Trauma and Stressor Related Disorders in DSM 5-TR

Trauma and Stressor Related Disorders

• Reactive Attachment Disorder

• Disinhibited Social Engagement Disorder

• Posttraumatic Stress Disorder

• Acute Stress Disorder

• Adjustment Disorder

• Prolonged Grief Disorder

• Other Specific Trauma and Stressor Related Disorder

• Unspecified Trauma and Stressor Related Disorder

DSM 5-TR vs. DSM 4-TR

• In DSM IV-TR, Posttraumatic Stress Disorder was listed with the Anxiety Disorders, whereas in DSM 5-TR, a new category, Trauma- and Stressor-Related Disorders includes Posttraumatic Stress Disorder and Acute Stress Disorder.

• DSM-5-TR™ was released in March 2022. According to the APA, “Significant changes— including the addition of prolonged grief disorder and the inclusion of symptom codes for suicidal behavior and nonsuicidal self- injury, refinement of criteria, and comprehensive literature based updates to the text— appear in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), released by American Psychiatric Association Publishing in March.

Reactive Attachment Disorder (F94.1)

• A. Consistent pattern of inhibited or emotionally withdrawn behavior toward adult caregivers by both of the following:

  • Child rarely or minimally seeks comfort when distressed

  • Child rarely or minimally responds to comfort when distressed

• B. Persistent social and emotional disturbance by at least two following

  • Minimal social and emotional responsiveness

  • Limited positive affect

  • Episodes of unexplained irritability, sadness, fearfulness even during nonthreatening interactions with adult caregivers

• C. Child has extremes of insufficient care evidenced by

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults

  • Repeated changes of primary caregivers limit opportunity to form stable attachments

  • Rearing in unusual settings that severely limit opportunities to develop caregivers attachments

• D. Care in C is presumed to be responsible for disturbed behavior in Criterion A

• E. Criteria not met for autism spectrum disorder

• F. Evident before age 5

• G. Developmental age of 9 months or more

Reactive Attachment Disorder Specifiers

• Persistent

  • if present more than 12 months

• Severe

  • if child exhibits all symptoms of the disorder, with each symptom at relatively high levels

Reactive Attachment Disorder Issues

• An aversion to touch and physical affection.

  • Children with reactive attachment disorder often
    flinch, laugh, or even say “Ouch” when touched.
    Rather than producing positive feelings, touch and
    affection are perceived as a threat.

• Anger problems.

  • Anger may be expressed
    directly, in tantrums or acting out, or through
    manipulative, passive-aggressive behavior.
    Children with reactive attachment disorder may
    hide their anger in socially acceptable actions, like
    giving a high five that hurts or hugging someone
    too hard.

• Difficulty showing genuine care and affection.

  • For example, children with reactive attachment
    disorder may act inappropriately affectionate with
    strangers while displaying little or no affection
    towards their parents.

• Control issues.

  • Most children
    with reactive attachment disorder
    go to great lengths to remain in
    control and avoid feeling helpless.
    They are often disobedient,
    defiant, and argumentative.

• Underdeveloped conscience.

  • Children with reactive attachment
    disorder may act like they don’t
    have a conscience and fail to
    show guilt, regret, or remorse after
    behaving badly.

    
    

Disinhibited Social Engagement Disorder Throughout Life

• The social familiarity of this condition violates cultural boundaries.

• Children in very early childhood are overly familiar with strangers or unfamiliar adults.

• In preschoolers there may be attention getting behaviors.

• Middle-school children with this condition are verbally and physically overfamiliar ; exhibiting inauthentic emotional expressions.

• These signs are most relevant in adult related interactions.

• Adolescents peer relationships are negatively effected manifesting in conflict, “superficial” relationships, or awkward social situations.

