Director Mindful Ohio Affiliate Faculty IATP This training is not affiliated with the American Psychiatric Association About Todays Presenter Licensed Supervising Professional Clinical Counselor MH ID: 658877
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Slide1
Trauma and the DSM-5®*
Jamie Marich, Ph.D., LPCC-S, LICDC-CS.Director, Mindful OhioAffiliate Faculty, IATP
*This training is not affiliated with the American Psychiatric Association Slide2
About Today’s Presenter
Licensed Supervising Professional Clinical Counselor (MH)
Licensed Supervising Independent Chemical Dependency Counselor
Member of the American Academy of Experts on Traumatic Stress
Author,
EMDR Made Simple
&
Trauma and the Twelve Steps
Thirteen years of experience working in social services and counseling; includes three years of experience in civilian humanitarian aid in Bosnia-Hercegovina
Specialist in addictions, trauma, abuse, dissociative disorders, performance enhancement, grief/loss, and pastoral counseling
Trained in several specialty interventions for trauma
Creator of the
Dancing Mindfulness
practice Slide3
What led you to this conference?Slide4
Learning Objectives
Define trauma and describe, in a general sense, how unresolved trauma may manifest in clinical settingsList and discuss the diagnoses covered in the new DSM-5® chapter, Trauma and Stressor-Related DisordersArticulate how other diagnoses in the DSM may be better explained by trauma, or exacerbated by the effects of unresolved trauma
Discuss how the new DSM-5® will impact the helping
profession’s
conceptualization of clinical traumaSlide5
TraumaSlide6
“Once you’ve been bitten by a snake, you’re afraid even of a piece of rope.”
-Chinese ProverbSlide7
Large T Trauma vs. small t traumaSlide8
Trauma: Large-T or “Big” T
Examples include:
combat, natural disasters, sexual abuse, assault, other violent
crimes
“Big T” trauma is what the psychological community references in speaking about the PTSD diagnosis. Slide9
DSM-IV-TR Nutshell Definition of PTSD
(Posttraumatic Stress Disorder ) (APA, 2000)
Actual or perceived threat of injury or death - response of hopelessness or horror (Criterion A)
Re-experiencing
of the trauma
Avoidance
of stimuli associated with the trauma
Heightened arousal
symptoms
Duration of symptoms longer than 1 month
Functional impairment due to disturbances Slide10
DSM-5 ® Nutshell Definition of PTSD
(Posttraumatic Stress Disorder ) (American Psychiatric Association, 2013)
Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation: direct experiencing, witnessing (Criterion A)
Intrusion
symptoms (Criterion B)
Avoidance
of stimuli associated with the trauma (Criterion C)
Cognitions and Mood:
negative alterations (Criterion D)
Arousal and reactivity
symptoms (Criterion E)
Duration of symptoms longer than 1 month
Functional impairment due to disturbances Slide11
DSM-IV-TR Criteria: PTSD
The person has been exposed to a traumatic event in which both of the following were present:
The
person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or
others.
The
person's response involved intense fear, helplessness, or
horror.
Note
: In children, this may be expressed instead by disorganized or agitated
behavior.
Slide12
DSM-IV-TR Criteria: PTSD
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
R
ecurrent
and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
(Note
: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed
.)
Recurrent
distressing dreams of the event.
(Note
: In children, there may be frightening dreams without recognizable content
.)
Acting
or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
(Note
: In young children, trauma-specific reenactment may occur.)
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Physiological
reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic
event
.Slide13
DSM-IV-TR Criteria: PTSD
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
Efforts
to avoid thoughts, feelings, or conversations associated with the
trauma.
Efforts
to avoid activities, places, or people that arouse recollections of the trauma
.
Inability
to recall an important aspect of the
trauma.
Markedly
diminished interest or participation in significant
activities.
Feeling
of detachment
or
estrangement from others .
Restricted range of affect (e.g., unable to have loving feelings) .Sense
of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span
).Slide14
DSM-IV-TR Criteria: PTSD
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. Difficulty
falling or staying
asleep
2. Irritability
or outbursts of
anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated
startle response
E.
Duration
of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F.
The
disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Slide15
Trauma: small-t
Not necessarily life threatening, but definitely life-alteringExamples include g
rief/loss, divorce, verbal abuse/bullying, and just about everything else…
If it was traumatic to the person, then it’s traumatic.
According to the adaptive information processing model, “little t” trauma can be just as valid and as clinically significant as “Big T” trauma.Slide16
DSM Fun Facts…
PTSD entered into the DSM-III in 1980, largely as a result of the Vietnam War Other names had been used unofficially in the field over the years: soldier’s heart shell shock
battle fatigue
operational exhaustion
hysteria Slide17
DSM-5Slide18
DSM-5
For the latest updates on DSM-5, visit the official website at www.dsm5.orgSlide19
DSM-5: Trauma & Stressor-Related Disorders
Reactive
Attachment Disorder
Disinhibited
Social Engagement Disorder
Acute
Stress Disorder
Posttraumatic
Stress Disorder
Adjustment
Disorders
Unspecified & Unclassified Traumatic Stress Disorder Slide20
Posttraumatic Stress Disorder: DSM-5 Criteria
Exposure to actual or threatened death, serious injury,
or
sexual
violence,
in one
(or more)
of the following ways
:
Directly
experiencing the traumatic event(s
).
