L3 - Trauma and Stressor-Related Disorders PDF

Trauma and Stressor-Related Disorders: Include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include: - Reactive Attachment Disorder (RAD) - Disinhibited Social Engagement Disorder (DSED) - Posttraumatic stress diso...

Trauma and Stressor-Related Disorders: Include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include: - Reactive Attachment Disorder (RAD) - Disinhibited Social Engagement Disorder (DSED) - Posttraumatic stress disorder (PTSD) - Acute stress disorder - Adjustment disorders DSM-IV VS. DSM-5: PTSD is no longer classified as an Anxiety Disorders;it is now included in the DSM-5 chapter: Trauma and Stressor-Related Disorders Many individuals exposed to traumatic or stressful events exhibit a phenotype characterized by: (rather than anxiety- or fear-based symptoms) - Anhedonic and dysphoric symptoms - Externalizing angry and aggressive symptoms - Dissociative symptoms Because of these variable expressions of clinical distress after catastrophic or aversive events, these disorders are categorized as trauma- and stressor-related disorders Reactive Attachment Disorder (RAD): Is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior RAD has been reconfigured from one disorder with two subtypes(DSM IV) into two distinctive disorders in DSM-5 - RAD: an emotionally withdrawn/inhibited phenotype - DSES: an indiscriminately social/ disinhibited phenotype Social neglect (the absence of adequate caregiving during childhood) is a diagnostic requirement of both RAD and DSED - Prevalence is less than 10% - Symptoms develop between 9 months to 5 years Diagnostic Criteria: A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: 1. The child rarely or minimally seeks comfort when distressed. 2. The child rarely or minimally responds to comfort when distressed. B. A persistent social and emotional disturbance characterized by at least two of the following: 1. Minimal social and emotional responsiveness to others. 2. Limited positive affect. 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers. C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C). E. The criteria are not met for autism spectrum disorder. F. The disturbance is evident before age 5 years. G. The child has a developmental age of at least 9 months. Specify if: - Persistent: present for more than 12 months - Specify current severity: specified as severe when all symptoms are present at high levels Associated Features: 1- developmental delays esp. cognition and language 2- Signs of severe neglect (e.g., malnutrition or signs of poor care) Differential Diagnosis: 1. Autism Spectrum Disorder: a. differentiated by: Presence of restricted interests and ritualized behaviors, specific deficit in social communication, selective attachment behaviors b. RAD: History of neglect 2. Intellectual Disability: (Intellectual Developmental Disorder) a. Children exhibit social and emotional skills comparable to their cognitive skills b. Do not demonstrate the profound reduction in positive affect and emotion regulation difficulties seen in children with RAD c. Developmentally delayed children with a cognitive age of 7-9 months should form selective attachments, regardless of chronological age RAD: Children lack preferred attachments despite having attained a developmental age of at least 9 months 3. Depressive Disorders: a. Associated with reductions in positive affect b. Limited evidence (suggests impairments in attachment) Young children with depressive disorders still seek and respond to caregivers' comforting efforts Disinhibited Social Engagement Disorder (DSED): Marked by disinhibition and externalizing behavior Diagnostic Criteria: A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults. 2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries). 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings. 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but include socially disinhibited behavior. C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g.:, the disturbances in Criterion A began following the pathogenic care in Criterion C). E. The child has a developmental age of at least 9 months. Specify if: - Persistent: present for more than 12 months - Specify current severity: specified as severe when all symptoms are present at high levels Differential Diagnosis: Attention-Deficit/Hyperactivity Disorder (ADHD): Similarity: Social impulsivity DSED: Do not show difficulties with attention or hyperactivity Posttraumatic Stress Disorder (PTSD): Diagnostic Criteria: >6 years: ≤6 years: A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others *Especially primary caregivers Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of *A parent or caregiver figure actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first (Excluded) responders collecting human remains; police officers repeatedly exposed to details of child abuse) Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not Note: In children older than 6 years, repetitive play necessarily appear distressing and may be expressed may occur in which themes or aspects of the as play reenactment traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content Note: It may not be possible to ascertain that the and/or affect of the dream are related to the traumatic frightening content is related to the traumatic event. event(s). Note: In children there may be frightening dreams with recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic Note: In children 6 or under, trauma-specific event(s) were recurring. (Such reactions may occur reenactment may occur in play. on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated C. One (or more) of the following symptoms, with the traumatic event(s), beginning after the representing either persistent avoidance of stimuli traumatic event(s) occurred, as evidenced by one or associated with the traumatic event(s) or negative both of the following: alterations in cognitions and mood associated with 1. Avoidance of or efforts to avoid distressing the traumatic event(s), must be present, beginning memories, thoughts, or feelings about or after the event(s) or worsening after the event(s): closely associated with the traumatic event(s). Persistent Avoidance of Stimuli 2. Avoidance of or efforts to avoid external 1. Avoidance of or efforts to avoid activities, places, reminders (people, places, conversations, or physical reminders that arouse recollections of the activities, objects, situations) that arouse traumatic event(s). distressing memories, thoughts, or feelings 2. Avoidance of or efforts to avoid people, about or closely associated with the traumatic conversations, or interpersonal situations that arouse event(s). recollections of the traumatic event(s).  