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Trauma and the DSM-5®* Jamie Marich, Ph.D., LPCC-S, LICDC-CS Trauma and the DSM-5®* Jamie Marich, Ph.D., LPCC-S, LICDC-CS

Trauma and the DSM-5®* Jamie Marich, Ph.D., LPCC-S, LICDC-CS - PowerPoint Presentation

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Trauma and the DSM-5®* Jamie Marich, Ph.D., LPCC-S, LICDC-CS - PPT Presentation

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

event traumatic trauma dsm traumatic event dsm trauma disorder criteria related symptoms death stress persistent children disturbance exposure social

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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