Post Traumatic Stress Disorder: Understanding the Changes in the DSM-5

1. Kathleen O’Rahilly Linda ManeyYenny Montenegro, Mariela Sanchez & Sadia Perveen – contributors Post Traumatic Stress Disorder:Understanding the Changes in the DSM-5

2. Creation of DSM-5 • Basis for Proposals • Principles guiding revisions: • Intention, Research Evidence, Continuity, No Unnecessary Constraints • Experts and Subgroup Committees • Field Trials (5th ed.; DSM–5; American Psychiatric Association, 2013)

3. Classification • PTSD was listed as an Anxiety Disorder within the DSM- IV • Considered placing it with: • Stress Induced Fear –Circuitry Disorders • Internalizing Disorder • Dissociative Disorder • Now listed as Trauma and Stressor Related Disorder (Friedman, M. J., 2013)

4. Broad vs. Narrow Definition • The subcommittee debated over the benefits of broad or narrow definitions of PTSD • They ultimately decided on a broad definition • Post field test results indicated that the broad symptom criterion resulted in a comparatively high test retest reliability (Friedman, M. J., 2013)

5. Factor Structure • Under the DSM-IV PTSD followed a three factor structure model • Confirmatory factor analysis has failed to support the use of this model • supported distinction of Intrusion and Arousal • not supported the grouping of Avoidance & Numbing • Follow up research shows support for this model but greater support for a 5 factor model (Friedman, M. J., 2013)

6. Subtype: Dissociative • Dissociative subtype • Marked by symptoms of depersonalization or derealization • Creation supported by evidence of: • FMRIs • Different etiology • Distinctive treatment • Not all individuals who meet criteria for PTSD have high levels of dissociation whereas most individuals with high dissociation have PTSD (Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D., 2012)

7. Subtype: Preschool • Preschool subtype • Implausibly low prevalence • high verbal and cognitive demands • alternative algorithm • Evidence supports the criterion, convergent, discriminant, and predictive validities of the preschool subtype • ( Scheeringa et al., 2011)

8. Diagnosis: Ages 6 and above • A. Exposure to actual or threatened death, serious injury or sexual violence in one (or more)of the following ways: • Directly experiencing • Witnessing it in person as it occurs • Learning that it occurred to a close family member or close friend (must have been violent or accidental) • Experiencing repeated or extreme exposure to aversive details of the event (5th ed.; DSM–5; American Psychiatric Association, 2013)

9. Diagnosis: Ages 6 and above B. Presence of one (or more)of the following intrusion symptoms associated with the trauma, occurring after the trauma • Recurrent involuntary and distressing memories • Recurrent distressing dreams with related content • Dissociative reactions- feel or act as if event were recurring • Intense or prolonged psychological distress to cues which symbolize or resemble aspects of the event • Marked physiological reactions to reminders of the traumatic event C. Persistent Avoidance of Stimuli associated with the trauma marked by one (or more)of the following • Avoiding activities, places, or physical reminders of the event • Avoiding people, conversations, or interpersonal situations (5th ed.; DSM–5; American Psychiatric Association, 2013)

10. Diagnosis: Ages 6 and above • D. Negative alterations in cognitions & mood associated with the event beginning or worsening after the event , evidenced by two (or more)of the following: • Inability to remember an important aspect of the event • Persistent exaggerated negative beliefs or expectations about self, world or others • distorted cognitions about the cause or consequence of the event leading to blame themselves or others • Persistent negative emotional state • Markedly diminished interest in significant activities • Feelings of detachment from others • Persistent inability to experience positive emotions (5th ed.; DSM–5; American Psychiatric Association, 2013)

11. Diagnosis: Ages 6 and above E. Marked alterations in arousal and reactivity associated with the event evidenced in two (or more)of the following ways: • Irritable behavior and angry outbursts • Reckless or self destructive behavior • Hypervigilance • Exaggerated startle response • Problems with concentration • Sleep disturbance F.more than one month & G.Disturbancecauses clinically significant distress or impairment in social, occupational or other functioning (5th ed.; DSM–5; American Psychiatric Association, 2013)

12. Diagnosis: Ages Under 6 • Exposure • Learning that it occurred to a parent or caregiver • Doesn’t include repeated exposure to details • B. Intrusion • dreams content need not be related • Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed in play reenactment • Arousal • Doesn’t include reckless behavior • D. Avoidance or negative alterations in cognition (5th ed.; DSM–5; American Psychiatric Association, 2013)

13. Diagnosis Ages Under 6 • Negative alterations in cognitions • Doesn’t include • Inability to remember aspect of event • Persistent exaggerated negative beliefs or expectations • Persistent distorted cognitions about the cause or consequence • Persistent negative emotional state • Feelings of detachment from others • Persistent inability to experience positive emotions • Instead includes • Increased frequency of negative emotional states • Socially withdrawn behavior • Persistent reduction in expression of positive emotions (5th ed.; DSM–5; American Psychiatric Association, 2013)

14. Differences Between Diagnosis (5th ed.; DSM–5; American Psychiatric Association, 2013)

15. Rethinking The Stressor: A Cluster • Debate: what qualifies as a traumatic event ? • some professionals suggested that the criterion be removed • stressor was too integral to be eradicated as a criteria • Many felt the definition of traumatic events should be restricted to only those which were directly experienced • Many individuals with PTSD indirectly experience a trauma • limit the types of trauma which may be experienced indirectly (Friedman, M. J. 2013)

16. DSM-IV Criteria A2 • Needed to demonstrate an intense emotional response • Many individuals deny having such an experience • Not a risk factor • Not a protective factor • A2 was not included in the DSM-5 (Friedman, M. J. 2013)

