Trauma and Stressor Related Disorder DSM (all except PTSD) Flashcards
social neglect (absence of adequate caregiving during childhood) is a requirement in diagnosis of which disorders
reactive attachment disorder
disinhibited social engagement disorder
what distinguished reactive attachment disorder and disinhibited social engagement disorder
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 internalizing disorder with depressive symptoms and withdrawn behaviour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
what is the “consistent pattern” of behaviour that characterizes criterion A of reactive attachment disorder
inhibited, emotionally withdrawn behaviour toward adult caregivers
there is a pattern of “markedly disturbed and developmentally inappropriate attachment behaviours”
criterion A for reactive attachment disorder
a consistent pattern of INHIBITED, emotionally WITHDRAWN behaviour towards adult caregivers manifested by BOTH of the following:
- child rarely or minimally SEEKS comfort when distressed
- child rarely or minimally RESPONDS to comfort when distressed
criterion B for reactive attachment disorder
a persistent social and emotional disturbance characterized by at least TWO 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
criterion C for reactive attachment disorder
child has experienced a pattern of EXTREMES of insufficient care as evidenced by at least 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 (i.e frequent changes in foster care)
- rearing in UNUSUAL SETTINGS that severely limit opportunities to form selective attachments (i.e institutions with high child-to-caregiver ratio)
criterion D for reactive attachment disorder
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)
criterion E for reactive attachment disorder
criteria not met for autism spectrum disorder
criterion F for reactive attachment disorder
disturbance is evident BEFORE age 5 years
criterion G for reactive attachment disorder
child has developmental age of at least 9 months
what specifiers exist for reactive attachment disorder
- “persistent”–> present for more than 12 months
- severity
describe what would be considered “severe” reactive attachment disorder
when a child exhibits ALL the symptoms of the disorder, with each symptom manifesting at relatively high levels
reactive attachment disorder symptoms must be present before what age
5
developmental age of a child must be above what age to diagnose reactive attachment disorder
at least 9 months
how do summarize the criteria for reactive attachment disorder
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
what is the essential feature of reactive attachment disorder
absent or grossly underdeveloped attachment between the child and putative caregiving adults
are children with reactive attachment disorder believed to have the capacity to form selective attachments
yes
however, because of limited opportunities during early development, they fail to show the behavioural manifestations of selective attachments
reactive attachment disorder often occurs with what other features
developmental delays–> especially cognition and language (due to severe neglect)
may have stereotypies
may have other signs of severe neglect ie malnutrition
how prevalent is reactive attachment disorder even in populations of severely neglected children
less than 10% of such children
*thus considered relatively rare though actual prevalence is unknown
does reactive attachment disorder occur in older children
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
name risk factors for reactive attachment disorder
social neglect is both a requirement or dx and the only known risk factor
name a factor that determines prognosis of reactive attachment disorder
quality of the caregiving environment following serious neglect
**the majority of severely neglected kids do not develop the disorder
ddx reactive attachment disorder
autism spectrum disorder
intellectual disability
depressive disorders
list some of the features that overlap between reactive attachment disorder and autism
both may show:
dampened expression of positive emotions
cognitive and language delays
impairments in social reciprocity
stereotypies
how do you distinguish between reactive attachment disorder and autism spectrum disorder
- differential histories of neglect (+RAD)
- presence of restricted interests or ritualized behaviours (+ASD)
- specific deficit in social communication (+ASD)
- specific deficit in selective attachment behaviours (+RAD)
do kids with reactive attachment disorder show deficits in social communicative functioning
no–> its generally comparable to their overall intellectual level
how do you distinguish reactive attachment disorder from intellectual disability
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
list conditions associated with neglect
cognitive delays
language delays
stereotypies
criterion A for disinhibited social engagement disorder
a pattern of behaviour in which a child ACTIVELY APPROACHES and interacts with UNFAMILIAR ADULTS and exhibits at least TWO of the following:
- reduced or absent reticence in approaching and interacting with unfamiliar adults
- overly familiar verbal or physical behaviour (that is not consistent with culturally sanctioned or with age-appropriate social boundaries)
- diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings
- willingness to go off with an unfamiliar adult with minimal or no hesitation
criterion B for disinhibited social engagement disorder
behaviours in criterion A are not limited to impulsivity (i.e in ADHD) but include socially DISINHIBITED behaviour
criterion C for disinhibited social engagement disorder
child has experiences a pattern of extremes of INSUFFICIENT CARE as evidenced by at least 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 (i.e frequent changes in foster care)
- rearing in UNUSUAL SETTINGS that severely limit opportunities to form selective attachments (i.e institutions with high child-to-caregiver ratio)
criterion D for disinhibited social engagement disorder
the care in criterion C is presumed to be responsible for the disturbed behaviour in criterion A
criterion E for disinhibited social engagement disorder
child has developmental age of at least 9 months
what are the specifiers available for disinhibited social engagement disorder
- persistent (at least 12 months)
- severity (severe if have all symptoms of disorder to relatively high levels)
describe the essential feature of disinhibited social engagement disorder
pattern of behaviour that involves culturally INappropriate, OVERLY FAMILIAR behaviour with relative strangers –> violates social boundaries of the culture
at what age are children able to start forming selective attachments
9 months
do kids with disinhibited social engagement disorder always have signs of disordered attachment
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
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)
about 20%
*rarely seen in other settings
neglect beginning after what age is UNLIKELY to result in disinhibited social engagement disorder
age 2
“there is no evidence that neglect beginning after age 2 years is associated with manifestations of the disorder”
what is the course of disinhibited social engagement disorder
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)
how does the presentation of disinhibited social engagement disorder shift r from toddlerhood to preschool years? from preschool to middle childhood?
