DSM – 5 and
Trauma and StressorRelated Diagnosis
Kate Hilton, DPC, LPC, NCC
Dawn Ellison, DPC, LPC, NCC
Fondren Institute for Psychotherapy
Jackson MS
Trauma in the DSM
• In layman’s terms, trauma typically refers to both
the event that produces distress and the ensuing
distress in an individual (Briere & Scott, 2006)
• PTSD diagnosis presupposes exposure to traumatic
event
• What counts as a traumatic event?
o DSM-III—combat, violent assault, natural disasters
(outside the range of usual human experience)
o DSM-III-R—expanded to include learning about or
witnessing friend or family member exposure to lifethreatening event
DSM-IV
Defines a traumatic event as:
• Involving actual or threatened death or serious
injury or threat to one’s physical integrity (self or
other)
• Witnessing or learning about event
• Subjective feeling of intense fear, horror or
helplessness
• Sudden and unpredictable
• Shocking in nature (APA, 2000)
DSM-5
• Traumatic event is described as exposure to actual
or threatened death, serious injury, or sexual
violence
• Adds experiencing repeated or extreme exposure
to aversive details of the traumatic event
(collecting human remains; police officers
repeatedly exposed to details of child abuse)
• Specifies repeated exposure is not through
electronic media, television, movies, or pictures–
unless exposure is work related (APA, 2013)
• Developmentally inappropriate sexual experiences
without physical violence or injury (children)
PTSD in the DSM
• Specific diagnostic syndrome related to
posttraumatic symptoms emerged in publication of
DSM-III (APA, 1980)
• Debilitating effects of war experience (Vietnam)—
paralleled symptoms of victims of other forms of
severe trauma (rape, natural disaster)
• Reactions were unique symptom profile not
captured by mood or anxiety disorders
• Post-Vietnam syndrome became PTSD (North, Suris,
Davis & Smith, 2009)
Trauma & Stressor
Related Diagnoses
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
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PTSD in DSM IV
Criterion A1: Person experienced/witnessed/confronted with
event where there was threat of or actual death/serious injury.
May also have involved a threat to physical well-being.
Criterion A2: Person responded to event with fear, anxiety,
helplessness, or horror.
Criterion B: 1or more re-experiencing symptoms:
• Frequently upsetting thoughts or memories about a traumatic
event.
• Recurrent nightmares.
• Acting/feeling as if traumatic event were happening again “flashback.”
• Distress when reminded of the traumatic event.
• Physically responsive (high heart rate or sweating) to reminders
of the trauma.
PTSD in DSM IV
Criterion C: 3 or more avoidance symptoms
• Avoid thoughts, feelings, conversations about the trauma.
• Avoid places or people that remind you of the trauma.
• Have difficult time remembering important parts of the trauma.
• A loss of interest in important, once positive, activities.
• Feeling distant from others.
• Difficulties having positive feelings, such as happiness or love.
• Sense of foreshortened future.
Criterion D: 2 or more hyperarousal symptoms
• Having a difficult time falling or staying asleep.
• Feeling irritable, having anger outbursts.
• Having difficulty concentrating.
• Feeling constantly “on guard” or like danger is lurking around every
corner.
• Being “jumpy” or easily startled.
Criterion E: Duration is more than 1 month
Criterion F: Interferes with social, occupational or other areas of functioning
PTSD in DSM-5
• PTSD was removed from anxiety disorders
• Criterion A2 (response involves “fear, helplessness, or
horror”) removed from DSM-5
• 3 clusters are divided into 4 clusters in DSM-5
o
o
o
o
Avoidance
Re-experiencing
Persistent negative changes in mood and cognition
Arousal
• 3 new symptoms were added
• Other symptoms revised to clarify symptom expression
• Separate diagnostic criteria for “preschool” (children 6
years or younger)
• New dissociative subtype for PTSD added
PTSD in DSM-5:
CHANGES TO CRITERION A
Criterion A1 is expanded: Trauma involves actual or threatened
event, including:
• Death
• Serious injury
• Sexual violence
Four types of exposure
• Directly experienced
• Witnessed
• Learned happened to a loved one (must be accidental or
violent)
• Repeated, extreme exposure to details (first responders, police –
media exposure doesn’t count)
Criterion A2 (Person responded to event with fear/anxiety/
helplessness/horror) is removed.
