Assistance with Biopsychosocial and Diagnosis.
Background Information
The client, Felicia, was referred by her primary care physician for an outpatient evaluation. The
client’s main complaint is constantly feeling “on edge.” During the initial appointment, the social
worker listened with compassion and empathy to Felicia’s concerns. While listening to her concerns, the
social worker evaluated her for signs and symptoms using a biopsychosocial approach while assessing
for competence and overall health. Using the biopsychosocial method allows the social worker to look at
all aspects of Felicia’s life, including her biological, psychological, and social factors and how they all
interact with one another and affect Felicia (Gray, 2016).
Biological
The social worker analyzed and gathered data during the initial appointment concerning the
biological aspects of Felicia’s life. Felicia is a forty-year-old female who reports constant worry. Felicia
explained that she has never liked to be alone and would cry inconsolably when her mother tried
dropping her off for kindergarten. Felicia also mentioned going to counseling when she was nine years
old after her parents divorced because of her “clinginess.” Separation anxiety is often seen in children
when they first begin attending school but can occur at all ages and in many situations” (Gray, 2016,
p.163). Children with separation anxiety usually get upset and are inconsolable over things that
generally should not upset someone that bad. If separation anxiety or other anxiety disorders are not
treated during childhood, they can persist into adulthood (Gray, 2016).
Psychological
When assessing Felicia, the social worker also considered psychological aspects. During the
initial appointment, Felicia denies any feelings of worthlessness, hopelessness, guilt, or suicidal
ideation. She also reported no change in weight, sleeping habits, or psychomotor changes indicative of
depressive mood disorders (Gray, 2016). However, Felicia talked about her excessive worrying with her
main complaint of always being on edge. Felicia reports that her live-in boyfriend of ten years abruptly
left her. She conveys feelings of sadness, difficulty concentrating and feeling tense and fatigued.
According to the Diagnostic and Statistical Manual of Mental Disorder (DSM–5; American Psychiatric Association, 2013), some criteria for Generalized anxiety disorder are “feeling on edge, being easily fatigued, difficulty in concentrating, and muscle tension” (p. 37). Felicia admits to worrying about several things, such as making enough money, fear that something terrible would happen if she left the house, and “agonized” about making mistakes at work regarding her routine tasks. According to the DSM-5 (2013), “the essential feature of generalized anxiety disorder is excessive anxiety and worry about several events or activities” (p. 222).
Social
Felicia is an administrative assistant. She has never married and has no children. Felicia reports
that she has never liked to be alone and has had a boyfriend since age sixteen. Felicia also reports a
change in social routine and activities since her live-in boyfriend of ten years left her for another
woman. Felicia reports that before losing her boyfriend, she was successful at work, had an excellent
social network of friends, and jogged regularly. Felicia now reports excessive worry about routine job
tasks, leaving her house to go anywhere during the day or night out of fear something may happen to
her. Felicia’s excessive worry and anxiety have taken a toll on her social life, as she cannot leave her
house. Felicia reports being at home allows her to relax. There she can enjoy a good movie or book.
Anxiety can be produced from a life stressor such as losing a loved one, changes in the environment, or
moving. People with anxiety tend to avoid situations and places that make their anxiety peak, as
“anxiety rarely occurs in isolation” (Gray, 2016, p. 162).
Competence
Felicia has insight into her problems by being aware of her feelings and noticing changes in her social and physical routines and sought help through her primary care physician and followed through with a referral to be evaluated in an outpatient setting. Felicia’s other strengths include having a great job as an administrative assistant, having no suicide ideation, and capable of living a successful life as she was doing before her breakup (Gray, 2016).
References
American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders
(DSM) (5thed.). Arlington, VA.
Gray, S. (2016). Psychopathology: A competency-based assessment model for social workers (4thed.)
Brooks/Cole.
