COUC 546 Week 7 Research Paper: Final Example

Evidence-Based Research Paper: Trauma- and Stressor-Related Disorders, From Causes and Assessment to Treatment and a Biblical Perspective

Introduction

Most adults will live through at least one event that threatens their life or safety, and many will live through several. For a minority, the event does not stay in the past. Nightmares, intrusive memories, constant alertness and a changed sense of self follow them for months or years. The DSM-5 groups these reactions, along with several related conditions, in a category called trauma- and stressor-related disorders (American Psychiatric Association, 2013). Clinical mental health counselors will meet people with these disorders in schools, agencies, churches, hospitals and private practice, often among clients who come in for something else. This paper describes the disorders in the category, considers their causes from biological, psychological, environmental and spiritual angles, explains how counselors can evaluate them, reviews the evidence for treatment, offers a biblical perspective and identifies directions for future research.

Overview of the Disorders

What sets this DSM-5 category apart is that its diagnoses name their cause: none can be given unless the person has gone through a traumatic or stressful event, which is why the manual moved posttraumatic stress disorder (PTSD) out of the anxiety disorders and placed it in a chapter of its own (American Psychiatric Association, 2013). Five named disorders make up the chapter, plus residual diagnoses labeled other specified and unspecified.

Posttraumatic Stress Disorder

The PTSD diagnosis starts with an event in which life or bodily safety was at stake, through death, serious harm or sexual violence that occurred or was threatened; the person may have lived it directly, watched it, learned that it happened violently or accidentally to someone close, or met its details again and again on the job, as first responders do. Symptoms fall into four groups. The first is intrusion: unwanted memories, distressing dreams, flashbacks and strong reactions to reminders. The second is avoidance of memories, thoughts or reminders of the event. The third, new in DSM-5, covers lasting shifts in thought and mood, for example ongoing self-blame, distorted beliefs about oneself or the world, ongoing fear, shame or anger, loss of interest and feeling cut off from others. The fourth involves arousal and reactivity, including irritability, recklessness, hypervigilance, an exaggerated startle response and problems with concentration and sleep. Symptoms must last more than a month and cause significant distress or impairment. The manual adds a dissociative subtype and separate criteria for children six and younger. The dissociative subtype applies when a person with PTSD also experiences persistent feelings of being detached from oneself or of the surroundings seeming unreal, and the preschool criteria recognize that young children often show trauma through play and behavior rather than words.

Those criteria grew out of a careful review. Friedman et al. (2011) concluded that DSM-IV's Criterion A2, which demanded that the person react to the event with intense fear, helplessness or horror, added little and should be removed, that factor analyses supported four symptom clusters rather than three, and that the reactions of survivors include guilt, anger, numbing and negative beliefs as well as fear. Kring et al. (2016) note that this broadening helps clinicians recognize PTSD in people whose main experience is shame or rage.

PTSD is common enough that every counselor will encounter it. Ressler et al. (2022) estimate its prevalence at roughly 6% to 8% of the general population, rising to as much as a quarter of people in groups exposed to severe trauma, such as combat veterans, refugees and survivors of assault. Many people recover in the weeks after a trauma, but for those who develop the disorder, symptoms can persist for years and often occur alongside depression, substance use and physical health problems, which is one reason early recognition matters.

Acute Stress Disorder

Acute stress disorder describes severe reactions in the period from three days to one month after a trauma, drawing on the same kinds of symptoms. It was introduced partly to identify people at risk for later PTSD, but a review prepared for DSM-5 found that it missed most survivors who went on to develop PTSD, and its authors recommended treating it as a description of severe early distress rather than a predictor (Bryant et al., 2011).

Adjustment Disorders

Adjustment disorders involve emotional or behavioral symptoms that begin within three months of a stressor, such as divorce, job loss or illness, and that are out of proportion to the stressor or significantly impair functioning. Symptoms are expected to resolve within six months after the stressor and its consequences end. Casey and Bailey (2011) describe these as among the most common and least studied diagnoses in mental health, with criteria that give little help in separating them from normal distress, depression or PTSD. They caution that the diagnosis is often treated as mild, yet it turns up often in studies of people who died by suicide, and adolescents given the diagnosis tend to fare poorly, so counselors should not dismiss it as a minor label.

