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18. Trauma and Stressor-Related Disorders > Trauma and Stressor Related Disorder DSM (all except PTSD) > Flashcards

Trauma and Stressor Related Disorder DSM (all except PTSD) Flashcards

1
Q

social neglect (absence of adequate caregiving during childhood) is a requirement in diagnosis of which disorders

A

reactive attachment disorder

disinhibited social engagement disorder

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2
Q

what distinguished reactive attachment disorder and disinhibited social engagement disorder

A

share common etiology (social neglect), differ in manifestation of distress

RAD–> internalizing disorder with depressive symptoms and withdrawn behaviour

DSED–> marked by disinhibition and externalizing behaviour

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3
Q

what is the “consistent pattern” of behaviour that characterizes criterion A of reactive attachment disorder

A

inhibited, emotionally withdrawn behaviour toward adult caregivers

there is a pattern of “markedly disturbed and developmentally inappropriate attachment behaviours”

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4
Q

criterion A for reactive attachment disorder

A

a consistent pattern of INHIBITED, emotionally WITHDRAWN behaviour towards adult caregivers manifested by BOTH of the following:

  1. child rarely or minimally SEEKS comfort when distressed
  2. child rarely or minimally RESPONDS to comfort when distressed
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5
Q

criterion B for reactive attachment disorder

A

a persistent social and emotional disturbance characterized by at least TWO of the following:

  1. minimal social and emotional responsiveness to others
  2. limited positive affect
  3. episodes of unexplained IRRITABILITY, SADNESS or FEARFULNESS that are evident even during nonthreatening interactions with adult caregivers
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6
Q

criterion C for reactive attachment disorder

A

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 (i.e frequent changes in foster care)
  3. rearing in UNUSUAL SETTINGS that severely limit opportunities to form selective attachments (i.e institutions with high child-to-caregiver ratio)
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7
Q

criterion D for reactive attachment disorder

A

the care in criterion C is presumed to be responsible for the disturbed behaviour in criterion A (i.e disturbance in criterion A began after the lack of adequate care in criterion C)

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8
Q

criterion E for reactive attachment disorder

A

criteria not met for autism spectrum disorder

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9
Q

criterion F for reactive attachment disorder

A

disturbance is evident BEFORE age 5 years

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10
Q

criterion G for reactive attachment disorder

A

child has developmental age of at least 9 months

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11
Q

what specifiers exist for reactive attachment disorder

A
  1. “persistent”–> present for more than 12 months
  2. severity
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12
Q

describe what would be considered “severe” reactive attachment disorder

A

when a child exhibits ALL the symptoms of the disorder, with each symptom manifesting at relatively high levels

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13
Q

reactive attachment disorder symptoms must be present before what age

A

5

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14
Q

developmental age of a child must be above what age to diagnose reactive attachment disorder

A

at least 9 months

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15
Q

how do summarize the criteria for reactive attachment disorder

A

a–> must have both, around seeking and responding to comfort

B–> social and emotional disturbances associated (must have 2)

C–> pattern of etiological neglect (must have experienced at least 1)

cant have ASD diagnosis

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16
Q

what is the essential feature of reactive attachment disorder

A

absent or grossly underdeveloped attachment between the child and putative caregiving adults

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17
Q

are children with reactive attachment disorder believed to have the capacity to form selective attachments

A

yes

however, because of limited opportunities during early development, they fail to show the behavioural manifestations of selective attachments

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18
Q

reactive attachment disorder often occurs with what other features

A

developmental delays–> especially cognition and language (due to severe neglect)

may have stereotypies

may have other signs of severe neglect ie malnutrition

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19
Q

how prevalent is reactive attachment disorder even in populations of severely neglected children

A

less than 10% of such children

*thus considered relatively rare though actual prevalence is unknown

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20
Q

does reactive attachment disorder occur in older children

A

per DSM it is “unclear” if it occurs in children older than 5 and thus the dx should be made with caution in kids older than 5–> unclear how this presentation would differ in older kids compared to younger

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21
Q

name risk factors for reactive attachment disorder

A

social neglect is both a requirement or dx and the only known risk factor

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22
Q

name a factor that determines prognosis of reactive attachment disorder

A

quality of the caregiving environment following serious neglect

**the majority of severely neglected kids do not develop the disorder

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23
Q

ddx reactive attachment disorder

A

autism spectrum disorder

intellectual disability

depressive disorders

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24
Q

list some of the features that overlap between reactive attachment disorder and autism

A

both may show:
dampened expression of positive emotions

cognitive and language delays

impairments in social reciprocity

stereotypies

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25
Q

how do you distinguish between reactive attachment disorder and autism spectrum disorder

