Post Traumatic Stress Disorder:Understanding the Changes in the

DSM-5

Kathleen O’RahillyLinda Maney

Yenny Montenegro, Mariela Sanchez & Sadia Perveen – contributors

Creation of DSM-5

Basis for Proposals

Principles guiding revisions:

Intention, Research Evidence, Continuity, No

Unnecessary Constraints

Experts and Subgroup Committees

Field Trials

(5th ed.; DSM–5; American Psychiatric Association, 2013)

Classification PTSD was listed as an Anxiety Disorder within

the DSM- IV

Considered placing it with:

Stress Induced Fear –Circuitry Disorders

Internalizing Disorder

Dissociative Disorder

Now listed as Trauma and Stressor Related

Disorder (Friedman, M. J., 2013)

Broad vs. Narrow Definition

The subcommittee debated over the benefits of

broad or narrow definitions of PTSD

They ultimately decided on a broad definition

Post field test results indicated that the broad

symptom criterion resulted in a comparatively

high test retest reliability

(Friedman, M. J., 2013)

Factor Structure Under the DSM-IV PTSD followed a three factor

structure model Confirmatory factor analysis has failed to

support the use of this model

▪ supported distinction of Intrusion and Arousal

▪ not supported the grouping of Avoidance & Numbing

Follow up research shows support for this model but greater support for a 5 factor model

(Friedman, M. J., 2013)

Subtype: Dissociative Dissociative subtype

Marked by symptoms of depersonalization or derealization

Creation supported by evidence of:▪ FMRIs ▪ Different etiology ▪ Distinctive treatment▪ Not all individuals who meet criteria for

PTSD have high levels of dissociation whereas most individuals with high dissociation have PTSD

(Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D., 2012)

Subtype: Preschool

Preschool subtype

Implausibly low prevalence

▪ high verbal and cognitive demands

▪ alternative algorithm

Evidence supports the criterion, convergent,

discriminant, and predictive validities of the

preschool subtype

( Scheeringa et al., 2011)

Diagnosis: Ages 6 and above

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

1. Directly experiencing2. Witnessing it in person as it occurs3. Learning that it 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 event

(5th ed.; DSM–5; American Psychiatric Association, 2013)

Diagnosis: Ages 6 and above

B. Presence of one (or more) of the following intrusion symptoms associated with the trauma, occurring after the trauma

1. Recurrent involuntary and distressing memories 2. Recurrent distressing dreams with related content3. Dissociative reactions- feel or act as if event were recurring 4. Intense or prolonged psychological distress to cues which

symbolize or resemble aspects of the event 5. Marked physiological reactions to reminders of the traumatic

event

C. Persistent Avoidance of Stimuli associated with the trauma marked by one (or more) of the following

6. Avoiding activities, places, or physical reminders of the event7. Avoiding people, conversations, or interpersonal situations

(5th ed.; DSM–5; American Psychiatric Association, 2013)

Diagnosis: Ages 6 and above

D. Negative alterations in cognitions &

mood associated with the event beginning or worsening after the event , evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the event

2. Persistent exaggerated negative beliefs or expectations about self, world or others

3. distorted cognitions about the cause or consequence of the event leading to blame themselves or others

4. Persistent negative emotional state 5. Markedly diminished interest in significant activities 6. Feelings of detachment from others7. Persistent inability to experience positive emotions

(5th ed.; DSM–5; American Psychiatric Association, 2013)

Diagnosis: Ages 6 and above

E. Marked alterations in arousal and reactivity associated with the event evidenced in two (or more) of the following ways:

1. Irritable behavior and angry outbursts 2. Reckless or self destructive behavior 3. Hypervigilance 4. Exaggerated startle response5. Problems with concentration6. Sleep disturbance

F. more than one month & G.Disturbance causes clinically significant distress or impairment in social, occupational or other functioning (5th ed.; DSM–5; American Psychiatric Association, 2013)

Diagnosis: Ages Under 6

A. Exposure Learning that it occurred to a parent or

caregiver Doesn’t include repeated exposure to details

B. Intrusion dreams content need not be related Spontaneous and intrusive memories may

not necessarily appear distressing and may be expressed in play reenactment

C.Arousal Doesn’t include reckless behavior

D. Avoidance or negative alterations in cognition(5th ed.; DSM–5; American Psychiatric Association, 2013)

Negative alterations in cognitions Doesn’t include

▪ Inability to remember aspect of event▪ Persistent exaggerated negative beliefs or expectations▪ Persistent distorted cognitions about the cause or consequence▪ Persistent negative emotional state▪ Feelings of detachment from others▪ Persistent inability to experience positive emotions

