Trauma- and Stressor-Related Disorders

“CHAPTER 6 Trauma- and Stressor-Related Disorders

“Trauma- and Stressor-Related Disorders Quick Guide to Trauma- and Stressor-Related Disorders Various types of stress and trauma are responsible for the disorders we’ll consider in this chapter. By now, you know the drill: The link indicates where a more detailed discussion begins. Primary Trauma- and Stressor-Related Disorders Reactive attachment disorder. There is evidence of pathogenic care in a child who habitually doesn’t seek comfort from parents or surrogates. Disinhibited social engagement disorder. There is evidence of pathogenic care in a child who fails to show normal reticence in the company of strangers. Posttraumatic stress disorder. These adolescents or adults repeatedly relive a severely traumatic event, such as combat or a natural disaster. Posttraumatic stress disorder in preschool children. Children repeatedly relive a severely traumatic event, such as car accidents, natural disasters, or war. Acute stress disorder. This condition is much like posttraumatic stress disorder, except that it begins during or immediately after the stressful event and lasts a month or less. Adjustment disorder. Following a stressor, an individual develops symptoms that disappear once the cause of stress has subsided. Other specified, or unspecified, trauma- and stressor-related disorder. Patients whose stress or trauma appears related to other presentations may be classified in one of these categories. Other Problems Related to Trauma or Stress Problems related to abuse or neglect. An astonishing number of Z-codes (V-codes in ICD-9) cover the categories of difficulties that arise from neglect or from physical or sexual abuse of children or adults. Separation anxiety disorder. The patient becomes anxious when separated from parent, other attachment figure, or home. INTRODUCTION Another new chapter for the DSMs incorporates certain diagnoses formerly listed as anxiety, developmental, or adjustment disorders. The unifying factor here is that something traumatic or stressful in the patient’s history appears to be at least partly responsible for the symptoms that develop. It is part of a trend toward grouping together patients of any age who have the right mix of symptoms, rather than separating patients by developmental stage. Many diagnoses include statements about what is not causative, but here is the only full DSM-5 section that presumes any etiology at all, let alone one rooted in the psychology of a pathological developmental process. In the instances of reactive attachment and disinhibited social engagement disorders, there must be evidence of pathogenic care; for posttraumatic stress disorder (PTSD) and its cousins, a horrific event; for adjustment disorder a stressful—well, stressor. The respective criteria sets permit us to check off the fulfilled criteria and go on our way, perhaps thinking that we’ve solved the puzzle. While we rejoice that we’ve successfully determined a cause–effect relationship, nagging at the back of our minds must be a sense that there is more to the story. Otherwise, why do some people become symptomatic while others, exposed to the (as nearly as we can tell) exact same stimulus, go untrammeled on their way? Furthermore, studies have demonstrated that, sooner or later, significant stressors will visit the majority of us. Shouldn’t we conclude that the stimulus in question is necessary, but not sufficient, for the outcome observed? At least this DSM-5 chapter has herded most of these etiology-specific diagnoses into one corral, where we can keep a watchful eye on them. F43.10 [309.81] Posttraumatic Stress Disorder Many people who survive severely traumatic events will develop PTSD. Survivors of combat are the most frequent victims, but it is also encountered in those who have experienced other disasters, both natural and contrived. These include rape, floods, abductions, and airplane crashes, as well as the threats that may be posed by a kidnapping or hostage situation. Children can have PTSD as a result of inappropriate sexual experience, whether or not actual injury has occurred. PTSD can be diagnosed even in those who have only learned about severe trauma (or its threat) suffered by someone to whom they are close—children, spouses, other close relatives. One or two in every 1,000 patients who have undergone general anesthesia have afterwards reported awareness of pain, anxiety, helplessness, and the fear of impending death during the procedure; up to half of them may subsequently develop PTSD symptoms. Implicitly excluded from the definition are stressful experiences of ordinary life, such as bereavement, divorce, and serious illness. Awakening from anesthesia while your surgery is still in progress, however, would qualify as a traumatic event, as would learning about a spouse’s sudden, accidental death or a child’s life-threatening illness. Watching TV images of a calamity would not be a sufficient stressor (except if the viewing was related to the person’s job). After some delay (symptoms usually don’t develop immediately after the trauma), the person in some way relives the traumatic event and tries to avoid thinking about it. There are also symptoms of physiological hyperarousal, such as an exaggerated startle response. Patients with PTSD also express negative feelings such as guilt or