DSM-5:Trauma-and Stressor-

Related Disorders
Criteria, Changes, and Clinical Implications

Jennifer Sweeton, Psy.D.

Oklahoma City VA Medical Center
Trauma- and Stressor-Related Disorders
1. Posttraumatic Stress Disorder
2. Acute Stress Disorder
3. Adjustment Disorders
4. Reactive Attachment Disorder
5. Disinhibited Social Engagement Disorder
6. Other Specified Trauma- and Stressor-Related
Disorder
7. Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder (proposed
for Section III, a section describing conditions that need
more research)
 PTSD Before
Criterion A1: Person experienced/witnessed/confronted with event where there was threat of or
actual death/serious injury. May also have involved a threat to physical well-being.
Criterion A2: Person responded to event with fear, anxiety, helplessness, or horror.
Criterion B: 1+ re-experiencing symptoms:
Frequently upsetting thoughts or memories about a traumatic event.
Recurrent nightmares.
Acting/feeling as if traumatic event were happening again - flashback.
Distress when reminded of the traumatic event.
Physically responsive (high heart rate or sweating) to reminders of the trauma.
Criterion C: 3+ avoidance symptoms
Avoid thoughts, feelings, conversations about the trauma.
Avoid places or people that remind you of the trauma.
Have difficult time remembering important parts of the trauma.
A loss of interest in important, once positive, activities.
Feeling distant from others.
Difficulties having positive feelings, such as happiness or love.
Sense of foreshortened future.
Criterion D: 2+ hyperarousal symptoms
Having a difficult time falling or staying asleep.
Feeling irritable, having anger outbursts.
Having difficulty concentrating.
Feeling constantly on guard or like danger is lurking around every corner.
Being jumpy or easily startled.
Criterion E: 1+ month
Criterion F: Interferes with life/functioning
 PTSD After Criteria A + B
CHANGES TO CRITERION A:
1. Criterion A1 is expanded:

Trauma involves actual or threatened event, including:

1. Death
2. Serious injury
3. Sexual violence

Four types of exposure

1. Directly experienced
2. Witnessed
3. Learned happened to a loved one (must be accidental or violent)
4. Repeated, extreme exposure to details (first responders, police media exposure doesnt count)

2. Criterion A2 (Person responded to event with fear/anxiety/helplessness/horror) is removed.

CHANGES TO CRITERION B:

Exact same 5 symptoms.

Notable revisions
B1: Memories
Versus DSM-IV recollections (images, thoughts, perceptions)
B3: Flashbacks
Emphasis on dissociation and continuum of reactions
 PTSD After Criteria C + D
CRITERION C CHANGES:

Numbing separated from avoidance.

Same 2 sx as DSM-IV
C1: Avoid memories, thoughts, feelings
C2: Avoid external reminders
Addresses problematic ambiguity in DSM-IV
Conversations moved from C1 to C2 to create clear distinction between internal and
external stimuli

CRITERION D CHANGES (most heavily revised cluster):

Now called Negative alterations in cognition and mood

Numbing symptoms from DSM-IV plus two new symptoms
D1: Amnesia (not due to TBI or intoxication)
D2:Negative beliefs (broader version of previous foreshortened future symptom)
D3: Distorted cognitions and blame (from cognitive model of PTSD think stuck
points)
D4: Negative emotions (fear, horror, anger, guilt, shame)
D5: Diminished interest
D6: Detachment or estrangement
D7: Inability to experience positive emotions
 PTSD After Criteria E-H
CHANGES TO CRITERION E:
Cluster is now called Arousal and Reactivity used to be hyperarousal cluster (Criterion D)
Similar to DSM-IV but with one new symptom:
E1: Irritable behavior and angry outbursts
E2: Reckless or self-destructive behavior (new emphasis on behavior). Ex: reckless driving, excessive
alcohol use, suicidal behavior
E3: Hypervigilance
E4: Exaggerated startle
E5: Problems with concentration
E6: Sleep disturbance

CHANGES TO CRITERIA F-H:

None!
Changes to PTSD in DSM-5
PTSD was removed from anxiety disorders; trauma is heterogeneous, and response
may involve anger, dissociation, etc.

Now have four symptom clusters: avoidance, re-experiencing, persistent negative

changes in mood and cognition, and arousal.