  
  

Disinhibited Social Engagement Disorder Criteria

• A. Pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of following

  • Reduced or absence reticence in approaching and interacting with unfamiliar adults

  • Overly familiar verbal or physical behaviors (that is not consistent with culturally sanctioned and age-appropriate social boundaries

  • Diminished or absent checking back with adult caregivers after venturing away, even in unfamiliar settings

  • Willingness to go off with unfamiliar adult with minimal or
    no hesitation

• B. Behaviors 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 one of the following:

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults

  • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes of foster care)

  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high care-to-caregiver ratios)

• D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbance in Criterion A began following the pathogenic care in Criterion C)

• E. The child has a developmental age at least 9 months

  
  

Disinhibited Social Engagement Disorder Specifiers

• Specify if:

  • Persistent: if disorder present more than 12 months

• Specify current severity

  • Specify as severe if child exhibits symptoms of the disorder with symptoms at relatively high level

Disinhibited Social Engagement Disorder Features/Behaviors

• Lack of reticence in approaching and interacting with unfamiliar adults

• Overly familiar verbal or physical behaviors such as hugging strangers, or sitting on the laps of unfamiliar adults

• Willingness to approach a complete stranger for comfort or food, to be picked up, or to receive a toy

• Diminished or absent checking back with adult caretaker when in unfamiliar situations

• Evidence of inadequate social and emotional caretaking, sometimes with a history of repeated changes in the primary caretaker

Attachment Disorders Causes

• A baby cries and no one responds or offers comfort.

• A baby is hungry or wet, and they aren’t attended to for hours.

• No one looks at, talks to, or smiles at the baby, so the baby feels alone.

• A young child gets attention only by acting out or displaying other extreme behaviors.

• A young child or baby is mistreated or abused.

• Sometimes the child’s needs are met and sometimes they aren’t. The child never knows what to expect.

• The infant or young child is hospitalized or separated from their parents.

• A baby or young child is moved from one caregiver to another (the result of adoption, foster care, or the loss of a parent, for example).

• The parent is emotionally unavailable because of depression, illness, or substance abuse.

• Sometimes the circumstances that cause attachment problems are unavoidable, but the child is too young to understand what has happened and why.

• To a young child, it just feels like no one cares and they lose trust in others and the world becomes an unsafe place.

  
  

Posttraumatic Stress Disorder in the DSM

The reclassification of PTSD as a trauma- and stressor-related disorder in DSM-5 is based on a common etiology (i.e. exposure to a traumatic event), rather than symptoms, which is similar to how other medical fields label diagnoses.

PTSD Criteria

• A. Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following:

  • 1. Directly experiencing event

  • 2. Witnessing, in person, the event as it occurred to others

  • 3. Learning of the traumatic event occurred to close family member or close friend. 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 (e.g., first responder collecting human remains; police officers repeatedly expose to details of child abuse).

    • Criterion A4 does not apply to exposure to electronic media, television, movies, or pictures, unless this exposure is work related.

• B. Presence of one or more of following intrusive symptoms associated with the traumatic event, beginning after traumatic event

  • 1. Recurrent, involuntary, and intrusive distressing memories of event (Children older than 6 repetitive play may occur in which themes of the traumatic event are expressed)

  • 2. Recurrent distressing dreams in which content & or affect of the dream are related to the traumatic event (Children there may be frightening dreams without recognizable content)

  • 3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the trauma was recurring

    • May occur on continuum where most extreme expression is complete loss of awareness of present surroundings.

    • Children may engage in trauma-specific reenactment during play.

  • 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the trauma

  • 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the trauma

• C. Persistent avoidance of stimuli associated with traumatic events beginning after event occurred evidenced by one of following: (one)

  • 1. Avoidance or efforts to avoid distressing memories, thoughts, or feelings about event or closely associated with traumatic event

  • 2. Avoidance or efforts to avoid external reminders (people, places, conversations, activities, object or situations) that arouse distressing memories, thoughts or feelings about event

• D. Negative alterations in cognitions and moods associated with the traumatic events, beginning or worsening after trauma. Two of following:

  • 1. Inability to remember an important aspect of the trauma, typically due to dissociative amnesia

  • 2. Persistent and exaggerated negative beliefs about oneself, others or world

  • 3. Persistent distorted cognitions about the cause or consequences of the traumatic event that lead to the individual blaming himself/herself or others.

