Chapter 7
Trauma- and Stressor-Related Disorders

The term trauma refers to an emotional response to a severely distressing event such as combat, sexual assault, a severe accident, abuse, or exposure to a natural or human-caused disaster (Halpern & Tramontin, 2007; Norris & Elrod, 2006; Ursano, McCaughey, & Fullerton, 1994). Traumatic or stressful events or circumstances may be physically or emotionally harmful to an individual and can involve a single experience or a long-lasting or repetitive event or events. Trauma and stress affect clients in a variety of ways, all of which can threaten their physical, social, cognitive, emotional, or spiritual well-being (Gerrity & Flynn, 1997; Halpern & Tramontin, 2007; Norris et al., 2002). There is one common factor encompassing all traumatic experiences—these situations overwhelm a person's ability to cope (Halpern & Tramontin, 2007; Norris & Elrod, 2006).

Major Changes From DSM-IV-TR to DSM-5

The Trauma- and Stressor-Related Disorders chapter in the DSM-5 is a new chapter of disorders that includes PTSD, acute stress disorder, adjustment disorders, reactive attachment disorder (RAD), and a new category, disinhibited social engagement disorder (DSED). In the DSM-IV-TR, PTSD and acute stress disorder were categorized as anxiety disorders; RAD was categorized as disorders usually first diagnosed in infancy, childhood, and adolescence; and adjustment disorders had its own diagnostic category. The DSM-5 placed these disorders together based on their common roots in external events or triggers (APA, 2013a). Categorizing these disorders according to common etiology (i.e., trauma or psychological stressors preceding the disorder), as opposed to common phenomenology, has both clinical utility and heuristic value (First, 2010; First et al., 2004). Because many of these disorders are similar enough to be grouped together but distinct enough to subsist as separate disorders, counselors can more easily distinguish them from one another. For example, including PTSD and adjustment disorders in the same diagnostic classification allows counselors to more easily identify marked differences between these diagnoses. Second, because these disorders are grouped according to cause as opposed to symptoms, researchers can easily create testable theoretical explanations for trauma-based disorders (Friedman et al., 2011).

Aside from being an entirely new chapter, the most significant change for this section is the stressor criterion for acute stress disorder and PTSD. Acute stress disorder and PTSD now note that a traumatic event can be either directly or indirectly experienced or witnessed (APA, 2013a). This means that a traumatic event that was experienced by a close family member or friend can result in possible PTSD or acute stress disorder for the client. There have also been significant changes for children in this chapter. The diagnostic threshold for PTSD has been modified to include children and adolescents, and the DSM-5 contains developmentally appropriate criteria for children 6 years or younger. The childhood diagnosis RAD formerly had two subtypes, inhibited and disinhibited. However, in the DSM-5, these subtypes are now separate disorders, RAD and DSED. Both disorders address a child's ability to form meaningful/secure attachments as a result of social neglect or other stressors and have common etiology of gross neglect from caregivers. The difference, however, is that children diagnosed with DSED can have some form of attachment to their caregivers. Unlike children diagnosed with RAD, children diagnosed with DSED struggle to conform to social boundary norms and can be in danger of inappropriate interactions with strangers. Most other changes to disorders within this section are primarily semantic.

Essential Features

Potentially traumatic events include combat, sexual and physical assault, robbery, being kidnapped or taken hostage, terrorist attacks, torture, disasters, severe automobile accidents, child abuse, and life-threatening illnesses (Frances, 2013; Halpern & Tramontin, 2007). Trauma also extends to witnessing death or serious injury by violent assault, accidents, war, or disaster. References to stressor-related events in the DSM-5 include circumstances that cause less adverse emotional effects for a shorter period of time (APA, 2013a). Whereas these events can still markedly disturb an individual, sometimes to the point of social or occupational impairment, adverse emotional effects decrease once the stressor is removed (APA, 2013a). Examples of stressor-related events include relationship breakups, business difficulties or loss of a job, marital problems, or living in a crime-ridden neighborhood. Developmental events, such as going away from school or retiring, can also cause serious stress.

Note

Counselors should note that different people will react differently to similar events. One person may experience an event as traumatic whereas another person would not suffer trauma as a result of the same event. Not all people who experience a potentially traumatic event will become psychologically traumatized.

As with many disorders found within Part One of this book, prevalence of trauma-based disorders among the general population is high (APA, 2013a; Morrison, 2006). According to the National Comorbidity Survey Replication (Kessler, Berglund, et al., 2005), the past year prevalence of PTSD was 3.5%, with a 3.6% lifetime prevalence among men and 9.7% prevalence among women. Currently, no population-based epidemiological studies have been conducted to examine prevalence rates in children; however, children who have been exposed to specific traumatic events are at greater risk of prevalence of PTSD. Depending on the trauma or stressor, prevalence rates for acute stress disorder vary from 6% to 94% (Gibson, 2007). The prevalence of RAD is estimated to be 1% of children under age 5 (Widom, Czaja, & Paris, 2009). However, children who are orphaned or placed in foster care at an early age have a higher chance of developing RAD. The prevalence of adjustment disorders has been reported to be between 2% and 8% in community samples of children, adolescents, and older adults (Portzky, Audenaert, & van Heeringen, 2005). In general hospital settings, 12% of inpatients are referred to mental health treatment for adjustment disorders, compared with 10% to 30% of individuals in mental health outpatient settings. Individuals from low socioeconomic status backgrounds have a higher chance of being treated for adjustment disorders due to increased exposure to life stressors (Portzky et al., 2005).

Differential Diagnosis

The onset of trauma-related disorders discussed in this chapter can be associated with increased risk of anxiety, depression, disordered eating, sleep disturbances, substance use problems, and suicidal ideation (APA, 2013a; Friedman et al., 2011). It is not uncommon for individuals diagnosed with a traumatic disorder to also exhibit symptoms of somatic symptom disorder, impulse-control disorder, and ADHD. Symptoms of these disorders have also been linked to dissociative disorders. Many survivors of traumatic events, especially children, are often misdiagnosed with ADHD (Gibson, 2007; Widom et al., 2009). Children diagnosed with RAD are often mistaken for children with ADHD or ODD and often have behavioral problems during childhood and adolescence (Widom et al., 2009).