Criterion A2 removed (no fear, helplessness, or horror required)

Criterion A1 (now just A) clarified

Avoidance and numbing symptoms split

Three new symptoms added

Several symptoms revised

Separate PTSD criteria for children 6 or younger

Dissociative subtype added

 PTSD After
Criterion A: Exposure to 1+ event(s) that involved death/threatened death, actual/threatened serious injury, or
threatened sexual violation. Events were experienced in 1+ following ways:
The event was experienced by the person.
The event was witnessed by the person as it occurred to someone else.
The person learned about event where relative/friend experienced actual or threatened violent or accidental death.
The person experienced repeated exposure to distressing details of an event.
Criterion B: 1+
1. Unexpected/expected reoccurring, involuntary, intrusive upsetting memories of trauma
2. Repeated upsetting dreams where the content of dreams related to the trauma
3. Dissociation (ex: flashbacks) where person feels as though the trauma is happening again
4. Strong/persistent distress upon exposure to cues inside or outside of person's body connected to trauma
5. Strong bodily reaction upon exposure to a reminder of the trauma
Criterion C: Frequent avoidance of reminders associated with trauma, as demonstrated by 1+:
1. Avoidance of thoughts, feelings, or physical sensations that bring up memories of trauma
2. Avoidance of people, places, conversations, activities, objects, situations that bring up memories of trauma
Criterion D: 3+ negative changes in thoughts/mood that occurred/worsened following trauma:
1. The inability to remember an important aspect of the traumatic event
2. Persistent, elevated negative evaluations about one's self, others, or the world
3. Elevated self-blame or blame of others about the cause or consequence of a trauma
4. A negative emotional state (for example, shame, anger, fear) that is pervasive
5. Loss of interest in activities that one used to enjoy
6. Feeling detached from others
7. The inability to experience positive emotions (for example, happiness, love, joy)
Criterion E: 3+ changes in arousal that started or worsened following a trauma:
1. Irritability or aggressive behavior
2. Impulsive or self-destructive behavior
3. Feeling constantly "on guard" or like danger is lurking around every corner
4. Heightened startle response
5. Difficulty concentrating
6. Problems sleeping
Criteria F-H: Same as DSM-IV
 PTSD Subtypes
Preschool Subtype (under 6 years old) - Relative to adult PTSD:
No changes to Criteria A, B, C symptoms
Criterion B no change (1 Sx needed)
Need only 1 symptom from either Criterion C or D
Criterion D: Contains 4 out of 7 of the adult symptoms. No:
Amnesia
Persistent blame of self/other
Sense of foreshortened future (now persistent, elevated negative evaluations about one's self,
others, or the world)
Criterion E: Contains 5 out of 6 of the adult symptoms. No:
Reckless behavior

Dissociative Subtype:
When PTSD includes significant dissociative symptoms.
Feeling detached from ones own mind/body/experience, or
World seems unreal/dreamlike
Symptoms not due to substance use or medical condition
Applies to both age groupings
 PTSD Changes Implications
More restrictive, more difficult to diagnose?
Criterion A: New definition addresses ambiguity of confronted with in DSM-IV.
Definition is narrower, more restrictive perhaps?
D7 is more specific than the previous version, which mentioned overall restricted
range of affect.
Broader, easier to diagnose?
However, less restrictive now that A2 has been deleted.
D4 is non-specific, just mentions overall negative emotions. Concern about overlap
with anger/angry outbursts described in Criterion E.
The criteria has been broadened to include other emotional reactions to trauma
than fear.
According to NCPTSD: National estimates of PTSD prevalence suggest that DSM-5
rates were slightly lower than DSM-IV. Revision of Criterion A1 in DSM-5 narrowed
qualifying traumatic events such that the unexpected death of family or a close friend
due to natural causes is no longer included. Research suggests this is the greatest
contributor (>50%) to discrepancy for meeting DSM-IV but not DSM-5 criteria.
PTSD assessment measures (CAPS, PCL) being revised by the NCPTSD.
Possible treatment implications symptoms align nicely with cognitive theory of PTSD
 PTSD Checklist for DSM-5 = PCL-5
20 items, which match DSM-5 criteria
PCL-5 most closely resembles PCL-IV (PCL-S)
Symptoms rated on scale 0-4, not 1-5
Three versions of the PCL-5:
Without Criterion A
With Criterion A
With Life Events Checklist for DSM-5 (LEC-5) and extended Criterion A
Currently no PCL-5 version corresponding to PCL-M or PCL-C, but this is in the
works.
Cut scores TBD. Recommended to consider symptom scores of 2 as moderate.
 PCL-5

PCL-5 Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience.
Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been
bothered by that problem in the past month. In the past month, how much were you bothered by:

Not at all = 0; A little bit = 1; Moderately = 2; Quite a bit = 3; Extremely = 4

1.Repeated, disturbing, and unwanted memories of the stressful experience?

