Trauma and Stressor Related Disorders Trauma and Stressor Related Disorders Additional Content Attribution [MUSIC PLAYING] FEMALE SPEAKER: Well, I just keep thinking what if something happens? I mean I've always had trouble concentrating. But this time, it's different. FEMALE SPEAKER: Different, how? FEMALE SPEAKER: Well, you know how like you were talking on your cell phone or something and it cuts out. You lose the connection. It's kind of like that. My mind just goes blank. And when I'm at the hospital and it happens, I flip out. I could give the patient the wrong medication or something. What if it's early dementia? I mean I've read about that happening. I read an article just the other day about people in their 30s and 40s getting that. That's horrible. FEMALE SPEAKER: It sounds like you're constantly nervous that you'll go blank and that something bad will happen. You mentioned having other symptoms. Like what? FEMALE SPEAKER: Well, at work, my temper. I flip out on patients sometimes and on other nurses. I just freak out. I even started snapping at my daughter. And that has never happened before. FEMALE SPEAKER: Well, I understand. You're feeling anxious. And you're having some temper issues, which are sort of out of character for you. How are things going at home? FEMALE SPEAKER: Well, I'm not sleeping very well at all. One of my favorite things used to be to curl up at night with a book. But I can't concentrate. I have this whole stack of books by my bedside table. I mean they're history books. And I love reading about history. But I haven't even touched them. And my husband got so upset the other day because he brought me this kit for scrap-booking, which is something I used to really enjoy doing. But I just took them back to the store. I could not deal with that either. FEMALE SPEAKER: Well, it seems like you're not finding relaxation in the things that used to enjoy doing. Now, when you returned your husband's gift, you said that you couldn't deal with that. What exactly couldn't you deal with? ©2013 Laureate Education, Inc. 1 Trauma and Stressor Related Disorders FEMALE SPEAKER: The expense. You have no idea what these scrap-making materials cost. I could spend that much in groceries in a week. And I thought-- So that I lie in bed at night at 3:00 AM worrying about, just money, money, money, money, money. And my husband and I both work. We work really long hours. But it's just not enough. We really should have started saving for college. I mean my eldest is going to start college in a few years. And I don't know what we're going to do. We don't have the money. FEMALE SPEAKER: Did you talk to your husband about your concerns? FEMALE SPEAKER: Yeah. Yeah. We talk. Alex, my husband, he's 12 years older than me. I mean we get along fine. But I worry about him. I mean at work for example, he's been up for this really big promotion. But now it looks like he's not going to get it. And his health, he's got a whole history of early heart attacks in his family. And I just worry about that. I mean he hasn't shown any symptoms or anything. But I really, really, worry that one day something might happen to him. I mean the whole thing just feels like a crap shoot. With care reform now, what if they cut back on my hours at work? And what if I lose my job? Doctor, I cannot afford to lose this job. FEMALE SPEAKER: Any idea how long you've been having these symptoms, the lack of concentration, trouble sleeping, problems relaxing? FEMALE SPEAKER: A while. Off and on, I guess. I went to see a counselor when I was in nursing school. I was Ms. Overachiever. I was making straight A's, but I couldn't help but worry that it was never enough. FEMALE SPEAKER:It sounds like you were feeling the pressure of trying to achieve your career goals. Did the counseling help you? FEMALE SPEAKER: Yeah. Yeah. I guess it did. I mean I went for a couple of months. And the counselor had me do this body scan exercise. And he suggested I should start meditating. But who had time to meditate. I was too busy making straight A's. ©2013 Laureate Education, Inc. 2 Trauma and Stressor Related Disorders Trauma and Stressor Related Disorders Additional Content Attribution IMAGES: Images provided by http://www.istockphoto.com/ MUSIC: Creative Support Services Los Angeles, CA Dimension Sound Effects Library Newnan, GA Narrator Tracks Music Library Stevens Point, WI Signature Music, Inc Chesterton, IN Studio Cutz Music Library Carrollton, TX Special Thanks: Fairland Center/Region One Mental Health ©2013 Laureate Education, Inc. 3 Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 Anxiety Disorders, Trauma, and the Obsessive–Compulsive Spectrum Anxiety is as universal as sadness. There are many things to fear in life, and not worrying about them would be a mistake. So at what point can one say that anxiety is irrational? Although the usual guideline is that emotions are excessive when they cause dysfunction, the boundary between normal and pathological anxiety can be arbitrary (Horwitz & Wakefield, 2012). Anxiety is a psychological experience, separated from syndromes with prominent physical symptoms. Yet it has long been known that internalizing disorders often