Etiology and Treatment

In the DSM-I (APA, 1952), individuals were diagnosed with gross stress reaction resulting from psychological problems that arose as a result of military or civilian experiences (Friedman et al., 2011). However, the concept of gross stress reaction was criticized for not providing a solid foundation for diagnosing criteria. The DSM-II (APA, 1968) disposed of that diagnosis and developed the alternative diagnosis of, situational reaction. Clinicians felt this diagnosis captured both traumatic and unpleasant events resulting from traumatic exposure. Both gross stress reaction and situational reaction were identified as being reversible and temporary disorders. However, in the late 1970s, mental health clinicians noticed patients were presenting with severe, chronic, and irreversible symptoms as a result of exposure to traumatic events. This resulted in the DSM-III (APA, 1980) diagnostic criteria for PTSD that remain in existence until now. Through the development of the diagnostic criteria for PTSD, the possible symptoms increased from 12 to 17 and the symptom clusters shifted (Friedman et al., 2011).

Implications for Counselors

It is important that counselors understand that the fundamental feature of trauma rather than anxiety served as the driving force for the movement of trauma- and stressor-related disorders into a separate chapter. This modification follows revisions within ICD-10 that also separate trauma from anxiety disorder (WHO, 2007). However, unlike the ICD-10, which keeps trauma and anxiety disorder in the same larger category, the sequential order of this chapter in the DSM-5 following anxiety disorders and obsessive-compulsive and related disorders reflects the close relationship between trauma and anxiety disorders. In addition to diagnostic similarities, these disorders were also grouped together in an effort to increase clinical utility (First, 2010).

The new Trauma- and Stressor-Related Disorders chapter will require counselors to closely examine traumatic and stressor-related experiences and closely evaluate new diagnostic criteria to categorize trauma and stressor-related impairments. With the lower diagnostic threshold for acute stress disorder and PTSD, counselors will need to be on alert for diagnostic inflation, especially as it relates to children under the age of 6 (Frances, 2013).

To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Trauma- and Stressor-Related Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, when diagnosing clients, counselors need to reference the DSM-5. It is essential that the diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder are clearly understood prior to diagnosis.

313.89 Reactive Attachment Disorder (F94.1)

We adopted John when he was 6 years old. He has never known his birth parents and, prior to our adoption, was shuffled from institution to institution. After having been with us for 1 year, John continued to be severely withdrawn, refusing any forms of affection even when he is upset. He doesn't seem to interact with any other children or seems fearful of anyone getting close to him. Even when others try to interact with him or comfort him he doesn't respond.—Emma (John's mom)

Reactive attachment disorder (RAD) is characterized by markedly disturbed and developmentally inappropriate social relatedness in children before the age of 5 (APA, 2013a; Schechter & Willheim, 2009; Widom et al., 2009). There is broad consensus among clinicians that this disorder results from an extremely inadequate caregiving environment and is directly associated with grossly pathological care. Children diagnosed with RAD continuously fail to initiate or respond to social interactions.

Essential Features

Typically seen before the age of 5, children diagnosed with RAD have not had the opportunity to form stable attachments and have experienced persistent disregard of their basic physical and emotional needs for comfort, stimulation, and affection (APA, 2013a; Schechter & Willheim, 2009; Widom et al., 2009). Symptoms of RAD include detachment, unresponsiveness or resistance to comforting, holding back emotions, withdrawal from others, and a mixture of approach and avoidance behaviors (APA, 2013a; Zeanah & Gleason, 2010). Children diagnosed with RAD have no developmental delays. Little epidemiological data exist for this disorder, but it is relatively uncommon. Only a minority of children with severe caretaking deficiencies or abnormalities develop RAD.

Major Changes From DSM-IV-TR to DSM-5

Formerly located within the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter in the DSM-IV-TR, RAD included two specifiers: inhibited and disinhibited type. Disinhibited type, characterized by indiscriminate social skills marked by a child's inability to exhibit appropriate attachments, is no longer included as a criterion for this disorder (APA, 2013a; Zeanah & Gleason, 2010). This specifier has been moved to a separate disorder (see next section).

Special Considerations

RAD is not diagnosed when children, despite abuse or maltreatment, can still form attachments and are not markedly maladjusted (Schechter & Willheim, 2009; Zeanah & Gleason, 2010). RAD should be differentiated from ASD, which can develop within a relatively supportive setting (APA, 2013a). Although RAD can present like ADHD, it is different because children who are diagnosed with ADHD will form attachments (Zeanah & Gleason, 2010). RAD is not applicable to children with developmental delays or neurological damage. Finally, RAD does not apply to rebellious behavior, which develops in preadolescent and adolescent children who previously had strong attachments with caregivers. Critics of this diagnosis point to limited research with contradictory findings (cf. Chaffin et al., 2006; Hanson & Spratt, 2000).

Common approaches to treating RAD are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver (Prior & Glaser, 2006). Prevention programs are also important, especially to target problematic early attachment behaviors in both children and caregivers. Cohen et al. (2010) identified important parameters mental health practitioners should focus on when working with children diagnosed with RAD. The first goal is ensuring the child is in a safe and stable environment that can provide for physical and emotional needs. The second goal focuses on how the child can begin to develop an appropriate, healthy attachment with his or her primary caregiver(s).

Counselors should be aware that neglected children are often at risk for developmental delays, dialectical deficits/disorders, and neglect of medical concerns (Prior & Glaser, 2006). Counselors must remember that all cases of abuse, neglect, and exploitation must be reported. Therefore, counselors need to be familiar with their local and state laws regarding mandated reporting, and their actions need to be in compliance with the ACA Code of Ethics (ACA, 2014).

Cultural Considerations

As stated previously, there has been little research on RAD (Zeanah & Gleason, 2010). This means that counselors should pay particular attention when making a diagnosis of RAD, especially for cultural groups in which attachment has not been thoroughly studied (APA, 2013a). Because attachment behavior varies greatly from one cultural group to another, counselors must use caution to ensure that the child's attachment behavior is markedly disturbed and developmentally inappropriate as defined by the child's cultural norms.

Differential Diagnosis

Pervasive developmental disorders or developmental delays are commonly considered as differential diagnoses from RAD (APA, 2013a). However, criticisms of RAD are that the criteria from the DSM-IV-TR focused too much on social behavior and not attachment behavior, for example, how a child seeks comfort, support, nurturance, and protection from a preferred attachment figure in times of fear or distress. Focusing on social behavior runs the risk of overlapping with ASD rather than an attachment disorder.