personal responsibility (“I should have prevented it”). Aside from the traumatic event itself, other factors may play a role in the development of PTSD. Individual factors include the person’s innate character structure and genetic inheritance. Relatively low intelligence and low educational attainment are positively associated with PTSD. Environmental influences include relatively low socioeconomic status and membership in a minority racial or ethnic group. In general, the more horrific or more enduring the trauma, the greater will be the likelihood of developing PTSD. The risk runs to one-quarter of the survivors of heavy combat and two-thirds of former prisoners of war. Those who have experienced natural disasters such as fires or floods are generally less likely to develop symptoms. (Overall lifetime prevalence of PTSD is estimated at about 9%, though European researchers usually report lower overall rates.) Older adults are less likely to develop symptoms than are younger ones, and women tend to have somewhat higher rates than do men. About half the patients recover within a few months; others can experience years of incapacity. In children, the general outline is pretty much the same as the five general points given in the list of typical symptoms, though the emphasis on symptom numbers differs, as discussed below. Mood, anxiety, and substance use disorders are frequently comorbid. A new specifier reflects findings that in perhaps 12–14% of patients, dissociation is important in the development and maintenance of PTSD symptoms. Essential Features of Posttraumatic Stress Disorder Something truly awful has happened. One patient has been gravely injured or perhaps sexually abused; another has been closely involved in the death or injury of someone else; a third has only learned that someone close experienced an accident or other violence, whereas emergency workers (police, firefighters) may be traumatized through repeated exposure. As a result, for many weeks or months these patients: • Repeatedly relive their event, perhaps in nightmares or upsetting dreams, perhaps in intrusive mental images or dissociative flashbacks. Some people respond to reminders of the event with physiological sensations (racing heart, shortness of breath) or emotional distress. • Take steps to avoid the horror: refusing to watch films or television or to read accounts of the event, or pushing thoughts or memories out of consciousness. • Turn downbeat in their thinking: with persistently negative moods, they express gloomy thoughts (“I’m useless,” “The world’s a mess,” “I can’t believe anyone.”) They lose interest in important activities and feel detached from other people. Some experience amnesia for aspects of the trauma; others become numb, feeling unable to love or experience joy. • Experience symptoms of hyperarousal: irritability, excessive vigilance, trouble concentrating, insomnia, or an intensified startle response. The Fine Print The D’s: • Duration (1+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders [especially traumatic brain injury], mood and anxiety disorders, normal reactions to stressful events) Coding Notes Specify if: With delayed expression. Symptoms sufficient for diagnosis didn’t accumulate until at least six months after the event. With dissociative symptoms: Depersonalization. This indicates feelings of detachment, as though dreaming, from the patient’s own mind or body. Derealization. To the patient, the surroundings seem distant, distorted, dreamlike, or unreal. Barney Gorse “They’re gooks! The place is staffed with gooks!” Someone sitting behind Barney Gorse had dropped a book onto the tile floor, and that had set him off. Now he had backed into a corner in the waiting room of the mental health clinic. His pupils were widely dilated, and perspiration stood out on his forehead. He was panting heavily. He pointed a shaky finger at the Asian student who stood petrified on the other side of the room. “Get this goddamn gook out of here!” He made a fist and lumbered off in the direction of the student. “Hang on, Barney. It’s OK.” Barney’s new therapist took him firmly by the elbow and led him to a private office. They sat there in silence for a few minutes, while Barney’s breathing gradually returned to normal and the clinician reviewed his chart. Barney Gorse was 39 now, but he had been barely 20 when his draft number came up and he joined the Ninth Infantry Division in Vietnam. At that time President Nixon was “winding down the war,” which made it seem all the more painful when Barney’s squad was hit by mortar fire from North Vietnamese regulars. He had never talked about it, even during “anger displacement” group therapy with other veterans. Whenever he was asked to tell his story, he would fly into a rage. But something truly devastating must have happened to Barney that day. The reports mentioned a wound in the upper thigh; he had been the only member of his squad to survive the attack. He had been awarded a Purple Heart and a full pension. Barney hadn’t been able to remember several hours of the attack at all. And he had always been careful to avoid films and television programs about war. He said he’d had enough of it to last everybody’s lifetime; in fact, he had gone to some lengths to avoid thinking about it. He celebrated his discharge from the Army by getting drunk, which was how he remained for 6 