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Abnormal Psych

Terms in this set (51)

• Massive undertaking
• Involving hundreds of people - in medical, scientific and clinical fields - that were divided into 13 working groups representing expertise in their respective areas to draft diagnostic criteria. Supported by APA research staff.
• Work groups charged with the responsibility to review the entire research literature surrounding a diagnostic area, including old, revised and new diagnostic criteria in an intensive 6-year period.
• Over 12-year process
• Especially in the creation of new features believed to be more useful to clinicians
• Goal: to enhance clinical usefulness
• Reliable diagnoses important for guiding treatment goals, identifying prevalence rates, identifying client bases for trials and research, and documenting public health information such as morbidity and mortality rates.
• Focus: on characteristics of specific disorders and their implications for research and practice.
• Substantial progress in reliability but mental health continues to evolve. However, over past two decades substantial progress has been seen in cognitive neuroscience, brain imaging epidemiology, and genetics.
• Provides a guide to identify the most prominent symptoms that should be assessed when diagnosing a disorder. - with the understanding that boundaries between disorders are more porous than originally thought.
• DSM is a medical classification of disorders and works in conjunction with the ICD (International classification of Disorders - now in revision for its 10 revision).
• Often DSM and ICD-10 diagnoses are not in agreement.
• DSM V and ICD 11 - tried to rectify this by using a shared organizational structure, framework - to create a more harmonious agreement between the two.
• Both tried to enhance clinical useability by adding co-morbidity, organizational structure, and providing possible physiological causes for the disorder
• Tries to create a common language for communication to a variety of clinicians about the diagnosis of disorders.
• Description of disorders is based on current research and may have to be modified as new research results are improved.

Difficulty: speculative results do not belong in an official nosology, but at the same time it has to evolve in the context ongoing clinical research

Recognized that a too-rigid categorical system does not capture clinical experience or important scientific observations. Long observed that the boundaries between many disorder categories are more fluid over life course that DSM IV recognized, and many symptoms assigned to one category may also be part of other categories but in less or more severe forms.

