then you might consider acute stress disorder or PTSD as you make your diagnosis .
Now , the main takeaway from today is that , while these disorders share some overlap in types of symptoms , the diagnostic criteria differ in terms of the specifics of the precipitating event and the duration of symptoms . So , linton , how about a summary of what we've talked about today ?
Sure thing . Adjustment disorder develops within three months of an identifiable stressor . Common stressors include divorce , job loss and illness . Common symptoms include depression , anxiety and or conduct problems . If the symptoms resolve in less than six months , it is an acute form .
If the stressors become chronic and last longer than six months , it is the persistent form . The next is acute stress disorder . Follows exposure to actual or threatened death , serious injury or sexual violence . Symptoms last three days to one month after the trauma May predict the development of PTSD .
The client experiences intrusive symptoms , negative mood , disassociative symptoms , avoidance symptoms and arousal symptoms . Ptsd Follows exposure to actual or threatened death , serious injury or sexual violence . Symptoms are very similar to acute stress disorder . Symptoms last more than one month .
All right , Well said Well . Thank you all for tuning in today . We hope we've helped to demystify some of those trauma and stressor-related disorders . For you , and until we meet again , remember it's in there .