years. When he finally sobered up, he turned to drugs. Even they hadn’t been enough to obliterate the nightmares that still haunted him; he awakened screaming several times a week. Sudden noises would startle him into a panic attack. Now, thanks to disulfiram and a chaplain in the county jail where he had been held as a persistent public nuisance, Barney had been clean and sober for 6 months. On the condition that he would seek treatment for his substance use, he had been released. The specialists in substance misuse treatment had quickly recognized that he had other problems, and that had led him here. Last week when they met, the therapist had reminded him again that he needed to dig into his feelings about the past. Barney had responded that he didn’t have any feelings; they’d dried up on him. For that matter, the future didn’t look so good, either: “Got no job, no wife, no kids. I just wasn’t meant to have a life.” He got up and put his hand on the doorknob to leave. “It’s no use. I just can’t talk about it.” Evaluation of Barney Gorse Let’s summarize and restate the criteria that must be fulfilled to diagnose PTSD. 1. There must be severe trauma (criterion A). Barney’s occurred in the context of combat, but a variety of civilian stressors can also culminate in death, serious injury, or sexual abuse. Two features must be present for the stressor to be considered sufficiently traumatic: (a) It must involve the fact or threat of death, severe wounds or injuries, or sexual violation; and (b) it must be personally experienced by the patient in some way—through direct observation (not viewed on TV), through personal involvement, or through information obtained after the fact that it involved a relative or close friend. A first responder (police officer, ambulance attendant) could also qualify through repeated exposure to consequences of the horrific event (think workers at Ground Zero shortly after 9/11). Divorce and death of a spouse from cancer, though undeniably stressful, are relatively commonplace and expected; they don’t qualify. 2. Through some intrusive mechanism, the patient relives the stress. Barney had flashbacks (B3), during which he imagined himself actually back in Vietnam. He also experienced rather intense responses to an external cue (seeing a staff member who, to him, resembled a Viet Cong soldier). Less dramatic forms of recollection include recurrent ordinary memories, dreams, and any other reminder of the event that results in distress or physiological symptoms. 3. The patient attempts (wittingly or not) to achieve emotional distance from the stressful event by avoiding reminders of the trauma. The reminders can be either internal (feelings, thoughts) or external (people, places, activities). Barney refused to watch movies and TV programs or to talk about Vietnam (C). 4. The patient experiences expressions (two or more) of negative mood and thoughts related to the trauma. Barney’s included amnesia for much of his time in combat (D1), a persistently negative frame of mind (“I wasn’t meant to have a life”—D4), and the lack of positive mood states (his feelings had “dried up” on him, D7). 5. Finally, for PTSD, patients must have at least two symptoms of heightened arousal and reactivity associated with the traumatic event. Barney suffered from insomnia (E6) and a severe startle response (E4); others may experience general irritability, poor concentration, or excessive vigilance. As with all symptoms, the clinician would have to determine that these symptoms of arousal had not been apparent before Barney’s Vietnam trauma. Barney’s symptoms had persisted far longer than the required minimum of 1 month (F); were obviously stressful and impaired his functioning in a number of areas (G); and could not be attributed to the direct effects of substance use—now that he’d been clean and sober for half a year (H). The experience of severe trauma in combat and the typical symptoms would render any other explanation for Barney’s symptoms unlikely. A patient with intermittent explosive disorder might become aggressive and lose control, but wouldn’t have the history of trauma. Still, clinicians must always be alert to the possibility of another medical condition (H) that might produce anxiety symptoms and could be diagnosed instead of or in addition to PTSD. For example, head injuries would be relatively common among veterans of combat or other violent trauma; we’d have to mention and code any accompanying brain injury. Situational adjustment disorder shouldn’t be confused with PTSD: The severity of the trauma would be far less, and the effects would be transient and less dramatic. In PTSD, comorbidity is the rule rather than the exception. Barney had used drugs and alcohol; his clinician would have gathered additional information about use of other substances and mentioned them in his diagnostic summary. Of combat veterans who have PTSD, half or more also have a problem with a substance use disorder, and use of multiple substances is common. Anxiety disorders (phobic disorders, generalized anxiety disorder) and mood disorders (major depressive disorder and dysthymia) are likewise common in this population. Dissociative amnesia may also occur. Any coexisting personality disorder would be explored, but it is hard to make a definitive diagnosis when a patient is acutely ill from PTSD. Malingering is also a diagnosis