present with unexplained physical distress, particularly in specific cultures and social settings (Gone & Kirmayer, 2010). This may account for the overlap between anxiety and physical symptoms (Simms et al., 2012). Also, in clinical settings, anxiety and depression often coexist. One of the most common presentations of psychological distress in primary care is a mixture of both (Goldberg & Goodyer, 2005). It is not known which is primary, which is secondary, or whether both are manifestations of a common process. Although there is symptomatic overlap between anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive– compulsive disorder (OCD), these conditions have a different clinical presentation and are now in separate sections of the manual. (This chapter discusses all three.) It is not certain that this separation into categories on the basis of overt symptoms is valid, given that family members with one anxiety disorder tend to have another (Bienvenu et al., 2012) and because research on community 144 EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 5 populations shows a strong overlap between all syndromes related to anxiety and internalization (Tambs et al., 2009). Panic Disorder and Generalized Anxiety Disorder DSM-IV described five forms of anxiety disorder (panic, generalized anxiety disorder, OCD, phobia, and PTSD), two of which have now been moved into other groups. It may be worth looking back in history to see how all these distinctions came into use. DSM-II had a category called “anxiety neurosis,” which DSM-III divided into two types. One was more chronic (generalized anxiety disorder or GAD), characterized by constant worry and physical symptoms. The other was more acute (panic disorder), characterized by recurrent attacks. The main reason for this separation was the idea that GAD and panic have different pathological pathways and require different methods of treatment (Klein, 1987; Norton et al., 1995). The clinical picture of panic disorder is one of the classic syndromes in psychiatry. Its definition has not changed in DSM-5. GAD has been retained, but at one point, it was proposed to rename it as “generalized anxiety and worry disorder” (reflecting a key feature: worry about events that are unlikely to happen). Other proposed changes involved a less chronic course (excessive anxiety and worry occurring on more days than not for 3 months or more, instead of 6 months as in DSM-IV), a list of symptoms related more specifically to worry, a set of behaviors associated with worry, and a reduced number of required associated symptoms (one out of four rather than three out of six). Andrews and Hobbs (2010) tested these proposals in community and clinical samples and did not observe increased prevalence. As we have seen, however, even minor changes in wording in DSM manuals can lead to diagnostic “epidemics.” In the end, none of these changes appeared in the final version of DSM-5. EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 146 | Part II Specific D i ag n ose s GAD is still not a precise diagnosis, and it has high levels of comorbidity with other disorders, including phobias, depression, and substance abuse (Stein, 2001). Patients with GAD or major depressive disorder do have different symptom patterns (Kessler et al., 2010), which justifies the decision to separate them. Also, Moffitt et al. (2010), reporting on long-term follow-up studies of children who had been anxious and depressed, found that anxiety and mood problems show longitudinal stability and remain distinct over time. Phobias Phobias are familiar diagnoses. Because the classic picture of a specific phobia need not lead to serious dysfunction, specialists in psychiatry rarely see these cases. Agoraphobia, on the other hand, is not a phobia at all but, rather, a complication of panic disorder (Wittchen et al., 2010). One change in DSM-5 is the removal of the requirement that phobias be recognized by patients who suffer from them as irrational. Not all patients understand that point. But Zimmerman et al. (2010) found that making the change had little effect on diagnosis. Social phobia (now called social anxiety disorder) appears to be common (Davidson et al., 1993). However, given the high prevalence of symptoms of social anxiety and shyness in community populations, this category may be too broadly defined (Wakefield et al., 2005). To give a diagnosis to anyone who has trouble speaking in public or attending a social event could be another example of mission creep (not to speak of disease-mongering). Since antidepressants have been widely promoted for treatment of social anxiety, this diagnosis has opened a lucrative market for the pharmaceutical industry. Some have even suggested that it was invented specifically to market medication to a large number of people previously considered to be normally shy (Lane, 2007). Finally, separation anxiety disorder (formerly “school phobia”) has been moved from the childhood section to the anxiety disorders EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 7 chapter. We need more research about how this syndrome develops and changes in adult life. Posttraumatic Stress Disorder and Acute