Coding, Recording, and Specifiers

There is only one diagnostic code for RAD: 313.89 (F94.1). There are two specifiers for this disorder: persistent, which is used when the disorder has been present for more than 12 months, and severe, when there is evidence of all symptoms and each has a relatively high level of occurrence. There are no codes associated with these specifiers.

313.89 Disinhibited Social Engagement Disorder (F94.2)

We do not know what to do. Jamaal runs up to strangers and is willing to run away with anyone. One day he even got into a stranger's car while we were at the supermarket. He is distant from us and has been ever since we adopted him 1 year ago. I worry about his safety while at school or away from my partner and I.—Jamaal's father

Disinhibited social engagement disorder (DSED) is a new diagnosis in the DSM-5 (APA, 2013a; Zeanah & Gleason, 2010). This disorder represents the indiscriminately social/disinhibited subtype of the DSM-IV-TR childhood diagnosis of RAD (Zeanah & Gleason, 2010). Now considered a distinct disorder, DSED is characterized by a pattern of behavior in which the child actively approaches and interacts with unfamiliar adults (APA, 2013a; Zeanah & Gleason, 2010).

Essential Features

Children diagnosed with DSED do not exhibit developmentally appropriate discretion with unfamiliar adults and may engage in overly familiar behavior with strangers (APA, 2013a; Zeanah & Gleason, 2010). In familiar or unfamiliar settings, these children may venture away from a primary caregiver and often are willing to go off with an unfamiliar adult with minimal or no hesitation. Like RAD, the origin of these symptoms is grossly inadequate caregiving that failed to meet the child's basic emotional or physical needs and safety (Schechter & Willheim, 2009; Widom et al., 2009). Risk factors for DSED include repeated changes in caregivers or being raised in unconventional settings, such as an orphanage or institution that severely limited the child's ability to form secure attachments.

Special Considerations

Counselors need to be careful not to overdiagnose RAD or DSED in children who are adopted, living in a foster home, or have been mistreated by their caregiver (APA, 2013a). Children with RAD and DSED are presumed to have grossly disturbed internal models for relating to others; therefore, treatment should involve both the caretaker and the child (Prior & Glaser, 2006). Counselors should not attempt to change the child but rather should focus on changing the child's surroundings and creating positive interactions with caregivers. As with RAD, counselors must be sure the child with DSED is in a safe and stable environment where he or she can get appropriate care, and counselors should always be aware that neglected children are often at risk for developmental delays, dialectical deficits/disorders, and neglect of medical concerns (Prior & Glaser, 2006). All cases of abuse, neglect, and exploitation must be reported, and counselors need to be familiar with mandated reporting laws as well as the ACA Code of Ethics (ACA, 2014).

Cultural Considerations

There has been little research on DSED (Zeanah & Gleason, 2010). Similar to RAD, counselors should pay particular attention when making a diagnosis of DSED in cultures in which attachment has not been studied. Because attachment behavior varies greatly from one cultural group to another, counselors must use caution to ensure that the child's attachment behaviors are inappropriate as defined by the child's cultural norms.

Differential Diagnosis

DSED can be mistaken for ADHD (APA, 2013a; Frances, 2013). Although the symptoms of DSED are inattentiveness and impulsivity, the etiology of DSED, inadequate caregiving and neglect, is what differentiates this disorder from other impulse-control disorders or ADHD (Zeanah & Gleason, 2010). As with RAD, counselors must be sure to distinguish DSED from pervasive developmental disorders (Zeanah & Gleason, 2010). Counselors should also be sure the client does not have the genetic disorder Williams syndrome, characterized by mild to moderate intellectual disability (Zeanah & Gleason, 2010). Children with Williams syndrome have unique facial features and distinct personality traits of overfriendliness, anxiety, and high levels of empathy (National Institute of Neurological Disorders and Stroke, 2008).

Note

Counselors must be careful to differentiate RAD and DSED from PTSD. To do so, look for emotional regulation problems and aggression, as these are not core symptoms of either RAD or DSED. Whereas maladaptive care can be defined as trauma, problems with attachment to caregiver prior to 5 years old are distinct features of RAD and DSED and should not be misdiagnosed as PTSD.

Coding, Recording, and Specifiers

There is only one diagnostic code for DSED: 313.89 (F94.2). Counselors will note the same ICD-9-CM code is used for RAD and DSED (i.e., 313.89). A similar code, with .2 as opposed to the .1 given for RAD, is listed under the ICD-10-CM. The reason these are the same in the ICD-9-CM but not the ICD-10-CM is because the disinhibited type specifier, formerly listed under RAD in the DSM-IV-TR, has now been included the DSM-5 and the ICD-10-CM as a separate diagnosis. There are two specifiers for this disorder. The specifier persistent is used when the disorder has been present for more than 12 months, and severe is used when there is evidence of all symptoms and each has a relatively high level of occurrence. There are no codes associated with these specifiers.

309.81 Posttraumatic Stress Disorder (F43.10)

About a year ago, I was in a major car accident. Although I sustained only minor injuries, two of my friends were killed. At first, the accident seemed like just a bad dream. Then the nightmares started. Now, the sights and sounds of the accident haunt me all the time. I have trouble sleeping at night, and during the day I feel “on edge.” I jump whenever I hear a siren or screeching tires, and I avoid TV altogether as I might find a program that shows a car chase or accident scene. I avoid driving when possible. —Amanda

Posttraumatic stress disorder (PTSD) applies only if someone has been exposed to one or more traumatic or stressful events or circumstances. Without severe trauma, a diagnosis of PTSD cannot be made. A traumatic stressor is defined by the DSM-5 as “any event (or events) that may cause or threaten death, serious injury, or sexual violence to an individual, a close family member, or a close friend” (APA, 2013a, p. 830). Critics have argued that this definition does not include nonviolent trauma such as emotional abuse; therefore, counselors should be careful if considering traumas such as emotional neglect and verbal abuse as triggering stressors for PTSD (Frances, 2013).

As mentioned earlier, the past year prevalence of PTSD was 3.5%, with a 3.6% lifetime prevalence among men and 9.7% among women. No population-based epidemiological studies have been conducted to examine the prevalence rates in children; however, children who have been exposed to specific traumatic events are at greater risk of prevalence of PTSD.

Major Changes From DSM-IV-TR to DSM-5

PTSD was previously classified in the DSM-IV-TR as an anxiety disorder, but the criteria for it have undergone substantial changes in the DSM-5. Compared with the DSM-IV-TR, DSM-5 diagnostic criteria for PTSD include more explicit attention to what represents, and does not represent, a traumatic event. Within the diagnostic features description, APA (2013a) lists exposure to war as a combatant or civilian, childhood physical abuse, and threatened or actual sexual violence, with a wide range of examples, to give a clearer picture of traumatic exposure. References to concentration camps and being diagnosed with a life-threatening illness were removed, but the DSM-5 does clarify that medical illnesses in which a shocking or catastrophic event occurs (e.g., waking during surgery or anaphylactic shock) may be considered traumatic (APA, 2013a; Frances, 2013).

The DSM-5 also offers clarification in Criterion A.3, which states that accidental or violent traumatic events, such as automobile fatalities, in which a close family member or friend is involved can be traumatic (APA, 2013a). This clarification, although technically not new to the DSM, is controversial because of the potential for exploitation in forensic proceedings, which often use the diagnosis of PTSD for determination of disability or damages compensation. Because the symptoms of PTSD are entirely based on client self-reports, counselors should caution against the misuse of the PTSD diagnosis in forensic settings (Frances, 2013).

New to the DSM-5 is Criterion A.4, which includes recurring or intense exposure, such as extreme traumas frequently witnessed by police officers and first responders (APA, 2013a). The addition of this criterion is in response to research that supports the idea that individuals who have regular exposure to traumatic events, such as persons who handle the deceased and other first responders, are at risk for developing PTSD (Halpern & Tramontin, 2007; Ursano, 2004). Although this criterion does not apply to media, television accounts, photos, or movies, occupational exposure to events (e.g., exposure of reporters to traumatic events) is included.

Other major changes are the introduction of four, as opposed to three, diagnostic clusters. The change is a result of splitting up DSM-IV-TR Criterion C, avoidance and numbing, into two criteria: avoidance (Criterion C) and negative alterations in cognitions and mood (Criterion D). Avoidance and numbing were separated because of empirical evidence and clinical experiences that indicated at least one avoidance symptom (e.g., evasion of activities, thoughts, feelings, or conversations related to the event) was needed for an accurate PTSD diagnosis (Friedman et al., 2011). The cognition and mood criterion was added because research indicates that shifts in cognition and emotion dysregulation are common to all individuals diagnosed with PTSD. See Table 7.1 for a breakdown of the four clusters and associated examples.

Table 7.1 Diagnostic Criteria of Posttraumatic Stress Disorder (PTSD)

PTSD Diagnostic Clusters	Commonly Associated Examples
Exposure (Criterion A): Direct experience; witnessing the event(s) in person; learning that a friend or close family member was directly affected by a traumatic event; repeated exposure to averse details of a traumatic event (exposure to electronic media is not considered repeated exposure).
Cluster 1 (Criterion B): Intrusion	Recurrent, involuntary, and intrusive distressing memories or dreams of the traumatic event and dissociative reactions (i.e., flashbacks). In children, trauma-specific reenactment may occur in play.
	Intense distress or marked physiological reactions because of exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Cluster 2 (Criterion C): Avoidance (one or both)	Avoidance or attempts to avoid distressing memories, thoughts, or feelings or external reminders about or closely associated with the traumatic event.
Cluster 3 (Criterion D): Negative alterations in cognitions or mood (two or more)	Inability to recall an important aspect of the traumatic event, persistent negative beliefs of oneself, persistent distorted cognitions about the cause or consequences of the traumatic event, persistent negative emotional state, diminished interest in significant activities, or persistent inability to experience positive emotions. Represents myriad feelings a survivor can experience. Includes, but is not limited to, persistent and distorted sense of blame of self and others, estrangement, markedly diminished interest in activities, and problems remembering.
Cluster 4 (Criterion E): Arousal and reactivity (two or more)	Irritability and angry outbursts, recklessness, hypervigilance, exaggerated startle response, problems with concentration, or sleep disturbances.

Other changes to PTSD are related to subtypes. The DSM-5 includes the addition of two new subtypes: the preschool subtype and the dissociative subtype (APA, 2013a). The first, PTSD preschool subtype, is used for children under 6 years old. One of the most significant changes for counselors working with children is the inclusion of PTSD criteria for children 6 years and younger. Overall, counselors will find that the DSM-5 diagnostic threshold has been lowered for children. As opposed to the criteria for individuals over 6 years of age, the criteria for children 6 years and younger emphasize the impact of traumatic events on children when primary caregivers are involved (see Criterion A.2 for children 6 years and younger), clarify that play reenactment may serve as a catalyst for recurrent or intrusive memories, and only require that either persistent avoidance of stimuli or negative alterations in cognitions and mood be present. This is in contrast to the diagnostic criteria for individuals over the age of 6, which require that individuals avoid stimuli and have negative alterations in cognition and mood. The criteria for children under 6 also remove references related to recollection of the event and negative beliefs of self. For example, children under 6 are not necessarily capable of expressing feelings related to their negative beliefs or expectations of self. Problems related to work-related events and reckless, self-destructive behavior were also not included in this diagnostic set because they are not applicable to children.

The dissociative subtype is used when PTSD is seen with prominent dissociative symptoms, which are categorized as either depersonalization or derealization. Depersonalization includes feelings of detachment from one's own mind or body, “as if one were an outside observer of one's mental processes or body” (APA, 2013a, p. 272). Derealization includes experiences in which the world seems unreal, illusory, or distorted. Sometimes referred to as “complex PTSD,” these subtypes would most likely be seen when an individual has been exposed to multiple traumas, particularly in childhood, that result in a complex range of symptoms.

Another significant change in the DSM-5 was removal of what was formerly known in the DSM-IV-TR as Criterion A.2. This criterion mandated that a response of intense fear, helplessness, or horror to the event must be present to diagnose PTSD. This language was deleted because the reactions of intense fear, helplessness, or horror do not predict the onset of PTSD (APA, 2013c). Understanding a person's reaction to trauma is a complex task because emotional responses, like traumatic events, vary considerably; counselors should never attempt to identify a “normal” reaction to traumatic stress. Ursano et al. (1994) summarized this exposure well by stating, “Overall, most individuals exposed to traumatic events and disasters do quite well . . . but for some psychiatric illness, behavioral change, or alterations in physical health result. Certainly, no one goes through profound life events unchanged” (p. 5). Finally, what DSM-IV-TR called delayed onset is now called delayed expression.

Essential Features

Characteristic PTSD symptoms include daytime memories, images, or flashbacks of the event(s) (APA, 2013a). Individuals may experience physiological or emotional stress when they encounter reminders of the event, and any potential triggers, even if only remotely related to the event, must be avoided. Many persons with PTSD also become disconnected from others, find little meaning in life or the future, are indifferent in their relationships, have trouble sleeping and concentrating, and may seem to be constantly tense or “on guard.” Nightmares and survivor guilt are also common. Symptoms must be present for more than 1 month and, like most clinical diagnoses, cause significant impairment or distress.

Note

For a diagnosis of PTSD, there must be exposure to severe trauma. In addition, stress must be relived in some fashion and clients must attempt to avoid stimuli associated with the trauma, including memories or external reminders of the trauma. Clients must also have cognitive problems and marked changes in their emotional state. Symptoms must last over 1 month, and stress must cause significant distress or impairment. None of these issues may be due to a substance or medical condition.

Counselors should pay particular attention to ensure that all criteria are met for PTSD, not just exposure to an extreme stressor. These additional criteria, as stated previously, include intrusion, avoidance, negative alteration in cognitions and mood, and alterations in arousal and reactivity. These additional criteria are often referred to as “clusters” and are discussed in detail in the next section and outlined in Table 7.1.

Special Considerations

The new Trauma- and Stressor-Related Disorders chapter requires counselors to closely examine premorbid experiences and the new diagnostic criteria to categorize distress and functional impairments. Because all individuals respond to trauma differently, it is important that counselors understand that symptoms of PTSD manifest in various ways. Some clients will reexperience the trauma through nightmares and violent flashbacks, others will be unable to experience pleasure or will have negative core beliefs about themselves, and some others will display a combination of symptoms.

An important inclusion for counselors are the risk and prognostic factors in the DSM-5, which indicate a predictable pattern of elements that either place clients at risk or serve as protective factors. Separated by pre- and posttrauma, these include emotional, environmental, and genetic or physiological factors. Pretraumatic emotional factors include temperamental or psychiatric problems. Environmental factors include socioeconomic status, education level, and previous exposure to trauma. Genetic factors include gender and age. Inclusion of these elements is based on research that indicates factors such as age (Green & Solomon, 1995), gender (Rubonis & Bickman, 1991), ethnicity (Perilla, Norris, & Lavizzo, 2002), socioeconomic status (Bolin, 1986; Epstein, Fullerton, & Ursano, 1998), and marriage and familial status (Gleser, Green, & Winget, 1981; Solomon & Smith, 1994) can be predictive of survivor mental health outcomes. For example, racial/ethnic minority groups, females, younger adults, and individuals with a history of trauma often do not fare as well as their counterparts (Green et al., 1990; Norris & Elrod, 2006). It is important to note that these populations are also more frequently exposed to such stressors as rape, domestic violence, and acculturative stress.

Cultural Considerations

In addition to the risk and prognostic factors described previously, counselors should also carefully consider culture-related variation in the type of exposure, severity, and clinical expression of symptoms as well as the ongoing sociocultural context in relation to the client's diagnosis. Counselors must not forget that clinical presentation of symptoms is culturally specific and may significantly affect clinical expression, particularly with respect to avoidance/numbing and somatic symptoms (Hinton & Lewis-Fernández, 2010). For example, post-9/11 studies of Latino Americans found higher rates of panic attacks (13.4% to 16.8%), a risk factor for PTSD, compared with non-Latinos (5.5%; Hinton & Lewis-Fernández, 2010). This can primarily be explained by ataque de nervios (attack of nerves), a relatively common manifestation of distress among Latino Americans. Commonly reported symptoms include uncontrollable shouting, attacks of crying, and trembling. Also common are dissociative symptoms; seizure-like or fainting episodes and suicidal gestures are also prominent. Moreover, there is a cultural perception among some Latino Americans that older members of the community need to always maintain control of their emotions; this may account for instances of dissociation regarding emotional responses. For example, when asked about emotional responses to trauma, some Latino clients will respond “ese no era yo,” which translates to “that was not me” (Lewis-Fernández, Guarnaccia, Patel, Lizardi, & Diaz, 2005). Other examples include mental health clinicians working with Cambodians who experienced the torture and brutality inflicted by the Khmer Rouge regime (Van de Put & Eisenbruch, 2004). Some of the survivors described themselves as “thinking too much” (Van de Put & Eisenbruch, 2004, p. 137), which later was described as “Cambodian sickness” (p. 137). Although this study was conducted in the early 1980s, clinicians later noted their symptoms bore similarities to PTSD (Van de Put & Eisenbruch, 2004). Studies such as these reveal how imperative it is for counselors to develop multicultural expertise when working with trauma survivors and to include cultural considerations in all diagnostic assessments.

Differential Diagnosis

PTSD cannot be diagnosed if symptoms are present for less than 1 month. Instead, a diagnosis of acute stress disorder is made if symptoms are present for less than a month. Adjustment disorders should be assigned for clients who have experienced traumatic stress but do not express all other diagnostic criteria for a diagnosis of PTSD or, conversely, if a client presents with PTSD criteria but the stressor is not extreme enough to meet Criterion A (e.g., divorce, losing one's job, or business difficulties). Counselors should also consider other anxiety, depressive, dissociative, or psychotic disorders or traumatic brain injury. In terms of comorbid diagnoses, clients with PTSD are 80% more likely to meet diagnostic criteria for other psychiatric diagnosis (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Substance use disorder and conduct disorders are common and, among those who have experienced traumatic brain injury, co-occurrence of PTSD is 48%. Comorbidity is also high in children with PTSD, with ODD and separation anxiety disorder most frequently seen. Finally, counselors should look for neurocognitive disorders because clients who experience head injuries may experience a number of overlapping symptoms (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for PTSD: 309.81 (F43.10); however, counselors must indicate whether the diagnosis is for an adult or for a child under 6 in the written name of the disorder. Counselors may also select two specifiers, as applicable, for both adults and children under 6 years old. The first specifier indicates whether an individual has persistent and recurrent symptoms of dissociation. When indicating with dissociative symptoms, counselors will also identify a subtype of depersonalization or derealization. The specifier subtype will be indicated in the written name of the disorder, for example, 309.81 (F43.10) PTSD for children 6 years and younger, with dissociative symptoms, depersonalization. The second specifier for PTSD is with delayed expression, formerly known as delayed onset. Whereas the typical course of symptoms begins within the first 3 months, this newly renamed specifier recognizes that there may be a delay of months or even years before full criteria for PTSD are met. For counselors, this means that in the aftermath of the trauma, an individual may meet the criteria for acute stress disorder (see next section) rather than PTSD. There are no codes assigned to either of these specifiers. If panic attacks are present with PTSD, counselors may add the specifier with panic attacks.