to consider whenever there appears to be a possibility of material gain (insurance, disability, legal problems) resulting from an accident or physical attack. Although the vignette is imprecise on this point, Barney’s symptoms probably began by the time he was discharged from the military, so he would not rate the specifier with delayed onset. The vignette doesn’t provide encouragement to add with prominent dissociation. I’d give him a GAF score of 35. Pending further information on substance use, Barney’s diagnosis would read as follows: F43.10 [309.81] Posttraumatic stress disorder F10.20 [303.90] Alcohol use disorder, moderate, in early remission Z60.2 [V60.3] Lives alone Z56.9 [V62.29] Unemployed There is still considerable controversy over the specifier with delayed expression. Many experts deny that symptoms of PTSD can begin many months or years after the trauma. Nonetheless, it is there to use, should you ever find it appropriate. Posttraumatic Stress Disorder in Preschool Children There can be no doubt that preschool children are sometimes exposed to traumatic events. Mostly, these are car accidents, natural disasters, and war—in short, all the benefits contemporary life has to offer. The question is, do very young children respond with typical PTSD symptoms? The best evidence would seem to indicate that they do, but with a likelihood much lower (0–12%) than for older children. Table 6.1 compares the DSM-5 criteria for PTSD in young children, PTSD in adults, and acute stress disorder (to be discussed next). The revamped criteria for PTSD in young children are, as we would hope, more sensitive to symptoms in this age group. Based on interviews with parents, they yield rates in children who have survived severe burns of 25% and 10% at 1 month and 6 months, respectively. TABLE 6.1. Comparison of PTSD in Preschool Children, PTSD in Adults, and Acute Stress Disorder Child PTSD Adult PTSD Acute Stress Disorder Trauma Direct experience Direct experience Direct experience Witness (not just TV) Witness Witness Learn of Learn of Repeat exposure (not just TV) Learn of Repeat exposure (not just TV) Intrusion symptoms (1/5)a Intrusion symptoms (1/5) All symptoms (9/14) • Memories • Memories • Memories • Dreams • Dreams • Dreams • Dissociative reactions • Dissociative reactions • Dissociative reactions • Psychological distress• Physiological reactions • Psychological distress• Physiological reactions • Psychological distress or physiological reactions Avoid/Neg. emotions (1/6) Avoidance (1/2) • Avoids memories • Avoids memories • Avoids memories • Avoids external reminders • Avoids external reminders • Avoids external reminders Negative emotions (2/7) • Altered sense of reality of self or surroundings • Amnesia • Amnesia • Negative beliefs • Distortion → self-blame • Negative emotional state • Negative emotional state • Decreased interest • Decreased interest • Social withdrawal • Detached from others • Decreased positive emotions • No positive emotions • No positive emotions Physiological (2/5) Physiological (2/6) • Irritable, angry • Irritable, angry • Irritable, angry • Reckless, self-destructive • Hypervigilance • Hypervigilance • Hypervigilance • Startle • Startle • Startle • Poor concentration • Poor concentration • Poor concentration • Sleep disturbance • Sleep disturbance • Sleep disturbance Duration >1 month >1 month 3 days–1 month Purchasers of this ebook can download a copy of this table from www.guilford.com/morrison2-forms. aFractions indicate the number of symptoms required of the number possible in the following list. F43 [308.3] Acute Stress Disorder Based on the observation that some people develop symptoms immediately after a traumatic stress, acute stress disorder (ASD) was devised several decades ago. Even then, this wasn’t exactly new information; something similar was noted as far back as 1865, just after the U.S. Civil War. For many years it was termed “shell shock.” Like PTSD, ASD can also be found among civilians. Overall rates of ASD, depending on the nature of the trauma and personal characteristics of the individual, center on 20%. Though the number and distribution of symptoms is different, the criteria embody the same elements required for PTSD: • Exposure to an event that threatens body integrity • Reexperiencing the event • Avoidance of stimuli associated with the event • Negative changes in mood and thought • Increased arousal and reactivity • Distress or impairment The symptoms usually begin as soon as the patient is exposed to the event (or learns about it), but they must be experienced farther out than 3 days after the stressful event to fulfill the criterion for duration. This gets us to a period of time beyond the stressful event itself and its immediate aftermath. Should symptoms last longer than 1 month, they are no longer acute and no longer constitute ASD. Then many patients will be rolled over into a diagnosis of PTSD. This is the fate of as many as 80% of patients with ASD. However, patients with PTSD don’t usually enter through the ASD doorway; most are identified farther along the road than one month. Essential Features of Acute Stress Disorder Something truly awful has happened—grave injury or sexual abuse, or perhaps the traumatic death or injury of someone else. (It could have come about through learning another has experienced violence or injury, or through repeated