Instead includes▪ Increased frequency of negative emotional states▪ Socially withdrawn behavior▪ Persistent reduction in expression of positive emotions

Diagnosis Ages Under 6

(5th ed.; DSM–5; American Psychiatric Association, 2013)

Differences Between Diagnosis

Under 6 Over 6

Nightmares Content need not appear related

In children over 6 the content may not be

recognizable, but this diminishes with age

Exposure Either to self or caregiver figure

Self, close family, or close friend

Flashbacks May occur during play without appearing distressing

May occur during play

Inability to remember trauma

NOT A PART OF DIAGNOSIS

✓

Self destructive behavior

NOT A PART OF DIAGNOSIS

✓

Negative Cognitions/Avoid

ance

Need one or the other

Need both(5th ed.; DSM–5; American Psychiatric Association, 2013)

Rethinking The Stressor: A Cluster

Debate: what qualifies as a traumatic event ?

some professionals suggested that the criterion be

removed

stressor was too integral to be eradicated as a

criteria

Many felt the definition of traumatic events should be

restricted to only those which were directly

experienced

Many individuals with PTSD indirectly experience a

trauma

limit the types of trauma which may be experienced

indirectly

(Friedman, M. J. 2013)

DSM-IV Criteria A2

Needed to demonstrate an intense emotional

response

Many individuals deny having such an

experience

Not a risk factor

Not a protective factor

A2 was not included in the DSM-5

(Friedman, M. J. 2013)

Clarification of Intrusion Symptoms: B Cluster

Longer lasting reflective thought process were

excluded

more consistent with Depression

PTSD on the other hand is characterized by

intrusive distressing sensory, emotional

physiological or behavioral memories.

(Friedman, M. J. 2013)

Negative Alterations in Cognition & Mood: D

Cluster Two new criteria were added to this symptom index Persistent negative emotional state

▪ reaction to the “irritability or outbursts of anger”

▪ behavior was moved to symptom index E Persistent distorted blame of self or others about

the traumatic event ▪ predicts severity, chronicness, & functional

impairment

Inability to recall important events was reclassified as dissociative amnesia

(Friedman, M. J. 2013)

Alterations in Arousal: E Cluster

Now includes behavioral reactivity heightened arousal

Symptom expression may include reckless driving risky sexual behavior suicidal behavior, aggression

(Friedman, M. J. 2013)

Assessment

Validated measures in accordance with DSM-5 Clinician-Administered PTSD Scale for DSM-5

(CAPS-5) PTSD Checklist for DSM-5 (PCL-5) Life Events Checklist for DSM-5 (LEC-5)

Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA)

The Primary Care PTSD Screen (PC-PTSD)WWW.PTSD.VA.GOV

Treatment CBT and Cognitive restructuring Exposure therapy Medication

Children Under 6: TF-CBT

Play therapy Meditation

Prognosis(Jonah, D. E., Cusack, K., Fomeris, C. A., Forneris, C. A., Wilkins, T. M., Sonis, J. . . & Gaynes, B. N., 2013)

Intervention

These programs have been developed specifically for

use in schools and focus on a broad array of traumas

(Kataoka, Langley, Wong, Baweja & Stein, 2012) :

Psychological First Aid (PFA)

Cognitive-Behavioral Intervention for Trauma in

Schools (CBITS)

Multimodality Trauma Treatment (MMTT)

Aerobic Exercise (Diaz & Motta, 2007)

In Summary  DSM-IV DSM-5

Classification Anxiety Disorder Trauma & Stressor Related Disorder

Age Qualifiers None Under 6/ Over 6

Subtypes None, but specify if PTSD includes delayed onset

Dissociative or Preschool (Specify if either occurs with delayed onset)

Symptom Clusters Intrusion, Avoidance, & Arousal Intrusion, Avoidance, Arousal, Negative Cognitions

Diagnostic Menu 17 symptoms 20 symptoms

Symptoms Explicitly Linked To Trauma

7 symptoms All 20 symptoms

Traumatic Events More ambiguous More clearly defined

Exposure Larger amount of qualifying traumas that could be experienced indirectly