Diagnostic Criteria for PTSD 309.81 (F43.10)

The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

1. Exposure to actual or threatened death, serious injury, or sexual violation, in one (or more) of the following ways:
   1. Directly experiencing the traumatic event(s).
   2. Witnessing, in person, the event(s) as it occurred to others.
   3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
   4. 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).

      Note: Criterion A.4. does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
   1. 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.

   2. 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.

   3. 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.

   4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
   5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
3. 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:
   1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
   2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about, or that are closely associated with, the traumatic event(s).
4. 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:
   1. 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).
   2. 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”).
   3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individuals to blame himself/herself or others.
   4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
   5. Markedly diminished interest or participation in significant activities.
   6. Feelings of detachment or estrangement from others.
   7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
5. 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:
   1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
   2. Reckless or self-destructive behavior.
   3. Hypervigilance.
   4. Exaggerated startle response.
   5. Problems with concentration.
   6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
6. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
7. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

   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:

   1. 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).
   2. 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).

Posttraumatic Stress Disorder for Children 6 Years and Younger

1. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence, in one (or more) of the following ways:
   1. Directly experiencing the traumatic event(s).
   2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.

      Note: Witnessing does not include events that are witnessed only in electronic media, television, movies or pictures.

   3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.
2. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
   1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

      Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

   2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

      Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.

   3. Dissociative reactions (e.g., flashbacks) in which the child 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.) Such trauma-specific re-enactment may occur in play.
   4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
   5. Marked physiological reactions to reminders of the traumatic event(s).
3. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

   Persistent Avoidance of Stimuli

   1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
   2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).

   Negative Alterations in Cognitions

   3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
   4. Markedly diminished interest or participation in significant activities, including constriction of play.
   5. Socially withdrawn behavior.
   6. Persistent reduction in expression of positive emotions.
4. 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:
   1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
   2. Hypervigilance.
   3. Exaggerated startle response.
   4. Problems with concentration.
   5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
5. The duration of the disturbance is more than 1 month.
6. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior.
7. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

   Specify whether:

   With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

   1. 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).
   2. 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) 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).

From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, pp. 271–274. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission.)

Note

The dissociative and preschool subtypes are not mutually exclusive. An individual can be diagnosed with both the preschool and dissociative subtypes if criteria for both are met. In a forensic setting, it is recommended that the diagnosis of PTSD only be used when the individual has directly experienced the event (Frances, 2013).

Case Example

Officer Teixeira was referred to mental health support services by her husband, who is concerned about her “unpredictable mood swings” and nightmares. He stated these have been going on for about 9 months and seem to be getting worse. In addition, although no formal action has been taken, Officer Teixeira has had two complaints of using unwarranted force in apprehending offenders. When she comes into counseling, she reports she is seriously at risk of losing her current position. When asked if there are any recent events that might have contributed to her rapid change in behavior, she states she just hasn't been herself since one “horrific case” that took place 9 months ago involving a teenage girl.

Officer Teixeira vividly recalls the details of this case. “She was only 15 when she was attacked by a group of men on the way home from school. They took turns screaming abuse at her and then they each raped her. Finally, they tried to stab her to death and would almost certainly have succeeded had we not arrived on the scene. I don't know what is worse, the fact that this happened to her or the fact that this is by no means the worse case I have seen.”

She reports being unable to keep the memories of the attack out of her mind. At night, she has terrible dreams of rape and often wakes up screaming. She has had significant difficulty policing her route, especially those areas in which she has seen violence. Because of this, she has volunteered to take a desk job, something she never thought she would do. She also avoids any cases in which the victims have been raped, beaten, or abused. Despite these actions, she still feels as if her emotions are numbed and that she has no real future in the police force. At home, she is anxious, tense, and easily startled. She is unable to concentrate on anything and reports feeling helpless and shamed that she can't do more to help these victims.

Diagnostic Questions

1. Do Officer Teixeira's presenting symptoms meet the criteria for PTSD?
2. Which symptom(s) led you to select that diagnosis?
3. What rule-outs would you consider for Officer Teixeira's case?
4. What other information may be needed to make an accurate clinical diagnosis?

308.3 Acute Stress Disorder (F43.0)

I just don't know what has happened to Marie. A week ago she was completely normal, then all of a sudden she is a mess! Ever since she saw that apartment on fire she has been a complete wreck. She can't sleep, she can't work, and she seems like she is in a daze all the time.—Ronald (Marie's husband)

Introduced in the DSM-IV (APA, 1994), acute stress disorder identifies individuals experiencing acute stress responses, as opposed to transitory stress, as a result of exposure to a traumatic event. The inclusion of acute stress disorder was a major diagnostic landmark in the early 1990s because, for nearly a century, the presentation of trauma-like symptoms was referred to only in military populations. Terms such as “shell shock,” “war hysteria,” or “war neurosis” (Van der Kolk, McFarlane, & Weisaeth, 1996) were commonly used to describe soldiers' reactions to combat.

In addition to identifying acute stress reactions, the overarching goal of acute stress disorder in the DSM-IV-TR was to identify people who may be at risk for PTSD. More recent studies, however, have questioned the capacity of acute stress disorder to sufficiently identify persons at risk for PTSD (Bryant, Friedman, Spiegel, Ursano, & Strain, 2011). Therefore, counselors should not assume that acute stress disorder is a predictor of PTSD and instead use the criteria presented to help identify acute stress reactions and people who may benefit from early intervention. Research that acute stress disorder does not necessarily predict PTSD as well as evidence that acute posttraumatic reactions are exceedingly heterogeneous fueled changes to acute stress disorder in the DSM-5.

Major Changes From DSM-IV-TR to DSM-5

As is the case with PTSD, the exposure criterion (Criterion A) for acute stress disorder has changed from DSM-IV-TR to DSM-5. A diagnosis of acute stress disorder now requires that exposure to an extreme stressor must meet the following criteria: experiencing the event directly; witnessing the event in person; learning that an event occurred to a close family member or friend; or having repeated, first-hand experience with trauma that is not the result of non-work-related media, pictures, television, or movies (APA, 2013a). As with PTSD, the DSM-5 has expanded Criterion A for acute stress disorder to include repeated or extreme exposure and dropped the requirement for an emotional response of fear, helplessness, or horror.