The Two Childhood Attachment Disorders

Two childhood disorders complete the category. Both follow extremes of insufficient care, such as severe neglect, frequent changes of caregivers or institutional rearing. In reactive attachment disorder, a child rarely seeks or responds to comfort and shows limited positive emotion. In disinhibited social engagement disorder, a child approaches and goes off with unfamiliar adults with little hesitation. Zeanah and Gleason (2015) explain that these disorders are distinct from insecure attachment, which is common, and that they occur almost exclusively in children who have experienced serious deprivation.

Potential Causes

Because exposure to a stressor is required for every diagnosis in the category, the question of cause is really a question of vulnerability: why do some people develop a disorder after an event that others pass through? The answer involves the event itself, the person's history and biology, the environment after the event and the person's spiritual and moral world.

The Nature of the Event

Trauma is common, but its effects depend on what kind of trauma it is. In World Mental Health surveys across 24 countries, a large majority of adults reported at least one lifetime trauma, and those involving interpersonal violence, especially sexual violence, carried the highest risk of PTSD (Kessler et al., 2017). A loved one's sudden death, though less violent, contributed a large share of the overall burden because it is so common. For counselors, this means a history-taking interview has to name concrete kinds of events, since clients may not call an assault or a sudden death "trauma." The same surveys found that most people experience more than one traumatic event over a lifetime, so a counselor should expect layered histories, in which a recent event may reawaken the effects of earlier ones.

Risk Factors Before, During and After Trauma

Two meta-analyses describe the role of individual history and circumstances. Brewin et al. (2000) found that a previous psychiatric history, childhood abuse and a family history of mental illness predicted PTSD fairly consistently, while factors such as gender and age predicted it only in some populations, and that the severity of trauma, a lack of social support and additional stress afterward had somewhat stronger effects than characteristics present beforehand. Ozer et al. (2003) reached a related conclusion with a different set of studies: the strongest predictors were peritraumatic dissociation and emotional responses during the event, while prior trauma and prior adjustment had smaller effects. Together, these studies suggest that what happens during and after a trauma matters at least as much as who the person was before it.

Genetics and Heredity

Nature also plays a part. True et al. (1993) studied male twin pairs from the Vietnam era and found that genes explained a substantial part of the variance in PTSD symptoms once combat exposure was controlled, while the environment the twins shared growing up explained little. Ressler et al. (2022) put the heritable portion of PTSD risk at roughly 30% to 40% or more. Heritability does not mean that trauma is unimportant; it means that people differ in how strongly the same experience affects them.

Neurobiology

Ressler et al. (2022) describe PTSD as involving disrupted fear learning and its regulation. The circuit linking the amygdala, the hippocampus and the medial prefrontal cortex, which detects threat, places memories in context and dampens fear when danger has passed, functions differently in many people with PTSD. This helps explain why survivors may react to reminders as if the danger were present and why sleep and arousal are so often disturbed.

Environment and Early Care

For the childhood disorders, environment is the decisive factor. Reactive attachment disorder, like disinhibited social engagement disorder, arises when young children lack the consistent, responsive care through which attachments normally form, as in severe neglect or institutional care (Zeanah & Gleason, 2015). The same principle, that relationships shape how people respond to stress, runs through the adult research on social support.

Spiritual and Moral Dimensions

Trauma can wound a person's faith and conscience as deeply as it wounds the nervous system, and a full account of causes must include that dimension. Litz et al. (2009) gave the name moral injury to the enduring damage people can suffer after they commit, fail to stop or see acts that break their deepest moral convictions. Moral injury involves guilt, shame, a loss of trust in others or in God and a sense of being beyond forgiveness. It was first described among combat veterans, but counselors will recognize it in first responders, health care workers and survivors of abuse who blame themselves. Spiritual struggle does not cause PTSD on its own, but it can intensify and prolong suffering.