Negative Alterations in Cognitions 3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion) 4. Markedly diminished interest or participation in significant activities, including constriction of play. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive emotions. D. Negative alterations in cognitions and mood D. Alterations in arousal and reactivity associated associated with the traumatic event(s), beginning or with the traumatic event(s), beginning or worsening worsening after the traumatic event(s) occurred, as after the traumatic event(s) occurred, as evidenced by evidenced by two (or more) of the following: two (or more) of the following: 1. Inability to remember an important aspect of the 1. Irritable behavior and angry outbursts (with little traumatic event(s) (typically due to dissociative or no provocation) typically expressed as verbal or amnesia and not to other factors such as head injury, physical aggression toward people or objects alcohol, or drugs). (including extreme temper tantrums). 2. Persistent and exaggerated negative beliefs or 2. Hypervigilance. expectations about oneself, others, or the world (e.g., 3. Exaggerated startle response. “I am bad,” “No one can be trusted,” “The world is 4. Problems with concentration. completely dangerous,” “My whole nervous system 5. Sleep disturbance (e.g., difficulty falling or staying is permanently ruined”). asleep or restless sleep). 3. Persistent, distorted, cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity E. The duration of the disturbance is more than 1 associated with the traumatic event(s), beginning or month worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructing behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) F. Duration of the disturbance (Criteria A, B, C, D, F. The disturbance causes clinically significant and E) is more than 1 month distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior G. The disturbance causes clinically significant G. The disturbance is not attributable to the distress or impairment in social, occupational, or physiological effects of a substance (e.g., medication other important areas of functioning or alcohol) or another medical condition.  H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following: 1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate) Risk and Prognostic Factors: 1. Pre-traumatic Factors: Temperamental: - Childhood emotional problems by age 6 years (e.g., prior traumatic exposure, externalizing or anxiety problems) - Prior mental disorders (e.g., panic disorder, depressive disorder, or OCD) Environmental: - Lower socioeconomic status - Lower education - Exposure to prior trauma (especially during childhood) - Childhood adversity (e.g., economic deprivation, family dysfunction, parental separation or death) - Cultural characteristics (e.g., fatalistic or self-blaming coping strategies) - Lower intelligence - Minority racial/ethnic status - Family psychiatric history - Social support prior to event exposure is protective Genetic and Physiological: - These include female gender and younger age at the time of trauma exposure (for adults)  - Certain genotypes may either be protective or increase risk of PTSD after exposure to traumatic events 2. Peritraumatic Factor: Environmental: - Severity of the trauma - Perceived life threat - Personal injury - Interpersonal violence (particularly trauma perpetrated by caregiver or involving witnessed threat to caregiver in children) - for military personnel: being a perpetrator, witnessing atrocities, or killing the enemy - Dissociation that occurs during the trauma and persists afterward is a risk factor 3. Posttraumatic Factors: Temperamental: - Negative appraisals - Inappropriate coping strategies - Development of acute stress disorder Environmental: - Subsequent exposure to repeated upsetting reminders - Subsequent adverse life events - Financial or other trauma-related losses Social support (including family stability, for children) is a protective factor that moderates outcome after trauma Differential Diagnosis: - Adjustment Disorders: a. The stressor can be of any severity or type rather than that required by PTSD Criterion A b. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other PTSD criteria or criteria for another mental disorder c. An adjustment disorder is also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that does not meet PTSD criterion A (e.g., spouse leaving, being fired) - Other posttraumatic disorders and conditions: a. When symptoms arise or worsen after trauma exposure b. If the symptoms meet the criteria for another mental disorder, that diagnosis should be given instead of, or in addition to, PTSD c. Conditions are excluded if they are better explained by PTSD (e.g., panic disorder symptoms occurring only after trauma reminders) d. If the response to the trauma is severe, it may warrant a separate diagnosis (e.g., dissociative amnesia) - Acute Stress Disorder: Is restricted to a duration of 3 days to 1 month following exposure to the traumatic event - OCD: a. Recurrent intrusive thoughts meet the definition of an obsessions b. These intrusive thoughts are