Because of evidence that acute posttraumatic reactions are significantly varied and that the DSM-IV-TR's emphasis on dissociative symptoms was overly restrictive, acute stress disorder now requires the presence of nine out of 14 symptoms within five categories (APA, 2013a). There is no longer a requirement for individuals to have three or more dissociative symptoms. These categories, which do not differ from those associated with PTSD, include intrusion, negative mood, dissociative, avoidance, and arousal. Whereas these symptoms have not radically changed in the DSM-5, removing the requirement for dissociative symptoms represents a significant change to the diagnostic criteria and the way in which counselors conceptualize acute stress reactions.

Since the inclusion of acute stress disorder in the DSM, there have been many concerns regarding the dissociative requirements. First, results from research regarding dissociative symptoms as a predictor of PTSD are not conclusive (Breh & Seidler, 2007; Bryant et al., 2011; van der Velden et al., 2006). Second, requiring dissociative symptoms has the potential for disregarding other high-risk persons from being identified, thus limiting services that may be available (Bryant, 2003; Bryant et al., 2011). Third, there is significant literature that highlights dissociative symptoms as a common transient stress response not indicative of psychopathology (Bryant, 2007; Bryant et al., 2011). This argument is also applicable to arousal, which is often observed as a normal stress response and not pertinent to either acute stress disorder or PTSD.

Like other modifications made to the DSM-5, revised criteria for this disorder more closely match the definition of acute stress reaction in the ICD-10-CM. This more comprehensive description of acute stress is believed to be more useful because the focus is on symptoms—rather than specific clusters—that may warrant intervention (e.g., sleep disturbances) but do not necessarily predict PTSD. The ICD-10-CM goes further to claim that acute stress reactions cannot be categorized into specific response sets (Bryant et al., 2011); therefore, clusters are not useful in the detection of acute posttraumatic stress.

Essential Features

The clinical presentation for acute stress disorder is equivalent to PTSD with two exceptions. First, symptom duration of acute stress disorder is more than 3 days but less than 1 month (APA, 2013a). Second, acute stress disorder does not require symptom clusters. Although clinical presentation varies from person to person, it is not uncommon for those diagnosed with acute stress disorder to have some form of reexperiencing (e.g., flashbacks) or hypervigilance. Detachment or strong reactivity, whether physiological or emotional, is typical when survivors are exposed to reminders of the event. Others can experience reactivity in the form of heightened emotional responses, such as anger, aggression, grief, or problems with concentration (Bryant et al., 2011). Because of the short duration, acute stress disorder has no specifiers; it can be diagnosed in both children and adults.

Special Considerations

Recognizing the heterogeneity of stress responses among individuals, the DSM-5 diagnosis of acute stress disorder serves to help practitioners differentiate between transient stress responses, which are normal, and acute stress reactions, which may require clinical attention. Counselors must remember that strong emotional, behavioral, cognitive, physiological, and spiritual responses are common among survivors of traumatic events. Although these responses vary significantly from individual to individual, feelings of distress are common and are often normal reactions to a catastrophic event. Differentiating what is a normal reaction from an abnormal one can help counselors better determine which clients may require interventions or, in some cases, be at risk for developing PTSD.

Cultural Considerations

Children and adolescents who were diagnosed with acute stress disorder have been found to have a greater range of emotional difficulties when they experienced a trauma (Salmond et al., 2011). There may also be a difference in the level or duration of trauma examined in Western and non-Western studies. Western studies often focus on one-time events such as an accident or some similar event in which the sample is selected from a hospital, whereas many non-Western studies tend to focus on events that might be ongoing and do not have a specific start and stop time. The situations and environments between Western and non-Western studies are likely to lend themselves to looking at trauma from different perspectives (Bryant et al., 2011).

Differential Diagnosis

Counselors who work with clients who have experienced a brain injury in the context of the traumatic event will need to ensure symptoms are not better accounted for by a diagnosis of neurocognitive disorder attributable to traumatic brain injury. Panic attacks are not uncommon in clients who present with acute stress. If these attacks are unexpected and there is considerable anxiety about future attacks, then counselors will want to consider whether a diagnosis of panic disorder better accounts for the client's symptom profile.

It is also important to consider both duration of symptoms and the type of stressor when diagnosing acute stress disorder. In doing so, counselors must consider whether symptoms have been present for more than 1 month, so as to a rule out PTSD. Counselors must also consider whether the associated stressor meets the criteria for acute stress disorder as opposed to an adjustment disorder. The diagnosis of adjustment disorder is used when the stressor does not meet Criterion A for exposure to actual or threatened death, serious injury, or sexual violence. For example, a person losing his or her job would not meet Criterion A for acute stress disorder. Acute stress symptoms (as described in Criterion B) may be more appropriately diagnosed as an adjustment disorder when an individual does not meet or exceed the symptom profile for acute stress disorder. This is especially true for anger, guilt, and depressive symptoms, which are common to both acute stress disorder and adjustment disorders (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for acute stress disorder: 308.3 (F43.0). There are no specifiers associated with this disorder; however, counselors may add with panic attacks if the client experiences panic attacks concurrent with acute stress disorder.

Case Example

Vanessa, a 46-year-old television reporter, was part of a small group of journalists who were chosen to witness an execution by lethal injection. For several years, she had been following stories of capital punishment. This story was very personal to her, because she had interviewed members of the victim's family and covered their experiences as the inmate approached execution.

When asked to describe the experience, she stated it was ghastly. “His face turned an ash color, then purple. He seemed to be gasping for air and grimacing. At one point his body convulsed. It took approximately 20 minutes. All of which I will never forget.” Vanessa reported she was hoping she could remain objective since she was a reporter and had been covering capital punishment for quite some time.

Vanessa reported that since the execution nearly 2 weeks ago, she has had problems concentrating on her work. She can't stop thinking about the execution and finds herself replaying the scene where the person grimaced over and over in her mind. She has felt detached, almost like she was in a dream watching herself. She has problems sleeping and also problems getting along with her husband. “He just doesn't understand that I need to be left alone right now.”

Diagnostic Questions

1. Do Vanessa's presenting symptoms meet the criteria for a stress disorder? If so, which disorder?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select that diagnosis?
3. Would Vanessa be more accurately diagnosed with an adjustment disorder? If so, why? If not, why not?
4. What rule-outs would you consider for Vanessa's case?
5. What other information may be needed to make an accurate clinical diagnosis?

