The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of changes to post-traumatic stress disorder (PTSD), trauma and stress-related disorders, as well as reactive attachment disorders. This article outlines some of the major changes to these conditions.
According to the American Psychiatric Association (APA), the publisher of the DSM-5, there are some significant changes in this category from the diagnostic criteria that appeared in the previous edition, DSM-IV. These include changes to PTSD criteria, acute stress disorder, adjustment disorders, and reactive attachment disorder, a childhood concern.
Posttraumatic Stress Disorder (PTSD)
Post-traumatic stress disorder undergoes some major changes in the DSM-5. For example, the first criteria is far more explicit in what constitutes a traumatic event. “Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders,” notes the APA. “Language stipulating an individual’s response to the event — intense fear, helplessness or horror, according to DSM-IV — has been deleted because that criterion proved to have no utility in predicting the onset of PTSD.” So goodbye to the current Criterion A2 from the DSM-IV.
Instead of three major symptom clusters for PTSD, the DSM-5 now lists four clusters:
- Re-experiencing the event — For example, spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress.
- Heightened arousal — For example, aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-
vigilance or related problems.
- Avoidance — For example, distressing memories, thoughts, feelings or external reminders of the event.
- Negative thoughts and mood or feelings — For example, feelings may vary from a persistent and distorted sense of
blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
PTSD Preschool Subtype
DSM-5 will include the addition of two new subtypes. The first is called PTSD Preschool Subtype, which is used to diagnose PTSD in children younger than 6 years. Post-traumatic stress disorder is also now developmentally sensitive, meaning that diagnostic thresholds have been lowered for children and adolescents.
PTSD Dissociative Subtype
The second new PTSD subtype is called PTSD Dissociative Subtype. It is chosen when PTSD is seen with prominent dissociative symptoms. These dissociative symptoms can be either experiences of feeling detached from one’s own mind or body, or experiences in which the world seems unreal, dreamlike or distorted.
Acute Stress Disorder
Acute stress disorder in the DSM-5 has been updated in ways similar to the PTSD criteria, for consistency’s sake. That means the first criteria, Criterion A, “requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly.”
Also, according to the APA, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) has been eliminated. This criteria appeared to have little diagnostic utility.
Based on evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on dissociative symptoms is overly restrictive, individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal.
Adjustment disorders are reconceptualized in the DSM-5 as a stress-response syndrome. This takes them out of their residual, catch-all category and places them into a conceptual framework that these disorders represent a simple response to some type of life stress (whether traumatic or not).
This category of disorders remains a place to diagnose a person who doesn’t otherwise meet the criteria for another disorder in the DSM-5, such as a person who doesn’t meet the full criteria for major depression. The subtypes — depressed mood, anxious symptoms, or disturbances in conduct — from the DSM-IV remain the same for the DSM-5.
Reactive Attachment Disorder
Reactive attachment disorder is subdivided into two distinct disorders in the DSM-5, based upon the DSM-IV subtypes. So we now have reactive attachment disorder which is separate from disinhibited social engagement disorder.
According to the APA, “Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments. Although sharing this etiological pathway, the two disorders differ in
important ways.” The two disorders differ in many ways, including correlates, course, and response to intervention.
Reactive Attachment Disorder
The APA suggests that reactive attachment disorder more “closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults.” In reactive attachment disorder, there is a dampened positive affect — the child expresses joy or happiness in a very subdued or restrained manner.
Disinhibited Social Engagement Disorder
The APA further suggests that disinhibited social engagement disorder more closely resembles ADHD: “It may occur in children who do not necessarily lack attachments and may have established or even secure attachments.”