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Susan W. Gray

Psychopathology: A Competency-Based Assessment Model for Social Workers

Chapter 8 Trauma- and Stressor-Related Disorders

Characterizes those disorders where symptoms occur after exposure to a traumatic or stressful event

Usually, some combination anxiety (internalizing symptoms) or anger (externalizing symptoms) is a part of the symptom picture

Two disorders are included in this chapter that share a common etiology of social neglect - understood as the absence of adequate caregiving during childhood – and they are: reactive attachment disorder and disinhibited social engagement disorder

Reactive Attachment Disorder

Characterizes a rare disorder found in children who lack attachments despite the developmental capacity to form them

The core features of RAD disorder include failure to seek and respond to comforting when distressed - with social and emotional disturbances

Seen with at least 2 of the following: minimal emotion regulation, reduced positive affect, and episodes unexplained fearfulness and anxiety – children with a history of living in settings which limit attachment opportunities are at a higher risk

Symptoms begin before the age of 5 - usually can be seen while still an infant - and must have a developmental age of at least 9 months

The case of Annie Marozas illustrates the symptom picture for RAD

Disinhibited Social Engagement Disorder (DSED)

A disorder of a child’s social relatedness - 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

Behavior includes an inappropriate approach to unfamiliar adults, a lack of wariness of strangers, and a willingness to wander off with strangers

The child has experienced extremes of insufficient care that limits attachment opportunities

Can persist into middle childhood and adolescence but has not been described in adults

Jimmy John Clark illustrates the symptom picture for reactive attachment disorder

Posttraumatic Stress Disorder (PTSD)

Close exposure to the trauma seems to be a main aspect of developing PTSD - major reference points include the reaction to catastrophic events, such as:

Witnessing a homicide or suicide

Traffic accidents

Combat

Natural disasters

Sexual assault

Victimization (such as sexual molestation, robbery, aggravated assault)

Survivors of holocausts

Life events such as domestic violence or a diagnosis of HIV

PTSD Symptom Picture

The central feature of PTSD is exposure to actual or threatened death, serious injury or sexual violence – exposure does not include events seen only in electronic media, television, movies or pictures

Symptoms must last for more than one month and significantly affect important interpersonal areas of the person’s life such as family interaction and employment

PTSD is not reflective of another medical condition or the effects of a substance such as medication or alcohol

PTSD Symptom Picture Continued

Next, the practitioner considers 4 symptom clusters characterized as follows (note the diagnostic thresholds of PTSD for children 6 years of age and younger):

Re-experiencing the event - One or more of the following intrusion symptoms associated with the traumatic event(s) of (1) spontaneous memories of the traumatic event (Note: Children older than 6 years of age may engage in repetitive play showing themes of the trauma.); (2) recurrent dreams related to it (Note: Children may have frightening dreams where the content is vague or indistinguishable.); (3) flashbacks (Note: Children may reenact trauma through play.); (4) other intense or prolonged psychological distress; or/and (5) marked physiological reactions

Avoidance - One or both of the following (1) distressing memories, thoughts, feelings or external reminders of the event; and (2) efforts to avoid external reminders that provoke distressing memories thoughts or feelings associated with the traumatic event(s)

PTSD Symptom Clusters Continued

Negative thoughts and mood or feelings — Two or more of the following (1) an inability to remember key aspects of the event; (2) negative thoughts about oneself, others, or the world such as “I am bad,” or “No one can be trusted.”; (3) feelings that may vary from a persistent and distorted sense of blame of self or others; (4) a persistent negative emotional state such as fear, horror, anger guilt or shame; (5) a markedly diminished interest in activities to estrangement from others; (6) feelings of detachment or estrangement from others; or/and (7) to an inability to experience positive emotions such as happiness or loving feelings

Heightened arousal - As seen by two or more of the following (1) aggressive angry outbursts; (2) reckless or self-destructive behavior; (3) hypervigilance; (4) exaggerated startle response; (5) problems concentrating; or/and (6) sleep disturbances

PTSD Specifiers

Those exposed to a traumatic event may not exhibit PTSD features until years afterward – specify “with delayed expression”

The person may also experience dissociative symptoms – specify “with dissociative symptoms”