309. _ _ Adjustment Disorders (F43. _ _)

Two months ago was when it happened. My department announced budget cuts, and five out of eight of us were asked to leave. After 13 years I was just asked to go. No party, no compensation package, not even a good-bye. I don't know what I am going to do. I can't seem to do anything now; even getting out of bed is useless. I just sit around all day and cry. The rejection is unbearable. Getting another job and even being able to pay my mortgage just seems hopeless. —Patrick

Introduced in the DSM-III (APA, 1980) to describe individuals who did not meet the criteria for a mental disorder but experienced marked distress and impairment because of a life stressor, adjustment disorders focus on individuals who have difficulty coping with a particular source of stress. The stressor can include major life changes, such as retirement or going to school, or loss of something, such as the ending of an important relationship. Events that do not meet the criteria for acute stress disorder or PTSD but still cause marked distress, such as a business crisis or marital problems, are also included.

Major Changes From DSM-IV-TR to DSM-5

Previously listed as a separate chapter in the DSM-IV-TR, adjustment disorders are now integrated in the DSM-5 with other disorders in which an identifiable stressor precedes symptom onset. What differentiates adjustment disorders from other stressor-related disorders is that the identifiable stressor is not considered traumatic. The stressor may be a sole occurrence, such as losing one's job or ending a relationship, or may be a continuous set of stressful circumstances, such as relationship or occupational problems. Similar to acute stress disorder, adjustment disorders may be predictive of subsequent impairment. Therefore, the new location of this diagnosis helps increase clinical utility simply by its placement in the DSM-5.

Essential Features

Individuals diagnosed with adjustment disorders have impaired relationships in their personal or occupational life or have stress symptoms that exceed what would be expected as a result of the stressor. Reactions need to be somewhat inflated but temporary, with symptom reduction within 6 months once the stressor and its consequences have been removed.

Note

There is no “normal” reaction to a traumatic event. Counselors must remember that adjusting to life stressors is not indicative of mental illness. This category should only be used when an individual encounters a difficult life event and criteria of marked distress and significant impairment are met.

Adjustment disorders occur at all ages; however, symptomatology differs in children and adolescents. These differences are noted in the symptoms experienced, severity and duration of symptoms, and the outcome. Adolescent symptoms of adjustment disorders are more behavioral, such as conduct problems and temper tantrums, whereas adults experience more depressive symptoms, such as tearfulness and loss of pleasure in previously enjoyed activities.

Special Considerations

A major limitation of the diagnostic criteria for adjustment disorders is the amount of ambiguity within diagnostic criteria. Critics posit that there is too much room for interpretation (Frances, 2013; Paris, 2013). Therefore, counselors need to approach assigning a diagnosis of adjustment disorder with caution. Counselors should also keep in mind that adjustment disorders can accompany many mental disorders as well as medical illnesses. For example, individuals with adjustment disorders often have symptoms of tearfulness, feel loss of hope, and experience a lack of interest in work or social activity. Whereas many of these symptoms mirror MDD, unlike MDD, adjustment disorders are always triggered by an outside stressor and generally go away once the individual has been able to cope with the situation or the stressor has been removed.

Cultural Considerations

Stressors and the signs associated with the stressor will vary on the basis of the client's cultural influences. Individuals who routinely experience a high level of stress may be at greater risk for an adjustment disorder.

Differential Diagnosis

Adjustment disorders can be differentiated from acute stress disorder or PTSD because the stressor does not necessarily include exposure to actual or threatened death, serious injury, or sexual violence (Criterion A for PTSD and acute stress disorder). Counselors also need to consider MDD, personality disorder, or any other mental illness or medical condition that would reduce a client's ability to cope with life stressors. In the event that clients meet criteria for more stringent mental disorders, even in the face of a known stressor, counselors should diagnose the more stringent disorder. Counselors should also consider whether the symptom profile is a normative reaction to an unfortunate event. If the client's reaction is normative and expected, adjustment disorders should not be diagnosed.

Coding, Recording, and Specifiers

There is no diagnostic code for adjustment disorders. Coding and recording are contingent on the counselor choosing one of six specifiers: 309.0 (F43.21) with depressed mood; 309.24 (F43.22) with anxiety; 309.28 (F43.23) with mixed anxiety and depressed mood; 309.3 (F43.24) with disturbance of conduct; 309.4 (F43.25) with mixed disturbance of emotions and conduct; and 309.9 (F43.20) unspecified. Because depressed mood, anxiety, and disturbance of conduct are common to clients diagnosed with adjustment disorders, counselors must assign one of these specifiers to an adjustment disorder diagnosis. If an individual experiences mixed anxiety and depression, the counselor would choose the mixed specifier. Similarly, if an individual (most likely a child or adolescent) experiences mixed disturbance of conduct and emotion, the counselor would indicate these symptoms using the mixed specifier. For reactions that do not meet any of the aforementioned specifiers, the counselors would choose unspecified.

Because adjustment disorders are associated with a known stressor, counselors should also include reference to the stressor by using ICD-9-CM V codes or ICD-10-CM Z codes located in Other Conditions That May Be a Focus of Clinical Attention. For example, an adolescent experiencing depression and anxiety related to an unexpected pregnancy may be diagnosed with “309.28 (F43.23) adjustment disorder with mixed anxiety and depressed mood and V61.7 (Z64.0) problems related to unwanted pregnancy.”

Other Specified and Unspecified Trauma- and Stressor-Related Disorders

Other specified trauma- and stressor-related disorder (309.89 [F43.8]), along with the unspecified criterion (309.9 [F43.9]), replaces the NOS category in the DSM-IV-TR. The other specified category may now be used for diagnosis if the counselor wants to identify the specific reason that the full diagnosis is not met, for example, 309.89 (F43.8) other specified trauma- and stressor-related disorder, ataque de nervios.

The unspecified trauma- and stressor-related disorder (309.9 [F43.9]) diagnosis is used when clients have prominent trauma- and stressor-related symptoms but do not meet criteria for any of the specific disorders listed in this chapter. This diagnosis is also used in situations when the counselor chooses not to specify the reason that the criteria are not met. In either case, symptoms cause clinically significant impairment or distress. This diagnosis is also commonly used when counselors are unable to distinguish whether a medical illness or substance has played a causal role in the manifestation of symptoms.

Note

The ICD-9-CM diagnostic code for unspecified trauma and stressor-related disorder and unspecified adjustment disorder (309.9) is the same.