exposure for an emergency worker.) As a result, for up to a month the patient experiences many symptoms such as intrusive memories or bad dreams; dissociative experiences such as flashbacks or feeling unreal; the inability to experience joy or other love; amnesia for parts of the event; attempts to avoid reminders of the event (refusing to watch films or television or to read accounts of the event); pushing thoughts or memories out of consciousness. The patient may also experience symptoms of hyperarousal: irritability, hypervigilance, trouble concentrating, insomnia, or an intense startle response. The Fine Print The D’s: • Duration (3 days to 1 month) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders (especially traumatic brain injury), panic disorder, mood disorders, dissociative disorders, PTSD) Marie Trudeau Marie Trudeau and her husband, André, sat in the intake interviewer’s office. Marie was the patient, but she spent most of the time rubbing the knuckles of one hand and gazing vacantly into the room. André did most of the talking. “I just can’t believe the change in her,” he said. “A week ago, she was completely normal. Never had anything like this in her life. Heck, she’s never had anything wrong with her. Then, all of a sudden, boom! She’s a mess.” At André’s exclamation, Marie jerked around to face him and rose half out of her chair. For a few seconds she stood there, frozen except for her gaze, which darted from one side of the room to the other. “Aw, geez, I’m sorry, honey. I forgot.” He put his arm around her. Grasping her shoulders firmly but gently, he eased her back into the chair. He held her there until she began to relax her grip on his arm. A week earlier, Marie had just finished her gardening and was sitting in the back yard with a lemonade, reading a book. When she heard airplane engines, she looked up and saw two small planes flying high overhead, directly above her. “My God,” she thought, “they’re going to collide!” As she watched in horror, they did collide. She could see perfectly. The sun was low, highlighting the two planes brilliantly against the deep blue of the late afternoon sky. Something seemed to have been torn off one of them—the news media later reported that the right wing of one plane had ripped right through the cockpit of the other. Thinking to call 911, Marie picked up her portable phone, but she didn’t dial. She could only watch as two tiny objects suddenly appeared beside the stricken airplanes and tumbled toward her in a leisurely arc. “They weren’t objects, they were people.” It was the first time she had spoken during the interview. Marie’s chin trembled, and a lock of hair fell across her eye. She didn’t try to brush it back. As she continued to watch, one of the bodies hurtled into her yard 15 feet from where she was sitting. It buried itself 6 inches deep in the soft earth behind her rose bushes. What happened next, Marie seemed to have blanked out completely. The other body landed in the street a block away. Half an hour later, when the police knocked on her door, they found her in the kitchen peeling carrots for supper and crying into the sink. When André arrived home an hour after that, she seemed dazed. All she would say was “I’m not here.” In the 6 days since, Marie hadn’t improved much. Although she might start a conversation, something would appear to distract her, and she would usually trail off in midsentence. She couldn’t focus much better on her work at home. Amy, their 9-year-old daughter, seemed to be taking care of her. Sleep had slipped to a restless struggle, and three nights running Marie had awakened from a dream, trying to cry out but managing only a terrified squeak. She kept the blinds in the kitchen closed, so she wouldn’t even have to look into the back yard. “It’s like someone I saw in a World War II movie,” André concluded. “You’d think she’d been shell-shocked.” Evaluation of Marie Trudeau Anxiety and depressive symptoms are nearly universal following a severe stress. Usually these are relatively short-lived, however, and do not include the full spectrum of symptoms required for ASD. This diagnosis should only be considered when major symptoms last 3 days or more after personal exposure to a horrific event. Such an event was the plane crash Marie witnessed (criterion A2). She was dazed (B6) and emotionally unresponsive (B5), and could not recall what had happened during part of the accident (B7). When she could sleep at all (B10), she had nightmares (B2); she also avoided looking into the back yard (B9), startled easily (B14), and even in the interviewer’s office appeared hypervigilant (B12). From her inability to finish conversations, we infer poor concentration (B13), as she was distracted by intrusive recollections of the event (B1). As far as we are aware, she had had none of these symptoms (DSM-5 requires 9 of the 14 symptoms listed in criterion B) prior to witnessing the accident. Since then, just a week earlier (C), she had been unable to carry on with her work at home (D). Would any other diagnosis be possible? According to André, Marie’s previous health had been good, reducing the likelihood of another medical condition (E). We aren’t told whether she used alcohol or drugs, though the fact that she was drinking lemonade at the time of the crash could suggest that she did not. (OK, I’m definitely out on a limb here; her