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Trauma- and Stressor-Related Disorders DSM-5

Dr. Christine Chasek LIMHP, LADC, NCC

Trauma- and Stressor-Related Disorders

! What are Trauma- and Stressor-Related Disorders? ! New Category

! Criteria for specific Trauma- and Stressor-Related Disorders

! Treatment

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+What are Trauma- and Stressor- Related Disorders ? !  Include disorders in which exposure to a traumatic or

stressful event is listed explicitly as a diagnosis criterion.

!  The disorders include: !  Reactive Attachment Disorder !  Disinhibited Social Engagement Disorder !  Posttraumatic Stress Disorder !  Acute Stress Disorder !  Adjustment Disorders

+ Attachment Disorders

! In Infancy or Early Childhood: a pattern of disturbed or developmentally inappropriate attachment behaviors

There were two subtypes in DSM-IV-TR that are now defined as distinct disorders in DSM-5: 313.89 (F94.1) Reactive Attachment Disorder 313.89 (F94.2) Disinhibited Social Engagement Disorder This is a result of how different the disorders manifest themselves and the different responses to intervention that have been found to occur

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+Posttraumatic Stress Disorder pg 271 !  309.81 (F43.10) Posttraumatic Stress Disorder

!  ~Many changes in this disorder~

!  The stressor criterion is explicit in whether the individual experienced the trauma directly, indirectly, or witnessed the event.

!  The criteria regarding the person’s subjective reaction has been eliminated

!  There are 4 symptoms clusters now rather than 3: !  1) Re-experiencing, 2) Avoidance, 3) Persistent Negative Alterations in

Cognitions and Mood, 4) Arousal and Reactivity

!  Divided into two categories: Adults, Adolescents, and Children over 6; Children Under 6

!  Specify whether there are dissociative symptoms: !  Depersonalization

!  Derealization

And Delayed Expression

+Acute Stress Disorder pg 280

308.3 (F43.0) Acute Stress Disorder

The stressor criterion is explicit in whether the individual experienced the trauma directly, indirectly, or witnessed the event which includes exposure to actual or threatened death, serious injury, or sexual violation.

*Does not however include exposure through electronic media, television, movies, or pictures.

Must include the presence of any 9 of the 14 criteria listed in B in the categories of Intrusion Symptoms, Negative Mood, Dissociative Symptoms, Avoidance Symptoms, Arousal Symptoms. Duration of symptoms is between 3 days to 1 month after the trauma.

**The criteria regarding the person’s subjective reaction has been eliminated: ie “the person’s responses involved intense fear, helplessness, or horror”

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+Adjustment Disorders pg 286 The Diagnosis number is determined by the specifier (see page 287)

!  Re-conceptualized as an array of stress-response syndromes that occur after exposure to a distressing event- either traumatic or non-traumatic; need to be able to identify the stressor

!  The development of emotional or behavioral symptoms in response to an identifiable stressor occurring with 3 months of the onset of the stressor

!  The symptoms are significant as evidenced by !  Marked distress that is out of proportion to the severity of intensity of the stressor !  Significant impairment in social, occupational, or other important areas of functioning

!  Criteria is not met for any other mental disorder

!  The symptoms do not represent normal bereavement

!  The symptoms do not persist for more than 6 months after the stressor is terminated

!  Criteria and subtypes are unchanged.

+“Other” Trauma- Stressor Related Disorders

! Other Specified Trauma- and Stressor-Related Disorder pg 289 ! 309.89 (F43.8) ! Clinician Specifies a

reason for the diagnosis

! Unspecified Trauma- and Stressor-Related Disorder pg 290 ! 309.9 (F43.9) ! No reason specified

by the clinician

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+Assessments / Screenings !  The military has devoted many resources to assessing,

screening, and treating PTSD

!  http://www.ptsd.va.gov/professional/assessment/screens/index.asp

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! Medications

! Psychotherapy: ! Cognitive-behavioral therapy (CBT) ! Exposure Therapy (*Prolonged Exposure Therapy) ! Cognitive Restructuring ! Stress Inoculation Training

! Other ! Trauma Informed Care ! Neurocognitive Therapy ! Intensive Trauma Therapy

Trauma- and Stressor-Related Disorders Treatment

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Dissociative Disorders DSM-5

Dr. Christine Chasek LIMHP, LADC, NCC

+! What are the Dissociative Disorders?

!  Major changes in this category.

