ORahilly

Report
Kathleen O’Rahilly
Linda Maney
Yenny Montenegro, Mariela Sanchez & Sadia Perveen – contributors

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)

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)

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)

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)

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)

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)
A. Exposure to actual or threatened death, serious
injury or sexual violence in one (or more) of the
following ways:
1. Directly experiencing
2. Witnessing it in person as it occurs
3. Learning that it occurred to a close family member or
close friend (must have been violent or accidental)
4. Experiencing repeated or extreme exposure to aversive
details of the event
(5th ed.; DSM–5; American Psychiatric Association, 2013)
B. Presence of one (or more) of the following intrusion symptoms associated with
the trauma, occurring after the trauma
1. Recurrent involuntary and distressing memories
2. Recurrent distressing dreams with related content
3. Dissociative reactions- feel or act as if event were recurring
4. Intense or prolonged psychological distress to cues which symbolize or
resemble aspects of the event
5. 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
1. Avoiding activities, places, or physical reminders of the event
2. Avoiding people, conversations, or interpersonal situations
(5th ed.; DSM–5; American Psychiatric Association, 2013)
D. Negative alterations in cognitions & mood associated
with the event beginning or worsening after the event ,
evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the event
2. Persistent exaggerated negative beliefs or expectations about
self, world or others
3. distorted cognitions about the cause or consequence of the
event leading to blame themselves or others
4. Persistent negative emotional state
5. Markedly diminished interest in significant activities
6. Feelings of detachment from others
7. Persistent inability to experience positive emotions
(5th ed.; DSM–5; American Psychiatric Association, 2013)
E. Marked alterations in arousal and reactivity
associated with the event evidenced in two (or more)
of the following ways:
1.
2.
3.
4.
5.
6.
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.Disturbance causes
clinically significant distress or impairment in social,
occupational or other functioning
(5th ed.; DSM–5; American Psychiatric Association, 2013)
A. 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
C. Arousal
 Doesn’t include reckless behavior
D. Avoidance or negative alterations in cognition
(5th ed.; DSM–5; American Psychiatric Association, 2013)

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)
Under 6
Over 6
Nightmares
Content need not appear
related
In children over 6 the content
may not be recognizable, but
this diminishes with age
Exposure
Either to self or caregiver
figure
Self, close family, or close
friend
Flashbacks
May occur during play
without appearing
distressing
May occur during play
Inability to remember
trauma
NOT A PART OF
DIAGNOSIS
✓
Self destructive
behavior
NOT A PART OF
DIAGNOSIS
✓
Negative
Cognitions/Avoidance
Need one or the other
Need both
(5th ed.; DSM–5; American Psychiatric Association, 2013)

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)

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)

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)

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)

Now includes
 behavioral reactivity
 heightened arousal

Symptom expression may include
 reckless driving
 risky sexual behavior
 suicidal behavior,
 aggression
(Friedman, M. J. 2013)

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
 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)

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)
DSM-IV
DSM-5
Classification
Anxiety Disorder
Trauma & Stressor Related Disorder
Age Qualifiers
None
Under 6/ Over 6
Subtypes
Symptom Clusters
None, but specify if PTSD includes delayed
onset
Intrusion, Avoidance, & Arousal
Dissociative or Preschool
(Specify if either occurs with delayed onset)
Intrusion, Avoidance, Arousal, Negative Cognitions
Diagnostic Menu
17 symptoms
20 symptoms
Symptoms Explicitly Linked To
Trauma
Traumatic Events
7 symptoms
All 20 symptoms
More ambiguous
More clearly defined
Exposure
Larger amount of qualifying traumas that
could be experienced indirectly
Reduced and clarified indirect exposure events. However,
also now includes learning of traumatic events
Intense Emotional Response
Included as necessary criteria
Not included
Longer Lasting Reflective Thought
Processes
Irritability or Outbursts of Anger
Included as potential symptom
Not included
Included as potential symptom
Broken up so that emotional states and behavioral
reactions were not mixed
Inability To Recall Important
Included as potential symptom
Reclassified as dissociative amnesia
Sleep disturbance, irritable/angry outbursts,
difficulty concentrating, hypervigilance,
exaggerated startle response
Expanded to include behavioral reactivity, reckless
driving, risky sexual behavior, suicidal behavior, and
aggression
Events
Alterations In Arousal
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
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.
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
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 DSMIV 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.
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-disorderptsd/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
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.

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