What are the different types of trauma-related disorders?

There are two main trauma-related disorders according to DSM-5-TR:

Post traumatic stress disorder (PTSD).
Acute stress disorder.

Previously classified as anxiety disorders, these disorders have been grouped with other trauma- and stressor-related disorders in the DSM-5-TR. It should be noted that the DSM-5-TR does not require a person to have experienced a sense of fear, helplessness, or horror at the time of the traumatic event, in order to meet criteria for either of these disorders, as was the case in DSM-IV-TR.

The structure of the criteria has also changed (there are now four symptom clusters instead of three) and three new symptoms have been added. A summary of the DSM-5-TR criteria is provided in Table 13; however, readers are encouraged to refer to DSM-5-TR for a more detailed explanation of the changes made between editions. A case study example of how a person experiencing co-occurring PTSD and AOD use disorder may present is illustrated in Box 7.

Table 13: Types of trauma-related disorders

Disorder	Symptoms
Post traumatic stress disorder (PTSD)	PTSD is a disorder that may develop after a person has experienced or been exposed to a traumatic event during which the person perceived their own (or someone else’s) life or physical integrity to be at risk. Following the event, for at least one month, the person experiences some of the following symptoms: Re-experiencing: Spontaneously re-experiencing the event in the form of unwanted and intrusive memories, recurrent dreams or nightmares, or ‘flashbacks’. Avoidance: Avoiding memories, thoughts, feelings, or external reminders of the event (e.g., people, places or activities). Negative cognitions and mood: Feeling a distorted sense of blame of self or others, feeling detached from others or less interest in activities, or inability to remember key aspects of the event. Arousal: Aggressive, reckless, self-destructive behaviour, sleep disturbances, hypervigilance, or increased startle response. Symptoms may begin immediately after the traumatic event, or they may appear days, weeks, months or even years after the trauma occurred.
Acute stress disorder	Acute stress disorder is similar to PTSD but lasts for less than one month following exposure to a traumatic event. Acute stress disorder may remit within one month following exposure to the traumatic event, or it may progress to PTSD.

It should be noted that unlike the DSM-5-TR, the ICD-11 has not expanded the number of symptom clusters that are required to meet a diagnosis of PTSD. According to ICD-11, a diagnosis of PTSD continues to be based on the presence of re-experiencing, avoidance, and arousal symptoms. However, the ICD-11 has introduced a new diagnosis of complex PTSD that is characterised by an additional cluster of symptoms referred to as disturbances in self-organisation (see Table 14). These disturbances in self-organisation include difficulties in regulating emotion (e.g., problems calming down, feeling numb or emotionally shutdown), negative self-perception (beliefs about oneself as being not good enough, worthless, or a failure), and difficulties sustaining relationships and feeling close to others [155]. Although complex PTSD may arise in relation to any trauma, it is typically associated with prolonged or repeated interpersonal traumas or neglect that occur during childhood [158].

A person can either be diagnosed as having PTSD or complex PTSD, but not both. That is, according to ICD-11, a person who is experiencing re-experiencing, avoidance, and arousal symptoms, but not disturbances in self-organisation, may be diagnosed as having PTSD; whereas a person who is experiencing re-experiencing, avoidance, and arousal symptoms, and disturbances in self-organisation, may be diagnosed as having complex PTSD. Although DSM-5-TR does not recognise complex PTSD as a separate diagnosis, two of the three symptoms of disturbances in self-organisation (negative self-perception and difficulties sustaining relationships) are included within the DSM-5-TR’s newly added PTSD symptom cluster of negative cognitions and mood [155]. To bring these two different but overlapping concepts together, in these Guidelines, we refer to the broad diagnosis of PTSD but highlight that many people will experience it in its more complex form.

Another notable difference between the DSM-5-TR and ICD-11 is that the ICD-11 no longer classifies acute stress reaction as a mental disorder, but as one of the ‘Factors Influencing Health Status or Contact with Health Services’. In doing so, the ICD-11 recognised that these acute responses to trauma are considered to be normal given the severity of the stressor, and usually subside within a few days following the event or removal from the threatening situation.

Table 14: Symptoms of PTSD and complex PTSD according to ICD-11

	Symptoms	PTSD	Complex PTSD
Core PTSD symptoms	Re-experiencing: Re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories, flashbacks, or nightmares; may occur via one or multiple sensory modalities and is typically accompanied by strong or overwhelming emotions, particularly fear or horror, and strong physical sensations.
	Avoidance: Avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event(s).
	Arousal: Persistent perceptions of heightened current threat (e.g., hypervigilance, enhanced startle response).
Disturbances in self-organisation	Problems in affect regulation: E.g., problems calming down, feeling numb or emotionally shutdown.
	Negative self-perception: Beliefs about oneself as diminished, defeated or worthless, accompanied by feelings of shame, guilt or failure related to the traumatic event.
	Relationship difficulties: Difficulties in sustaining relationships and in feeling close to others.

Box 7: Case study G: What does co-occurring PTSD and AOD use look like? Julie’s story

Case study G: Julie’s story

Julie, a 35-year-old who identified as female, had presented for AOD treatment on a number of occasions for polydrug use, although she was primarily concerned with her use of heroin and prescription opioids. She had been using on and off for the past 20 years and struggled to control her alcohol and cannabis use. Her longest period of abstinence from heroin was six months. At the time of her presentation, she was receiving the Disability Support Pension and lived in accommodation provided by the Department of Housing with her partner, though they hadn’t been together for very long. Her most recent relapse occurred following a sexual assault by her former partner.

In Julie’s treatment file, one of Julie’s prior treating clinicians had noted a history of ‘childhood trauma’, but no specific details. Subsequent admissions referred to this having been ‘noted on previous admission’ with no further information provided. After Julie’s disclosure of the impact of the most recent assault, the AOD worker asked whether she had experienced any other traumatic events during her life, in childhood or as an adult, and provided some examples of the types of events she was referring to.

Julie was quiet for a moment and became teary, before stating that she had. The AOD worker gently assured Julie that she did not have to talk about anything that she did not want to but asked if it would be ok for them to ask her a few more questions so she could get an understanding of how those events may be contributing towards where she is now. Julie consented, aware that she could stop at any time, or take a break if needed. Julie went on to describe a history of multiple traumas including sexual abuse by a family member that took place over several years, and a number of physical and sexual assaults. Her most recent sexual assault occurred within the context of ongoing domestic violence by her previous partner.

Key Points

What are the primary concerns for Julie?
Where to from here?

Case study G continues in Chapter B7.