Reactive Attachment Disorder

• Reactive attachment disorder involves disturbed and developmentally inappropriate attachment behaviors.
• Children with this disorder do not preferentially seek comfort, support, protection, or nurturance from attachment figures.
• The disorder manifests as an absence or underdevelopment of attachment between the child and caregivers.
• Children with reactive attachment disorder are believed to have the capacity to form selective attachments.
• Children with reactive attachment disorder do not consistently seek or respond to comfort from caregivers when distressed.
• Children with reactive attachment disorder exhibit diminished or absent positive emotions during interactions with caregivers.
• Children with reactive attachment disorder have compromised emotion regulation and may display unexplained negative emotions.
• Diagnosis of reactive attachment disorder requires a developmental age of at least 9 months to ensure the child can form selective attachments.
• Diagnostic assessment of reactive attachment disorder is enhanced by multiple sources of input across different contexts.
• Disinhibited social engagement disorder is characterized by culturally inappropriate, overly familiar behavior with strangers.
• The overly familiar behavior seen in disinhibited social engagement disorder violates social boundaries.
• Diagnosis of disinhibited social engagement disorder requires a developmental age of at least 9 months.

Posttraumatic Stress Disorder (PTSD)

• PTSD involves characteristic symptoms following exposure to one or more traumatic events.
• Clinical presentation of PTSD varies among individuals.
• PTSD symptoms can be fear-based, anhedonic, dysphoric, arousal-related, reactive-externalizing, or dissociative.
• Criteria for PTSD differ for adults and children 6 years or younger, especially in numbering of criteria.
• Traumatic events in PTSD involve actual or threatened death, serious injury, or sexual violence.
• Exposure to trauma can be through direct experience, witnessing the event, learning about it, or indirect exposure via occupational duties.
• The impact of PTSD may be more severe when the stressor involves interpersonal and intentional harm.
• Directly experienced traumatic events include war, physical assault, kidnapping, terrorist attacks, torture, disasters, and severe accidents.
• Sexual trauma includes actual or threatened sexual violence or coercion.
• Bullying may qualify as a Criterion A1 experience if there is a credible threat of serious harm or sexual violence.
• For children, sexually violent events can include developmentally inappropriate sexual experiences without physical violence or injury.
• A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event unless catastrophic feelings are evoked.
• Witnessed events include observing threatened or serious injury, unnatural death, physical or sexual abuse, domestic violence, war, or disaster.
• Indirect exposure to traumatic events is limited to violent or accidental events affecting close relatives or friends.
• Professionals exposed to the grotesque effects of war, rape, genocide or abusive violence in the course of their duties can develop PTSD.
• Photos, videos, verbal or written accounts can cause indirect exposure.
• Exposure to multiple traumatic events can occur in various forms.
• Individuals may experience different types of traumatic events at different times or the same type repeatedly.
• When assessing PTSD, identify if there is a specific, discrete event that the individual considers the worst.
• The traumatic event can be re-experienced through recurrent, involuntary recollections (Criterion B1).
• PTSD intrusive recollections apply only to involuntary and intrusive distressing memories.
• Distressing dreams that replay or relate thematically to the trauma are a common symptom (Criterion B2).
• Individuals may experience dissociative states or "flashbacks" where they relive the event (Criterion B3).
• Intense distress (Criterion B4) or physiological reactivity (Criterion B5) can be triggered by stimuli resembling an aspect of the trauma.
• Individuals with PTSD often avoid stimuli associated with the trauma.
• Avoidance includes efforts to avoid thoughts, memories, or feelings (Criterion C1) and activities, conversations, or people that cause recollection (Criterion C2).
• Negative alterations in cognition or mood can include inability to remember key aspects of the trauma (Criterion D1) due to dissociative amnesia.
• Individuals may develop negative beliefs about themselves, others, and the world (Criterion D2).
• Persistent, erroneous cognitions about the causes of the trauma may lead to self-blame or blaming others (Criterion D3).
• A persistent negative mood state may emerge or worsen (Criterion D4).
• Individuals may lose interest in previously enjoyed activities (Criterion D5), feel detached from others (Criterion D6) or become unable to feel positive emotions (Criterion D7).
• Negative alterations in arousal and reactivity include irritable or angry behavior (Criterion E1).
• Individuals might engage in reckless or self-destructive behavior (Criterion E2) such as dangerous driving or substance abuse.
• Heightened vigilance for potential threats, both related and unrelated to the trauma, is common (Criterion E3).
• Individuals may exhibit an exaggerated startle response to unexpected stimuli (Criterion E4).
• Concentration difficulties, including memory problems, are frequently reported (Criterion E5).
• Sleep problems are common and can be associated with nightmares and safety concerns (Criterion E6).

PTSD Diagnosis and Specifiers

• PTSD diagnosis requires symptoms in Criteria B, C, D, and E to last more than 1 month (Criterion F).
• A current PTSD diagnosis requires meeting Criteria B, C, D, and E for at least the past month.
• A lifetime PTSD diagnosis requires meeting Criteria B, C, D, and E for at least 1 month at some point in time.
• Some individuals with PTSD experience persistent dissociative symptoms like depersonalization or derealization.
• The "with dissociative symptoms" specifier can be used to indicate the presence of these symptoms.