!  Derealization is now included in the name and structure of the depersonalization disorder and is now called Depresonalization/Derealization Disorder

!  Dissociative Fugue is now a specifier of Dissociative Amnesia rather than a separate disorder

!  Criteria for Dissociative Identity Disorder have been changed to indicate that symptoms of disruption to identity can be reported as well as observed; may also occur in everyday events not just traumatic ones

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+Diagnosis included in this category of disorders:

! Dissociative Identity Disorder

! Dissociative Amnesia

! Depersonalization/Derealization Disorder

! Other Specified Dissociative Disorder

! Unspecified Dissociative Disorder

+ 300.14 (F44.81) Dissociative Identity Disorder pg 292-298

!  Characterized by the presence of two or more distinct personality states or an experience of possession and recurrent episodes of amnesia. This is what Sybil suffered from. Remember Sybil??

!  Changes~ !  the inclusion of certain possession-form phenomena

and functional neurological symptoms have been added to account for a more diverse presentation of the disorder.

!  The transitions in identity may be observable by others or self-reported

!  Gaps in recall may occur in in everyday events not just traumatic ones

!  Kim Noble is a modern day woman with many Personalities; she was featured on Oprah; look her up- Fascinating! We have come a long way with treatment.

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+300.12 (F44.0) Dissociative Amnesia

pg. 298-302 !  Characterized by an inability to remember autobiographical

information; it is more than just being forgetful. These individuals lose time and can’t remember things about the self.

!  Need to assess for and code Dissociative Fugue: purposeful travel or bewildering wondering; this is coded 300.13 (F44.1) Dissociative Amnesia, with dissociative fugue

This disorder is the “plot” of 50 First Dates

+300.6 (F48.1) Depersonalization/Derealization Disorder pg 302-306 !  The essential feature of this disorder is experiences of

unreality or detachment from one’s mind, self, or body or surroundings; however the person does have intact reality testing.

!  Either one or both can be present for this diagnosis to be made.

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+Other and Unspecified Dissociative Disorder pg306-307

!  300.15 (F44.89) Other Specified Dissociative

Disorder

!  Used when there is evidence of Dissociative disorder criteria that causes significant distress but does not meet all the required criteria for a specific dissociative or other related disorder

!  Clinician describes the reasons for this diagnosis

!  300.15 (F44.9) Unspecified Dissociative

Disorder

!  Used when there is evidence of dissociative disorder criteria that causes significant distress but does not meet all the required criteria for a specific dissociative or other related disorder but the clinician does NOT want to describe the reasons for this diagnosis

+Treatment ! This class of disorders requires specialized

training in order to be effective as a clinician

! Psychotherapy: ! Cognitive-behavioral therapy (CBT)

! Medication ! There is no specific medication for dissociative

disorder, the medication is used to treat the symptoms related to the disorder such as depression

! Other ! Art Therapy ! Hypnosis ! Eye Movement Desensitization (EMDR)

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Feeding and Eating Disorders DSM-5

Dr. Christine Chasek LIMHP, LADC, NCC

+Feeding and Eating Disorders !  What are the Eating and Feeding Disorders?

!  Previously call Eating Disorders

!  Includes several feeding and eating disorders that were included in the DSM-IV-TR in the Disorders First Diagnosed in Infancy, Childhood, and Adolescence.

!  Characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption of or absorption of food that significantly affects physical health or psychosocial functioning.

!  This chapter is greatly expanded from DSM-IV-TR

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+Diagnoses included in this Disorder: ! Pica

! Rumination Disorder

! Avoidant/Restrictive Food Intake Disorder

!  Anorexia Nervosa

! Bulimia Nervosa

! **Binge-Eating Disorder

! Other Specified Feeding or Eating Disorder

! Unspecified Feeding or Eating Disorder

+Eating Disorders !  Characterized by severe disturbances in eating behavior

!  307.1 (the ICD-10 code depends on the subtype) Anorexia Nervosa !  Criteria are largely unchanged from DSM-IV-TR; however the

amenorrhea criteria has been eliminated and more clarity has been provided for some of the other criteria.

!  307.51 (F50.2) Bulimia Nervosa

!  The only change in criteria is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behaviors from twice weekly to once weekly.

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+New Disorder Alert!!! !  307.51 (F50.8) Binge Eating Disorder pg 350-353

!  This has been researched extensively and was in the Appendix of DSM-IV-TR

!  Criteria: recurrent episodes of binge-eating that must occur on average at least once per week for 3 months

!  An episode of binge-eating is defined as eating in a discrete period of time an amount of food that is definitely larger than most people would eat in a similar time under similar circumstances

!  Must be accompanied by a sense of lack of control

!  Must not be any “compensatory” behaviors to rid body of the food (this is bulimia criteria)

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Personality Disorders DSM-5

Dr. Christine Chasek LIMHP, LADC, NCC

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+! Did the Personality Disorders Change?