  • 4. Persistent negative emotional state (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 (inability to experience happiness, satisfaction, or loving feelings)

• E. Marked alterations in arousal and reactivity associated with the traumatic event (beginning or worsening after traumatic event occurred, expressed by two of following

  • 1. Irritable behavior and angry outbursts with little or no provocation and expressed as verbal or physical aggression toward people or objects

  • 2. Reckless or self-destructive behaviors.

  • 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 over one month (Criteria B, C, D, and E)

• G. Causes clinically significant distress or impairment in social, occupational or other functioning.

• H. Disturbance not caused by substance use or medical condition

  
  

PSTD Specifiers

• With dissociative symptoms

• Criteria met for PTSD and in response to stressor, individual experiences

  • Depersonalization

  • Derealization

• With delayed expression

Depersonalization

persistent or recurrent experiences of feeling detached from and as if one were and outsider observer of one’s mental processes or body (e.g., feeling as if one were in a dream or having sense of unreality of self or body, time moving slowly)

Derealization

persistent or recurrent experiences of unreality of surroundings (e.g., the wold around the individual is experienced as unreal, dreamlike, distant, or distorted

Delayed expression

of full diagnostic criteria are not met until at least 6 months after the event (although onset and expression or some symptoms may be immediate)

PTSD can occur due to

• War related

  • (shell shock, battle fatigue, combat fatigue)

• Acts of God/nature

  • volcanic eruptions

  • floods

  • tornadoes

  • hurricanes

  • mud slides

• Assault victims, rape victims

• Traumatic event witnessed

Veterans describe

• Depression

  • Many combat veterans are depressed

  • They have the classic symptoms of sleep disturbance, psychomotor retardation, feelings of worthlessness, difficulty in concentrating, etc

• Isolation

  • Complain of feeling like old men in you men's bodies

  • Feel isolated and distant from their peers

  • Veterans feel that most of their non-veteran peers would rather not hear what the combat experience was like; therefore, they feel rejected

• Rage

  • Veterans' rage is frightening to them and to others

  • For no apparent reason, many will strike out at whomever is near

  • Frequently, this includes their wives and children

  • Some of these veterans can be quite violent.

  • Often veterans will recount episodes in which they became inebriated and had fantasies that they were surrounded or confronted by enemy

• Avoidance of Feelings: Alienation

  • Spouses of many of the veterans complain that the men are cold, uncaring individuals

  • Veterans themselves will recount episodes in which they did not feel anything when they witnessed a death of a buddy in combat or the more recent death of a close family relative

  • Often somewhat troubled by these responses to tragedy; but, on the whole, they would rather deal with tragedy in their own detached way

  • They often describe themselves as being emotionally dead

• Survival Guilt

  • Others have died and some have not, the survivors often ask, "How is it that I survived when others more worthy than I did not?"

  • Survival guilt is an especially guilt-invoking symptom. It is not based on anything hypothetical. Rather, it is based on the harshest of realities, the actual death of comrades and the struggle of the survivor to live.

  • Often the survivor has had to compromise himself or the life of someone else in order to live. The guilt that such an act invokes or guilt over simply surviving may eventually end in self-destructive behavior by the survivor.

PTSD In Children 6 Years and Younger

• A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways

  • Directly experiencing the trauma

  • Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers

  • Learning that the traumatic event(s) occurred to a parent or caregiving figure.

• B. Presence of one or more of the following intrusion symptoms associated with the traumatic even after event

  • 1. Recurrent, involuntary, and intrusive distressing memories of event

    • Memories may not seem distressing, but appear as play reenactments

  • 2. Recurrent distressing dreams in which content & or affect of the dream are related to the traumatic event

    • May not be able to determine the frightening content is related to trauma

  • 3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the trauma was recurring

    • Reenactment may occur in play

  • 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the trauma

  • 5. Marked physiological reactions to reminders of the traumatic event

• C. One or more of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s). Following

  • Persistent Avoidance

    • Avoidance or efforts to avoid distressing memories, thoughts, or feelings about event

    • Avoidance or efforts to avoid external reminders that arouse distressing memories, thoughts or feels about event

  • Negative Alterations in Cognitions

    • Substantially increased frequency of negative emotional states

    • Markedly diminished interest or participation insignificant activities, constricted play

    • Socially withdrawn behavior

    • Persistent reduction in expressions of positive emotions

• D. Alterations in arousal and reactivity

  • 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums)

  • 2. Hypervigilance

  • 3. Exaggerated startle response

  • 4. Problems with concentration

  • 5. Sleep disturbance (difficulty falling or staying asleep, restless sleep)

• E. Disturbance more than one month

• F. Clinically significant distress or impairment in relationships with parent, siblings, peers, caregivers or school behaviors.