This means that DSM, like other medical disease classifications, should accommodate ways to introduce dimensional approaches to mental diseases, that even cut across current categories (this should increase a validity of a diagnosis).
It includes several different categories that may be helpful for the clinician:
Diagnosis itself
• Uses an Operationalized sets of criteria
• Diagnoses themselves have been re-ordered and re-grouped
• Subjected to scientific review
• Undergone field testing for interrater reliability
• Is a medical classification of disorders
• Creates a common language for communication between clinicians about the diagnoses of disorders
• Challenges - high rate of comorbidity
Excessive use and reliance on NOS (not otherwise specified) categories
Associated features supporting diagnosis
• Helpful to view disorders using a dimensional approach, rather than narrow categories as in previous DSM's, including medical risk factors and components
• Clustering disorders around externalizing and internalizing factors was helpful and provided an empirically supported framework
• Internalizing group representing disorders with prominent anxiety, depressive, and somatic symptoms
• Externalizing - representing disorders with prominent impulsive, disruptive conduct, and substance abuse symptoms)
• Present organizational structure is meant to serve as a bridge to new or clearer diagnostic approaches as new research findings become clearer.
Prevalence
Numbers of people suffering each disorder (mainly stats from USA)
Development and course
• Begins with diagnoses thought to reflect developmental processes that manifest early in life (e.g. neurodevelopmental, schizophrenia spectrum and other psychotic disorders)
• Followed by ones that manifest in adolescence or young adulthood(e.g. bipolar, depressive, and anxiety disorders)
• Ends with diagnoses relevant to adulthood and later life (e.g. neurocognitive disorders)
• Facilitates the comprehensive use of lifespan information as a way to assist in diagnostic decision making.
Risk and prognostic factors
Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behavior that are criteria for diagnosis.
Therefore diagnostic assessment must consider a person's symptoms differ from particular sociocultural norms. Boundaries between pathology and normality vary across cultures for specific types of behaviors.
Historically, the concept of the culture bound syndrome has been a key interest of cultural psychiatry. In DSM-5, this construct has been replaced by three concepts that offer greater clinical utility:
1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context {e.g., ataque de nervios). The syndrome mayor may not be recognized as an illness within the culture {e.g., it might be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group {e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress {e.g., ku.fungisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress {e.g., maladi moun). Causal explanations may be salient features of folk classifications of disease used by laypersons or healers.
A. Marked fear or anxiety about a specific object or situation {e,g., flying, heights, animals,
receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more,
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in Social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms {as in agoraphobia); objects or situations related to obsessions {as in obsessive-compulsive disorder); reminders of traumatic events (as in Posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations {as in social anxiety disorder).
Specify if: Code based on the phobic stimulus:
Animal (e.g., spiders, insects, dogs),
Natural environment (e.g., heights, storms, water).
Blood-injection-injury (e.g" needles, invasive medical procedures; fear of blood; other medical care; or fear of injections and transfusions, fear of injury)
Situational (e.g., airplanes, elevators, enclosed places, Other {e,g., situations that may lead to choking or vomiting,
Specific Phobia:
• Persistent, excessive, unreasonable fear triggered by the presence of a specific object or situation
• Examples: of other species (snakes, spiders), aspects of the environment (high places, water), or situations (airplanes or elevators), blood-injection-injury.
• When confronted with the situation - show an immediate fear response, often like a panic attack, but with a clear trigger.
A. Marked fear or anxiety about one or more social situations in which the individual is possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking) or performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection, or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:
Performance only: If the fear is restricted to speaking or performing in public.
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or "going crazy."
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy").
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviour designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).
Diagnostic features
• Frequency varies widely
• Worries about panic attacks usually center around physical concerns, e.g. may reflect a life-threatening illness, social concerns (embarrassment, fear of judgement), and concerns about mental functioning, such as "going crazy".
• Maladaptive behaviour changes occur as a means to avoid panic attacks - but restrict everyday activities instead.
• If agoraphobia is present, both diagnoses need to be made.
Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., "posttraumatic stress disorder with panic attacks"). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or "going crazy."
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. "
A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder-for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.
A. Excessive anxiety and worry {apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities {such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three {or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance {difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition {e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder {e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
There are three aspects to Panic Control Treatment. First, clients are taught about the nature of anxiety and panic and how the capacity to experience both is adaptive. By learning about the nature of the fight-or-flight response experienced during panic, clients come to understand that the sensations they experience during panic are normal and harmless. Clients are also taught to self-monitor their experiences with anxiety and panic through daily diaries.

The second part of treatment involves teaching people with panic disorder to control their breathing. First they are asked to hyperventilate, or over breathe. Hyperventilation is known to create a variety of unpleasant physical sensations (such as lightheadedness, dizziness, and tightness of the chest) that often occur during panic attacks. (You can see this for yourself by breathing very fast and deeply for 1 to 2 minutes.) By then learning how to control their breathing, they master a new coping tool that will reduce the likelihood that they themselves will create some of the symptoms they are so frightened of.

Third, clients are taught to identify their own automatic thoughts they have during panic attacks, as well as during anxiety-provoking situations. They are then taught about the logical errors that people who have panic are prone to making and learn to subject their own automatic thoughts to a logical reanalysis. For example, a person who fears having a heart attack at the first sign of heart r palpitations is asked to examine the evidence that this might be true. (When did the doctor last tell him that his heart was perfectly healthy? What is the likelihood of having a heart attack at age 30?) In later sessions the cognitive part of the treatment is focused on teaching people how to decatastrophize -that is, to learn how to think through what the worst possible outcome might be if they did have a panic attack (e.g., if they had a panic attack while driving, they might have to pull their car over to the side of the road until the attack subsided). The entire experience of panic usually becomes less terrifying once they learn to decatastrophize.

Finally, another part of the treatment involves expo- sure to feared situations and feared bodily sensations.
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder. (?Tourettes)
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Specify if:
With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.
Specify if:
Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., "I look ugly" or "I look deformed").
With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.
When a person is overwhelmed by terror and helplessness, "the whole apparatus for concerted coordinated and purposeful activity is smashed (Herman)
Three main categories:

Hyperarousal:
• Overwhelmed by stimuli - not able to filter out dangerous stimuli from the merely annoying.
• Body remains on high alert - autonomic nervous system is in chronic arousal; sympathetic nervous system is in chronic stimulation. Body has no resting phase, either awake or asleep.
• Startle easily, respond to daily events as dangerous, become explosive quickly, are easily irritated, and remain in a state of hypervigilance.

Intrusion:
• Memory of trauma encoded abnormally - intrudes into waking memory and sleep involuntarily and repetitively.
• Safe environments feel dangerous scared to encounter a reminder of the trauma.
• Feel impelled to re-create the trauma, consciously or unconsciously; attempt to integrate this into lives.
• Re-enactments appear involuntary - "fixated on the trauma" (Freud) even though want to move on with lives.
• Interferes with normal course of development - continues long after the experience.
• Experiences the event as if it were happening in the present.
• Nightmares "often include fragments of the event in exact form" - quality of immediacy.
• Encoded as indelible image/vivid sensation - can only be re-enacted in behaviour, rather than verbal narrative.
• Live in tension between compulsively re-enacting the event and at the same time trying to avoid re-living it.