How the Factors Interact

No single cause explains who develops these disorders. Kring et al. (2016) present the diathesis-stress model as a way of combining biological and psychological vulnerability with environmental stress, and the research on trauma fits it well. A person with a family history of anxiety and little support after an assault faces a different risk from a person with the same experience who has a strong family and community around them. For counselors, this interaction offers hope: some risk factors, such as heredity, cannot be changed, but social support, coping and meaning-making can be strengthened after a trauma has occurred.

Evaluation

Evaluation begins with a careful, respectful trauma history. Because the category requires exposure to a stressor, the counselor must establish what happened, when it happened and how the client responded, without pressing for details the client is not ready to share. Asking about specific types of events, rather than a single general question, improves accuracy (Kessler et al., 2017).

Standardized tools strengthen this process. For screening and tracking progress, counselors can use the PCL-5, a twenty-question self-report checklist whose scores held together well, stayed stable on retesting and agreed with related measures when it was first tested with college students who had experienced trauma (Blevins et al., 2015). For diagnosis, the CAPS-5, a clinician-administered structured interview, is the accepted standard; in two samples of veterans, its diagnoses showed strong agreement between raters and over time, and its severity scores were internally consistent and closely related to the earlier version of the interview (Weathers et al., 2018). Counselors who are not trained in the full interview can use the checklist to screen and refer for structured assessment when needed.

Differential diagnosis requires attention to time and severity. Symptoms in the first month after a trauma may meet criteria for acute stress disorder, but because that diagnosis predicts later PTSD poorly, survivors should be reassessed after the first month (Bryant et al., 2011). Distress that is out of proportion to a stressor but does not meet criteria for another disorder may fit an adjustment disorder, though the line between adjustment disorder and normal distress requires judgment (Casey & Bailey, 2011). Depression, substance use and other anxiety disorders often co-occur and should be screened. For children, evaluation of reactive attachment and disinhibited social engagement disorder depends on the caregiving history and observation of the child with familiar and unfamiliar adults (Zeanah & Gleason, 2015). Throughout, cultural expressions of distress, such as bodily complaints or spiritual language, should be explored rather than dismissed. Survivors from some communities may describe trauma mainly as headaches, fatigue or a troubled spirit, and refugees may carry losses that span years rather than a single event, so the counselor's questions should be adapted to the client's language and history.

Assessment also continues after diagnosis. Repeating a self-report measure such as the PTSD Checklist at regular intervals lets the counselor and client see whether treatment is working and adjust it if progress stalls. Safety assessment, including suicide risk and current danger in the client's environment, should be revisited throughout treatment, since people with PTSD may still be living with the source of their trauma, as in domestic violence.

Treatment Options

The evidence base for adult PTSD is strong. Cusack et al. (2016), reviewing 64 trials and grading the strength of evidence, found high-strength support for exposure therapy, including prolonged exposure, and moderate-strength support for a group that included cognitive processing therapy, EMDR, narrative exposure therapy, cognitive therapy and blended cognitive behavioral packages; for several of these, fewer than four people needed to be treated for one to lose the diagnosis. Powers et al. (2010) meta-analyzed 13 trials of prolonged exposure against wait-list or placebo conditions and found a large effect that was largely maintained at follow-up, with no significant difference from other active treatments. These therapies share a common element: helping the client approach, rather than avoid, the memory and its meaning in a safe and structured way.

In practice, counselors must decide when and how to begin trauma-focused work. Many clinicians start with a period of engagement, psychoeducation and coping skills, especially when clients are in crisis, actively using substances or still in danger, and then move to the memory work at the center of exposure and cognitive treatments. The research supports beginning trauma-focused treatment without long delays for most clients, since the effective therapies are themselves structured and paced. Co-occurring substance use, depression and suicidal thinking should be addressed alongside the PTSD rather than treated as reasons to postpone it indefinitely. Counselors who are not trained in a specific protocol should seek training and supervision or refer to colleagues who are.

