Trauma and Stressor-Related Disorders

Question 1

How many Trauma- and Stressor-Related Disorders are there and what are they?

Answer 1

1. Reactive Attachment Disorder
2. Disinhibited Social Engagement Disorder
3. Posttraumatic Stress Disorder
4. Acute Stress Disorder
5. Adjustment Disorders
6. Other Specified…
7. Unspecified…

Question 2

What is Reactive Attachment Disorder?

Answer 2

It is a disorder caused by a lack of attachment to any specific caregiver at an early age, and results in an inability for the child or infant to form normal, loving relationships with others and to fail to seek comfort, support, nurturance or protection from available caregivers when distressed. Children wit the disorder exhibit poor emotional regulation and display fear, sadness or irritability unpredictablyd.

Question 3

What are the diagnostic criteria for Reactive Attachment Disorder?

Answer 3

A. A consistent pattern of inhibited emotionally withdrawn behavior toward adult caregivers where child rarely seeks or responds to comfort when distressed
B. A persistent social and emotional disturbance characterized by 2 of 3: Minimal social/emotional responsiveness to others, limited positive affect, and episodes of unexplained irritability, sadness, or fearfulness that are evident during non threatening interactions with adult caregivers.
C. The 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; rearing in unusual settings that severely limit opportunities to form selective attachments
D. The care in criterion C is presumed to be responsible for the disturbed behavior in criteria A
E. The criteria are not met for autism spectrum disorder
F. The disturbance is evident before age 5 years
G. The child has a developmental age of at least 9 months

Question 4

What are the specifiers for Reactive Attachment Disorder?

Answer 4

IF: Persistent (present for 12+ months)
SEVERITY: Sever (when all symptoms are present and each symptom manifests at relatively high levels)

Question 5

Prevalence of Reactive Attachment Disorder and Disinhibited Social Engagement Disorder?

Answer 5

Rare in clinical settings. Among the severely neglected still less than 10% for RAD and about 20% for DSED

Question 6

Development and course of Reactive Attachment Disorder?

Answer 6

Neglect leading to the disorder can start in the first months of life; symptoms are exhibited between 9 months and 5 years and may persist for several years, not usually seen in children older than 5

Question 7

Risk for Reactive Attachment Disorder and Disinhibited Social Engagement Disorder?

Answer 7

Environmental (neglect) is only known risk

Question 8

Prognostic Factors for Reactive Attachment Disorder and Disinhibited Social Engagement Disorder?

Answer 8

Quality of post diagnosis caregiving helps with both disorders, but is less effective in the case of Disinhibited Social Engagement Disorder.

Question 9

Comorbidity of Reactive Attachment Disorder and Disinhibited Social Engagement Disorder?

Answer 9

Both: Conditions associated with neglect (cognitive & language delays, sterotypies, malnutrition)
RAD: depressive symptoms
DSED: ADHD

Question 10

Disinhibited Social Engagement Disorder

Answer 10

A pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers that violates the social boundaries of the culture in children with a developmental age of at least 9 months who have experienced social neglect. Child may not currently be experiencing the neglect or currently have difficulties forming selective attachments.

Question 11

Developmental age at which children can form selective attachments

Answer 11

9 months

Question 12

Diagnostic criteria for Disinhibited Social Engagement Disorder?

Answer 12

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of 4: Reduced or absent reticence in approaching and interacting with unfamiliar adults; overly familiar verbal or physical behavior; diminished or absent checking back with adult caregiver and venturing away, even in unfamiliar settings; willingness to go off with an unfamiliar adult with minimal or no hesitation
B. The haviors in Criteria A are not limited to impulsivity but include socially disinhibited behavior
C. The child has experienced a pattern of extremes of insufficient care as evidence by 1 of 3: 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, rearing in unusual settings that severely limit opportunities to form selective attachments
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in criteria A
E. The child has a developmental age of at least 9 months.

Question 13

Development of Disinhibited Social Engagement Disorder

Answer 13

Neglect takes must take place prior to 2 years old; no evidence supporting disorder development when neglect happens after age 2. Toddlers show indiscriminate social behavior and lack of reticence with strangers and go on to develop attention seeking behaviors in preschool. In middle childhood verbal and physical overfamiliarity and inauthentic expression of emotions are common, esp. with adults. Adolescents show indiscriminate behavior and conflicts with peers and tend to have more superficial relationships with peers. Adult manifestations are unknown.

Question 14

Diagonostic criteria for PTSD

Answer 14

A. Exposure to actual or threatened death, serious injury, or sexual violence (1/4)
B. Presence of intrusion symptoms associated with traumatic events, beginning after the traumatic events occurred (1/5)
C. Persistent avoidance of stimuli associated with the traumatic event(s) beginning after they occurred. (1/2)
D. Negative alterations in cognitions and mood associated with the traumatic events beginning or worsening after the traumatic events occurred. (2/7)
E. Marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after the traumatic events occurred (1/6)
F. Duration of the disturbance is more than 1 month
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance, or another medical condition.