• G. Not due to substance or medical condition

• Specifiers

  • Depersonalization

  • Derealization

• Specify

  • With delayed expression if all criteria not met until not met until 6 months after the event

Children with PTSD

• Angry outbursts

• Problems concentrating

• Acting younger than their age

  • Clingy

  • Whiny behavior

  • Thumb sucking

  • Toileting problems

• Increased alertness to the environment

• Repeating behavior that reminds them of the trauma

• No specific physical signs of PTSD exist; however, various physical findings have been noted in children with PTSD, including the following:

  • Smaller hippocampal volume

  • Altered metabolism in areas of the brain involved in threat perception (e.g., amygdala)

  • Decreased activity of the anterior cingulate

  • Low basal cortisol levels

  • Increased cortisol response to dexamethasone

  • Increased concentration of glucocorticoid receptors and, possibly, glucocorticoid receptor activity in the hippocampus

• Worry about dying at an early age

• Lose interest in activities

• Physical symptoms such as

  • Headaches

  • Stomachaches

  • Gastrointestinal upset

• Sudden and extreme emotional reactions

• Problems falling or staying asleep

• Irritability

Acute Stress Disorder Criteria

• A. Exposure to death, serious injury, or sexual violence

  • 1. Directly experiencing event

  • 2. Witnessing event in person as occurs with others

  • 3. Learning of event to close family member or close friend

    • (Note: in cases of actual or threatened death of a family member or friend , the events must be violent or accidental)

  • 4. Repeated or extreme exposure to aversive details

    • First responders/human remains

    • Police officers repeatedly exposed to details of childhood trauma and abuse

      • (Note: does not apply to exposure thru electronic media, television, movies, pictures, unless exposure is work related.

• B. Presence of nine or more of 5 from symptom categories

  • Intrusion symptoms

  • Negative mood

  • Dissociative symptoms

  • Avoidance symptoms

  • Arousal symptoms

• C. Stress-related disturbance does not meet criteria for
  another mental disorder or exacerbation of a preexisting
  disorder

• D. Not normal bereavement

• E. Symptoms do not persist for more than additional 6
  months

Adjustment Disorder

• A. Development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor

• B. These symptoms or behaviors are clinically significant as evidenced by one or more or both

  • Marked distress that is out of proportion to the severity or intensity of the stressor

  • Significant impairment in functioning

• C. The stress-related disturbance does not meet the criteria for another mental disorder & is not merely an exacerbation of a preexisting mental disorder.

• D. The symptoms do not represent normal bereavement & are not better explained by prolonged grief disorder.

• E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

Adjustment Disorders Specifiers

• F(43.21) With depressed mood

  • Low mood, tearfulness or feelings of hopelessness

• (F43.22) With anxiety

  • Nervousness, worry, jitteriness, or separation anxiety

• (F43.23) With mixed anxiety and depressed mood

  • Combination of depressed and anxious symptoms

• (F43.24) With disturbance of conduct

• (F43.25) With mixed disturbance

  • Emotional symptoms and disturbed content

• (F43.20) Unspecified

  • Unable to fit above

• Acute

  • can be used to indicate persistence of symptoms for less than 6 months

• Persistent (chronic)

  • The specifier n be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier therefore applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences

Prolonged Grief Disorder

• A. The death, at least 12 months ago, of a person who was close to the bereaved (for children and adolescents, at least 6 months ago).

• B. Since the death, the development of a persistent grief response characterized by one or both of the following symptoms, which have been present most days to a clinically significant degree.