Background
Information
The client, Felicia, was referred by her
primary care physician for an outpatient evaluation. The
client’s main complaint is constantly feeling “on edge.” During the initial appointment, the social
worker listened with compassion and empathy to Felicia’s concerns. While listening to her concern
s, the
social worker evaluated her for signs and symptoms using a biopsychosocial approach while assessing
for competence and overall health. Using the biopsychosocial method allows the social worker to look at
all aspects of Felicia’s life, including h
er biological, psychological, and social factors and how they all
interact with one another and affect Felicia (Gray, 2016).
Biological
The social worker analyzed and gathered data during the initial appointment concerning the
biological aspects of Felic
ia’s life. Felicia is a forty
–
year
–
old female who reports constant worry. Felicia
explained that she has never liked to be alone and would cry inconsolably when her mother tried
dropping her off for kindergarten. Felicia also mentioned going to counselin
g when she was nine years
old after her parents divorced because of her “clinginess.” Separation anxiety is often seen in children
when they first begin attending school but can occur at all ages and in many situations” (Gray, 2016,
p.163). Children wit
h separation anxiety usually get upset and are inconsolable over things that
generally should not upset someone that bad. If separation anxiety or other anxiety disorders are not
treated during childhood, they can persist into adulthood (Gray, 2016).
Psy
chological
When assessing Felicia, the social worker also considered psychological aspects. During the
initial appointment, Felicia denies any feelings of worthlessness, hopelessness, guilt, or suicidal
ideation. She also reported no change in weight, s
leeping habits, or psychomotor changes indicative of
depressive mood disorders (Gray, 2016). However, Felicia talked about her excessive worrying
with her
main complaint of always being on edge. Felicia reports that her live
–
in boyfriend of
ten years abruptly
left her. She conveys feelings of sadness, difficulty concentrating and feeling tense and fatigued.
Background Information
The client, Felicia, was referred by her primary care physician for an outpatient evaluation. The
client’s main complaint is constantly feeling “on edge.” During the initial appointment, the social
worker listened with compassion and empathy to Felicia’s concerns. While listening to her concerns, the
social worker evaluated her for signs and symptoms using a biopsychosocial approach while assessing
for competence and overall health. Using the biopsychosocial method allows the social worker to look at
all aspects of Felicia’s life, including her biological, psychological, and social factors and how they all
interact with one another and affect Felicia (Gray, 2016).
Biological
The social worker analyzed and gathered data during the initial appointment concerning the
biological aspects of Felicia’s life. Felicia is a forty-year-old female who reports constant worry. Felicia
explained that she has never liked to be alone and would cry inconsolably when her mother tried
dropping her off for kindergarten. Felicia also mentioned going to counseling when she was nine years
old after her parents divorced because of her “clinginess.” Separation anxiety is often seen in children
when they first begin attending school but can occur at all ages and in many situations” (Gray, 2016,
p.163). Children with separation anxiety usually get upset and are inconsolable over things that
generally should not upset someone that bad. If separation anxiety or other anxiety disorders are not
treated during childhood, they can persist into adulthood (Gray, 2016).
Psychological
When assessing Felicia, the social worker also considered psychological aspects. During the
initial appointment, Felicia denies any feelings of worthlessness, hopelessness, guilt, or suicidal
ideation. She also reported no change in weight, sleeping habits, or psychomotor changes indicative of
depressive mood disorders (Gray, 2016). However, Felicia talked about her excessive worrying with her
main complaint of always being on edge. Felicia reports that her live-in boyfriend of ten years abruptly
left her. She conveys feelings of sadness, difficulty concentrating and feeling tense and fatigued.
