Week 7: PTSD and Stress-Related Disorders

What are Trauma- and Stressor-Related Disorders?

These disorders occur after the exposure to a traumatic or stressful event. Symptoms can be understood within an anxiety- or fear-based context. Anxiety is regarded as a warning signal that helps alert a person to impending or imminent danger and enables the person to deal with the threat of harm. Fear is similar, but is markedly different.

How is fear different than anxiety?

It is seen as a response to a definite and/or known hazard. Anxiety is a response to an unknown or unspecified threat. Fear is an acute reaction, while anxiety is considered chronic.

What is exposure to trauma marked by?

Is marked by a range of symptoms depending o the persons: Age, Previous exposure to trauma, Temperament and Environmental factors

What are the two disorders that share a common etiology of social neglect?

Reactive attachment disorder and disinhibtied social engagement disorder

How does Reactive Attachment Disorder manifest?

manifested by internalizing anxiety and withdrawn behavior and depressive symptoms.

How does Disinhibited Social Engagement Disorder manifest?

marked by externalizing angry and aggressive behavior and disinhibition

What are the trauma disorders?

Reactive Attachment Disorder 319.89 (F94.1), Disinhibited Social Engagement Disorder 313.89 (F94.2), Posttraumatic Stress Disorder 309.81 (F43.10), Acute Stress Disorder 308.3 (F43.0), Adjustment Disorders 309.XX (F43.XX)Other Specified Trauma- and Stressor-Related Disorder

What is Reactive Attachment Disorder 319.89 (F94.1)?

Fairly new diagnosis to the DSM. Seen in children who have experienced various types of adverse environments. It results from inadequate caregiving environments in early childhood and encompasses a distinct pattern of a child who is emotionally withdrawn and inhibited.

What can RAD symptom picture lead to?

controlling, aggressive, or delinquent behaviors, trouble relating to peers and other problems. The disorder tends to be a lifelong challenge.

What is the Prevailing Pattern of RAD?

We don’t know. We see a higher prevalence among children placed in foster care.

What is the Differential Assessment for RAD?

Failure to seek and respond to comforting when distressed. Minimal emotional regulation. Reduced positive affect. Episodes of unexplained fearfulness, inhibition, and anxiety. Children at a higher risk show a history of living in settings that limit attachment opportunities: Being separated, ignored, or neglected by their birth parents (or primary caretakers), placed in multiple foster homes where they can’t form relationships, or Raised in settings where there is minimal individualized care.

When do RAD symptoms begin?

before the age of 5, and usually can be seen while still an infant. The child has not bonded to an adult and is unable to trust and thus must have a developmental age of at least 9 months. The child has learned that the adults in his/her care are untrustworthy. Basic needs for comfort, affection, and nurturing have not been met, and loving, caring attachments with others were never established. The child may not know how the love attachment will look different between parents and teacher or Rabbi

What does the practitioner needs to rule out before diagnosing RAD?

autism spectrum disorder. Look for the severe social neglect - which will help distinguish this disorder from autism spectrum disorder. Also restrictive interests and repetitive behaviors characteristic of ASD are not seen in children with this.

What is the RAD specifier of “persistent?”

can be applied when the disorder has been present for at least 1 year.

What is the the severity of specifier of “severe” used for RAD?

when the child exhibits all symptoms of the disorder and at relatively high levels.

What we might see in RAD?

Someone who is insecure, emotionally withdrawn, struggling with social and emotional reciprocity – may be unable to seek out and respond to comforting at times of distress – fearful and unhappy. Emotional regulation is disturbed. Irritable. Avoidant of relationships and attachments to just about anyone - Failing to seek emotional comfort when distressed - alone with their distress. Look for the severe social neglect - which will help distinguish this disorder from autism spectrum disorder. Also restrictive interests and repetitive behaviors characteristic of ASD are not seen in children with this.

What is Disinhibited Social Engagement Disorder 313.89 (F94.2)?

This is a disorder of a child’s social relatedness and the central feature is that the child has experienced serious neglect or pathogenic care (such as severe parental neglect, abuse, or mishandling) very early in life.

What is the Differential Assessment for DSED?