clinician needs to rule out a substance use disorder.) Brief psychotic disorder would be ruled out by the lack of delusions, hallucinations, or disorganized behavior or speech. Patients with ASD are likely to have severe depressive symptoms (“survivor’s guilt”), to the point that a concomitant diagnosis of major depressive disorder may sometimes be justified; Marie deserves further investigation along those lines. Until then, with a GAF score of 61, her diagnosis would be straightforward: F43.0 [308.3] Acute stress disorder Adjustment Disorder Patients with adjustment disorder (AD) may be responding to one stress or to many; the stressor may happen once or repeatedly. If the stressor goes on and on, it can even become chronic, as when a child lives with parents who fight continually. In clinical situations, the stressor has usually affected only one person, but it can affect many (think flood, fire, and famine). However, almost any relatively commonplace event could be a stressor for someone. Those most often cited for adults are getting married or divorced, moving, and financial problems; for adolescents, they are problems at school. Whatever the nature of the stressor, patients feels overwhelmed by the demands of something in the environment. As a result, they develop emotional symptoms such as low mood, crying spells, complaints of feeling nervous or panicky, and other depressive or anxiety symptoms—which must not, however, meet criteria for any defined mood or anxiety disorder. Some patients have mainly behavioral symptoms—especially ones we might think of as conduct symptoms, such as driving dangerously, fighting, or defaulting on responsibilities. The course is usually relatively brief; DSM-5 criteria specify that the symptoms must not persist longer than 6 months after the end of the stressor or its consequences. (Some studies report that a large minority of patients continue to have symptoms longer than the 6-month limit.) Of course, if the stressor is one that will be ongoing, such as a chronic illness, it may take a very long time for the patient to adjust. Although AD has been reported in 10% or more of adult primary care patients, and in huge percentages of mental health patients, one recent study found a prevalence of only 3%; many of these patients were being inappropriately treated with psychotropic medications, and in only two cases had the AD diagnosis been made. The discrepancies probably rest on the rather poorly developed criteria and on the (mistaken) view of AD as a residual diagnosis. AD is found in all cultures and age groups, including children. It may be more firmly anchored in adults than in adolescents, whose early symptoms often evolve into other, more definitive mental disorders. The reliability and validity of AD tend to be quite low. In a recent study, in under two-thirds of patients receiving the clinical diagnosis of AD could it be subsequently confirmed with ICD-10 criteria. Personality disorders or cognitive disorders may make a person more vulnerable to stress, and hence to AD. Patients in whom AD is diagnosed often misuse substances as well. Essential Features of Adjustment Disorder A stressor causes someone to develop depression, anxiety, or behavioral symptoms—but the response exceeds what you’d expect for most people in similar circumstances. After the stressor has ended, the symptoms might drag on, but not longer than 6 more months. The Fine Print The D’s: • Duration (starts within 3 months of stressor’s onset, stops within 6 months of stressor’s end) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (just about everything you can name: substance use and physical disorders, mood and anxiety disorders, trauma-related disorders, somatic symptom disorder, psychotic disorders, conduct and other behavior disorders, milder reactions to life’s stresses, normal bereavement) Coding Notes Specify: F43.21 [309.0] With depressed mood. The patient is mainly tearful, sad. F43.22 [309.24] With anxiety. The patient is mainly nervous, tense, or fearful of separation. F43.23 [309.28] With mixed anxiety and depressed mood. Symptoms combine the preceding. F43.24 [309.3] With disturbance of conduct. The patient behaves inappropriately or unadvisedly, perhaps violating societal rules, norms, or the rights of others. F43.25 [309.4] With mixed disturbance of emotions and conduct. The clinical picture combines emotional and conduct symptoms. F43.20 [309.9] Unspecified. Use for other maladaptive stress-related reactions, such as physical complaints, social withdrawal, work or academic inhibition. Specify if: Acute. The condition has lasted less than 6 months. Persistent (or chronic). 