Susan W. Gray
Psychopathology: A Competency-Based Assessment Model for Social Workers
Chapter 8
Trauma- and Stressor-Related Disorders
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Characterizes those disorders where symptoms occur after exposure to a traumatic or stressful event
Usually, some combination anxiety (internalizing symptoms) or anger (externalizing symptoms) is a part of the symptom picture
Two disorders are included in this chapter that share a common etiology of social neglect – understood as the absence of adequate caregiving during childhood – and they are: reactive attachment disorder and disinhibited social engagement disorder
2
Reactive Attachment Disorder
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Characterizes a rare disorder found in children who lack attachments despite the developmental capacity to form them
The core features of RAD disorder include failure to seek and respond to comforting when distressed – with social and emotional disturbances
Seen with at least 2 of the following: minimal emotion regulation, reduced positive affect, and episodes unexplained fearfulness and anxiety – children with a history of living in settings which limit attachment opportunities are at a higher risk
Symptoms begin before the age of 5 – usually can be seen while still an infant – and must have a developmental age of at least 9 months
The case of Annie Marozas illustrates the symptom picture for RAD
Disinhibited Social Engagement Disorder (DSED)
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
A disorder of a child’s social relatedness – the central feature is that the child has experienced serious neglect or pathogenic care (such as severe parental neglect, abuse or mishandling) very early in life
Behavior includes an inappropriate approach to unfamiliar adults, a lack of wariness of strangers, and a willingness to wander off with strangers
The child has experienced extremes of insufficient care that limits attachment opportunities
Can persist into middle childhood and adolescence but has not been described in adults
Jimmy John Clark illustrates the symptom picture for reactive attachment disorder
Posttraumatic Stress Disorder (PTSD)
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Close exposure to the trauma seems to be a main aspect of developing PTSD – major reference points include the reaction to catastrophic events, such as:
Witnessing a homicide or suicide
Traffic accidents
Combat
Natural disasters
Sexual assault
Victimization (such as sexual molestation, robbery, aggravated assault)
Survivors of holocausts
Life events such as domestic violence or a diagnosis of HIV
PTSD Symptom Picture
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
The central feature of PTSD is exposure to actual or threatened death, serious injury or sexual violence – exposure does not include events seen only in electronic media, television, movies or pictures
Symptoms must last for more than one month and significantly affect important interpersonal areas of the person’s life such as family interaction and employment
PTSD is not reflective of another medical condition or the effects of a substance such as medication or alcohol
PTSD Symptom Picture Continued
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Next, the practitioner considers 4 symptom clusters characterized as follows (note the diagnostic thresholds of PTSD for children 6 years of age and younger):
Re-experiencing the event – One or more of the following intrusion symptoms associated with the traumatic event(s) of (1) spontaneous memories of the traumatic event (Note: Children older than 6 years of age may engage in repetitive play showing themes of the trauma.); (2) recurrent dreams related to it (Note: Children may have frightening dreams where the content is vague or indistinguishable.); (3) flashbacks (Note: Children may reenact trauma through play.); (4) other intense or prolonged psychological distress; or/and (5) marked physiological reactions
Avoidance – One or both of the following (1) distressing memories, thoughts, feelings or external reminders of the event; and (2) efforts to avoid external reminders that provoke distressing memories thoughts or feelings associated with the traumatic event(s)
PTSD Symptom Clusters Continued
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Negative thoughts and mood or feelings — Two or more of the following (1) an inability to remember key aspects of the event; (2) negative thoughts about oneself, others, or the world such as “I am bad,” or “No one can be trusted.”; (3) feelings that may vary from a persistent and distorted sense of blame of self or others; (4) a persistent negative emotional state such as fear, horror, anger guilt or shame; (5) a markedly diminished interest in activities to estrangement from others; (6) feelings of detachment or estrangement from others; or/and (7) to an inability to experience positive emotions such as happiness or loving feelings