Question 15

Specifiers for PTSD

Answer 15

WHETHER: With dissociative symptoms (Depersonalizations or Derelaization)
IF: With Delayed Espression (full criteria met 6 or more months after the event)

Question 16

PTSD differences for children under 6

Answer 16

A, Can’t just be exposed to aversive details
B. Instructions may be play reenactment so, and frightening dreams may not seem directly related to the event.
C. More specific criteria for avoidance:
Persistent avoidance and Negative Alteration in Cognitions
NO CRITERIA SPECIFYING Alterations IN cognitions and mood

Question 17

PTSD Criteria A:: Exposure to actual or threatened death, serious injury, o sexual violence in one (or more) of the following ways.

Answer 17

1. Directly experiencing the traumatic event(s)
2. Witnessing, in person, the events as it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have. Been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic events

Question 18

PTSD Criteria B: Presence of one or more of the following intrusion symptoms associated with the traumatic events, beginning after the traumatic events occurred:

Answer 18

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic events.
3. Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic events were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events.
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events.

Question 19

PTSD Criteria C: Persistent avoidance of stimuli associated with the traumatic events, beginning after the traumatic events occurred, as evidenced by one or both of the following:

Answer 19

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events
2. Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or slowly associated with the traumatic events

Question 20

PTSD Criteria D: Negative alterations in conditions and mood associated with the traumatic events beginning or worsening after the traumatic events occurred as evidenced by two or more of the following

Answer 20

1. Inability to remember an important aspect of the traumatic events
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
3. Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself or others
4. Persistent negative emotional state
5. Markedly diminished interest of participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions

Question 21

PTSD Criteria E: Marked alterations in arousal and reactivity associated with the traumatic events beginning or worsening after the traumatic events occurred, as evidenced by two or more of the following:

Answer 21

1. Irritable behavior and angry outbursts with little or no provocation, typically expressed as verbal or physical aggression toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep distrubance

Question 22

PTSD Prevalence

Answer 22

8.7% Lifetime 75 yo US Adults
3.5% 12 month US Adults (higher in high risk groups)
.5-1.0% in Europe, Asian, African and Latin American Countries

Question 23

PTSD Age Range

Answer 23

1 year to Death

Question 24

Types of Risk factors for PTSD

Answer 24

Pretraumatic
Peritraumatic
Posttraumatic

Question 25

Pretraumatic PTSD Risk Factors

Answer 25

Temperamental- childhood emotional problems by age 6 years, prior mental disorders, panic disorders, depressive disorder, OCD
Evironmental- Lower SES, exposure to prior trauma, childhood adversity, cultural characteristics, lower intelligence, minority racial/ethnic status, and a family psychiatric history; social support is protective
Genetic and Physiological- These include femal gender and younger age at the time of adult exposure; genotype can protect or increase risk

Question 26

Peritraumatic PTSD Risk Factors

Answer 26

Environmental- severity of trauma, perceived life threat, personal injury, interpersonal violence, and, for military personnel, being a perpetrator witnessing atrocities, or killing the enemy

Question 27

Posttraumatic PTSD Risk Factors

Answer 27

Temperamental- negative appraisals, inappropriate coping strategies and development of acute stress disorder.
Environmental- These include subsequent exposure to repeated upsetting remainders, subsequent adverse life events, and financial or other trauma-related losses. Social support (Family stability for children) is a protective factor.

Question 28

PTSD Prevalence

Answer 28

More prevalent in females across the lifespan, but this may be because females are more likely to suffer from trauma.

Question 29

PTSD Comorbidity

Answer 29

Substance use and conduct disorder are common, more so in men
Children- ODD and separation anxiety disorder are most common

Question 30

Acute Stress Disorder

Answer 30

Similar to PTSD with symptoms lasting from 3 days to 1 month following exposure to a traumatic event.

Question 31

Adjustment Disorder Diagnostic Criteria

Answer 31

A. The development of emotional or behavioral symptoms in response to an identifiable stressors occurring within 3 months of the onset of the stressors
B. These symptoms or behaviors 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; Significant impairment in social, occupational, or other important areas of functioning
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
D. The symptoms do not represent normal bereavement
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

Question 32

Adjustment Disorder Specifiers

Answer 32

WHETHER:
With depressed mood- low mood, tearfulness, or feelings of hopelessness are predominant
With anxiety- Nervousness, worry, jitteriness, or separation anxiety is predominant
With mixed anxiety and depressed mood
With disturbance of conduct
With mixed disturbance of emotions and conduct
Unspecified- for maladaptive reaction that are not classifiable as one of the specific subtypes of adjustment disorder

Question 33

Adjustment Disorder Prevelance

Answer 33

Common- 5-20% outpatient and up to 50% inpatient

Question 34

Adjustment Disorder Risk

Answer 34

Environmental- Individuals from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for adjustment disorders.