Medication can also help. Pooling 112 studies, Watts et al. (2013) found effects for several medications, including the antidepressants paroxetine, sertraline, fluoxetine and venlafaxine, though psychotherapies such as cognitive therapy, exposure therapy and EMDR showed larger effects. They also found smaller effects in studies with more veterans and larger effects in studies with more women, a reminder that populations differ. Counselors should coordinate with prescribers when clients use medication.

Treatment for the other disorders in the category is less developed. For acute stress reactions, early support, psychoeducation and monitoring are appropriate, with trauma-focused treatment for those whose symptoms persist. Casey and Bailey (2011) report that there are very few intervention studies for adjustment disorders, so counselors usually draw on brief, problem-focused and supportive approaches. These usually aim to reduce the stressor where possible, strengthen coping and support, and help the client find meaning in the change, with referral for more intensive care if symptoms worsen or suicidal thinking appears. For reactive attachment and disinhibited social engagement disorders, the most important intervention is providing the child with stable, responsive caregiving, along with support for caregivers (Zeanah & Gleason, 2015).

For clients with moral injury, standard treatments may need to be supplemented. Litz et al. (2009) proposed strategies that address guilt and shame directly, including making meaning of the event and taking steps toward repair, and many clients will want their faith involved in that work. Family and group approaches can also help. Partners and family members often need education about PTSD, especially about avoidance and irritability, which can strain relationships, and group treatment can reduce the isolation that many survivors feel.

A Biblical Perspective

Scripture does not treat suffering as unusual or shameful. The Psalms include laments in which the writer cries out from the depths, complains that God seems far away and describes sleepless nights and a body worn down by distress (English Standard Version Bible, 2001/2016, Psalm 88). Including such prayers in Scripture gives traumatized believers permission to bring their pain honestly to God rather than hiding it. Job's story shows that terrible suffering is not necessarily a punishment for sin, a truth that matters to survivors who blame themselves. Job's friends sat with him in silence for seven days before they spoke, and their silence was wiser than their later explanations (English Standard Version Bible, 2001/2016, Job 2:13). Counselors can learn from both halves of that story.

Scripture also speaks of restoration. Isaiah describes a messenger sent to bind up the brokenhearted and proclaim liberty to captives (English Standard Version Bible, 2001/2016, Isaiah 61:1), words Jesus applied to his own ministry. Paul writes that God comforts believers in their affliction so that they can comfort others (English Standard Version Bible, 2001/2016, 2 Corinthians 1:3-4). Joseph, after years of betrayal and imprisonment, could tell his brothers that what they meant for evil God meant for good (English Standard Version Bible, 2001/2016, Genesis 50:20), not denying the harm but placing it within a larger story.

From this perspective, evidence-based treatment and faith are not rivals. Exposure therapy, cognitive processing and medication can be understood as means of the healing God desires, while prayer, Scripture and the community of the church address the spiritual wounds that research on moral injury describes. Christian counselors should integrate faith only as clients wish, respecting those of other beliefs, and should avoid suggesting that a lack of faith causes or prolongs symptoms. For believers who want it, the gospel's message of forgiveness can speak directly to the guilt and shame that trauma often leaves behind.

The church can be part of healing or part of the harm. Congregations that offer presence, practical help and patience, weeping with those who weep as Paul instructs (English Standard Version Bible, 2001/2016, Romans 12:15), embody the comfort Scripture describes. Congregations that rush survivors toward forgiveness, suggest that strong faith should prevent symptoms or ignore abuse within their own walls can deepen the wound. Christian counselors can help churches become safer places by offering education about trauma and by encouraging pastors to refer members for professional care.