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)
what are risk factors for disinhibited social engagement disorder
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
does the quality of the caregiving environment following serious neglect affect prognosis in disinhibited social engagement disorder
somewhat, but only MODESTLY–> in many cases, the disorder PERSISTS (at least through adolescence) even in children whose caregiving environments are markedly improved
ddx disinhibited social engagement disorder
ADHD (overlap in terms of some social impulsivity)
criterion A for acute stress disorder
exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- directly experiencing the traumatic event
- witnessing in person the event as it occurs to others
- learning that the event occurred to a close family member or close friend (must have been violent or accidental)
- experiencing repeated or extreme exposure to aversive details of the traumatic events
criterion B for acute stress disorder
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)
what are the “intrusion” symptoms in acute stress disorder
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
what is the duration/time criteria for acute stress disorder (criterion C)
3 days to 1 month after trauma exposure
sx typically begin immediately after the trauma but then persist
what is a factor that affects prevalence of acute stress disorder
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
what % of people who go on to develop PTSD initially present with acute stress disorder
about half
which gender is more at risk for developing acute stress disorder
females
what is a physiological risk factor for developing acute stress disorder
elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure
list temperamental risk factors for acute stress disorder
prior mental disorder
high levels of neuroticism
greater preceived severity of the traumatic event
avoidant coping style
catastrophic appraisal of the traumatic experience
ddx acute stress disorder
adjustment disorders
panic disorders
dissociative disorders
PTSD
OCD
psychotic disorders
TBI
criterion A for adjustment disorders
the development of EMOTIONAL or BEHAVIOURAL symptoms in response to an identifiable stressor occurring WITHIN 3 months of the onset of the stressor
criterion B for adjustment disorders
these symptoms or behaviours are CLINICALLY SIGNIFICANT as evidenced by one or both of the following:
- 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
- significant impairment in social, occupational or other important areas of functioning
criterion C for adjustment disorder
the stress related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder
criterion D for adjustment disorder
the symptoms do not represent normal bereavement
criterion E for adjustment disorder
once the stressor or its consequences have terminated, the symptoms do not persist for more than SIX months
list the specifiers available for adjustment disorder
- with depressed mood
- with anxiety
- with mixed anxiety and depressed mood
- with disturbance of conduct
- with mixed disturbance of emotions and conduct
- unspecified
+
acute (less than 6 months) vs persistent (chronic) (lasting more than 6 months)
what is the essential feature of adjustment disorder
the presence of emotional or behavioural symptoms in response to an identifiable stressor
does the stressor in adjustment disorder have to be one single event
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)
does adjustment disorder increase risk of SI/SAs
yes–> associated with increased risk of suicide attempts and completed suicide
what is the prevalence of adjustment disorders in those in outpatient mental health treatment
5-20% (with adjustment disorder as a principal diagnosis)
how common are adjustment disorders in hospital psychiatric consultation settings
the MOST COMMON diagnosis
frequently reaches 50%
what is a risk factor for adjustment disorder
those from disadvantaged life circumstances may be at increased risk of stressors and thus at increased risk of adjustment disorder
ddx adjustment disorder
MDD
PTSD
acute stress disorder
personality disorders
psychological factors affecting other medical conditions
normative stress reactions
list examples that may fall under the “other specified” designation of trauma and stressor related disorders
- adjustment like disorder with delayed onset of symptoms that occur more than 3 months after the stressor
- adjustment like disorders with prolonged duration of more than 6 months without prolonged duration of stressor
- ataque de nervios
- other cultural syndromes
- persistent complex bereavement disorder
what is persistent complex bereavement disorder
an example of “other specified trauma and stressor related disorders”
characterized by severe and persistent grief and mourning reactions
what is the treatment for reactive attachment disorder
main tx is PSYCHOSOCIAL + ensure a stable caregiving environment with stable attachment figures
what is the treatment for disinhibited social engagement disorder
main tx is PSYCHOSOCIAL + ensure a stable caregiving environment and to LIMIT CONTACT with non-caregiving adults
what treatments have been investigated to manage adjustment disorder
psychotherapy including CBT and brief supportive therapy