The case of Buddy Jackson illustrates someone who experienced a delayed onset of PTSD

Acute Stress Disorder (ASD)

ASD looks a lot like PTSD but emphasizes the severe reaction that some people have within the first month immediately following a trauma --- ASD includes any 9 of 14 symptoms in the following categories:

Intrusion – As seen by: (a) recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: Children may engage in repetitive play where themes or aspects of traumatic event(s) are communicated.) (b) the content and/or affect of recurrent, distressing dreams related to traumatic event(s); (c) dissociative reactions such as flashbacks and these reactions can range on a continuum with the most extreme reaction being a complete loss of awareness of one’s surroundings (Note: Children may reenact trauma-specific themes in play.); (d) intense or prolonged reactions (either psychological or physiological) in response to cues that resemble (or may symbolize) an aspect of the traumatic event(s)

Negative mood – Persistent inability to experience positive emotions such as happiness, satisfaction or loving feelings

ASD Symptom Categories Continued

Dissociation – Understood as (a) an altered sense of reality of one’s surroundings or oneself much like being in a daze or time has slowed or seeing oneself from another’s perspective, or (b) being unable to remember important features of the traumatic event(s) and typically not due to dissociative amnesia or a head injury, alcohol or drug use

Avoidance – Considered to be (a) efforts to avoid distressing memories, thoughts or feeling about (or closely associated with) the traumatic event(s), and (b) trying to avoid external reminders such as avoiding people, ;laces, conversations, activities or situations that provoke distressing memories, thoughts or feelings about (or closely associated with) the traumatic event(s)

Arousal – Regarded as (a) sleep disturbances, (b) irritability or angry outbursts typically seen as verbal or physical aggression toward others or objects, (c) hypervigilance, (d) difficulty concentrating, (e) an exaggerated startle response

The following case of Louise Ann Brown illustrates acute stress disorder

The Adjustment Disorders

Adjustment disorders generally occur as a reaction to a life-threatening event and tend to last longer - assessing for adjustment disorders includes:

Distress is out of proportion to the severity or intensity of the stressor(s)

Once the stressor or its consequences have ended, symptoms do not persist for more than an additional 6 months

Consider 6 of the following specifiers:

With depressed mood – low mood, tearfulness, or feelings of hopelessness are prevalent;

With anxiety – nervousness, worry, jitteriness, or separation anxiety are predominant;

With mixed anxiety and depressed mood – a combination of depression and anxiety;

With disturbance of conduct – when disturbed conduct is predominant;

With mixed disturbance of emotions and conduct – both emotional symptoms (such as depression, anxiety) and a disturbance of conduct are present; and

Unspecified – for maladaptive reactions that are not seen as one of the specific subtypes of adjustment disorder

Jeannette Hutton illustrates symptoms of an adjustment disorder

Other Specified (and Unspecified) Trauma- and Stressor-Related Disorders

Specified trauma- and stressor-related disorder - applies when the person’s symptom picture does not meet full criteria for any of the disorders in this chapter

Unspecified trauma- and stressor-related disorder - applies to those who present with symptoms characteristic of a trauma- and stressor-related disorder and used in situations when the practitioner elects not to specify the reason that diagnostic criteria

Comparing the DSM-IV-TR Multiaxial System and the DSM-5

Obsessive-compulsive and related disorders is a new DSM-5 chapter which includes 4 new disorders - hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition

Trichotillomania (hair-pulling disorder) was moved from “impulse-control disorders not elsewhere classified” in the DSM-IV to the DSM-5 classification as an obsessive-compulsive disorder

A specifier was expanded and added to body dysmorphic disorder and hoarding disorder- good or fair insight, poor insight, and absent insight/delusional (or when the person is convinced that the obsessive-compulsive disordered beliefs are true)

Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may surface with perceived defects of flaws in physical appearance

The specifier “with obsessive-compulsive symptoms” moved from the anxiety disorders to the DSM-5 category of obsessive-compulsive and related disorders

Two additional diagnoses - (1) other specified obsessive-compulsive and related disorder which applies when diagnostic criteria are not met but the practitioner can stipulate reasons why, and (2) unspecified obsessive-compulsive and related disorder used when there is insufficient information to make a diagnosis