Stress Disorder These diagnoses are placed by DSM-5 in a separate chapter related to trauma and stress. Yet almost all mental disorders have some relationship to adverse life events. Moreover, disorders considered to be “posttraumatic” also reflect biological predispositions as well as social factors that shape their clinical presentation. The idea that PTSD is one of the few disorders for which we know the etiology is mistaken. Most people who are exposed to trauma do not develop PTSD, and those who do usually have high neuroticism, previous traumas, and prior symptoms (McNally, 2009). PTSD was a new diagnosis in DSM-III, and it has been controversial ever since. The criteria have often been criticized, and they have changed in every edition of the manual. Yet clinicians seem to love this diagnosis, probably because it suggests an etiology. Researchers may be more likely to understand that its causes are highly complex, but practitioners can be tempted by the simplicity of cause and effect. The DSM-5 definition combines a putative cause (a traumatic event) with a set of characteristic symptoms. Criterion A describes the trauma: an event that is life-threatening, could lead to serious injury, or involves sexual violence. Although a subjective reaction of distress is no longer specifically required, “traumas” should be stressors that would be threatening to anyone. However, the door is left open for a much broader concept. DSM-5 allows for directly experiencing the traumatic event, witnessing in person an event occurring to others, learning that a violent or accidental event occurred to a close family member or close friend, or exposure to details of traumatic events in the line of work. An exclusion states that this criterion does not apply to exposure through electronic media, television, movies, or pictures, unless it is work-related. EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 148 | Part II Specific D i ag n ose s Clearly, this definition widens the scope of the “A criterion” and could lead to increased prevalence and increased diagnosis. The question remains: What is meant by the word “traumatic” (Breslau & Kessler, 2001)? It is clear when one experiences a direct threat to one’s own life. But being a bystander or an observer is not clear (Friedman et al., 2011). These problems have affected the validity of research on PTSD ever since the diagnosis was included in DSM-III (Spitzer et al., 2007). DSM-IV criteria were broad, producing a community prevalence as high as 7.8% (Kessler et al., 1995). In short, the most serious concern is that DSM-5 has not narrowed down the definition of a traumatic event. One can only hope that clinicians will use their common sense and not overdiagnose a condition that already suffers from inflated prevalence. Four groups of symptoms characterize PTSD: intrusion (re-experiencing the trauma), avoidance of situations that elicit memories, alterations in cognition and mood (this feature is new in DSM-5), and increased arousal. All symptoms must last more than 1 month. These clinical features of PTSD must be present, and one cannot diagnose it in their absence (which can happen in practice). Moreover, the diagnosis of PTSD describes a heterogeneous syndrome (Rosen & Lilienfeld, 2008). Some cases are prototypical, but as with so many other mental disorders, symptoms vary, and there are no biological markers. Clinicians should keep in mind that the nature of a trauma makes little difference to response (Roberts et al., 2012). There tends to be too much focus on the severity of trauma in clinical practice. Patients who report a trauma may receive a diagnosis whether or not symptoms are actually related to an event. Moreover, the definition of a trauma is not always observed so that divorce or bereavement can sometimes be counted as “traumatic.” With the expansion of PTSD, the majority of the population could end up being considered as “survivors.” McNally (2009) notes that overdiagnosis weakens the concept and fails to focus on its key idea: the psychological impact of severe trauma. Yet even exposure to life-threatening combat in wartime does not predictably lead to PTSD (McNally, 2009). EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 4 9 Another problem concerns the extent to which PTSD is a reaction to trauma as opposed to the uncovering of a temperamental vulnerability to stressful events. PTSD is a syndrome that reflects intrinsic sensitivities as much as adversities. Most people exposed to trauma, even severe trauma, never develop PTSD (Paris, 2000). The most common response to exposure is not mental disorder but, rather, resilience and recovery. In fact, PTSD is as much a consequence of personality as of events. For example, McFarlane (1989) showed that PTSD in firefighters was best predicted by traits of neuroticism prior to exposure rather than by the danger of the fire. The same conclusion has emerged from studies of PTSD in large community samples (Breslau et al., 1991). In summary, the major unsolved problem with PTSD, as with so many other disorders in DSM-5, is an unclear boundary with normality. It is easy to expand a category to the point that it describes phenomena