Reduced and clarified indirect exposure events. However, also now includes learning of

traumatic eventsIntense Emotional

ResponseIncluded as necessary criteria Not included

Longer Lasting Reflective Thought Processes

Included as potential symptom Not included

Irritability or Outbursts of Anger

Included as potential symptom Broken up so that emotional states and behavioral reactions were not mixed

Inability To Recall

Important Events

Included as potential symptom Reclassified as dissociative amnesia

Alterations In Arousal Sleep disturbance, irritable/angry outbursts, difficulty concentrating, hypervigilance, exaggerated startle

response

Expanded to include behavioral reactivity, reckless driving, risky sexual behavior,

suicidal behavior, and aggression

ResourcesAmerican Academy of Child & Adolescent Psychiatry www.aacap.org

Pamphlets: PTSD, The Depressed Child, Children and Grief, Talking to Children about Terrorism and War

National Child Traumatic Stress Network www.nctsnet.org‘After the Hospital: Helping My Child Cope-What Parents Can Do’; ‘Caring for Children Who Have Experienced Trauma-A Workshop for Parents; ‘Checklist for School Personnel to Evaluate and Implement the Mental Health Component of Your School Crisis and Emergency Plan’

Coping With A Crisis: Informational booklet produced by the National Institute of Mental Health

The National Center for Post Traumatic Stress Disorder: PTSD Research Quarterly: Advancing Science and Promoting Understanding of Traumatic Stress. www.ptsd.gov

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brock, S. E., & Cowan, K. (2004). Coping After a Crisis. Principal Leadership, 4(5), 9-13. Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A Multisite,

Randomized Controlled Trial For Children With Sexual Abuse–related PTSD Symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393-402. Diaz, A. B., & Motta, R. (2007). The Effects of An Aerobic Exercise Program On

Posttraumatic Stress Disorder Symptom Severity In Adolescents. International Journal of Emergency Mental Health, 10(1), 49-59.

Dyregrov, A., & Yule, W. (2006). A review of PTSD in children. Child and Adolescent Mental Health, 11(4), 176-184.

Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2008). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press.

Friedman, M. J. (2013). Finalizing PTSD in DSM‐5: Getting Here From There and Where to Go Next. Journal of traumatic stress, 26(5), 548-556.

Kaplan, L. M., Kaal, K., Bradley, L., & Alderfer, M. A. (2013). Cancer-related traumatic stress reactions in siblings of children with cancer. Families, Systems, & Health, 31(2), 205-217. doi:10.1037/a0032550

References

Kataoka, S., Langley, A., Wong, M., Baweja, S., & Stein, B. (2012). Responding to students with PTSD in schools. Child and adolescent psychiatric clinics of North America, 21(1), 119.

Kilpatrick, D.G., Resnick. H.S., Milanak, M.E., Miller, M.W., Keyes, K.M., Friedman, M.J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM- IV and DSM-5 criteria. Journal of Traumatic Stress, 26, 537-547.

Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640-647.

Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale,

clinical and neurobiological evidence, and implications. Depression and Anxiety, 29(8), 701-708.

Merikangas, K. et al. (2010). Lifetime prevalence of mental disorders in the U.S. Adolescent Comorbidity Survey Replication-Adolescent Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 980-988.

References

National Institute of Mental Health. (2014). Post-Traumatic Stress Disorder (PTSD). Retrieved from National Institute of Mental Health website: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml#part4

Pervanidou, P. (2008). Biology of post-traumatic stress disorder in childhood and adolescence. Journal Of Neuroendocrinology, 20(5), 632-638. doi: 10.1111/j.1365-2826.2008.01701.x

Posttraumatic Stress Disorder (PTSD). (n.d.). Posttraumatic Stress Disorder (PTSD). Retrieved May 7, 2014, from http://www.aacap.org/aacap/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Posttraumatic_Stress_Disorder_70.aspx

PTSD: National Center for PTSD. (2014). Clinician-Adminstered PTSD Scale for DSM-5 (CAPS-5). Retrieved from http://www.ptsd.va.gov/professional/ assessment/adult-int/caps.asp

References

PTSD: National Center for PTSD. (2014). Life Events Checklist for DSM-5 (LEC-5). Retrieved from http://www.ptsd.va.gov/professional/ assessment/temeasures/lifeeventschecklist.asp Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52 (8), 853-860.

Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane, T.M. (2013). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Interview available from the National Center for PTSD at www.ptsd.va.gov.

References