Stressor and Trauma Related Disorders

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1. Criteria (Reactive A): Consistent pattern of inhibited, emotionally withdrawn

Attachment Dis- behavior towards adult caregivers, manifested by both of
order) the following:
1. Rarely/minimally seeks comfort when distressed
2. Rarely or minimally responds to comfort when dis-
tressed

B): Persistent social and emotional disturbance character-

ized 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 fearful-
ness that are evident even during non-threatening interac-
tions with adult caregivers

C): 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
2. Repeated changes of primary caregivers that limit op-
portunity to develop stability
3. Rearing in unusual settings that limit opportunity to form
selective attachments

D): The problems noted in A must be somewhat related to

the patterns of C

E): Criteria not met for ASD

F): Evident before age 5

G): Child is at least 9 months

**specify if with:
1. persistent
2. current severity

2.

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Rule Out (Reac- 1) Autism spectrum disorder
tive Attachment 2) Intellectual disability
Disorder) 3) Depressive disorder

3. Prevalence Rates US rate: Unknown, relatively rare in most settings (seen in

(Reactive Attach- less than 10% of severely neglected children)
ment Disorder) International rate: Unknown, it is seen in other cultures,
but little is known in terms of how attachment is in other
cultures (more research necessary)

4. Cultural Consid- Similarity across cultures & nations

erations (Reac-
tive Attachment
Disorder)

5. Gender Consid- males diagnosed earlier than females; more males in

erations (Reac- childhood, but more females in adulthood
tive Attachment
Disorder)

6. Development Onset: Usually present in the first few months (even pre-di-
and Course agnosis). Manifests similarly in children between 9 months
(Reactive and 5 years old (diagnostic ages).
Attachment Course: if untreated, symptoms will likely persist for many
Disorder) years
Recovery: Little is known in terms of how long recovery will
take and relapse

7. Risk Factors (Re- ¢Serious social neglect

active Attach- ¢ Quality of caregiving environment
ment Disorder)

8. Other Notes (Re- o Comorbid with cognitive delay, language delay, stereo-
active Attach- typies
ment Disorder) o Comorbid with medical conditions such as malnutrition
o Can result in depressive symptoms
o Little is known about if this diagnosis can manifest later
in life and its symptoms

9.
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Criteria (Disin- A): Pattern of behavior in which a child actively approach-
hibited Social En- es and interacts with unfamiliar adults and exhibits at
gagement Disor- LEAST TWO of the following:
der) 1. No inhibition in talking in terms of approaching/interact-
ing with unfamiliar adults
2. Overly familiar verbal or physical behavior
3. Diminished or absent checking with caregiver after ven-
turing away, even in unfamiliar settings

B): Criterion A is not limited to impulsivity but include

socially disinhibited behavior

C): 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
2. Repeated changes of primary caregivers that limit op-
portunity to develop stability
3. Rearing in unusual settings that limit opportunity to form
selective attachments

D): The problems noted in Criterion A must be somewhat

related to the patterns in Criterion C

E): Child is at least 9 months

**specify if with:
1.persistent
2.current severity

10. Rule Out (Disin- 1) ADHD

hibited Social En-
gagement Disor-
der)

11. Prevalence Rates US Rates: Unknown, seems to be rare (occurs in about

(Disinhibited So- 20% of children who lived in severe neglect situations);
cial Engagement seen rarely in clinical settings
Disorder) International Rates: Inhibition with stranger interactions in

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youth is seen within many cultures, but unknown in terms
of prevalence

12. Develop- -Onset: Usually within the first months of life (but usually
ment/Course not if neglect begins post age 2)
(Disinhibited -Course: Unless treated, will impact social relationships
Social and behaviors in youth/adolescents (lack of research re-
Engagement garding how it impacts adults); usually related to attention
Disorder) seeking behaviors, peer conflicts, and superficial friend-
ships
-Recovery: Unknown

13. Risk Factors ¢Children who exposed to attachments that range from
(Disinhibited So- disturbed to secure
cial Engagement ¢ Social neglect (interestingly, no signs in children who
Disorder) experience neglect after age 2)
¢ Neurobiological vulnerability to stress from neglect (re-
search is shaky)
¢ Modestly related to quality of caregiving environment; can
facilitate treatment, but can persist even once environment
is stable

14. Other Notes (Dis- o Comorbid with developmental delays (cognitive/lan-

inhibited Social guage delays, stereotypies)
Engagement Dis- o Comorbid with malnutrition and poor self-care
order) o Disorder can persist even after issues with neglect are
no longer present
o Even though ADHD is a rule-out for this disorder, it can
also be a comorbidity

15. Criteria (PTSD) A): Exposure to actual or threatened death, serious injury,
or sexual violence in ONE or more OF THE FOLLOWING:
1. Directly experiencing the trauma
2. Witnessing in person the event(s) occur to another
3. Learning of the trauma which occurred to a close family
member or friend
4. Experiencing repeated or extreme exposure to adverse
details of the trauma