A
  1. differential histories of neglect (+RAD)
  2. presence of restricted interests or ritualized behaviours (+ASD)
  3. specific deficit in social communication (+ASD)
  4. specific deficit in selective attachment behaviours (+RAD)
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26
Q

do kids with reactive attachment disorder show deficits in social communicative functioning

A

no–> its generally comparable to their overall intellectual level

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27
Q

how do you distinguish reactive attachment disorder from intellectual disability

A

kids with ID would not show the profound reduction in positive affect and emotion regulation difficulties seen in reactive attachment disorder

kids with ID (if have intellectual age of 7-9 months) should still show selective attachments regardless of chronological age

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28
Q

list conditions associated with neglect

A

cognitive delays

language delays

stereotypies

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29
Q

criterion A for disinhibited social engagement disorder

A

a pattern of behaviour 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 behaviour (that is not consistent with culturally sanctioned or with age-appropriate 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
30
Q

criterion B for disinhibited social engagement disorder

A

behaviours in criterion A are not limited to impulsivity (i.e in ADHD) but include socially DISINHIBITED behaviour

31
Q

criterion C for disinhibited social engagement disorder

A

child has experiences 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 (i.e frequent changes in foster care)
  3. rearing in UNUSUAL SETTINGS that severely limit opportunities to form selective attachments (i.e institutions with high child-to-caregiver ratio)
32
Q

criterion D for disinhibited social engagement disorder

A

the care in criterion C is presumed to be responsible for the disturbed behaviour in criterion A

33
Q

criterion E for disinhibited social engagement disorder

A

child has developmental age of at least 9 months

34
Q

what are the specifiers available for disinhibited social engagement disorder

A
  1. persistent (at least 12 months)
  2. severity (severe if have all symptoms of disorder to relatively high levels)
35
Q

describe the essential feature of disinhibited social engagement disorder

A

pattern of behaviour that involves culturally INappropriate, OVERLY FAMILIAR behaviour with relative strangers –> violates social boundaries of the culture

36
Q

at what age are children able to start forming selective attachments

A

9 months

37
Q

do kids with disinhibited social engagement disorder always have signs of disordered attachment

A

no–> condition can present in children who show no signs of disordered attachment

may be seen in children with a history of neglect who lack attachments or whose attachments to caregivers range from disturbed to secure

38
Q

what is the prevalence of disinhibited social engagement disorder in HIGH RISK populations (those who have been severely neglected and subsequently placed in foster care or raised in institutions)

A

about 20%

*rarely seen in other settings

39
Q

neglect beginning after what age is UNLIKELY to result in disinhibited social engagement disorder

A

age 2

“there is no evidence that neglect beginning after age 2 years is associated with manifestations of the disorder”

40
Q

what is the course of disinhibited social engagement disorder

A

if neglect occurs early and signs of the disorder appear, clinical featuers of the disorder appear to be moderately STABLE over time (particularly if neglect persists)

41
Q

how does the presentation of disinhibited social engagement disorder shift r from toddlerhood to preschool years? from preschool to middle childhood?

A

toddler–> indiscriminate social behaviour, lack of reticence with unfamiliar adults

preschool–> attention seeking behaviours; verbal and social intrusiveness most prominent

middle childhood–> verbal and physical overfamiliarity as well as INAUTHENTIC expressions of emotions (particularly with adults)

peer relationships are most affected in adolescence –> both indiscriminate behaviour and conflicts apparent, extends from mostly towards adults to peers as well

(disorder not described in adults)

42
Q

what are risk factors for disinhibited social engagement disorder

A

serious social neglect is both diagnostic requirement and also only known risk factor –> specifically neglect before the age of 2

majority of neglected children do not develop this however

has not been described in kids experiencing neglect only after age 2

43
Q

does the quality of the caregiving environment following serious neglect affect prognosis in disinhibited social engagement disorder

A

somewhat, but only MODESTLY–> in many cases, the disorder PERSISTS (at least through adolescence) even in children whose caregiving environments are markedly improved

44
Q

ddx disinhibited social engagement disorder

A

ADHD (overlap in terms of some social impulsivity)

45
Q

criterion A for acute stress disorder

A

exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

  1. directly experiencing the traumatic event
  2. witnessing in person the event as it occurs to others
  3. learning that the event occurred to a close family member or close friend (must have been violent or accidental)
  4. experiencing repeated or extreme exposure to aversive details of the traumatic events
46
Q

criterion B for acute stress disorder

A

presence of NINE (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance and arousal, beginning or worsening after the traumatic event occured (see next cards)