Witnessing
, in person, the traumatic event(s) as
it
occurred to
others.Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or
accidental.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); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.Slide21
Posttraumatic Stress Disorder:
DSM-5 Criteria B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred
:
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.)
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
.)Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) are
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.)
Intense
or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s
).
Marked
physiological reactions to
internal or external cues that symbolize or resemble an aspect of the traumatic event(s).reminders
of the traumatic event(s)Slide22
Posttraumatic Stress Disorder:
DSM-5 Criteria C. 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
:
Avoidance of or efforts to avoid
distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s
).
Avoidance of or efforts to avoid external
reminders
(people
, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings
about
or
closely associated with the traumatic event(s)Slide23
Posttraumatic Stress Disorder: DSM-5 Criteria
D. 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
:
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)
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”).
Persistent
,
distorted cognitions about
the cause or consequences of the traumatic event(s
) that lead the individual to blame himself/herself or others.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.Feelings
of detachment or estrangement from
others.
Persistent
inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving feelings)Slide24
Posttraumatic Stress Disorder: DSM-5 Criteria
E. 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:
Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
Reckless
or self-destructive
behavior.
Hypervigilance.
Exaggerated
startle
response.
Problems
with
concentration.
Sleep
disturbance (e.g., difficulty falling or staying asleep or restless sleep
).Slide25
Posttraumatic Stress Disorder: DSM-5 Criteria
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G.
The
disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
.
H.
The
disturbance is not
attributable
to the
physiological
effects of a substance (e.g., medication,
alcohol
) or another medical
condition.
Slide26
Posttraumatic Stress Disorder: DSM-5 Criteria
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:
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).
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
).
Subtype: PTSD in children younger than 6 yearsSlide27
Acute Stress Disorder:DSM-5 Criteria
Exposure to actual or threatened death, serious injury, or
sexual violation,
in one or more of the following ways
:
Directly
experiencing the traumatic event(s)
.
Witnessing
, in person, the traumatic event(s) as they occurred to
others.
Learning
that the
event(s
) occurred to a close family member or close friend;
in cases
of actual or threatened death must have been violent or accidental.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); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.Slide28
Acute Stress Disorder: DSM-5 Criteria
B. Presence of nine or more of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening
after the traumatic event(s) occurred
:
Intrusion Symptoms
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). (
Note:
In children,
repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.)
Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s).
(Note:
In children,
there may be frightening dreams without recognizable content.)
D
issociative 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.)
Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).Slide29
Acute Stress Disorder: DSM-5 Criteria
Negative Mood5.
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Dissociative Symptoms
6.
An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing).
7.
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).Slide30
Acute Stress Disorder: DSM-5 Criteria
Avoidance Symptoms8
.
Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Arousal Symptoms
10.
Sleep disturbance (e.g., difficulty falling asleep or staying asleep, restless sleep).
11.
Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
Hypervigilance.
Problems with concentration.
Exaggerated startle response.Slide31
Acute Stress Disorder: DSM-5 Criteria
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure (Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria)D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder.Slide32
Adjustment Disorders: DSM-5 Criteria
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:
1.
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.
2.
Significant impairment in social, occupational, or other important areas of functioning.Slide33
Adjustment Disorders:DSM-5 Criteria
C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.Slide34
Adjustment Disorders:DSM-5 Criteria
Specify whether: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 disorderSlide35
DSM-5: Section III
Persistent Complex Bereavement DisorderSlide36
Persistent Complex Bereavement Disorder: DSM-5 Criteria
A. The individual experienced the death of someone with whom he or she had a close relationship.B. Since
the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant
degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
Persistent
yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including
behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure.
Intense
sorrow and emotional pain in response to the
death.
Preoccupation
with the
deceased.
Preoccupation
with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.Slide37
Persistent Complex Bereavement Disorder: DSM-5 Criteria
C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
Reactive distress to the death
Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death.
Experiencing disbelief or emotional numbness over the loss.
Difficulty
with positive reminiscing about the
deceased.
Bitterness
or anger related to the
loss.
Maladaptive
appraisals about oneself in relation to the deceased or the death (e.g.,
self-blame).
Excessive
avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased
); in
children, this may include avoidance of thoughts and feelings regarding the deceased.Slide38
Persistent Complex Bereavement Disorder: DSM-5 Criteria
Social/Identity Disruption7. A desire to die in order to be with the
deceased.
8.
Difficulty
trusting other individuals since the
death.
9.