B): Presence of ONE OR MORE of the following trauma

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related intrusive symptoms that occurred post-trauma:
1. Recurrent, involuntary, and intrusive distressing memo-
ries
2. Recurrent distressing dreams that are trauma-relate
3. Dissociative reactions (flashbacks) in which you feel as
if the event is happening again
4. Intense/prolonged psychological distress at exposure to
internal stimuli
5. Marked physiological reaction to exposure to inter-
nal/external cues

C): Persistent avoidance of stimuli associated with trauma

seen in ONE OR MORE OF THE FOLLOWING:
1. Avoidance of or efforts to avoid distressing memories,
thoughts, or feelings associated with the trauma
2. Avoidance of or efforts to avoid external reminders that
arouse thoughts/feelings associated with the trauma

D): Negative alterations in cognition/mood associated with

the trauma as seen in TWO OR MORE OF THE FOLLOW-
ING:
1. inability to remember aspects of the trauma
2. Persistent/exaggerated negative beliefs or expectations
about oneself, others, or the world
3. Persistent, distorted cognitions of cause of trauma
4. Persistent negative emotional state
5. Marked diminished interest in activities
6. Feels of detachment or estrangement from others
7. Persistent inability to experience positive emotions

E): Alteration in arousal/reactivity associated with trauma

in TWO OR MORE OF THE FOLLOWING:
1. Irritability behavior/mood
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep Problems

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F): Duration of symptoms more than ONE MONTH
G): Causes clinically signifiacnt distress
H): Not attributed to AMC or SUD

**Specify if with:
1) With dissociative symptoms: TWO forms that cannot
be attributed to substance misuse: DEPERSONALIZA-
TION (recurrent experiences of feeling detached/outside
observer) and DEREALIZATION (recurrent experience of
unreality of surroundings; "dream-like")
2) With delayed expression: Diagnostic criteria is met 6
months post-trauma

16. Rule Out (PTSD) 1) Adjustment disorders

2) Other posttraumatic disorders and conditions
3) Acute stress disorder
4) Anxiety disorders and OCD
5) MDD
6) Personality Disorders
7) Dissociative disorders
8) Conversion disorders
9) Psychotic disorders
10) Traumatic brain injury

17. Prevalence Rates US rates: ~8.7%

(PTSD) US & Europe estimates: Lower worldwide (~.5-1%)
Higher among veterans and those exposed to traumatic
exposure more often (e.g., police)
Highest among survivors of military-trauma, sexual as-
sault, captivity, and ethnicially/politically motivated geno-
cide/internment.
Tends to be lower amongst children and elderly.
Higher in Latino, African American, American Indian than
Caucasian and Asian American

18. Cultural Consid- May differ across culture (increased likelihood of trauma
erations (PTSD) exposure; social norms; expression of symptoms)

19. Gender Consid- More common in women than men (about 2:1 ratio); likely
erations (PTSD) due to more likely to get traumatized as a female
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20. Develop- Onset: can occur at any age (usually must be 1 or old-
ment/Course er though...); symptoms usually begin within 3 months
(PTSD) post-trauma (however, symptoms can be delayed for mul-
tiple months/years)
Course: Varies, some recover within 3 months of symp-
toms appearing, while others have persistent symptoma-
tology for years; linked to mental/physical disability; linked
to high health care utilization

21. Risk Factors ¢Pretrauma: psychiatric comorbidity, previous trauma,

(PTSD) emotional problems (if child), low SES, culture, social sup-
port, genetic factors, being a female and younger
¢ Peritrauma: Severity of trauma, perceived life threat, in-
jury, being in the military, being a perpetrator, killing the
perpetrator, and witnessing atrocities. Dissociation during
and/or after the trauma.
¢ Post-trauma: Negative appraisals and coping, developing
ASD, subsequent trauma exposure, financial loss, social
support

22. Other Notes o Age can exacerbate PTSD symptoms; with declining
(PTSD) health, worsening cognitive functioning, & social isolation
being the main factors
o Can impact children/adolescents strongly in terms of
their social interactions (e.g., avoidant or partaking in risky
behaviors)
o Linked to suicidal ideation/risk
o 80% more likely to meet criteria for another MH disorder
(especially TBI and depression)

23. Criteria (Acute A): Exposure to actual or threatened death, serious injury,
Stress Disorder) or sexual violence in ONE OR MORE OF THE FOLLOW-
ING:
1. Directly experiencing the trauma
2. Withnessing in person the event(s) occur to another
3. Learning of the trauma which occurred to a close fa-
miliar member or friend [IMPORTANT: in case of actu-
al/threatened death must be accidental or violent]
4. Experiencing repeated or extreme exposure to adverse
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details of trauma (e.g., first responders collecting human
remains) [NOTE: Cannot apply to electronic, TV, movie, or
picture exposure unless work related]