PTSD in DSM-5:
CHANGES TO CRITERION B
Criterion B (intrusion) has:
• Exact same 5 symptoms.
• Endorse at least 1
B1: Memories
• Versus DSM-IV recollections (images, thoughts,
perceptions)
B3: Flashbacks
• Emphasis on dissociation and continuum of reactions
Note: In children look for repetitive play/ trauma specific
renactment
PTSD in DSM-5:
CHANGES TO CRITERION C
CRITERION C: Avoidance
• Numbing separated from avoidance (moved to D).
• From 7 symptoms to 2 symptoms; endorse at least 1
o C1: Avoid memories, thoughts, feelings
o 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
PTSD in DSM-5:
CHANGES TO CRITERION D
CRITERION D : Negative alterations in cognition and mood
• Endorse at least 2
• 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 in DSM-5:
CHANGES TO CRITERION E-H
CHANGES TO CRITERION E: Arousal and Reactivity
• Used to be hyperarousal cluster (Criterion D)
• Endorse at least 2
• Similar to DSM-IV but with one new symptom:
• E1: Irritable behavior and angry outbursts
• E2: Reckless or self-destructive behavior (new emphasis
on behavior). Ex: reckless driving, excessive alcohol use,
suicidal behavior
• E3: Hypervigilance
• E4: Exaggerated startle
• E5: Problems with concentration
• E6: Sleep disturbance
PTSD in DSM-5
CHANGES TO CRITERIA F-G: None
F. Duration is more than 1 month
G. Clinically significant distress or impairment
Added Criterion H:
H. Not attributed to the physiological effects of a
substance or other medical condition.
Specify
• With dissociative symptoms
• With delayed expression – 6 months post event
Preschool Subtype:
6 Years or Younger
Criterion A. In children (younger than 6 years),
exposure to actual or threatened death, serious
injury, or sexual violence, as follows:
• 1) Direct exposure
• 2) Witnessing, in person, (especially as the event
occurred to primary caregivers) Note: Witnessing
does not include viewing events in electronic
media, television, movies, or pictures.
• 3) Indirect exposure, learning that a parent or
caregiver was exposed
Preschool Subtype:
6 Years or Younger
• Criterion B –1 (or more) symptoms
o Intrusion symptoms may display as…
• Play reenactment may not appear distressing
• Dreams- content may not be related to trauma
• Criterion C – 1 (or more) symptoms
o Avoidance symptoms
o Alteration in cognitions or mood
o Preschool does not include: amnesia; foreshortened future;
persistent blame of self or others; reckless behavior
• Criterion D – 2 (or more) symptoms
o Arousal symptoms
o Extreme temper tantrums
Preschool Subtype:
6 Years or Younger
• Criterion E – Duration more than 1 month
• Criterion F – Clinically significant distress /impairment
• Criterion G – Not due to medical condition /
medication
• Specifiers:
o Dissociative symptoms
• Depersonalization
• Derealization
o Delayed onset
• Criteria not met until 6 months after event
Dissociative Subtype of
PTSD
New subtype for both age groupings of PTSD
diagnosis:
• Meets PTSD diagnostic criteria
• Experiences additional high levels of
depersonalization or derealization
• Dissociative symptoms are not related to substance
use or other medical condition
Trauma- and StressorRelated 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
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Acute Stress Disorder
in DSM IV
A. PTSD A Criterion
• A1 & A2 symptoms
B. Dissociative symptoms (3 or more)
• 1. Numbing, detachment, & emotional
responsiveness
• 2. Reduction in awareness (“dazed”)
• 3. Derealization
• 4. Depersonalization
• 5. Dissociative Amnesia
ASD in DSM IV
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C. 1 or more PTSD Intrusion Symptoms
D. 1 or more PTSD Avoidance Symptoms
E. 1 or more PTSD Arousal Symptoms
F. Clinically Significant Distress or Impairment
G. Duration more than 2 days and less than 1 month
H. Not due to other cause (Intoxication, medical
condition, etc.)
Changes to ASD in DSM-5
• Criterion A changes same as PTSD updates – A1 is
clarified; A2 is deleted.
• Criterion B – Person now must meet any 9 of the 14
symptoms from 5 categories: intrusion (4), negative
mood (1), dissociation (2), avoidance (2), and
arousal (5)
o It was concluded that DSM-IV’s ASD criteria was too heavily
focused on dissociation; dissociation is no longer required
for diagnosis.