• In addition, the symptom(s) have occurred nearly every day for at least the last month:

  • 1. intense yearning/longing for the deceased person

  • 2. preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death)

• C. Since the death, at least three (3) of the following symptoms have been present most days to a clinically significant degree. In addition, the symptoms have occurred nearly every day for at least the last month

  • 1. Identity disruption (e.g., feeling as though part of oneself has died) since the death.

  • 2. Marked sense of disbelief about the death.

  • 3. Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders).

  • 4. Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death.

  • 5. Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future).

  • 6. Emotional numbness (absence or marked reduction of emotional experience) as a result of the death.

  • 7. Feeling that life is meaningless as a result of the death.

  • 8. Intense loneliness as a result of the death

• D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• E. The duration and severity of the bereavement reaction clearly exceeds expected social, cultural or religious norms for the individual’s culture and context.

• F. The symptoms are not better explained by major depressive disorder, posttraumatic stress disorder, or another mental disorder, or attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

  
  

Other Specified Trauma and Stressor-Related Disorder

1. Adjustment-like disorders with delayed onset symptoms
   that occur more than 3 months after the stressor.

2. Adjustment-like disorders with prolonged duration of more
   than 6 months without prolonged duration of stressor.

3. Persistent response to trauma with PTSD-like symptoms

4. Ataque de nervious

5. Other cultural syndromes

Therapy treatment

• Cognitive therapy

• Exposure therapy

  • Allows client to safely encounter the frightening issues of their experience. what you find frightening. New approach may involve "virtual reality" programs for the client to reexperience the trauma in a safe, but simulated setting.

• “Eye movement desensitization and reprocessing (EMDR).

  • EMDR combines exposure therapy with a series of guided eye movements that help you process traumatic memories and change how you react to traumatic memories”

SSRIs

• Sertraline (Zoloft) 50 mg-200 mg

• Paroxetine (Paxil) 20 mg-60 mg

• Fluoxetine (Prozac) 20 mg- 60 mg

SNRIs

• Mirazapine (Rameron) 7.5 mg-45 mg

• Venlafaxine (Effexor) 75 mg-300 mg

• Nefazodone (Serzone) 200 mg-600 mg

Anticonvulsants

• Carbamazepine (Tegretol).

  • Requires monitoring of white blood cell counts due to risk of agranulocytosis. Will self-induce its own metabolism and increase the metabolism of other medications including oral contraceptives.

• Divalproex (Depakote).

  • Requires monitoring of liver function tests due to risk of hepatotoxicity and platelet levels due to risk of thrombocytopenia.

  • Target dosage is 10 times the patient's weight in pounds.

• Lamotrigine (Lamictal).

  • Requires slow titration according to the package insert due to risk of serious rash.

• Topiramate (Topimax).

  • Requires clinical monitoring for glaucoma, sedation, dizziness and ataxia

Second Line Medications

• Prazosin (Minipress)

  • If symptoms include insomnia or recurrent nightmares, a drug called prazosin (Minipress) may help.

  • A Soldier's Double-Edged Sword: How PTSD Affects the 21st Century Warrior video

• Tricyclic Antidepressants (such as Imipramine)

• Monoamine Oxidase Inhibitors (MAOIs) (such as Phenelzine)

Memantine (Namenda)

is a drug of potential interest in preventing neurodegeneration by protecting against glutamatergic destruction of neurons through its antagonism of the NMDA receptor. This drug could be potentially useful in preventing hypothesized neurodegeneration in the hypothalamus and memory loss in PTSD.

Ketamine

is an anesthetic agent which modulates the balance between glutaminergic activity at the NMDA receptor and serotonergic activity at the 5-HT receptors. This agent is showing promise for treatment of refractory depression in research trials currently (39). A recent trial showed beneficial effects in PTSD as well (40). The limitations so far include a short term benefit of a few weeks and the anesthetic nature of the drug and potential for addiction.”

Ecstasy for PSTD

• The Food and Drug Administration has determined that illicit drug ecstasy is a “breakthrough therapy” for post-traumatic stress disorder (PTSD) treatment.

• Methylenedioxymethamphetamine (MDMA), commonly referred to as ecstasy is in final trials for use with PTSD