B): Presence of NINE OR MORE of the following trau-

ma-related intrusive symptoms that occured post trauma
in any of the FIVE categories:
1. Intrusion:
a. Recurrent, involuntary, and intrusive memories of the
trauma (NOTE: in children may occur in repetitive play)
b. Recurrent distressing dreams in which the content are
related to the trauma (NOTE: children may not recog-
nize/remember content)
c. Dissociative reactions (flashbacks) in which look or feel
there (NOTE: children may occur in play)
d. Intense or prolonged psychological distress/ intense
physiological reactions in response to internal/external
cues related to trauma
2. Negative Mood:
a. Persistent inability to experience positive emotions
3. Dissociative Symptoms:
a. An altered sense of the reality of one's surround-
ings/oneself (e.g., seeing self in other's perspective, in a
daze)
b. Inability to remember important aspects of the trauma
(cannot be due to substance misuse or hear injury)
4. Avoidance Symptoms:
a. Effort to avoid distressing memories/thoughts/feelings
associated with trauma
b. Effort to avoid external reminders (people/place/things)
of trauma
5. Arousal Symptoms:
a. Sleep disturbance (falling, staying asleep; restless
sleep)
b. Irritability; aggression to people/object
c. Hypervigilance
d. Problems with concentration

**Duration of symptoms is 3 days to 1 month post trauma.

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Sxs usually immediate and need to last 3-30 days to meet
criteria

24. Rule Out (Acute 1) Adjustment disorders

Stress Disorder) 2) Panic disorder
3) PTSD
4) OCD
5) Dissociative disorders
6) TBI
7) Psychotic disorders

25. Prevalence Rates US rates: Unknown, although it tends to occur in only

(Acute Stress about 20% of trauma cases, with a higher prevalence in
Disorder) interpersonal traumatic events (e.g., assault, rape, wit-
nessing a shooting)
US & Europe estimates: Unknown; culture tends to be
related to expression of dissociation/traumatic symptoms,
can be diagnosis difficult

26. Cultural Consid- May differ across culture (increased likelihood of trauma
erations (Acute exposure; social norms; expression of symptoms)
Stress Disorder)

27. Gender Consid- More common in women than men (about 2:1 ratio); likely
erations (Acute due to more likely to get traumatized as a female; also may
Stress Disorder) be linked to neurobiological differences

28. Development/ Onset: Must occur/persist between 3-30 days post-trauma

Course (Acute Course: About 50% of people with PTSD initially had ASD;
Stress Disorder) however, not all of people with ASD progress to have
PTSD (important to remember that after 30 days it be-
comes PTSD if symptoms persist); important to remember
that children may express symptoms differently; linked to
impaired social/interpersonal/occupational functioning

29. Risk Factors ¢High levels of negative affect (neurotocism); greater per-
(Acute Stress ceived severity of trauma
Disorder) ¢ Exagerated negative appraisals pre/post-trauma
¢ History of prior trauma

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¢ Being female
¢ Elevated reactivity (e.g., startle responses) pre-trauma

30. Criteria (Adjust- A. The development of emotional/behavioral symptoms in

ment Disorder) response to an identifiable stressor that occurred within 3
MONTHS of symptom onset
B. Symptoms/behaviors are clinically significant by ONE+
of following
a. Marked distress that is out of proportion to the severity
of the stressor (NOTE: take into account context and cul-
ture)
b. Social/occupational/functional impairment
C. Stress-related disturbance does not meet criteria for
another MH disorder and is not related to the exacerbation
of another MH 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

Specify whether:
1) With depressed mood: low mood, tearfulness, hopeless
2) With anxiety: nervousness, worry, jittery, separation
anxiety
3) With mixed anxiety and depressed mood: Combination
of depressed and anxious mood (1 and 2)
4) With disturbance of conduct
5) With mixed disturbance of emotions and conduct: De-
pression/Anxious symptoms as well as conduct distur-
bance are present
6) Unspecified: Reactions that are not

31. Rule Out (Adjust- 1) MDD

ment Disorder) 2) PTSD and/or ASD
3) Personality Disorder
4) Psychological factors affective other medical conditions
(e.g., having a chronic illness)
5) Normative stress response

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32. Prevalence Rates US rates: Fairly common, in outpatient MH treatment cen-
(Adjustment Dis- ters tends to range from 5-20%; in hospital psychiatric
order) consultation settings it is very common (~50%)
US & Europe estimates: Unknown; culture tends to be
related to expression of dissociation/traumatic symptoms,
can be diagnosis difficult and should be taken into account

33. Cultural Consid- May differ across culture (increased likelihood of trauma
erations (Adjust- exposure; social norms; expression of symptoms)
ment Disorder)

34. Gender Consid- More common in women than men (about 2:1 ratio); likely
erations (Adjust- due to more likely to get traumatized as a female; also may
ment Disorder) be linked to neurobiological differences

35. Development Onset: Tends to manifest within 3 months of stressor on-

and Course set; but remit within 6 months of stressor ending
(Adjustment Course: Symptom onset tends to be immediate (especially
Disorder) if the event is acute; e.g., fired from job), but can be
persistent/chronic; can lead to decreased performance at
work/school; can affect social relationships

36. Risk Factors (Ad- ¢Disadvantaged life circumstances (tending to experience

justment Disor- a higher rate of stressors)
der)

37. Other Notes (Ad- o Can impact the treatment of other medical conditions
justment Disor- (e.g., increased length of stay; decreased compliance)
der) o Can accompany MH disorders and medical disorders;
important to diagnose only if symptoms are not explain-
able by other MH/medical disorder(s)

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