Future Research Considerations

Several areas need further study. First, Ressler et al. (2022) describe how genetic findings and a growing understanding of fear circuitry could lead to new treatments and to ways of predicting who is most at risk, but much of that work remains to be translated into clinical practice. Biomarkers that predict who will develop PTSD after a trauma could make early prevention far more efficient than current screening. Second, although several psychotherapies work, Cusack et al. (2016) found too few direct comparisons to say which works best for whom, and data on adverse effects were largely missing. Third, Watts et al. (2013) found smaller effects in veteran samples, which calls for research on improving outcomes in that population. Fourth, adjustment disorders need clearer criteria and more treatment research, given their frequency and their association with suicide (Casey & Bailey, 2011). Fifth, research on reactive attachment and disinhibited social engagement disorders, especially on treatment, is still limited (Zeanah & Gleason, 2015). Finally, moral injury needs better measurement and controlled studies of spiritually integrated interventions, building on the framework of Litz et al. (2009). Research on how spiritual and religious coping affects recovery, both positively and negatively, would help counselors know when to encourage faith practices and when spiritual struggle itself needs attention. Studies of trauma treatment delivered in community settings, including churches and schools, would also show whether the results of controlled trials hold in everyday practice.

Conclusion

Trauma- and stressor-related disorders show, perhaps more clearly than any other category, how the events of a life and the makeup of a person interact. Trauma is common, but its effects depend on what happened, on vulnerability shaped by genes and history, on the support that follows and on the meaning a person makes of it. Counselors who take careful histories, use validated measures, offer evidence-based treatment and attend to the spiritual wounds of trauma can help many clients recover. For Christian counselors, that work is also a way of taking part in the restoration Scripture promises, binding up wounds with skill, patience and hope.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489-498. https://doi.org/10.1002/jts.22059

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748-766. https://doi.org/10.1037/0022-006X.68.5.748

Bryant, R. A., Friedman, M. J., Spiegel, D., Ursano, R., & Strain, J. (2011). A review of acute stress disorder in DSM-5. Depression and Anxiety, 28(9), 802-817. https://doi.org/10.1002/da.20737

Casey, P., & Bailey, S. (2011). Adjustment disorders: The state of the art. World Psychiatry, 10(1), 11-18. https://doi.org/10.1002/j.2051-5545.2011.tb00003.x

Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. https://doi.org/10.1016/j.cpr.2015.10.003

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769. https://doi.org/10.1002/da.20767

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., Degenhardt, L., de Girolamo, G., Dinolova, R. V., Ferry, F., Florescu, S., Gureje, O., Haro, J. M., Huang, Y., Karam, E. G., Kawakami, N., Lee, S., Lepine, J.-P., Levinson, D., ... Koenen, K. C. (2017). Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology, 8(sup5), Article 1353383. https://doi.org/10.1080/20008198.2017.1353383

Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2016). Abnormal psychology: The science and treatment of psychological disorders (13th ed.). Wiley.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003

Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52-73. https://doi.org/10.1037/0033-2909.129.1.52

Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635-641. https://doi.org/10.1016/j.cpr.2010.04.007

Ressler, K. J., Berretta, S., Bolshakov, V. Y., Rosso, I. M., Meloni, E. G., Rauch, S. L., & Carlezon, W. A., Jr. (2022). Post-traumatic stress disorder: Clinical and translational neuroscience from cells to circuits. Nature Reviews Neurology, 18(5), 273-288. https://doi.org/10.1038/s41582-022-00635-8

True, W. R., Rice, J., Eisen, S. A., Heath, A. C., Goldberg, J., Lyons, M. J., & Nowak, J. (1993). A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms. Archives of General Psychiatry, 50(4), 257-264. https://doi.org/10.1001/archpsyc.1993.01820160019002

Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541-e550. https://doi.org/10.4088/JCP.12r08225

Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., Keane, T. M., & Marx, B. P. (2018). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment, 30(3), 383-395. https://doi.org/10.1037/pas0000486

Zeanah, C. H., & Gleason, M. M. (2015). Annual research review: Attachment disorders in early childhood: Clinical presentation, causes, correlates, and treatment. Journal of Child Psychology and Psychiatry, 56(3), 207-222. https://doi.org/10.1111/jcpp.12347