not related to any traumatic event c. Compulsions are usually present in OCD, while other symptoms of PTSD or acute stress disorder are generally absent - Anxiety Disorders: a. Panic disorder/ avoidance, irritability, and anxiety of GAD: involves arousal and dissociative symptoms that are not linked to a specific traumatic event b. Symptoms of separation anxiety disorder are clearly related to being away from home or family, rather than to a traumatic event - MDD: a. May occur with or without a preceding traumatic event and should be diagnosed if other PTSD symptoms are absent b. Specifically, MDD does not include any PTSD Criterion B (intrusive symptoms) or Criterion C (avoidance). Nor does it include a number of symptoms from PTSD Criterion D (negative alterations in mood) or E (arousal and reactivity) - Personality Disorders: Interpersonal difficulties that began or worsened after a traumatic event may indicate PTSD rather than a personality disorder, in which such difficulties would be expected independently of any traumatic exposure - Dissociative Disorders: a. Dissociative amnesia, dissociative identity disorder, and depersonalization- derealization disorder: may or may not be preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms b. If full PTSD criteria are met, the subtype "PTSD with dissociative symptoms" should be considered - Conversion Disorder (Functional Neurological Symptom Disorder): a. The new onset of somatic symptoms in the context of posttraumatic distress may indicate PTSD rather than conversion disorder - Psychotic Disorder: Flashbacks in PTSD should be differentiated from: Illusions, hallucinations, and other perceptual disturbances that occur: Schizophrenia Brief psychotic disorder Other psychotic disorders Depressive and bipolar disorders with psychotic features Delirium Substance/medication-induced disorders Psychotic disorders due to other medical conditions  - Traumatic Brain Injury (TBI): a. Symptoms of PTSD may appear after a brain injury resulting from a traumatic event (e.g., accidents, bomb blasts, acceleration/deceleration trauma) b. An event causing head trauma may also be considered a psychological trauma, TBI-related neurocognitive symptoms are not mutually exclusive and may occur concurrently c. Distinguishing between PTSD and neurocognitive disorder symptoms from TBI may be possible based on distinctive symptoms: PTSD: Re-experiencing and avoidance. TBI: Persistent disorientation and confusion (more specific to TBI than to PTSD) Acute Stress Disorder: A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: Intrusion symptoms: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). Note: ın children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Negative Mood: 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings) Dissociative Symptoms: 6. An altered sense of reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing). 7. Inability to remember an important aspect of traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). Avoidance Symptoms: 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Arousal Symptoms: 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). 11. Irritable behavior and angry outburst (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response. C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder. Adjustment Disorders: A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following: 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. 2. Significant impairment in social, occupational, or other important areas of functioning. C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisiting mental disorder. D. The symptoms do not represent normal bereavement. E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. Specify whether: Depressed mood: Low mood, tearfulness, or feeling of hopelessness are predominant Anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant Mixed anxiety and depressed mood: A combination of both Disturbance of conduct: Disturbance of conduct is predominated Mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression,anxiety) and a disturbance of conduct are predominant Unspecified: Maladaptive reactions that are not fitting other categories Diagnostic Features: - Can be a single event (e.g., ending a romantic relationship) or multiple stressors (e.g., business difficulties and marital issues) - Recurrent (e.g., seasonal business crises, unfulfilling sexual relationships) - Continuous (e.g., persistent painful illness with increasing disability, living in a crime-ridden area) - Stressors can affect: An individual, an entire family, and larger group or community (e.g., natural disasters) - Developmental events (e.g., going to school,leaving a parental home, reentering a parental home, getting married, becoming a parent, failing to attain occupational goals, retirement) - Adjustment disorders may be diagnosed after the death of a loved one when the intensity, quality, or persistence of grief reactions exceeds what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account. - Increased risk of suicide attempts and completed suicides Other Specified Trauma- and Stressor-Related Disorder: Used when symptoms do not fully meet criteria for a specific disorder but cause significant distress or impairment Examples include: - Adjustment-like disorders with delayed onset that occur more than 3 months after the stressor - Adjustment-like disorders with prolonged duration (more than 6 months) without prolonged duration of stressor - Ataque de nervios - Other cultural syndromes - Persistent complex bereavement disorder Unspecified Trauma- and Stressor-Related Disorder: - It applies when symptoms do not fully fit a specific disorder but cause clinically significant distress - ​This category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific trauma- and stressor-related disorder - It includes presentations where there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings)