DSM-5: Trauma-and Stressor- Related Disorders, Study notes of Acting

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DSM-5:Trauma-and Stressor-

Related Disorders

Criteria, Changes, and Clinical Implications

Jennifer Sweeton, Psy.D.

Oklahoma City VA Medical Center

Trauma- and Stressor-Related Disorders

1. Posttraumatic Stress Disorder

2. Acute Stress Disorder

3. Adjustment Disorders

4. Reactive Attachment Disorder

5. Disinhibited Social Engagement Disorder

6. Other Specified Trauma- and Stressor-Related

Disorder

7. Unspecified Trauma- and Stressor-Related

Disorder

 Persistent Complex Bereavement Disorder (proposed

for Section III, a section describing conditions that need

more research)

PTSD After – Criteria A + B…

CHANGES TO CRITERION A:

1. Criterion A1 is expanded:

Trauma involves actual or threatened event, including:

1. Death
2. Serious injury
3. Sexual violence

Four types of exposure

1. Directly experienced
2. Witnessed
3. Learned happened to a loved one (must be accidental or violent)
4. Repeated, extreme exposure to details (first responders, police – media exposure doesn’t count)
5. Criterion A2 (Person responded to event with fear/anxiety/helplessness/horror) is removed.

CHANGES TO CRITERION B:

• Exact same 5 symptoms.
• Notable revisions
  • B1: Memories
    • Versus DSM-IV recollections (images, thoughts, perceptions)
  • B3: Flashbacks
    • Emphasis on dissociation and continuum of reactions

CRITERION C CHANGES:

 Numbing separated from avoidance.

 Same 2 sx as DSM-IV

 C1: Avoid memories, thoughts, feelings

 C2: Avoid external reminders

 Addresses problematic ambiguity in DSM-IV

 Conversations moved from C1 to C2 to create clear distinction between internal and

external stimuli

CRITERION D CHANGES (most heavily revised cluster):

 Now called “Negative alterations in cognition and mood”

 Numbing symptoms from DSM-IV plus two new symptoms

◦ D1: Amnesia (not due to TBI or intoxication)

◦ D2:Negative beliefs (broader version of previous “foreshortened future” symptom)

◦ D3: Distorted cognitions and blame (from cognitive model of PTSD – think “stuck

points”)

◦ D4: Negative emotions (fear, horror, anger, guilt, shame)

◦ D5: Diminished interest

◦ D6: Detachment or estrangement

◦ D7: Inability to experience positive emotions

PTSD After – Criteria C + D…

Changes to PTSD in DSM-

 PTSD was removed from anxiety disorders; trauma is heterogeneous, and response

may involve anger, dissociation, etc.

 Now have four symptom clusters: avoidance, re-experiencing, persistent negative

changes in mood and cognition, and arousal.

 Criterion A2 removed (no fear, helplessness, or horror required)

 Criterion A1 (now just ‘A’) clarified

 Avoidance and numbing symptoms split

 Three new symptoms added

 Several symptoms revised

 Separate PTSD criteria for children 6 or younger

 Dissociative subtype added

PTSD After…

 Criterion A: Exposure to 1+ event(s) that involved death/threatened death, actual/threatened serious injury, or

threatened sexual violation. Events were experienced in 1+ following ways: ◦ The event was experienced by the person. ◦ The event was witnessed by the person as it occurred to someone else. ◦ The person learned about event where relative/friend experienced actual or threatened violent or accidental death. ◦ The person experienced repeated exposure to distressing details of an event.

 Criterion B: 1+

1. Unexpected/expected reoccurring, involuntary, intrusive upsetting memories of trauma
2. Repeated upsetting dreams where the content of dreams related to the trauma
3. Dissociation (ex: flashbacks) where person feels as though the trauma is happening again
4. Strong/persistent distress upon exposure to cues inside or outside of person's body connected to trauma
5. Strong bodily reaction upon exposure to a reminder of the trauma  Criterion C: Frequent avoidance of reminders associated with trauma, as demonstrated by 1+:
6. Avoidance of thoughts, feelings, or physical sensations that bring up memories of trauma
7. Avoidance of people, places, conversations, activities, objects, situations that bring up memories of trauma  Criterion D: 3+ negative changes in thoughts/mood that occurred/worsened following trauma:
8. The inability to remember an important aspect of the traumatic event
9. Persistent, elevated negative evaluations about one's self, others, or the world
10. Elevated self-blame or blame of others about the cause or consequence of a trauma
11. A negative emotional state (for example, shame, anger, fear) that is pervasive
12. Loss of interest in activities that one used to enjoy
13. Feeling detached from others
14. The inability to experience positive emotions (for example, happiness, love, joy)  Criterion E: 3+ changes in arousal that started or worsened following a trauma:
15. Irritability or aggressive behavior
16. Impulsive or self-destructive behavior
17. Feeling constantly "on guard" or like danger is lurking around every corner
18. Heightened startle response
19. Difficulty concentrating
20. Problems sleeping  Criteria F-H: Same as DSM-IV

PTSD Changes – Implications

• More restrictive, more difficult to diagnose?
  • Criterion A: New definition addresses ambiguity of “confronted with” in DSM-IV. Definition is narrower, more restrictive perhaps?
  • D7 is more specific than the previous version, which mentioned overall restricted range of affect.
• Broader, easier to diagnose?
  • However, less restrictive now that A2 has been deleted.
  • D4 is non-specific, just mentions overall negative emotions. Concern about overlap

with anger/angry outbursts described in Criterion E.