Inappropriate approach to unfamiliar adults. A lack of wariness of strangers. Willingness to wander off with strangers. The child does not discriminate between parents and strangers. The child seeks attention from just about everyone. The child who has experienced extremes of insufficient care such as: (being separated, ignored, or neglected by their birth parents (or primary caretakers), or placed in multiple foster homes, or raised in settings where there is minimal individualized care that limits attachment opportunities is placed at a higher risk for developing). The diagnosis is not considered before the child is developmentally able to form attachments – roughly 9 months of age.

What are Key differences between RAD and DSED?

A lack of comfort-seeking when distressed vs. lack of capacity for self-regulation in social situations (overly emotive).

Shows a limited interest in interaction with unfamiliar adults vs. Shows an interest in, and willingness to interact with, unfamiliar adults.

Symptom presentation is less clear in adolescence vs. Social and verbal intrusiveness and attention seeking are more often seen during childhood, and superficial peer relationships along with enhanced peer conflicts in adolescence.

More vulnerable to internalizing disorders such as MDD vs Greater risk for developing externalizing disorders such as ADHD, ODD, and CD

What is Posttraumatic Stress Disorder 309.81 (F43.10)?

was first named in the DSM-III (1980). Longitudinal studies suggest that this can become a chronic problem, often persisting for decades.

What are the major reference points of PTSD?

Witnessing a homicide or suicide, Traffic accidents, Combat or wartime experience, Natural disasters, Sexual assault, Sudden death of a loved one, Survivors of holocausts, Life events such as DV or a diagnosis of HIV

How is PTSD a subjective experience?

Some people can simply walk away from a terrible automobile accident in which they had been pried out with the ‘jaws of life’ - Others re-experience the automobile accident in their dreams and waking thoughts, endure a numbing of responsiveness, and evade or shun everything that reminds them of the accident. Some people may not react until years afterward. Different levels of stress and trauma appear to influence memory in different ways - Excessive amounts of stress can cause significant memory impairment. The body’s physiological responses culminate in the release of steroid hormones - Some people who experience trauma may not make the connection between the traumatic event and feeling depressed and/or anxious, abusing substances, cognitive difficulties, domestic violence, or marital problems.

Prevailing Pattern of PTSD?

Lifetime prevalence is between 3.% among men and 9.7% among women. Difference between men and women - do women internalize more? For adolescents between 12 and 17, the 6-month prevalence rates was 3.7% among boys and 6.3% among girls. For adults, the 12-month prevalence is about 3.5%. Rates are higher among veterans, police, firefighters, or emergency medical personnel. The highest rates are among survivors of rape, military combat and captivity, and ethnically or politically motivated captivity and genocide.

What is the Differential Assessment of PTSD?

The close exposure to the trauma seems to be the main aspect of developing this. Combat experiences and sexual assault are the most common traumas associated with this. 18.7% of Vietnam vets have developed this. Among those who lived closest to the World Trade Center, 20% were diagnosed with this. For children older than age 6 and for adults, exposure to actual or threatened death, serious injury, or sexual violence are the most common precipitants to this. Consider whether the event was experienced directly, witnessed, or experienced indirectly. Just let the memories come back - don’t ask closed-ended questions.

What are the symptom clusters of PTSD?

Re-experiencing the event, Avoidance, Negative thoughts and mood or feelings, Heightened arousal

What is re-experiencing the even in PTSD?

Spontaneous memories, Recurrent dreams, Flashbacks, Intense or prolonged psychological distress, Marked physiological reactions

What is avoidance?

Distressing memories, thoughts, feelings, or external reminders. Efforts to avoid external reminders that provoke distressing memories thoughts or feelings associated with the trauma

What are negative thoughts and mood or feelings?

An inability to remember key aspects of the event. Negative thoughts about oneself, others, or the world. Feelings that may vary from persistent and distorted sense of blame of self or others. Persistent negative emotional state such as fear, horror, anger, guilt. Emotions take over. A marked diminished interest in activities to estrangement from others. Feelings of detachment or estrangement from others. An inability to experience positive emotions.

What is heightened arousal in PTSD?

Aggressive angry outbursts. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems concentrating. Sleep disturbances.

What is the time criteria for PTSD?