17. Clarification of Intrusion Symptoms: B Cluster • Longer lasting reflective thought process were excluded • more consistent with Depression • PTSD on the other hand is characterized by intrusive distressing sensory, emotional physiological or behavioral memories. (Friedman, M. J. 2013)

18. Negative Alterations in Cognition & Mood: D Cluster • Two new criteria were added to this symptom index • Persistent negative emotional state • reaction to the “irritability or outbursts of anger” • behavior was moved to symptom index E • Persistent distorted blame of self or others about the traumatic event • predicts severity, chronicness, & functional impairment • Inability to recall important events was reclassified as dissociative amnesia (Friedman, M. J. 2013)

19. Alterations in Arousal: E Cluster • Now includes • behavioral reactivity • heightened arousal • Symptom expression may include • reckless driving • risky sexual behavior • suicidal behavior, • aggression (Friedman, M. J. 2013)

20. Assessment • Validated measures in accordance with DSM-5 • Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) • PTSD Checklist for DSM-5 (PCL-5) • Life Events Checklist for DSM-5 (LEC-5) • Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) • The Primary Care PTSD Screen (PC-PTSD) WWW.PTSD.VA.GOV

21. Treatment • CBT and Cognitive restructuring • Exposure therapy • Medication Children Under 6: • TF-CBT • Play therapy • Meditation • Prognosis (Jonah, D. E., Cusack, K., Fomeris, C. A., Forneris, C. A., Wilkins, T. M., Sonis, J.. . &Gaynes, B. N., 2013)

22. Intervention • These programs have been developed specifically for use in schools and focus on a broad array of traumas (Kataoka, Langley, Wong, Baweja & Stein, 2012) : • Psychological First Aid (PFA) • Cognitive-Behavioral Intervention for Trauma in Schools (CBITS) • Multimodality Trauma Treatment (MMTT) • Aerobic Exercise (Diaz & Motta, 2007)

23. In Summary

24. Resources American Academy of Child & Adolescent Psychiatry www.aacap.org Pamphlets: PTSD, The Depressed Child, Children and Grief, Talking to Children about Terrorism and War National Child Traumatic Stress Network www.nctsnet.org ‘After the Hospital: Helping My Child Cope-What Parents Can Do’; ‘Caring for Children Who Have Experienced Trauma-A Workshop for Parents; ‘Checklist for School Personnel to Evaluate and Implement the Mental Health Component of Your School Crisis and Emergency Plan’ Coping With A Crisis: Informational booklet produced by the National Institute of Mental Health The National Center for Post Traumatic Stress Disorder: PTSD Research Quarterly: Advancing Science and Promoting Understanding of Traumatic Stress. www.ptsd.gov

25. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Brock, S. E., & Cowan, K. (2004). Coping After a Crisis. Principal Leadership, 4(5), 9-13. Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A Multisite, Randomized Controlled Trial For Children With Sexual Abuse–related PTSD Symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393-402. Diaz, A. B., & Motta, R. (2007). The Effects of An Aerobic Exercise Program On Posttraumatic Stress Disorder Symptom Severity In Adolescents. International Journal of Emergency Mental Health, 10(1), 49-59.

26. References Dyregrov, A., & Yule, W. (2006). A review of PTSD in children. Child and Adolescent Mental Health, 11(4), 176-184. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2008). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press. Friedman, M. J. (2013). Finalizing PTSD in DSM‐5: Getting Here From There and Where to Go Next. Journal of traumatic stress, 26(5), 548-556. Kaplan, L. M., Kaal, K., Bradley, L., & Alderfer, M. A. (2013). Cancer-related traumatic stress reactions in siblings of children with cancer. Families, Systems, & Health, 31(2), 205-217. doi:10.1037/a0032550

27. References Kataoka, S., Langley, A., Wong, M., Baweja, S., & Stein, B. (2012). Responding to students with PTSD in schools. Child and adolescent psychiatric clinics of North America, 21(1), 119. Kilpatrick, D.G., Resnick. H.S., Milanak, M.E., Miller, M.W., Keyes, K.M., Friedman, M.J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM- IV and DSM-5 criteria. Journal of Traumatic Stress, 26, 537-547. Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640-647. Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety, 29(8), 701-708. Merikangas, K. et al. (2010). Lifetime prevalence of mental disorders in the U.S. Adolescent Comorbidity Survey Replication-Adolescent Sample. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 980-988.

28. References National Institute of Mental Health. (2014). Post-Traumatic Stress Disorder (PTSD). Retrieved from National Institute of Mental Health website: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml#part4 Pervanidou, P. (2008). Biology of post-traumatic stress disorder in childhood and adolescence. Journal Of Neuroendocrinology, 20(5), 632-638. doi: 10.1111/j.1365-2826.2008.01701.x Posttraumatic Stress Disorder (PTSD). (n.d.). Posttraumatic Stress Disorder (PTSD). Retrieved May 7, 2014, from http://www.aacap.org/aacap/Families_and_Youth/Facts_for_Families/ Facts_for_Families_Pages/Posttraumatic_Stress_Disorder_70.aspx PTSD: National Center for PTSD. (2014). Clinician-Adminstered PTSD Scale for DSM-5 (CAPS-5). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

29. References PTSD: National Center for PTSD. (2014). Life Events Checklist for DSM-5 (LEC-5). Retrieved from http://www.ptsd.va.gov/professional/ assessment/temeasures/lifeeventschecklist.asp Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. Journal of Child Psychology and Psychiatry, 52 (8), 853-860. Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane, T.M. (2013). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Interview available from the National Center for PTSD at www.ptsd.va.gov.