Chapter 7. Trauma- and Stressor-Related Disorders

Abstract

The chapter on trauma- and stressor-related disorders consists of a cluster of disorders that require identification of a triggering external event. This was a new chapter in DSM-5. Previously, all of the disorders had been listed in other chapters. This chapter also features the only diagnosis that is new to the main DSM-5-TR text: prolonged grief disorder, which in DSM-5 had been listed in the ?Conditions for Further Study? chapter in Section III, where it was called persistent complex bereavement disorder.Posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) were moved from the chapter on anxiety disorders. Both PTSD and ASD are characterized by heterogeneous symptoms, not only anxiety, and one consequence of this classification change was to emphasize the importance of assessing the breadth of reactions to an external trauma or stressor. At the same time, both disorders often present with prominent anxiety, and an alternative conceptualization of both PTSD and ASD would characterize them on an anxiety spectrum of disorders, alongside, for example, obsessive-compulsive disorder, which was also moved from the anxiety disorders into its own chapter in DSM-5.A PTSD diagnosis requires the presence of symptoms from each of four symptom clusters: intrusion symptoms (previously known as reexperiencing), avoidance symptoms, negative alterations in cognition and mood, and arousal symptoms. DSM-5 more explicitly recognized the heterogeneity of acute post-trauma response by eliminating the requirement that individuals with ASD have symptoms from multiple symptom clusters. Instead, it is necessary to have at least nine of 14 symptoms. In practice, this could mean that one individual with ASD could have all four intrusion symptoms, whereas another might have none.PTSD and ASD are most clearly delineated by duration, with PTSD persisting at least 1 month after the external event and ASD lasting no more than 1 month. For both PTSD and ASD, the initial stressor criterion now specifies whether the trauma was experienced, witnessed, or experienced indirectly. Unlike DSM-IV, DSM-5 did not require an assessment of the patient?s initial subjective response for either disorder. Finally, diagnostic thresholds for PTSD were lowered for children and adolescents, and a preschool subtype was added.Two of the chapter?s disorders?reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED)?are initially found in childhood, although both may have lifelong consequences. Children with RAD have responded to the absence of expectable caregiving by a cluster of withdrawn and inhibited symptoms, whereas those with DSED have symptoms described as indiscriminately social and disinhibited.Adjustment disorder had previously served as a residual category for people who were distressed but did not meet criteria for a more discrete disorder. The adjustment disorders were reconceptualized in DSM-5 as an array of stress-response syndromes that occur after exposure to a distressing event. As in DSM-IV, the adjustment disorders should include a specifier that identifies the predominant disturbance (e.g., depressed mood, anxiety, disturbance of conduct, or a combination).It has long been recognized that it is normal for people to grieve the death of a loved one. Clinicians and researchers have increasingly identified a subgroup of people whose emotional reaction appears to be excessive in intensity for over a year. The diagnosis of prolonged grief disorder has been introduced within the main body of DSM-5-TR to meet this clinical concern.DSM-5-TR explores the growing evidence that culture affects clinical expression. For example, non-Western groups appear to respond to PTSD with less avoidance and more somatic symptoms such as dizziness and shortness of breath. Although DSM-5-TR emphasizes categories of disorders, it also includes discussion of how developmental issues can affect symptomatology. For example, children younger than 6 years can be traumatized by life-threatening events such as the threat of abandonment, and a primary presenting complaint might be nightmares, with or without traumatic content.The trauma- and stressor-related disorders can usefully bring together seemingly unrelated symptoms. For example, an adult might present with complaints related to anxiety, depression, paranoia, social isolation, and substance use. Without a careful history that looks for trauma, the clinician might conceptualize the patient as having half a dozen diagnoses rather than a single trauma- and stressor-related diagnosis that synthesizes a disparate set of problems. At the same time, comorbidities are common among the disorders discussed in this chapter, and, if found, should generally be identified along with the disorder directly related to the trauma or stress.