Feeling
alone or detached from other individuals since the
death.
10.
Feeling
that life is meaningless or empty without the
deceased,
or the belief that one cannot function without the
deceased.11. Confusion about one’s role in life or a diminished sense of one’s identity (e.g., feeling that a part of oneself died with the deceased).12. Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities
).Slide39
Persistent Complex Bereavement Disorder: DSM-5 Criteria
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The
bereavement reaction
is out
of proportion
to or
inconsistent with cultural, religious, or age-appropriate norms.
Specify if:
With Traumatic Bereavement:
bereavement due to homicide or suicide with persistent distressing preoccupations regarding the traumatic nature
of the death
(often in response to loss reminders),
including
the deceased’s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the deathSlide40
Other Diagnoses
Major depressive disorderPersistent depressive disorder (dysthymia)
Other anxiety disorders
Disruptive mood
dysregulation
disorder (new)
Oppositional defiant disorder
Conduct disorder Slide41
DSM-5 ®
Other Conditions That May Be a Focus of Clinical AttentionSlide42
Problems Related to Family Upbringing
Parent-Child Relational ProblemSibling Relational ProblemUpbringing Away from ParentsChild Affected by Parental Relationship DistressSlide43
Other Problems Related to Primary Support Group
Relationship Distress with Spouse or Intimate PartnerDisruption of Family by Separation or DivorceHigh Expressed Emotion Level within FamilyUncomplicated BereavementAbuse and NeglectSlide44
Child Maltreatment and Neglect Problems
Child Physical AbuseChild Sexual AbuseChild NeglectChild Psychological AbuseSlide45
Adult Maltreatment and Neglect Problems
Spouse or Partner Violence, PhysicalSpouse or Partner Violence, SexualSpouse or Partner NeglectSpouse or Partner Abuse, PsychologicalAdult Abuse by Nonspouse or NonpartnerSlide46
Educational and Occupational Problems
Academic or Educational ProblemProblem Related to Current Military Deployment StatusOther Problem Related to EmploymentSlide47
Housing and Economic Problems
Housing ProblemsHomelessnessInadequate HousingDiscord with Neighbor, Lodger, or LandlordProblem Related to Living in a Residential Institution
Economic Problems
Lack of Adequate Food or Safe Drinking Water
Extreme Poverty
Low Income
Insufficient Social Insurance or Welfare Support
Unspecified Housing or Economic ProblemSlide48
Other Problems Related to the Social Environment
Phase of Life ProblemProblem Related to Living AloneAcculturation DifficultySocial Exclusion or RejectionTarget of (Perceived) Adverse Discrimination or PersecutionUnspecified Problem Related to Social EnvironmentSlide49
Problems Related to Crime or Interaction with the Legal System
Victim of CrimeConviction in Civil or Criminal Proceedings without ImprisonmentImprisonment or Other IncarcerationProblems Related to Release from PrisonProblems Related to Other Legal CircumstancesSlide50
Other Health Service Encounters for Counseling and Medical Advice
Sex CounselingOther Counseling or ConsultationSlide51
Problems Related to Other Psychosocial, Personal, and Environmental Circumstances
Religious or Spiritual ProblemProblems Related to Unwanted PregnancyProblems Related to MultiparityDiscord with Social Service Provider, Including Probation Officer, Case Manager, or Social Services Worker
Victim of Terrorism or Torture
Exposure to Disaster, War, or Other Hostilities
Other Problem Related to Psychosocial Circumstances
Unspecified Problem Related to Unspecified Psychosocial CircumstancesSlide52
Other Circumstances of Personal History
Other Personal History of Psychological TraumaPersonal History of Self-HarmPersonal History of Military DeploymentOther Personal Risk FactorsProblem Related to LifestyleAdult Antisocial Behavior
Child or Adolescent Antisocial BehaviorSlide53
Problems Related to Access to Medical and Other Health Care
Unavailability or Inaccessibility of Health Care FacilitiesUnavailability or Inaccessibility of Other Helping AgenciesSlide54
Nonadherence to Medical Treatment
Nonadherence to Medical TreatmentOverweight or ObesityMalingeringWandering Associated with a Mental DisorderBorderline Intellectual FunctioningSlide55
IATP
Assessment
as
intervention Slide56
Best Practices for Assessment
Do not re-traumatize! Do consider the role of shame in addiction, trauma, and griefDo be genuine, build rapport from the first greeting Do ask open-ended questions Do be non-judgmental
Do make use of the stop sign when appropriate
Do assure the client that they may not be alone in their experiences (if appropriate)
Do have closure strategies ready Slide57
To contact today’s presenter:
Jamie
Marich, Ph.D
., LPCC-S,
LICDC-CS
Mindful Ohio
jamie@jamiemarich.com
www.mindfulohio.com
www.jamiemarich.com
www.drjamiemarich.com
www.dancingmindfulness.com
www.TraumaTwelve.com
Phone: 330-881-2944