6+ months duration of symptoms, though still not lasting more than 6 months after the stressor has ended. Clarissa Wetherby “I know it’s temporary, and I know I’m overreacting. I sure don’t want to, but I just feel upset!” Clarissa Wetherby was speaking of her husband’s new work schedule. Arthur Wetherby was foreman on a road-paving crew whose current job was to widen and resurface a portion of the interstate highway just a few miles from the couple’s house. Because the section the crew was working on involved an interchange with another major highway, the work had to be done at night. For the past 2 months, Arthur had slept days and gone to work at 8:00 P.M. Clarissa worked the day shift as cashier in a restaurant. Except on weekends, when he tried to revert to a normal sleep schedule so he could be with her, they hardly ever saw one another. “I feel like I’ve been abandoned,” she said. The Wetherbys had been married only 3 years, and they had no children. Each partner had been married once before; each was 35. Neither drank or used drugs. Clarissa’s only previous encounter with the mental health system had occurred 7 years earlier, when her first husband had left her for another man. “I respected his right not to continue living a lie,” she said, “but I felt terribly alone and humiliated.” Clarissa’s symptoms now were much as they had been then. Most of the time when she was at work, she felt “about normal” and maintained good interest in what she was doing. But when alone at home in the evenings, she would be overwhelmed by waves of sadness. These left her virtually immobilized, unable even to turn on the television for company. She often cried to herself and felt guilty for giving in to her emotions. “It’s not as if someone had died, after all.” Although she had some difficulty getting to sleep at night, she slept soundly in the morning. Her weight was constant, her appetite was good, and she had no suicidal ideas or death wishes. She did not report any problems with her concentration. She denied ever having mania symptoms. The previous time she’d sought help, she had remained depressed and upset until a few weeks after the divorce was final. Then she seemed suddenly able to put it behind her and begin dating once again. “I know I’ll feel better, once Arthur gets off that schedule,” she said. “I guess it just makes me feel worthless, playing second fiddle to an overpass.” Evaluation of Clarissa Wetherby As she herself recognized, Clarissa’s reaction to the stress of her husband’s work schedule might be considered extreme by some observers. That is one of the important points of this diagnosis: The patient’s misery seems disproportionate to the apparent degree of the stress that has caused it (criterion B1). Her history provides a clue as to the source of her reaction: She was reminded of that awful time when her previous husband abandoned her—for good, and under circumstances that she considered humiliating. It is important, however, always to consider carefully whether a patient’s reaction occurs as a nonpathological response to a genuine danger, which was not the case with Clarissa. The time course of Clarissa’s symptoms was right for AD: They developed shortly after she learned about Arthur’s new work schedule (A). Although we have no way of knowing how long this episode might last, her previous episode ended after a few months, when the aftermath of her divorce had subsided (E). Of course, bereavement didn’t enter into her differential diagnosis (D). Note that AD is not intended as a residual diagnosis, though it is often used that way. Nonetheless, it does come at the end of a long differential diagnosis that comprises every other condition listed in DSM-5 (C). For Clarissa, the symptoms of mood disorder were the most prominent. She had never been manic, so could not qualify for a bipolar disorder. She had low mood, but only when alone in the evenings (not most of the day). She maintained interest in her work (rather than experiencing loss of interest in nearly all activities). Without at least one of these symptoms, there could not be a diagnosis of major depressive disorder, regardless of her guilt feelings, low energy, and trouble getting to sleep at night. Of course, her symptoms had lasted far less than 2 years, ruling out dysthymia. Although she remained fully functional at work, she was seriously distressed, fulfilling the severity requirement. The question of PTSD (and acute stress disorder) often arises in the differential diagnosis of AD. Each of those diagnoses requires that the stressor threaten serious harm and that the patient react with a variety of responses; Clarissa did not fulfill these conditions. She similarly did not have symptoms that would suggest generalized anxiety disorder, another diagnosis prominent in the differential for AD. A personality disorder may worsen (and hence become more apparent) with stress, but there is no hint that Clarissa had any lifelong character pathology. I’d assign her a GAF score of 61. F43.21 [309.0] Adjustment disorder, with depressed mood, acute Although some data support the utility of AD, which has been used clinically for decades, I recommend reserving it as a diagnosis of “almost last resort.” There are several reasons for this warning. For one thing, we probably too often use it when we simply have no better idea of what is going on. For another, the DSM-5 criteria do not tell us how we are to differentiate ordinary events from those that are stressful enough to cause depression, anxiety, or aberrant behavior. I suspect that an event is singled out solely on the basis that it causes and emotional or behavioral problem, and that seems to me a tad circular. F94.1 [313.89] Reactive Attachment Disorder F94.2 [313.89] Disinhibited Social Engagement Disorder In two apparently rare but extremely serious disorders, children who have been mistreated (by accident or design) respond by becoming either extremely withdrawn or pathologically outgoing. For neither disorder do we have a lot of information, placing these two among the least well understood of mental