0 1 2 3 4
2.Repeated, disturbing dreams of the stressful experience?
0 1 2 3 4
3.Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were
actually back there reliving it)?
0 1 2 3 4
4.Feeling very upset when something reminded you of the stressful experience?
0 1 2 3 4
5.Having strong physical reactions when something reminded you of the stressful experience (for example,
heart pounding, trouble breathing, sweating)?
0 1 2 3 4
6.Avoiding memories, thoughts, or feelings related to the stressful experience?
0 1 2 3 4
7.Avoiding external reminders of the stressful experience (for example, people, places, conversations,
activities, objects, or situations)?
0 1 2 3 4
8.Trouble remembering important parts of the stressful experience?
0 1 2 3 4
9.Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts
such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely
dangerous)?
0 1 2 3 4
 Clinician-Administered PTSD Scale for
DSM-5 (CAPS-5)

Contains 30 items which correspond to DSM-5 criteria.

Prompts were revised for DSM-5 and readability
Improved sequence of prompts
Now top to bottom instead of left to right (simplifies administration, helps organize
note-taking)
Interim ratings of Frequency and Intensity combined into single 0-4 Severity rating
 CAPS-5 Item 1:

In the past month, have you had any unwanted

memories of (EVENT) while you were awake, so not
counting dreams? [Rate 0=Absent if only during dreams] 0 Absent
1 Mild / subthreshold
How does it happen that you start remembering
(EVENT)?
2 Moderate / threshold
[If not clear:] (Are these unwanted 3 Severe / markedly elevated
memories, or are you thinking about 4 Extreme / incapacitating
[EVENT] on purpose?) [Rate
0=Absent unless perceived as
involuntary and intrusive]

How much do these memories bother you?

Are you able to put them out of your mind and
think about something else?