Heightened arousal – As seen by two or more of the following (1) aggressive angry outbursts; (2) reckless or self-destructive behavior; (3) hypervigilance; (4) exaggerated startle response; (5) problems concentrating; or/and (6) sleep disturbances
PTSD Specifiers
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Those exposed to a traumatic event may not exhibit PTSD features until years afterward – specify “with delayed expression”
The person may also experience dissociative symptoms – specify “with dissociative symptoms”
The case of Buddy Jackson illustrates someone who experienced a delayed onset of PTSD
Acute Stress Disorder (ASD)
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
ASD looks a lot like PTSD but emphasizes the severe reaction that some people have within the first month immediately following a trauma — ASD includes any 9 of 14 symptoms in the following categories:
Intrusion – As seen by: (a) recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: Children may engage in repetitive play where themes or aspects of traumatic event(s) are communicated.) (b) the content and/or affect of recurrent, distressing dreams related to traumatic event(s); (c) dissociative reactions such as flashbacks and these reactions can range on a continuum with the most extreme reaction being a complete loss of awareness of one’s surroundings (Note: Children may reenact trauma-specific themes in play.); (d) intense or prolonged reactions (either psychological or physiological) in response to cues that resemble (or may symbolize) an aspect of the traumatic event(s)
Negative mood – Persistent inability to experience positive emotions such as happiness, satisfaction or loving feelings
ASD Symptom Categories Continued
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Dissociation – Understood as (a) an altered sense of reality of one’s surroundings or oneself much like being in a daze or time has slowed or seeing oneself from another’s perspective, or (b) being unable to remember important features of the traumatic event(s) and typically not due to dissociative amnesia or a head injury, alcohol or drug use
Avoidance – Considered to be (a) efforts to avoid distressing memories, thoughts or feeling about (or closely associated with) the traumatic event(s), and (b) trying to avoid external reminders such as avoiding people, ;laces, conversations, activities or situations that provoke distressing memories, thoughts or feelings about (or closely associated with) the traumatic event(s)
Arousal – Regarded as (a) sleep disturbances, (b) irritability or angry outbursts typically seen as verbal or physical aggression toward others or objects, (c) hypervigilance, (d) difficulty concentrating, (e) an exaggerated startle response
The following case of Louise Ann Brown illustrates acute stress disorder
The Adjustment Disorders
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Adjustment disorders generally occur as a reaction to a life-threatening event and tend to last longer – assessing for adjustment disorders includes:
Distress is out of proportion to the severity or intensity of the stressor(s)
Once the stressor or its consequences have ended, symptoms do not persist for more than an additional 6 months
Consider 6 of the following specifiers:
With depressed mood – low mood, tearfulness, or feelings of hopelessness are prevalent;
With anxiety – nervousness, worry, jitteriness, or separation anxiety are predominant;
With mixed anxiety and depressed mood – a combination of depression and anxiety;
With disturbance of conduct – when disturbed conduct is predominant;
With mixed disturbance of emotions and conduct – both emotional symptoms (such as depression, anxiety) and a disturbance of conduct are present; and
Unspecified – for maladaptive reactions that are not seen as one of the specific subtypes of adjustment disorder
Jeannette Hutton illustrates symptoms of an adjustment disorder
Other Specified (and Unspecified) Trauma- and Stressor-Related Disorders
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Specified trauma- and stressor-related disorder – applies when the person’s symptom picture does not meet full criteria for any of the disorders in this chapter
Unspecified trauma- and stressor-related disorder – applies to those who present with symptoms characteristic of a trauma- and stressor-related disorder and used in situations when the practitioner elects not to specify the reason that diagnostic criteria
Comparing the DSM-IV-TR Multiaxial System and the DSM-5
© Susan W. Gray – Chapter 8 Trauma- and Stressor- Related Disorders
Obsessive-compulsive and related disorders is a new DSM-5 chapter which includes 4 new disorders – hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition
Trichotillomania (hair-pulling disorder) was moved from “impulse-control disorders not elsewhere classified” in the DSM-IV to the DSM-5 classification as an obsessive-compulsive disorder