• No one symptom of the 14 is required for a
diagnosis.
Changes to ASD in DSM-5
• Criterion C – Duration 3 days to 1 month
• Criterion D – Clinically significant distress /
impairment (social, occupational, other)
• Criterion E – Not due to substance or medical
condition
Trauma- and StressorRelated 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
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Adjustment Disorders in
DSM-IV
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 either of the following:
1.
2.
Marked distress that is in excess of what would be expected from exposure to the stressor
Significant impairment in social or occupational (academic) functioning
C. The stress-related disturbance does not meet the criteria for
another specific Axis I disorder and is not merely an
exacerbation of preexisting Axis I or Axis II disorder.
D. The symptoms do not represent Bereavement
E. Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6 months
Specify if:
Acute – less than 6 months
Chronic – longer than 6 months
Adjustment Disorders
in DSM-5
• Re-conceptualized as a “heterogeneous array” of
stress-responses
• Similar to DSM-IV Criteria
• Stressors are not necessarily traumatic
o Ending of a romantic relationship
o Business or marriage problems
o Common developmental events
Adjustment Disorders in
DSM-5
• Criterion 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).
• Criterion B – These symptoms or behaviors are
clinically significant, as evidenced by one or both of
the following:
o Distress is out of proportion to the severity or intensity of the
stressor
• external context
• cultural factors
o Significant impairment in social, occupational, or other
important areas of functioning.
Adjustment Disorders
in DSM-5
• Criterion C – The stress-related disturbance does not
meet the criteria for another mental disorder and is
not merely an exacerbation of a preexisting mental
disorder.
• Criterion D – The symptoms do not represent normal
bereavement.
o Conditions for Further Study - Persistent complex bereavement disorder
• Criterion E – Once the stressor or its consequences
have terminated, the symptoms do not persist for
more than an additional 6 months.
Adjustment Disorders
in DSM-5
• Specify:
o With depressed mood: Low mood, tearfulness, or feelings of
hopelessness are predominant.
o With anxiety: Nervousness, worry, jitteriness, or separation
anxiety is predominant.
o With mixed anxiety and depressed mood: A combination of
depression and anxiety is predominant.
o With disturbance of conduct: Disturbance of conduct is
predominant.
o With mixed disturbance of emotions and conduct: Both
emotional symptoms (e.g., depression, anxiety) and a
disturbance of conduct are predominant.
o Unspecified: For maladaptive reactions that are not
classifiable as one of the specific subtypes of adjustment
disorder.
Adjustment Disorders
Fact Sheet
• Common
o 5-20% outpatient
o 50% in inpatient
• Risk factors
o High rate of stressors
• Culture matters
• Comorbidity
o Commonly accompany medical illnesses or disorders
o Comorbid with any disorder as long as criteria are met
o Associated with increased risk of suicide attempts and
completion
Trauma- and StressorRelated 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
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Reactive Attachment
Disorder in DSM IV
Categorized as disorders usually first diagnosed in infancy,
childhood, or adolescence.
A. Markedly disturbed and developmentally inappropriate
social relatedness in most contexts beginning before
age 5 years, as evidenced by:
1.
2.
Failure to initiate or respond appropriately to social to contact
Diffuse attachments
A.
B.
C.
Disregard of emotional needs
Disregard of physical needs
Lack of stable attachment
B. Not accounted for by developmental delays
C. Pathogenic care as evidenced by
D. Criterion C is responsible for disturbance
Specify if:
o Inhibited
o Disinhibited
Changes in DSM-5
• Now two disorders:
o Reactive attachment disorder
o Disinhibited social engagement disorder
• Based on two subtypes of reactive
attachment disorder in DSM-IV
o Emotionally withdrawn / inhibited
o Indiscriminately social / disinhibited
• Characterized by:
o Social/emotional disturbance
o Exposure to extremes of insufficient care
Reactive Attachment
Disorder in DSM-5
Criterion A – Consistent pattern of inhibited, emotionally
withdrawn behavior toward adult caregivers,
manifested by both of the following:
• The child rarely or minimally seeks comfort when
distressed.
• The child rarely or minimally responds to comfort when
distressed.
Criterion B – Persistent social and emotional disturbance
characterized by 2 or more of the following:
• Minimal social and emotional responsiveness to others.
• Limited positive affect.
• Episodes of unexplained irritability, sadness, or fearfulness
that are evident even during nonthreatening
interactions with adult caregivers.