• The criteria has been broadened to include other emotional reactions to trauma than fear.

 According to NCPTSD: “National estimates of PTSD prevalence suggest that DSM- rates were slightly lower than DSM-IV. … Revision of Criterion A1 in DSM-5 narrowed

qualifying traumatic events such that the unexpected death of family or a close friend due to natural causes is no longer included. Research suggests this is the greatest contributor (>50%) to discrepancy for meeting DSM-IV but not DSM-5 criteria.”

 PTSD assessment measures (CAPS, PCL) being revised by the NCPTSD.

 Possible treatment implications – symptoms align nicely with cognitive theory of PTSD

PTSD Checklist for DSM-5 = PCL-

 20 items, which match DSM-5 criteria

 PCL-5 most closely resembles PCL-IV (PCL-S)

 Symptoms rated on scale 0-4, not 1-

 Three versions of the PCL-5:

◦ Without Criterion A

◦ With Criterion A

◦ With Life Events Checklist for DSM-5 (LEC-5) and extended Criterion A

 Currently no PCL-5 version corresponding to PCL-M or PCL-C, but this is in the

works.

 Cut scores TBD. Recommended to consider symptom scores of 2 as moderate.

Clinician-Administered PTSD Scale for

DSM-5 (CAPS-5)

 Contains 30 items which correspond to DSM-5 criteria.

 Prompts were revised for DSM-5 and readability

 Improved sequence of prompts

 Now top to bottom instead of left to right (simplifies administration, helps organize

note-taking)

 Interim ratings of Frequency and Intensity combined into single 0-4 Severity rating

In the past month, have you had any unwanted

memories of (EVENT) while you were awake, so not

counting dreams? [Rate 0=Absent if only during dreams]

How does it happen that you start remembering

(EVENT)?

[If not clear:] (Are these unwanted memories, or are you thinking about [EVENT] on purpose?) [Rate 0=Absent unless perceived as involuntary and intrusive]

How much do these memories bother you?

Are you able to put them out of your mind and

think about something else?

Circle: Distress = Minimal Clearly Present Pronounced

Extreme

How often have you had these memories in the past

month? _# of times ___________

Key rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present,

some difficulty dismissing memories

Severe = at least 2 X week / pronounced distress,

considerable difficulty dismissing memories

0 A bsent 1 Mild / subthreshold 2 Moderate / threshold 3 Severe / markedly elevated

4 Extreme / incapacitating

CAPS-5 Item 1:

Changes to AST in DSM-

 Criterion A changes same as PTSD updates – A1 is clarified; A2 is deleted.

 It was concluded that DSM-IV’s AST criteria was too heavily focused on dissociation,

thus, dissociation is no longer required for diagnosis.

 Person now must meet any 9 of the 14 dissociation, avoidance, arousal, negative

mood, and/or intrusion symptoms.

 No one symptom of the 14 is required for a diagnosis.

AST After…

 Criterion A. same as ptsd

 Criterion B. 9+ symptoms

◦ (1) Subjective sense of numbing, detachment from others, or reduced responsiveness to events ◦ (2) An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing)

◦ (3) Inability to remember at least one important aspect of the traumatic event ◦ (4) Spontaneous or cued recurrent, involuntary and intrusive distressing memories of the event

◦ (5) Recurrent distressing dreams related to the event ◦ (6) Dissociative reactions in which the individual feels or acts as if the traumatic event were recurring ◦ (7) Intense or prolonged psychological distress or physiological reactivity at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event ◦ (8) Persistent avoidance of thoughts, conversations, or feelings that arouse recollections of the trauma

◦ (9) Persistent avoidance of activities, places, or physical reminders that arouse recollections of trauma

◦ (10) Sleep disturbance (e.g., difficulty in falling asleep, restless sleep, or staying asleep) ◦ (11) Hypervigilence

◦ (12) Irritable, angry or aggressive behavior ◦ (13) Exaggerated startle response

◦ (14) Agitation or restlessness

 Criterion C. Duration 3+ or more days and less than 1 month after the traumatic event

 Criterion D. causes clinically significant distress or impairment

 Criterion E. Disturbance not due to direct physiological effects of a substance or a general medical condition, and is not better accounted for by brief psychotic disorder

Trauma- and Stressor-Related Disorders

 Posttraumatic Stress Disorder

 Acute Stress Disorder

 Adjustment Disorders

 Reactive Attachment Disorder

 Disinhibited Social Engagement Disorder

 Other Specified Trauma- and Stressor-Related

Disorder

 Unspecified Trauma- and Stressor-Related

Disorder

 Persistent Complex Bereavement Disorder

(proposed for Section III, a section describing

conditions that need more research)

Changes to Adjustment Disorders

in DSM-

 Reconceptualized as a stress-response syndrome.

 No longer a catch-all category.

 ***Stressors are not necessarily traumatic!

 Diagnose when person does not meet criteria for another disorder in the DSM-5,

 Subtypes did not change in DSM-