A specifier was expanded and added to body dysmorphic disorder and hoarding disorder- good or fair insight, poor insight, and absent insight/delusional (or when the person is convinced that the obsessive-compulsive disordered beliefs are true)
Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may surface with perceived defects of flaws in physical appearance
The specifier “with obsessive-compulsive symptoms” moved from the anxiety disorders to the DSM-5 category of obsessive-compulsive and related disorders
Two additional diagnoses – (1) other specified obsessive-compulsive and related disorder which applies when diagnostic criteria are not met but the practitioner can stipulate reasons why, and (2) unspecified obsessive-compulsive and related disorder used when there is insufficient information to make a diagnosis
SWK 7705 – Assessment & psychopathology
Chapter 8
Trauma- and Stressor-Related Disorders
Characterizes those disorders where symptoms occur after exposure to a traumatic or stressful event
Usually, some combination anxiety (internalizing symptoms) or anger (externalizing symptoms) is a part of the symptom picture
Two disorders are included in this chapter that share a common etiology of social neglect – understood as the absence of adequate caregiving during childhood – and they are: reactive attachment disorder and disinhibited social engagement disorder
2
Reactive Attachment Disorder
Characterizes a rare disorder found in children who lack attachments despite the developmental capacity to form them (sometimes known as attachment disorder)
The core features of RAD disorder include failure to seek and respond to comforting when distressed – with social and emotional disturbances
Seen with at least 2 of the following: minimal emotion regulation, reduced positive affect, and episodes unexplained fearfulness and anxiety – children with a history of living in settings which limit attachment opportunities are at a higher risk
Symptoms begin before the age of 5 – usually can be seen while still an infant – and must have a developmental age of at least 9 months
Symptoms may lead to controlling, aggressive, or delinquent behaviors; trouble relating to peers
The case of Annie Marozas in the text illustrates the symptom picture for RAD
Disinhibited Social Engagement Disorder (DSED)
A disorder of a child’s social relatedness – the central feature is that the child has experienced serious neglect or pathogenic care (such as severe parental neglect, abuse or mishandling) very early in life
Behavior includes an inappropriate approach to unfamiliar adults, a lack of wariness of strangers, and a willingness to wander off with strangers
Is not diagnosed before 9mth or after age 5
The child has experienced extremes of insufficient care that limits attachment opportunities
Can persist into middle childhood and adolescence but has not been described in adults
Prevalence estimated at approx. 20% in children placed in foster care or raised in institutions
Jimmy John Clark illustrates in the text the symptom picture for DSED
Posttraumatic stress disorder (PTSD)
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury (APA, 2020)
PTSD has been known by many names in the past, such as “shell shock” during the years of World War I and “combat fatigue” after World War II, but PTSD does not just happen to combat veterans
PTSD can occur in all people, of any ethnicity, nationality or culture, and at any age
It affects approximately 3.5 percent of U.S. adults every year, and an estimated one in 11 people will be diagnosed with PTSD in their lifetime
Women are twice as likely as men to have PTSD
Three ethnic groups – U.S. Latinos, African Americans, and American Indians – are disproportionately affected and have higher rates of PTSD than non-Latino whites
Posttraumatic Stress Disorder (PTSD)
Close exposure to the trauma seems to be a main aspect of developing PTSD – major reference points include the reaction to catastrophic events, such as:
Witnessing a homicide or suicide
Traffic accidents
Combat
Natural disasters
Sexual assault
Victimization (such as sexual molestation, robbery, aggravated assault)
Survivors of holocausts
Life events such as domestic violence or a diagnosis of HIV
Posttraumatic stress disorder (PTSD)
It’s normal to feel afraid during and after a traumatic situation (National Library of Medicine, 2021)
The fear triggers a “fight-or-flight” response which is your body’s way of helping to protect itself from possible harm; it causes changes in your body such as the release of certain hormones and increases in alertness, blood pressure, heart rate, and breathing
In time, most people recover from this naturally, but people with PTSD do not feel better; they feel stressed and frightened long after the trauma is over
In some cases, the PTSD symptoms may start later on or come and go over time
