What Have We Learned About Trauma and Stress Over the Years?

Phebe Tucker, MD,  DLFAPA;

For those who have experienced trauma and suffer a subsequent mental health disorder, ongoing research is identifying psychotherapies, medications, and lifestyle changes that can help.

SPECIAL REPORT: ANXIETY & STRESS DISORDERS

With many local, national, and international events impacting society, there is much focus on large-scale trauma and stressors. The COVID-19 pandemic, international terrorism, warfare, global climate change, and political conflict are just a few. Many psychiatrists treat the aftermath of more personal trauma, including sexual and physical assault, sudden loss of loved ones, serious motor vehicle accidents, various injuries, and adverse child experiences captured in the familiar Adverse Childhood Experience rating scale.¹

Our understanding of the role of trauma in mental health has evolved exponentially over time with clinical research. As a medical student in the 1980s, I recall learning about the new diagnosis of posttraumatic stress disorder (PTSD) and acute stress disorder (ASD; lasting up to 4 weeks), which were placed among anxiety disorders in DSM-III.² At that time, I discussed with my resident an adult patient who had suffered severe childhood trauma and fit the criteria for PTSD; I was told that experiencing trauma was a rare event. Research shows that trauma is not infrequent over a lifetime, although the lifetime prevalence of PTSD is less than 10% internationally, varying with trauma severity, demographics, and other factors. Fast forward to DSM-5,³ when PTSD and ASD were removed from anxiety disorders and included in a separate category—trauma and stressor-related disorders—appearing alongside reactive attachment disorder and disinhibited social engagement disorder. With the current DSM-5-TR,⁴ PTSD was defined a bit differently for children and adults. Adjustment disorders now grace this category as does the brand-new prolonged grief disorder—no doubt partly inspired by the COVID-19 pandemic.

Also in This Special Report

Unraveling the Threads of Trepidation: The Prevalence and Evolving Contours of Anxiety and Traumatic Stress

Itamar Shapira, MD; and Charles B. Nemeroff, MD, PhD

What Is Complex Posttraumatic Stress Disorder and How Does It Relate to Borderline Personality Disorder?

Jana Gutierrez, MD; and Phebe Tucker, MD

Many DSM diagnoses mirror those in the International Classification of Diseases (ICD). One notable exception is the evolution of complex PTSD (CPTSD) in ICD-11.⁵ ICD-10 included the diagnosis of enduring personality change after catastrophic experience, describing personality-related late-onset sequelae of complex trauma⁶; however, this diagnosis was replaced by CPTSD in the transition to ICD-11. Individuals with CPTSD have experienced severe, chronic, and repeated trauma. They meet the full criteria for PTSD, as well as having affect dysregulation, negative self-concept, and disturbances in relationships. The overlap with borderline personality disorder points to a complexity in diagnosis and treatment, as discussed in articles in this issue.

For the minority of those who have experienced trauma and suffer a subsequent mental health disorder, ongoing research is identifying psychotherapies, medications, and lifestyle changes that can help, and our authors present some. Over time, research has identified neurobiological characteristics of PTSD and traumatic exposure as well as recovery and resilience. Among these, that epigenetic DNA changes after trauma has been shown to cause lasting illness⁷ and, on a more optimistic note, may even add to resilience.⁸

Dr Tucker is professor emeritus and volunteer faculty in the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma College of Medicine in Oklahoma City and a member of the Psychiatric Times editorial board.

References

1. VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14(4):245-258.

2. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. American Psychiatric Association; 1980.

3. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2013.

4. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association; 2022.

5. International Classification of Diseases, 11th Revision. World Health Organization; 2019.

6. The ICD-10 Classification of Mental and Behavioural Disorders. World Health Organization; 1993.

7. Nemeroff CB, Seligman F. The pervasive and persistent neurobiological and clinical aftermath of child abuse and neglect. J Clin Psychiatry. 2013;74(10):991-1001.

8. Lewis CR, Tafur J, Spencer S, et al. Pilot study suggests DNA methylation of the glucocorticoid receptor gene (NR3C1) is associated with MDMA-assisted therapy treatment response for severe PTSD. Front Psychiatry. 2023;14:959590.