Reactive Attachment
Disorder in DSM-5
Criterion C – Child has experienced pattern of extremes of
insufficient care as evidenced by 1 or more 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 care-giving adults.
• Repeated changes of primary caregivers that limit opportunities
to form stable attachments.
• Rearing in unusual settings that severely limit opportunities to form
selective attachments.
Criterion D –Care in Criterion C is presumed to be responsible
for the disturbed behavior in Criterion A.
Criterion E – The criteria are not met for autism spectrum disorder.
Criterion F – The disturbance is evident before age 5 years.
Criterion G – The child has a developmental age of at least 9
months
Specify :
• Persistent (more than 12 months)
•
Current Severity (ex: severe)
Reactive Attachment
Disorder Fact Sheet
• Capacity for attachment is present, but
opportunities in early life were scarce
• Comorbidity
o Developmental delays due to neglect (cognitive &
language)
o Depressive symptoms
• “Relatively rare” even in populations of severely
neglected children <10%
Trauma- and StressorRelated 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
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Disinhibited Social
Engagement Disorder in
DSM-5
Criterion 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 ageappropriate 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.
Criterion B – The behaviors in Criterion A are not limited to
impulsivity (as in ADHD) but include socially disinhibited
behavior.
Disinhibited Social
Engagement Disorder in
DSM-5
Criterion 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.
3. Rearing in unusual settings that severely limit opportunities to
form selective attachments .
Criterion D – The care in Criterion C presumed to be responsible for
disturbed behavior in Criterion A.
Criterion E – The child has a developmental age of at least 9 months.
Specify: Persistent (more than 12 months)
Current severity (ex: severe)
Development in Disinhibited
Social Engagement Disorder
• Young ages
o Fail to show reticence (reluctance) when interacting with strangers
• Preschool
o Attention seeking
o Verbal & social intrusiveness
• Elementary
o All of the above
o Inauthentic expressions of emotion
• Adolescence
o Extends to peers
o Superficial relationships
Disinhibited Social Engagement
Disorder Fact Sheet
• Neglect before 2-years old
• Behavior violates the social boundaries of the
culture
• May co-occur with delays, or show signs of current
neglect
• May have a wide range of attachments from
disturbed to secure
• Unknown prevalence
o Rare
o Even in high-risk populations only 20%
Implications
• More helpful and specific treatment planning.
• Research will increase and improve
Trauma- and StressorRelated 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
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Other Specified Traumaand Stressor-Related
Disorder
• Symptoms cause clinically significant distress or
impairment in functioning, but full criteria for
another disorder in this category is not met.
• Examples:
o Adjustment Disorder with delayed onset (3 or more months after
the stressor)
o Adjustment Disorder lasts more than 6 months without prolonged
duration of stressor
o Conditions - Persistent complex bereavement disorder
o Other cultural syndromes (Glossary of Cultural Concepts of
Distress)
Unspecified Trauma- and
Stressor-Related Disorder
• Symptoms characteristic of a trauma- and stressorrelated disorder that cause distress/impairment, but
do not meet full criteria for other disorders in this
class.
• Use this diagnosis for situation when you do not
want to, or cannot, specify the reason(s) that
criteria are not met for another disorder.
o Ex: When there is not enough information to make a more
specific diagnosis (due to a short consult, emergency room
visit, etc).
Differences
• Other-Specified
o The clinician chooses to communicate the specific reason
o Should always be accompanied by a reason
• Unspecified
o Clinician chooses not to specify
o Is never accompanied by a reason
o Insufficient information (Ex: Emergency room)
Trauma- and StressorRelated 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
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Related Diagnoses
“Placement of this chapter reflects the close
relationship between these diagnoses and disorders in
the surrounding chapters on…
o Anxiety
o Obsessive-compulsive and related
o Dissociative Disorders”
References
American Psychiatric Association. (2014). Changes in
DSM-5. Retrieved from http://www.dsm5.org
American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.).
Arlington, VA: Author.
Courtois, C. A. (2013). PTSD in the DSM-5. Retrieved
from www.drchriscourtois.com.
Friedman, M. J. (2013). Trauma and stress-related
disorders in DSM-5. National Center for PTSD.
Sweeton, J. (2014). DSM-5: Trauma-and stressorR=related disorders: Criteria, changes, and clinical
implications. Oklahoma City: VA Medical Center