The symptoms must last for more than 1 month!!!!!!!! Significantly affect social, occupational, or some other significant interpersonal area of an individual’s life. Rule out another medical condition or the effects of a substance such as medication or alcohol. Remember, some people may not show signs of this for many years. Make sure you’re not dealing with: (Anxiety and OCD, Major depressive disorder, Dissociative disorders, Conversion disorder).

What is Acute Stress Disorder 308.3 (F43.0)?

It can be considered when all the elements of PTSD are present, but for less than 1 month!!!!!! If symptoms persist for longer than one month, they would no longer be considered acute. One difference between this and PTSD is that we see dissociation in this that we do not see in PTSD.

What is the Differential Assessment for ASD?

Look for if the traumatic events were experienced directly, witnessed, or experienced indirectly. Approximately half of those who develop PTSD initially presented with this.

What are Symptoms of ASD?

Intrusion, negative mood, dissociation, avoidance, arousal

What is Intrusion in ASD?

Intrusive and distressing memories of the traumatic event, Re-experiencing the feelings of the event, Dissociative reactions such as flashbacks. Intense or prolonged reactions in response to cues that resemble an aspect of the event

What is Dissociation in ASD?

An altered sense of reality to one’s surroundings – being in a daze & Being unable to remember important features of the traumatic events.

What is Avoidance in ASD?

Efforts to avoid distressing memories, thoughts, feelings, about the event. Trying to avoid external reminders such as avoiding people, places, conversations…

What is Arousal in ASD?

Sleep disturbances, Irritability, Hypervigilance, Difficulty concentrating, An exaggerated startle response.

What is Adjustment Disorder 309.XX (F43.XX)?

This diagnosis is reserved for individuals who exhibited clinically significant distress but did not meet the criteria for a more discrete disorder. Think about the individual who is going through a difficult time (death, breakup, going to college). The difficulty is likely time limited in that the person will likely resolve that which is distressing. The person can typically put his/her finger down on what it is that has distressed him/her.

What is the Prevailing Pattern Adjustment Disorder?

Very common!

What is the Differential Assessment Adjustment Disorder?

They differ from PTSD in that PTSD generally occurs as a reaction to a life-threatening event and tends to last longer. They are short term, and symptoms generally resolve within 6 months after the stressor or has ended. The disorders do interfere with social functioning, and performance during the period of adaptation to a significant life change or stressful event. The stressor may have affected the individual’s social network (e.g., bereavement, martial separation) or may be represented by a major developmental transition or crisis (e.g., going to college, becoming a parent, retirement).

What do you have to do for diagnostic purposes for adjustment disorder?

see if the person’s distress is out of proportion to the severity or intensity of the stressors. This person is having a hard time with a stressor. Onset can be specified as acute (lasting for less than 6 months), or chronic (lasting longer than 6 months).

What specifiers does the social worker have to consider with adjustment disorder?

(5) With depressed mood, With anxiety, With mixed anxiety and depressed mood, With disturbance of conduct, Unspecified: for maladaptive reactions that are not seen as one of the specific subtypes of adjustments.

What is Other Specified Trauma- and Stressor-Related Disorder 309.89 (F43.8)?

applies when the person’s symptom picture does not meet full criteria for any of the other disorders. We may see: Adjustment-like disorders with delayed onset of symptoms that occur more than 3 months after the stressor. Adjustment-like disorders with prolonged duration of more than 6 months without prolonged duration of stressor. Ataque de nervios, which is generally reserved for individuals of Latino descent, and characterized by symptoms of intense emotionally upset including acute anxiety, anger4, or grief; screaming and shouting uncontrollably; attacks and crying; trembling; heat in the chest rising to the head; and becoming verbally and physically aggressive. Other cultural syndromes as listed in the DSM-5 “Glossary of Cultural Concepts of Distress.” Persistent bereavement disorder

What is Unspecified Trauma- and Stressor-Related Disorder 309.90 (F43.9)?

applies when the person’s symptom picture does not meet full criteria for any of the other disorders and no reason is given

What disorders can be understood by symptoms within an anxiety- or fear-based context?

PTSD, ASD, and Adjustment Disorders

What is understood where the more prominent features are expressed as anxiety with withdrawn behavior and depressive symptoms?

RAD

What is marked by externalizing angry and aggressive behavior and expressions of disinhibitions?

DSED