Circle: Distress = Minimal Clearly Present Pronounced

Extreme

How often have you had these memories in the past

month? # of times __________

Key rating dimensions = frequency / intensity of distress

Moderate = at least 2 X month / distress clearly present,
some difficulty dismissing memories
Severe = at least 2 X week / pronounced distress,
considerable difficulty dismissing memories
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-Related
Disorder
Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
Changes to AST in DSM-5
Criterion A changes same as PTSD updates A1 is clarified; A2 is deleted.
It was concluded that DSM-IVs AST criteria was too heavily focused on dissociation,
thus, dissociation is no longer required for diagnosis.
Person now must meet any 9 of the 14 dissociation, avoidance, arousal, negative
mood, and/or intrusion symptoms.
No one symptom of the 14 is required for a diagnosis.
 AST After
Criterion A. same as ptsd
Criterion B. 9+ symptoms
(1) Subjective sense of numbing, detachment from others, or reduced responsiveness to events
(2) An altered sense of the reality of ones surroundings or oneself (e.g., seeing oneself from
anothers perspective, being in a daze, time slowing)
(3) Inability to remember at least one important aspect of the traumatic event
(4) Spontaneous or cued recurrent, involuntary and intrusive distressing memories of the event
(5) Recurrent distressing dreams related to the event
(6) Dissociative reactions in which the individual feels or acts as if the traumatic event were
recurring
(7) Intense or prolonged psychological distress or physiological reactivity at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event
(8) Persistent avoidance of thoughts, conversations, or feelings that arouse recollections of the
trauma
(9) Persistent avoidance of activities, places, or physical reminders that arouse recollections of
trauma
(10) Sleep disturbance (e.g., difficulty in falling asleep, restless sleep, or staying asleep)
(11) Hypervigilence
(12) Irritable, angry or aggressive behavior
(13) Exaggerated startle response
(14) Agitation or restlessness
Criterion C. Duration 3+ or more days and less than 1 month after the traumatic event
Criterion D. causes clinically significant distress or impairment
Criterion E. Disturbance not due to direct physiological effects of a substance or a general medical
condition, and is not better accounted for by brief psychotic disorder
AST Changes - Implications
No more emphasis on dissociation means the diagnosis is now broader.
New changes may better predict PTSD due to dropping dissociation requirement .
Studies find that one reason ASD does not adequately predict PTSD is the old
dissociation symptom requirement, which resulted in us overlooking many who
are at high risk for developing PTSD.
Recognizes the heterogeneity of early posttraumatic stress responses (does not
require specific symptom clusters for diagnosis).
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-Related
Disorder
Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
Changes to Adjustment Disorders
in DSM-5
Reconceptualized as a stress-response syndrome.
No longer a catch-all category.
***Stressors are not necessarily traumatic!
Diagnose when person does not meet criteria for another disorder in the DSM-5,
Subtypes did not change in DSM-5
 Adjustment Disorders After
The development of emotional or behavioral symptoms in response to an identifiable stressor(s)
occurring within 3 months of the onset of the stressor(s).
These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
Marked distress that is out of proportion to the severity or intensity of the stressor, taking into
account the external context and the cultural factors that might influence symptom severity and
presentation.
Significant impairment in social, occupational, or other important areas of functioning.
The stress-related disturbance does not meet the criteria for another mental disorder and is not
merely an exacerbation of a preexisting mental disorder.
The symptoms do not represent normal bereavement.
Once the stressor or its consequences have terminated, the symptoms do not persist for more than
an additional 6 months.
Specify:
With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
With mixed anxiety and depressed mood: A combination of depression and anxiety is
predominant.
With disturbance of conduct: Disturbance of conduct is predominant.
With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression,
anxiety) and a disturbance of conduct are predominant.
Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of
adjustment disorder.
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-Related
Disorder
Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
 Changes to Reactive Attachment Disorder
in DSM-5
Now split into two disorders, based on DSM-IV subtypes.
Reactive attachment disorder
Disinhibited social engagement disorder.
APA: Both of these disorders are the result of social neglect or other situations that limit
a young childs opportunity to form selective attachments. Although sharing this etiological
pathway, the two disorders differ in important ways.
APA: Reactive attachment disorder more closely resembles internalizing disorders; it is
essentially equivalent to a lack of or incompletely formed preferred attachments to
caregiving adults. There is a dampened positive affect
Characterized by:
Emotionally withdrawn behavior
Social/emotional disturbance
Exposure to extremes of insufficient care
Social neglect/deprivation, repeated changes in caregivers, rearing in unusual settings
Reactive Attachment Disorder After
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult
caregivers, manifested by both of the following:
The child rarely or minimally seeks comfort when distressed.
The child rarely or minimally responds to comfort when distressed.
B. Persistent social and emotional disturbance characterized by 2+ of the following:
Minimal social and emotional responsiveness to others.
Limited positive affect.
Episodes of unexplained irritability, sadness, or fearfulness that are evident even
during nonthreatening interactions with adult caregivers.
C. Child has experienced pattern of extremes of insufficient care as evidenced by 1+:
Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort, stimulation, and affection met by caregiving adults.
Repeated changes of primary caregivers that limit opportunities to form stable
attachments.
Rearing in unusual settings that severely limit opportunities to form selective
attachments .
Care in Criterion C is presumed to be responsible for the disturbed behavior in
Criterion A.
The criteria are not met for autism spectrum disorder.
The disturbance is evident before age 5 years.
The child has a developmental age of at least 9 months.
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-Related
Disorder
Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
Changes to Disinhibited Social Engagement
Disorder in DSM-5
APA: Disinhibited social engagement disorder more closely resembles ADHD: It may
occur in children who do not necessarily lack attachments and may have established or
even secure attachments.
More externalizing.
Characterized by:
Reduced/absent reticence when interacting with unfamiliar adults
Behaviors not limited to impulsivity but include socially disinhibited behavior
Exposure to extremes of insufficient care
Disinhibited Social Engagement Disorder After
A. A pattern of behavior in which a child actively approaches and interacts with
unfamiliar adults and exhibits at least two of the following:
Reduced or absent reticence in approaching and interacting with unfamiliar adults.
Overly familiar verbal or physical behavior (that is not consistent with culturally
sanctioned and with age-appropriate social boundaries).
Diminished or absent checking back with adult caregiver after venturing away, even
in unfamiliar settings.
Willingness to go off with an unfamiliar adult with minimal or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but include
socially disinhibited behavior.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by
at least one of the following:
Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort, stimulation, and affection met by caregiving adults.
Repeated changes of primary caregivers that limit opportunities to form stable
attachments.
Rearing in unusual settings that severely limit opportunities to form selective
attachments .
The care in Criterion C presumed to be responsible for disturbed behavior in
Criterion A.
The child has a developmental age of at least 9 months.
Disinhibited Social Engagement and Reactive
Attachment Disorders Changes - Implications
Distinguishing between the two disorders may lead to more helpful and specific
treatment planning.
Given the new distinction, research on the two disorders will likely increase, and
improve (may be fewer discrepant findings, etc.).
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-
Related Disorder
Unspecified Trauma- and Stressor-Related
Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
Other Specified Trauma- and Stressor-
Related Disorder
Cause clinically significant distress or impairment in functioning predominate, but full
criteria for another disorder in this category is not met.
Ex:
AD lasts 6+ months without prolonged duration of stressor
AD does not begin for 3+ month after the stressor
Subthreshold PTSD
Persistent complex bereavement disorder
Ataques nervios
Other cultural syndromes
Trauma- and Stressor-Related Disorders
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Other Specified Trauma- and Stressor-Related
Disorder
Unspecified Trauma- and Stressor-
Related Disorder
Persistent Complex Bereavement Disorder
(proposed for Section III, a section describing
conditions that need more research)
 Unspecified Trauma- and Stressor-Related
Disorder
Symptoms characteristic of a trauma- and stressor-related disorder that cause
distress/impairment, but do not meet full criteria for other disorders in this class.
Use this diagnosis for situation when you do not want to, or cannot, specify the
reason(s) that criteria are not met for another disorder. Ex: When there is not
enough information to make a more specific diagnosis (due to a short consult,
emergency room visit, etc).