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.

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.

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).

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).

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.

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.

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).

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.