Short Answer NO; same as DSM-IV-TR

Now let me tell you the Longer answer…………

+What is a Personality Disorder?

!  10 Specific personality Disorders

!  A Personality Disorder is an: !  enduring pattern of inner experience and behavior that deviates markedly

from the expectations of the individual�s culture; !  is pervasive and inflexible; !  has an onset in early adolescence or early adulthood; !  is stable over time; and !  leads to distress or impairment.

!  From DSM-IV-TR to DSM-5: There was to be a major revision of personality disorders however the research was not conclusive to make a major change. Therefore, more research is needed and is on-going. Personality disorders are also in Section III of the DSM-5.

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+Personality Disorders

!  Paranoid Personality Disorder

!  Schizoid Personality Disorder

!  Schizotypal Personality Disorder

!  Antisocial Personality Disorder

!  Borderline Personality Disorder

!  Histrionic Personality Disorder

!  Narcissistic Personality Disorder

!  Avoidant Personality Disorder

!  Dependent Personality Disorder

!  Obsessive-compulsive Personality Disorder

!  Personality change due to another medical condition

!  Other Specified Personality Disorder and Unspecified Personality Disorder

+ Personality Disorders

!  Cluster A : These individuals often appear odd or eccentric

!  301.0 (F60.0) Paranoid Personality Disorder pg 649: pattern of distrust and suspiciousness

!  301.20 (F60.1) Schizoid Personality Disorder pg 652: detachment from social relationships, restricted range of emotional expression

!  301.22 (F21) Schizotypal Personality Disorder pg 655:acute discomfort in close relationships, cognitive or perceptual distortions, eccentric behavior

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+ Personality Disorders

!  Cluster B : These individuals appear dramatic, emotional, or erratic

!  301.7 (F60.2) Antisocial Personality Disorder, pg 659: disregard for and violation of the rights of others !  https://www.youtube.com/watch?v=0qyCR9tPDgM

!  301.83 (F60.3) Borderline Personality Disorder, pg 663 : pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity

!  301.50 (F60.4) Histrionic Personality Disorder pg. 667: pattern of excessive emotionality and attention seeking

!  301.81(F60.81) Narcissistic Personality Disorder pg. 669: pattern of grandiosity, need for admiration, and lack of empathy

https://www.youtube.com/watch?v=FRTgvq-Wfi4

+ Personality Disorders !  Cluster C : These individuals often appear anxious or fearful

!  301.82 (F60.6) Avoidant Personality Disorder, pg 672 – pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation

!  301.6 (F60.7) Dependent Personality Disorder, pg 675- pattern of submissive and clinging behavior related to an excessive need to be taken care of

!  301.4 (F60.5) Obsessive-Compulsive Personality Disorder, pg 678 - pattern of preoccupation with orderliness, perfectionism, and control

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+ Other Personality Disorders

!  310.1 (F07.0) Personality Change Due to Another Medical Condition pg 682

!  301.89 (F60.89) Other Specified Personality Disorder pg 684

!  301.9 (F60.9) Unspecified Personality Disorder pg 684 !  the personality pattern meets the general criteria for a personality

disorder and traits of several different personality disorders are present, but the criteria for any specific disorder is not met; clinician can choose to specify or not

+Treatment Options !  CBT : Cognitive Behavioral Therapy

!  DBT : Dialectic Behavioral Therapy

!  Medications – some work

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+Other Categories of Mental Disorders Included in DSM-5 !  Sleep Wake Disorders: Provides greater specificity for sleep

disorders to highlight that sleep disorders are needing of their own clinical attention rather than as a part of a medical condition

!  Somatic Symptoms and Related Disorders : Used to be Somatoform Disorders; Hypochondrias has been removed

!  Sexual Dysfunctions: More specification regarding the differences in gender specific sexual dysfunctions have been made

!  Neurocognitive Disorders: Includes the disorders of delirium, dementia, and amnestic disorders; all renamed

!  Paraphilic Disorders: Major changes include specifiers “in a controlled environment” and “in remission”; changed from Paraphilia to Paraphilic Disorders

+Next Steps for DSM 5- What does this mean for you?

Making the Switch : Deciding when and how

THE TIME IS NOW!!!

!  As a group (your practice) decide when to change and have a plan

!  Things to consider that may influence your decision: !  The new ICD-10 will be mandatory 10-1-15.

!  Frequently Asked Questions Document _APA

!  Frequently Asked Questions Value Options

!  Frequently asked Questions Medicaid/Medicare

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+Questions / Wrap Up / Evaluations

! Questions?

! Thank you for coming!!