Researchers do not know why some people get PTSD and others do not; genetics, neurobiology, risk factors, and personal factors may affect whether you get PTSD after a traumatic event
Posttraumatic stress disorder (PTSD)
Who is at risk for post-traumatic stress disorder (PTSD)? (National Library of Medicine, 2021)
You can develop PTSD at any age. Many risk factors play a part in whether you will develop PTSD. They include:
Your sex; women are more likely to develop PTSD
Having had trauma in childhood
Feeling horror, helplessness, or extreme fear
Going through a traumatic event that lasts a long time
Having little or no social support after the event
Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home
Having a history of mental illness or substance use
PTSD Symptom Picture
The central feature of PTSD is exposure to actual or threatened death, serious injury or sexual violence – exposure does not include events seen only in electronic media, television, movies or pictures
Sexual assault and combat experiences are the most common traumas associated with PTSD
Other examples of tragedy that can cause PTSD include events like those from 9/11 which showed that PTSD not only impacts those affected but their families, significant others, those who witnessed the event, first responders, and society as a whole
Symptoms must last for more than one month and significantly affect important interpersonal areas of the person’s life such as family interaction and employment
PTSD is not reflective of another medical condition or the effects of a substance such as medication or alcohol
PTSD Symptom Picture Continued
Next, the practitioner considers 4 symptom clusters characterized as follows (note the diagnostic thresholds of PTSD for children 6 years of age and younger):
Re-experiencing the event – One or more of the following intrusion symptoms associated with the traumatic event(s) of (1) spontaneous memories of the traumatic event (Note: Children older than 6 years of age may engage in repetitive play showing themes of the trauma.); (2) recurrent dreams related to it (Note: Children may have frightening dreams where the content is vague or indistinguishable.); (3) flashbacks (Note: Children may reenact trauma through play.); (4) other intense or prolonged psychological distress; or/and (5) marked physiological reactions
Avoidance – One or both of the following (1) distressing memories, thoughts, feelings or external reminders of the event; and (2) efforts to avoid external reminders that provoke distressing memories thoughts or feelings associated with the traumatic event(s)
PTSD Symptom Clusters Continued
Negative thoughts and mood or feelings — Two or more of the following (1) an inability to remember key aspects of the event; (2) negative thoughts about oneself, others, or the world such as “I am bad,” or “No one can be trusted.”; (3) feelings that may vary from a persistent and distorted sense of blame of self or others; (4) a persistent negative emotional state such as fear, horror, anger guilt or shame; (5) a markedly diminished interest in activities to estrangement from others; (6) feelings of detachment or estrangement from others; or/and (7) to an inability to experience positive emotions such as happiness or loving feelings
Heightened arousal – As seen by two or more of the following (1) aggressive angry outbursts; (2) reckless or self-destructive behavior; (3) hypervigilance; (4) exaggerated startle response; (5) problems concentrating; or/and (6) sleep disturbances
PTSD Specifiers
Those exposed to a traumatic event may not exhibit PTSD features until years afterward – specify “with delayed expression”
This is if the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate)
The person may also experience dissociative symptoms – specify “with dissociative symptoms”
This is when the individual’s symptoms meet the criteria for POST, and the individual experiences persistent or recurrent symptoms of either of the following:
Depersonalization: persistent or recurrent experiences of feeling detached from and as if one were an outside observer of one’s mental processes or body
Derealization: persistent or recurrent experiences of unreality of surroundings
The case of Buddy Jackson in the texts illustrates someone who experienced a delayed onset of PTSD
Acute Stress Disorder (ASD)
ASD looks a lot like PTSD but emphasizes the severe reaction that some people have within the first month immediately following a trauma — ASD includes any 9 of 14 symptoms in the following categories:
Intrusion – As seen by: (a) recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: Children may engage in repetitive play where themes or aspects of traumatic event(s) are communicated.) (b) the content and/or affect of recurrent, distressing dreams related to traumatic event(s); (c) dissociative reactions such as flashbacks and these reactions can range on a continuum with the most extreme reaction being a complete loss of awareness of one’s surroundings (Note: Children may reenact trauma-specific themes in play.); (d) intense or prolonged reactions (either psychological or physiological) in response to cues that resemble (or may symbolize) an aspect of the traumatic event(s)