Constriction of self:
• Shutting down of self/alteration in sate of consciousness.
• Numbing, trance, or dissociation
• Changes in perception - event is happening to someone else;
• Alteration of time sense - events are happening in slow motion;
• Changes in self-defence system - actions are replaced by detached calm and 'voluntary surrender'.
• Protect victim against conscious experience of unbearable pain - pain held in body and mind split off from consciousness.
• Symptoms - difficult to treat.
• Ensures trauma remains walled off from awareness - prevents integration.
• Restrictiveness often mistaken for characteristics of the personality- not the result of trauma.
• Cause an increase in magical and superstitious thinking - interferes with ability to plan for future - loss of self confidence and trust of oneself.
Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) 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 event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), be- ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically ex- pressed 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 disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms: The individual's symptoms meet the criteria for post- traumatic stress disorder, and in addition, in response to the stressor, the individual ex- periences persistent or recurrent symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxica- tion) or another medical condition (e.g., complex partial seizures).
Specify if: With delayed expression: 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).
Posttraumatic Stress Disorder for Children 6 Years and Younger (not dealt with here)
Diagnostic features
• Women are twice as likely as men to develop TSD
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: 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 event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse).
Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of nine (or more} of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:
Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s} are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in re- sponse to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Dissociative Symptoms
6. An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury , alcohol, or drugs).
Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely asso- ciated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, ob- jects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically ex- pressed as verbal or physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response .
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.
Diagnostic Features
• The essential feature of acute stress disorder is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events.
A. The development of emotional or behavioral symptoms in response to an identifiable
stressor(s) occurring within 3 months of the onset of the stressor(s).
B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
2. 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.
Specify 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: A combination of depression and anxiety is predominant.
With disturbance of conduct: Disturbance of conduct is predominant.
With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.
Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder.
• More stable and better-integrated a personality and more favorable a person's life situation, more quickly he/she will recover from a severe stress reaction. Resilient Personality (e.g. journalist Alan Johnson)
• Effectiveness of brief therapy - found that treatment immediately following the traumatic event significantly reduced the PTSD symptoms.
Short Term Model (5 steps - interchangeable)
• Time limited - 4-6 weeks (gives hope that they won't be a basket case forever)
• Give clients some introduction to trauma and what it is
1. Retelling the story- allows catharsis.
• Very important to get into the sensory aspects
• Tell story in as much detail as possible esp. the horror of it.
• Primary goal - to accompany person through the trauma
• Breaking the isolation - do not have to deal with this on your own (core feature of trauma is isolation)
• Thoughts/feelings during the incident - "What were you thinking? What was worst moment?" (empowers)
• Doing nothing is doing something - it is often what has helped them to survive - did the best they could
• Ask about feelings: "How did you feel when...happened? What did they feel in their bodies
• Try to them fill in the memory gaps. In traumatic situations - tunnel vision
• Don't focus too much on feeling (need both containment and their defenses) - focus on meaning and mastery.
2. Normalizing
• Do not normalize too soon
• Prepare patient for what might happen - physiological and psychological symptoms, flight or fight response, arousal
• Emphasize that it will take time but they will get better, but that there always might be triggers.
3. Reframing
• Stress the survivor status
• They are here to tell you the story because they have lived to tell the tale.
• "How do you think you dealt with the situation? (knowing what you know now)
• "If you were in the situation again would you do it differently?" - survivor guilt
• Separate the intent through actual behavior through shock
• Victim feels disempowered - probe for what they did.
• What would you tell someone now how to survive (very often realize did what they could and would/could do nothing different)
• Help clients to express anger and revenge fantasies
• Relaxation techniques - very important
4. Mastery
• Humor
• Relaxation
• History of things that make them feel good - do one a day. Need to look after themselves more not less
• Restore balance and harmony. In trauma things get out of balance - but the things you enjoy are still there - need to re-connect.
• Nurture self
• Check out how they coped before
• Use support systems, even organizations
• Planting things, creating, rebuilding
• Avoid medication only without the therapy - if anesthetized nothing new is learnt and no future mastery.
5. Meaning
• Try to find some meaning -"I can help others who have been through this experience"
• "If this hadn't happened, then I wouldn't have realized that..."
Anxiety in the functioning of the normal personality.
• Anxiety is a painful emotional experience which is produced by excitations in the internal organs of the body.
• Excitations result from internal or external stimulation and are governed by the autonomic nervous system.
• Anxiety differs from other painful states, such as tension, pain, and melancholy by some specific quality of consciousness.
• First part of Freud's new theory:
(1) Anxiety develops automatically whenever the psyche is overwhelmed by an influx of stimuli (external or internal) too great to be mastered or discharged (most frequently arise from id).
(3) When anxiety develops automatically - is traumatic (prototype = birth).
(5) Automatic anxiety is characteristic of infancy - weakness and immaturity of the ego at that time of life (adult life in cases of so-called actual anxiety neurosis)
Second part of the new theory:
(6) In the course of growth, the young child learns to anticipate the advent of a traumatic situation (produced by danger or anticipation of) and reacts with anxiety before it becomes traumatic = signal anxiety.
(8) Arises out of ego - mobilizes ego to meet or to avoid the impending traumatic situation.
(8) There is a characteristic set or sequence of danger situations in early and later childhood which persist as such to a greater or less degree throughout life unconsciously.
(10) Signal anxiety is a reduced form of anxiety, and plays a great role in normal development.
Typical danger situations that may occur in sequence in the child's life.
• Separation from a person who is important to the child as a source of gratification - "loss of the object, or as 'loss of the loved object" (0-2 yrs)
• Loss of love of a person in its environment i.e. even though the person is present, the child may fear the loss of its love - the "loss of the object's love. ( 2 and 21/2 - 3 years)
• Guilt, or disapproval and punishment by the superego. (5-6 years)
• Persist to some degree throughout life unconsciously - neurotic patients - to an excessive degree.
• Function of anxiety is by no means pathological in itself - it is a necessary part of mental life and growth.

Different Types of Anxiety: These three types of anxiety do not differ among themselves in quality - all are unpleasant. They differ only in respect to their sources.
• Reality anxiety - source of the danger lies in the external world (fear of the external world).
• Neurotic anxiety - threat resides in an instinctual object-choice of the id - person is afraid of being overwhelmed by an uncontrollable urge to commit some act or think some thought which will prove harmful to him/herself (fear of the id).
• Moral anxiety - source of the threat is the conscience of the superego system - afraid of being punished by the conscience for doing or thinking something which is contrary to the standards of the ego-ideal (fear of the superego).
However,
• Person who is experiencing anxiety is not aware of its actual source - blend of two/ three.
• Sole function - to act as a danger signal to the ego so that when conscious, the ego can deal with the danger.
• Anxiety is painful, but serves a necessary function by alerting a person to the presence of internal and external dangers. Being alerted he can do something to ward off or avoid the danger.
• On the other hand if the danger cannot be averted anxiety may pile up and finally overwhelm the person - nervous breakdown.