Trauma and the DSM-5®*

1. Trauma and the DSM-5®* Jamie Marich, Ph.D., LPCC-S, LICDC-CS . Director, Mindful Ohio Affiliate Faculty, IATP *This training is not affiliated with the American Psychiatric Association

2. About Today’s Presenter • Licensed Supervising Professional Clinical Counselor (MH) • Licensed Supervising Independent Chemical Dependency Counselor • Member of the American Academy of Experts on Traumatic Stress • Author, EMDR Made Simple & Trauma and the Twelve Steps • Thirteen years of experience working in social services and counseling; includes three years of experience in civilian humanitarian aid in Bosnia-Hercegovina • Specialist in addictions, trauma, abuse, dissociative disorders, performance enhancement, grief/loss, and pastoral counseling • Trained in several specialty interventions for trauma • Creator of the Dancing Mindfulness practice

3. What led you to this conference?

4. Learning Objectives • Define trauma and describe, in a general sense, how unresolved trauma may manifest in clinical settings • List and discuss the diagnoses covered in the new DSM-5® chapter, Trauma and Stressor-Related Disorders • Articulate how other diagnoses in the DSM may be better explained by trauma, or exacerbated by the effects of unresolved trauma • Discuss how the new DSM-5® will impact the helping profession’s conceptualization of clinical trauma

5. Trauma

6. “Once you’ve been bitten by a snake, you’re afraid even of a piece of rope.”-Chinese Proverb

7. Large T Trauma vs. small t trauma

8. Trauma: Large-T or “Big” T Examples include: combat, natural disasters, sexual abuse, assault, other violent crimes “Big T” trauma is what the psychological community references in speaking about the PTSD diagnosis.

9. DSM-IV-TR Nutshell Definition of PTSD(Posttraumatic Stress Disorder ) (APA, 2000) • Actual or perceived threat of injury or death - response of hopelessness or horror (Criterion A) • Re-experiencing of the trauma • Avoidance of stimuli associated with the trauma • Heightened arousal symptoms • Duration of symptoms longer than 1 month • Functional impairment due to disturbances

10. DSM-5 ® Nutshell Definition of PTSD(Posttraumatic Stress Disorder ) (American Psychiatric Association, 2013) • Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation: direct experiencing, witnessing (Criterion A) • Intrusion symptoms (Criterion B) • Avoidance of stimuli associated with the trauma (Criterion C) • Cognitions and Mood: negative alterations (Criterion D) • Arousal and reactivity symptoms (Criterion E) • Duration of symptoms longer than 1 month • Functional impairment due to disturbances

11. DSM-IV-TR Criteria: PTSD • The person has been exposed to a traumatic event in which both of the following were present:  • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. • The person's response involved intense fear, helplessness, or horror. • Note: In children, this may be expressed instead by disorganized or agitated behavior.

12. DSM-IV-TR Criteria: PTSD B. The traumatic event is persistently re-experienced in one (or more) of the following ways:  Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.) Recurrent distressing dreams of the event. (Note: In children, there may be frightening dreams without recognizable content.) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

13. DSM-IV-TR Criteria: PTSD C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  Efforts to avoid thoughts, feelings, or conversations associated with the trauma. Efforts to avoid activities, places, or people that arouse recollections of the trauma . Inability to recall an important aspect of the trauma. Markedly diminished interest or participation in significant activities. Feeling of detachment or estrangement from others . Restricted range of affect (e.g., unable to have loving feelings) . Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

14. DSM-IV-TR Criteria: PTSD • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: • 1. Difficulty falling or staying asleep2. Irritability or outbursts of anger3. Difficulty concentrating4. Hypervigilance5. Exaggerated startle response • E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.  • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

15. Trauma: small-t Not necessarily life threatening, but definitely life-altering Examples include grief/loss, divorce, verbal abuse/bullying, and just about everything else… If it was traumatic to the person, then it’s traumatic. According to the adaptive information processing model, “little t” trauma can be just as valid and as clinically significant as “Big T” trauma.

16. DSM Fun Facts… • PTSD entered into the DSM-III in 1980, largely as a result of the Vietnam War • Other names had been used unofficially in the field over the years: soldier’s heart shell shock battle fatigue operational exhaustion hysteria

17. DSM-5

18. DSM-5 For the latest updates on DSM-5, visit the official website at www.dsm5.org

19. DSM-5: Trauma & Stressor-Related Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Acute Stress Disorder • Posttraumatic Stress Disorder • Adjustment Disorders • Unspecified & Unclassified Traumatic Stress Disorder

20. Posttraumatic Stress Disorder: DSM-5 Criteria Exposure to actual or threatened death, serious injury, or sexual violence, in one (or more) of the following ways: Directly experiencing the traumatic event(s). Witnessing, in person, the traumatic event(s) as it occurred to others. Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental. 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); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.

21. Posttraumatic Stress Disorder: DSM-5 Criteria B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 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.) 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.) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are 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.) Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).reminders of the traumatic event(s)

22. Posttraumatic Stress Disorder: DSM-5 Criteria 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: Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 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)

23. Posttraumatic Stress Disorder: DSM-5 Criteria 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: 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) 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”).  Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)

24. Posttraumatic Stress Disorder: DSM-5 Criteria E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. Reckless or self-destructive behavior. Hypervigilance. Exaggerated startle response. Problems with concentration. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

25. Posttraumatic Stress Disorder: DSM-5 Criteria 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, occupational, 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.