Negative mood – Persistent inability to experience positive emotions such as happiness, satisfaction or loving feelings
ASD Symptom Categories Continued
Dissociation – Understood as (a) an altered sense of reality of one’s surroundings or oneself much like being in a daze or time has slowed or seeing oneself from another’s perspective, or (b) being unable to remember important features of the traumatic event(s) and typically not due to dissociative amnesia or a head injury, alcohol or drug use
Avoidance – Considered to be (a) efforts to avoid distressing memories, thoughts or feeling about (or closely associated with) the traumatic event(s), and (b) trying to avoid external reminders such as avoiding people, ;laces, conversations, activities or situations that provoke distressing memories, thoughts or feelings about (or closely associated with) the traumatic event(s)
Arousal – Regarded as (a) sleep disturbances, (b) irritability or angry outbursts typically seen as verbal or physical aggression toward others or objects, (c) hypervigilance, (d) difficulty concentrating, (e) an exaggerated startle response
The following case of Louise Ann Brown in the text illustrates acute stress disorder
The Adjustment Disorders
Adjustment disorders generally occur as a reaction to a life-threatening event and tend to last longer – assessing for adjustment disorders includes:
Distress is out of proportion to the severity or intensity of the stressor(s)
Once the stressor or its consequences have ended, symptoms do not persist for more than an additional 6 months
Consider 6 of the following specifiers:
With depressed mood – low mood, tearfulness, or feelings of hopelessness are prevalent;
With anxiety – nervousness, worry, jitteriness, or separation anxiety are predominant;
With mixed anxiety and depressed mood – a combination of depression and anxiety;
With disturbance of conduct – when disturbed conduct is predominant;
With mixed disturbance of emotions and conduct – both emotional symptoms (such as depression, anxiety) and a disturbance of conduct are present; and
Unspecified – for maladaptive reactions that are not seen as one of the specific subtypes of adjustment disorder
Jeannette Hutton in the text illustrates symptoms of an adjustment disorder
Differences between AD & PTSD (Brown, 2019)
Stressor: common stressors in AD are changes in life events that are significant such as sickness, unemployment, and moving; PTSD triggers are more serious events related to sexual violence, serious injury, etc.
Duration: AD manifests w/in 3 months of onset and should not last more than 6 months whereas PTSD symptoms last for more than a month and delayed expression can occur
Symptoms: AD symptoms are less intense and not as frequent; PTSD symptoms are more intense, intrusive, and distressing
Other Specified (and Unspecified) Trauma- and Stressor-Related Disorders
Specified trauma- and stressor-related disorder – applies when the person’s symptom picture does not meet full criteria for any of the disorders in this chapter
The practitioner can communicate the reason the person’s symptom presentation does not meet criteria; some examples are included in the text
Unspecified trauma- and stressor-related disorder – applies to those who present with symptoms characteristic of a trauma- and stressor-related disorder and used in situations when the practitioner elects not to specify the reason that diagnostic criteria
Comparing the DSM-IV-TR Multiaxial System and the DSM-5
Obsessive-compulsive and related disorders is a new DSM-5 chapter which includes 4 new disorders – hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition
Trichotillomania (hair-pulling disorder) was moved from “impulse-control disorders not elsewhere classified” in the DSM-IV to the DSM-5 classification as an obsessive-compulsive disorder
A specifier was expanded and added to body dysmorphic disorder and hoarding disorder- good or fair insight, poor insight, and absent insight/delusional (or when the person is convinced that the obsessive-compulsive disordered beliefs are true)
Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may surface with perceived defects of flaws in physical appearance
The specifier “with obsessive-compulsive symptoms” moved from the anxiety disorders to the DSM-5 category of obsessive-compulsive and related disorders
Two additional diagnoses – (1) other specified obsessive-compulsive and related disorder which applies when diagnostic criteria are not met but the practitioner can stipulate reasons why, and (2) unspecified obsessive-compulsive and related disorder used when there is insufficient information to make a diagnosis