disorders that affect children (or adults, for that matter). Each disorder is conceived as a reaction to an environment in which the child experiences caregiving that is inconstant (frequent change of parent or surrogate) or pathological (abuse, neglect). One of two patterns then develops. In reactive attachment disorder (RAD), even young infants withdraw from social contacts, appearing shy or distant. Inhibited children will resist separation by tantrums or desperate clinging. In severe cases, infants may exhibit failure-to-thrive syndrome, with head circumference, length, and weight hovering around the 3rd percentile on standard growth charts. By contrast, a child’s response in disinhibited social engagement disorder (DSED) borders on the promiscuous. Small children eschew normal wariness and boldly approach strangers; instead of clinging, they may instead appear indifferent to the departure of a parent. In both subtypes, the abnormal responses are more obvious when the main caregiver is absent. Factors that indicate increased risk for either RAD or DSED include being reared in an orphanage or other institution; protracted hospitalizations; multiple and frequent changes in caregivers; severe poverty; abuse (the gamut of physical, emotional, and sexual); and a family riven by death, divorce, or discord. Complications associated with these disorders include stunted physical growth, low self-esteem, delinquency, anger management issues, eating disorders, malnutrition, depression or anxiety, and later substance misuse. In either disorder, a constant, nourishing relationship with a sensitive caregiver is required to reestablish adequate physical and emotional growth. Without such a remedy, the conditions tend to persist into adolescence. There has been almost no follow-up into adult life; despite a dearth of reliable information, you will (of course) find websites. DSM-IV listed these two conditions as subcategories of one disorder. Because of differences in symptoms, course, treatment response, and other correlates, DSM-5 now treats them as separate diagnoses—despite their supposed common etiology. However, some children will appear withdrawn when very young, then become disinhibited later, whereas others have symptoms of both conditions simultaneously. The upshot is that some observers find the dichotomy a bit forced. Essential Features of Reactive Attachment Disorder Adverse child care (abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to withdraw emotionally; the child neither seeks nor responds to soothing from an adult. Such children will habitually show little emotional or social response; far from having positive affect, they may experience periods of unprovoked irritability or sadness. The Fine Print The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior. The D’s: • Demographics (begins before age 5; child has developmental age of at least 9 months) • Differential diagnosis (autism spectrum disorder, intellectual disability, depressive disorders) Coding Notes Specify if: Persistent. Symptoms are present longer than 1 year. Severe. All symptoms are present at a high level of intensity. Essential Features of Disinhibited Social Engagement Disorder Adverse child care (abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to become unreserved in interactions with strange adults. Such children, rather than showing typical first-acquaintance shyness, will little hesitate to leave with a strange adult; they don’t “check in” with familiar caregivers, and readily become excessively familiar. In so doing, they may cross normal cultural and social boundaries. The Fine Print The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior. The D’s: • Demographics (child has developmental age of at least 9 months) • Differential diagnosis (autism spectrum disorder, intellectual disability, ADHD) Coding Notes Specify if: Persistent. Symptoms are present longer than 1 year. Severe. All symptoms are present at a high level of intensity. F43.8 [309.89] Other Specified Trauma- or Stressor-Related Disorder This diagnosis will serve to categorize those patients for whom there is an evident stressor or trauma, but who for a specific, stated reason don’t fulfill criteria for any of the standard diagnoses already mentioned above. DSM-5 gives several examples, including two forms of adjustment-like disorders (one form with delayed onset and another with prolonged duration relative to adjustment disorder). Others are as follows: Persistent complex bereavement disorder. For at least a year, a patient experiences intense grief for someone close who has died. There may be yearning and preoccupation of thoughts for the person, or continuing ruminations over the circumstance of death. A number of other symptoms express the patient’s loss of identity and reactive distress. Proposed criteria and discussion are given in Section III of DSM-5 on page 789. Various cultural syndromes. You’ll find a number of these in an appendix in DSM-5, page 833. F43.9 [309.9] Unspecified Trauma- or Stressor-Related Disorder This diagnosis will serve to categorize those patients for whom there is an evident stressor or trauma, but who don’t fulfill criteria for any of the standard diagnoses already mentioned above, and for whom you do not care to specify the reasons why the criteria are not fulfilled.”

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