47
Q

what are the “intrusion” symptoms in acute stress disorder

A

recurrent, involuntary, distressing memories of the event

recurrent distressing dreams in which content and/or affect of the dream are related to the event(s)

dissociative reactions in whcih person feels or acts as if the traumatic events were recurring

intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues

48
Q

what is the duration/time criteria for acute stress disorder (criterion C)

A

3 days to 1 month after trauma exposure

sx typically begin immediately after the trauma but then persist

49
Q

what is a factor that affects prevalence of acute stress disorder

A

the type of trauma experienced

i.e acute stress disorder is seen in less than 20% of cases of trauma that does not involve interpersonal assault, 13-20% of MVAs, 14% of mild TBI, 19% of assault, 10% severe burn

higher rates (20-50%) are reported following interpersonal traumatic events including assault, rape, witnessing mass shooting

50
Q

what % of people who go on to develop PTSD initially present with acute stress disorder

A

about half

51
Q

which gender is more at risk for developing acute stress disorder

A

females

52
Q

what is a physiological risk factor for developing acute stress disorder

A

elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure

53
Q

list temperamental risk factors for acute stress disorder

A

prior mental disorder

high levels of neuroticism

greater preceived severity of the traumatic event

avoidant coping style

catastrophic appraisal of the traumatic experience

54
Q

ddx acute stress disorder

A

adjustment disorders

panic disorders

dissociative disorders

PTSD

OCD

psychotic disorders

TBI

55
Q

criterion A for adjustment disorders

A

the development of EMOTIONAL or BEHAVIOURAL symptoms in response to an identifiable stressor occurring WITHIN 3 months of the onset of the stressor

56
Q

criterion B for adjustment disorders

A

these symptoms or behaviours are CLINICALLY SIGNIFICANT as evidenced by one or both of the following:

  1. marked distress that is OUT OF PROPORTION to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation
  2. significant impairment in social, occupational or other important areas of functioning
57
Q

criterion C for adjustment disorder

A

the stress related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder

58
Q

criterion D for adjustment disorder

A

the symptoms do not represent normal bereavement

59
Q

criterion E for adjustment disorder

A

once the stressor or its consequences have terminated, the symptoms do not persist for more than SIX months

60
Q

list the specifiers available for adjustment disorder

A
  1. with depressed mood
  2. with anxiety
  3. with mixed anxiety and depressed mood
  4. with disturbance of conduct
  5. with mixed disturbance of emotions and conduct
  6. unspecified

+

acute (less than 6 months) vs persistent (chronic) (lasting more than 6 months)

61
Q

what is the essential feature of adjustment disorder

A

the presence of emotional or behavioural symptoms in response to an identifiable stressor

62
Q

does the stressor in adjustment disorder have to be one single event

A

no, can be multiple stressors i.e marital problems and marked business difficulties

can also be recurrent or continuous (i.e living in a crime ridden neighborhood, persistent painful illness etc)

63
Q

does adjustment disorder increase risk of SI/SAs

A

yes–> associated with increased risk of suicide attempts and completed suicide

64
Q

what is the prevalence of adjustment disorders in those in outpatient mental health treatment

A

5-20% (with adjustment disorder as a principal diagnosis)

65
Q

how common are adjustment disorders in hospital psychiatric consultation settings

A

the MOST COMMON diagnosis

frequently reaches 50%

66
Q

what is a risk factor for adjustment disorder

A

those from disadvantaged life circumstances may be at increased risk of stressors and thus at increased risk of adjustment disorder

67
Q

ddx adjustment disorder

A

MDD

PTSD

acute stress disorder

personality disorders

psychological factors affecting other medical conditions

normative stress reactions

68
Q

list examples that may fall under the “other specified” designation of trauma and stressor related disorders

A
  1. adjustment like disorder with delayed onset of 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. ataque de nervios
  4. other cultural syndromes
  5. persistent complex bereavement disorder
69
Q

what is persistent complex bereavement disorder

A

an example of “other specified trauma and stressor related disorders”

characterized by severe and persistent grief and mourning reactions

70
Q

what is the treatment for reactive attachment disorder

A

main tx is PSYCHOSOCIAL + ensure a stable caregiving environment with stable attachment figures

71
Q

what is the treatment for disinhibited social engagement disorder

A

main tx is PSYCHOSOCIAL + ensure a stable caregiving environment and to LIMIT CONTACT with non-caregiving adults

72
Q

what treatments have been investigated to manage adjustment disorder

A

psychotherapy including CBT and brief supportive therapy

18. Trauma and Stressor-Related Disorders (2 decks)

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