26. Posttraumatic Stress Disorder: DSM-5 Criteria Specify whether: With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following: Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 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 intoxication) 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). Subtype:PTSD in children younger than 6 years

27. Acute Stress Disorder:DSM-5 Criteria Exposure to actual or threatened death, serious injury, or sexual violation, in one or more of the following ways: Directly experiencing the traumatic event(s)  . Witnessing, in person, the traumatic event(s) as they occurred to others. Learning that the event(s) occurred to a close family member or close friend; in cases of actual or threatened death must have been violent or accidental. 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); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

28. Acute Stress Disorder: DSM-5 Criteria 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 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.) 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.) 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.) Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

29. Acute Stress Disorder: DSM-5 Criteria • 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).

30. Acute Stress Disorder: DSM-5 Criteria • Avoidance Symptoms • 8.Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). • 9. 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). • Arousal Symptoms • 10.Sleep disturbance (e.g., difficulty falling asleep or staying asleep, restless sleep). • 11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. • Hypervigilance. • Problems with concentration. • Exaggerated startle response.

31. Acute Stress Disorder: DSM-5 Criteria 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.

32. Adjustment Disorders: DSM-5 Criteria Development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). 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.

33. Adjustment Disorders:DSM-5 Criteria 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.

34. Adjustment Disorders:DSM-5 Criteria • 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

35. DSM-5: Section III Persistent Complex Bereavement Disorder

36. Persistent Complex Bereavement Disorder: DSM-5 Criteria • A. The individual experienced the death of someone with whom he or she had a close relationship. • B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: • Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure. • Intense sorrow and emotional pain in response to the death. • Preoccupation with the deceased. • Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.

37. Persistent Complex Bereavement Disorder: DSM-5 Criteria • C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: • Reactive distress to the death • Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death. • Experiencing disbelief or emotional numbness over the loss. • Difficulty with positive reminiscing about the deceased. • Bitterness or anger related to the loss. • Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame). • Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased); in children, this may include avoidance of thoughts and feelings regarding the deceased.

38. Persistent Complex Bereavement Disorder: DSM-5 Criteria Social/Identity Disruption 7. A desire to die in order to be with the deceased. 8.    Difficulty trusting other individuals since the death. 9.    Feeling alone or detached from other individuals since the death. 10.  Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased. 11.  Confusion about one’s role in life or a diminished sense of one’s identity (e.g., feeling that a part of oneself died with the deceased). 12.  Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities).

39. Persistent Complex Bereavement Disorder: DSM-5 Criteria • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • E. The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms. • Specify if: • With Traumatic Bereavement: bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature of the death (often in response to loss reminders), including the deceased’s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death

40. Other Diagnoses • Major depressive disorder • Persistent depressive disorder (dysthymia) • Other anxiety disorders • Disruptive mood dysregulation disorder (new) • Oppositional defiant disorder • Conduct disorder

41. DSM-5 ® Other Conditions That May Be a Focus of Clinical Attention

42. Problems Related to Family Upbringing • Parent-Child Relational Problem • Sibling Relational Problem • Upbringing Away from Parents • Child Affected by Parental Relationship Distress

43. Other Problems Related to Primary Support Group • Relationship Distress with Spouse or Intimate Partner • Disruption of Family by Separation or Divorce • High Expressed Emotion Level within Family • Uncomplicated Bereavement • Abuse and Neglect

44. Child Maltreatment and Neglect Problems • Child Physical Abuse • Child Sexual Abuse • Child Neglect • Child Psychological Abuse

45. Adult Maltreatment and Neglect Problems • Spouse or Partner Violence, Physical • Spouse or Partner Violence, Sexual • Spouse or Partner Neglect • Spouse or Partner Abuse, Psychological • Adult Abuse by Nonspouse or Nonpartner

46. Educational and Occupational Problems • Academic or Educational Problem • Problem Related to Current Military Deployment Status • Other Problem Related to Employment

47. Housing and Economic Problems • Housing Problems • Homelessness • Inadequate Housing • Discord with Neighbor, Lodger, or Landlord • Problem Related to Living in a Residential Institution • Economic Problems • Lack of Adequate Food or Safe Drinking Water • Extreme Poverty • Low Income • Insufficient Social Insurance or Welfare Support • Unspecified Housing or Economic Problem

48. Other Problems Related to the Social Environment • Phase of Life Problem • Problem Related to Living Alone • Acculturation Difficulty • Social Exclusion or Rejection • Target of (Perceived) Adverse Discrimination or Persecution • Unspecified Problem Related to Social Environment

49. Problems Related to Crime or Interaction with the Legal System • Victim of Crime • Conviction in Civil or Criminal Proceedings without Imprisonment • Imprisonment or Other Incarceration • Problems Related to Release from Prison • Problems Related to Other Legal Circumstances

50. Other Health Service Encounters for Counseling and Medical Advice • Sex Counseling • Other Counseling or Consultation