that are not pathological. In reality, life is full of adversity—it never really gives us a break. The conclusion should be that PTSD has suffered from diagnostic inflation. PTSD is reserved for patients disabled by symptoms for months after a negative life event. Prior to 1 month, these reactions constitute an “acute stress reaction,” which is a much more common syndrome. There has always been a gap between reactions to adversity and the characteristic symptoms of PTSD. One cannot entirely blame DSM for that problem. There are political and historical reasons why PTSD has been defined in such a broad way. Like some other categories in psychiatry, it can be used to convey social meaning. The diagnosis carries a powerful emotional punch, and it provides validation for reactions to adversity. Patients may like the diagnosis because suffering from PTSD allows them to consider themselves as victims of circumstance. It is not an accident that the introduction of this diagnosis into the manual came at a time when large numbers of Vietnam veterans were being seen at VA hospitals, creating a need for a diagnostic concept to frame treatment (Young, 1997). But most war veterans do not develop PTSD, and those who seek treatment have other problems. Because of our sympathy for EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 150 | Part II Specific D i ag n ose s these men, rates of disorder in the veteran population have been greatly overestimated, and it was even found that some claimants for benefits on the basis of the diagnosis had never been in combat (McNally, 2003). Young (1997) concluded that many cases were shoehorned into a PTSD diagnosis to justify free treatment for a wide variety of symptoms. In summary, DSM-5 has tinkered with PTSD but has not addressed its fundamental problems. As it stands, the diagnosis fails to consider individual variations in response to life events, and it fails to correct the widely believed but oversimplified and mistaken impression that trauma is the sole or main cause of the disorder. Obsessive–Compulsive Disorder OCD and conditions in the OCD spectrum are now in a separate chapter. Although every psychiatrist sees patients with OCD, it is far from easy to treat (Stein & Fineberg, 2007). The definition has not changed in DSM-5. It describes a syndrome of obsessions and compulsions (most patients have both) that lead to significant dysfunction. The classical picture, in which patients can spend hours on rituals, is easy to diagnose, although the most severe cases present symptoms that seem uncomfortably close to psychosis. OCD is now considered to lie in a spectrum (Fineberg et al., 2010). It includes body dysmorphic disorder, trichotillomania, stereotypic movement disorder (tics), and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). But research on these conditions is thin. For example, although family studies show that all these disorders cluster together (Hollander et al., 2009), more lack spectrum disorders than those who have them. In the OCD spectrum, the decision to add a new diagnosis of “hoarding disorder” (Mataix-Cols et al., 2010) aroused some controversy. This syndrome may not qualify as a separately diagnosable mental disorder because it describes a single symptom EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 11 A nx i ety, Tra um a , O bs es s i v e – C o m p u l si v e | 1 5 1 (previously considered a sign of obsessive–compulsive personality disorder). Media reports have sometimes described patients dying as a result of being trapped in their own hoard, but such cases are rare. Hoarding is common in attenuated forms that have been estimated to affect as many as 5% of the general population (Samuels et al., 2008). Obviously, quite a few people hate to throw things out. (Interest in this problem even inspired a TV “reality” program.) But to diagnose a mental disorder, patients need to be functionally disabled. The DSM-5 definition includes difficulty in parting with possessions, associated with an urge to save them, the accumulation of possessions, and clinically significant distress or functional impairment. Although it may be useful to put this syndrome, which all clinicians see from time to time, in the manual, it remains to be seen whether it deserves separate categorization. Two other conditions have made an entry into this spectrum. Body dysmorphic disorder has been moved from somatic conditions, as has hair-pulling disorder (trichotillomania). Both have some common features with OCD, but no one knows why some people have obsessive thoughts and carry out rituals, whereas others worry about their appearance or pull their hair. This is uncharted territory. In summary, although the deck has been reshuffled, none of the anxiety disorders have been radically revised in DSM-5. (The changes in PTSD criteria do not seem to be major.) This is fortunate because these conditions have not yet been as much a focus of research as mood disorders. We need to know more before making further changes. EBSCO : eBook Collection (EBSCOhost) - printed on 6/12/2018 12:36 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost 
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