Diagnostic and statistical manual of mental disorders Dsm-5
Trauma- and Stressor-Related Disorders
Trauma- and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders. Placement of this chapter reflects the close relationship between these diagnoses and disorders in the surrounding chapters on anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders.
Psychological distress following exposure to a traumatic or stressful event is quite variable. In some cases, symptoms can be well understood within an anxiety- or fear-based context. It is clear, however, that many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms. Because of these variable expressions of clinical distress following exposure to catastrophic or aversive events, the aforementioned disorders have been grouped under a separate category: trauma- and stressor-related disorders. Furthermore, it is not uncommon for the clinical picture to include some combination of the above symptoms (with or without anxiety- or fear-based symptoms).
Such a heterogeneous picture has long been recognized in adjustment disorders, as well. Social neglect—that is, the absence of adequate caregiving during childhood—is a diagnostic requirement of both reactive attachment disorder and disinhibited social engagement disorder. Although the two disorders share a common etiology, the former is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while the latter is marked by disinhibition and externalizing behavior.
Reactive Attachment Disorder
Diagnostic Criteria 313.89 (F94.1)
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: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.
A persistent social and emotional disturbance characterized by at least two 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.
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 (e.g., frequent changes in foster care).
Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
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.
Specify if:
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Diagnostic Features
Reactive attachment disorder is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults.
Children with reactive attachment disorder are believed to have the capacity to form selective attachments. However, because of limited opportunities during early development, they fail to show the behavioral manifestations of selective attachments. That is, when distressed, they show no consistent effort to obtain comfort, support, nurturance, or protection from caregivers.
Furthermore, when distressed, children with this disorder do not respond more than minimally to comforting efforts of caregivers. Thus, the disorder is associated with the absence of expected comfort seeking and response to comforting behaviors. As such, children with reactive attachment disorder show diminished or absent expression of positive emotions during routine interactions with caregivers.
In addition, their emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained. A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments. For this reason, the child must have a developmental age of at least 9 months.
Associated Features Supporting Diagnosis
Because of the shared etiological association with social neglect, reactive attachment disorder often co-occurs with developmental delays, especially in delays in cognition and language. Other associated features include stereotypies and other signs of severe neglect (e.g., malnutrition or signs of poor care) Smyke et al. 2002; Zeanah et al. 2005.
Prevalence
The prevalence of reactive attachment disorder is unknown, but the disorder is seen relatively rarely in clinical settings. The disorder has been found in young children exposed to severe neglect before being placed in foster care or raised in institutions. However, even in populations of severely neglected children, the disorder is uncommon, occurring in less than 10% of such children Gleason et al. 2011.
Development and Course
Conditions of social neglect are often present in the first months of life in children diagnosed with reactive attachment disorder, even before the disorder is diagnosed. The clinical features of the disorder manifest in a similar fashion between the ages of 9 months and 5 years Gleason et al. 2011; Oosterman and Schuengel 2007; Tizard and Rees 1975; Zeanah et al. 2004.
That is, signs of absent-to-minimal attachment behaviors and associated emotionally aberrant behaviors are evident in children throughout this age range, although differing cognitive and motor abilities may affect how these behaviors are expressed. Without remediation and recovery through normative caregiving environments, it appears that signs of the disorder may persist, at least for several years Gleason et al. 2011.
It is unclear whether reactive attachment disorder occurs in older children and, if so, how it differs from its presentation in young children. Because of this, the diagnosis should be made with caution in children older than 5 years.
Risk and Prognostic Factors
Environmental. Serious social neglect is a diagnostic requirement for reactive attachment disorder and is also the only known risk factor for the disorder. However, the majority of severely neglected children do not develop the disorder. Prognosis appears to depend on the quality of the caregiving environment following serious neglect Gleason et al. 2011; Smyke et al. 2012.
Culture-Related Diagnostic Issues
Similar attachment behaviors have been described in young children in many different cultures around the world. However, caution should be exercised in making the diagnosis of reactive attachment disorder in cultures in which attachment has not been studied.
Functional Consequences of Reactive Attachment Disorder
Reactive attachment disorder significantly impairs young children’s abilities to relate interpersonally to adults or peers and is associated with functional impairment across many domains of early childhood Gleason et al. 2011.
Obsessive-compulsive Disorder Sample Paper
The patient, Ms. Shalin, is a 35-year-old female of African American descent who was referred to the clinic by her doctor for psychiatric evaluation. The patient presented with insecurities of leaving her doors unlocked and it was serious such that every time she would report for work, she had to go back home like twice to check whether her door was closed. She always reported to work late primarily because she kept checking repeatedly whether she had locked her door. Her work performance was poor and this resulted in most of her employers terminating her employment.
The patient has a history of diabetes type 2 which has been kept under control. She is currently on buspirone and occasionally uses alcohol. She has a positive family history of anxiety disorder and bipolar disease. The patient has agreed to and signed the informed consent. Assessment reveals a well-groomed 35-year-old lady, with no acute distress. She is talkative but loses concentration after some time. She maintains eye contact while communicating. Her thoughts are preoccupied and circumstantial with compulsion and obsession. The clinical impression is a diagnosis of Obsessive-Compulsive Disorder (OCD) (APA, 2013).
Psychopharmacology
OCD can present a significant management challenge. OCD can be treated using pharmacotherapy. The patient displays an impairment in function, both at home and occupational functionality. Pharmacotherapy is therefore recommended (Greenberg, 2018). The treatment starts with prescription of Selective serotonin reuptake inhibitors (SSRIs) which are the recommended first line intervention for OCDs.
SSRIs inhibit serotonin transporter (SERT) at the presynaptic axon terminal to prevent serotonin reuptake. Evidence has shown that SSRIs for OCD are more efficacious when used in high doses (Kayser, 2020). For Prozac, doses up to 80 mg are accepted. Starting dose of Prozac 20 mg PO once a day in the morning. This should be increased gradually by 20 mg to achieve a maintenance dose of 20-60 mg if the desired clinical outcomes are not met (Salehi et al., 2019).
OCD, however, takes long to respond to SSRI therapy. Clomipramine, a TCA can be added to SSRI to improve the symptoms of OCD. TCA have more serious side effects hence the preference for SSRIs. Clomipramine is therefore used in lower doses when given in combination with SSRIs so as to achieve the benefits of clomipramine while minimizing the side effects in patients (DiVall & Woolley, 2019). The expected outcome of the drugs is to reduce the obsessions and compulsions which interfere with the patient’s performance both at home and at work.
Psychotherapy
Cognitive Behavioral Therapy (CBT) and pharmacotherapy are the first line choice of treatment for OCD and are proven to reduce symptoms significantly (Greenberg, 2018). The effectiveness of cognitive-behavioral therapy is the same as that of pharmacotherapy in the treatment of OCD although behavioral therapy has beneficial effects which are long lasting. Behavioral therapy can be applied for both inpatient and outpatients and should be undertaken by a trained and experienced psychotherapist, preferably a behaviorally trained psychologist.
Noteworthy is that most of behavioral approaches require total commitment from the patients. Further, for OCD patients, the primary goal of behavior therapy is exposure and response prevention (ERP). Often, the intervening behaviorist gradually exposes the patient to specific symptom triggers while at the same time training the patient on how to effectively suppress their response. While this is generally distressing to the patient, it tends to promote the cycle of learning and unlearning of the obsession and compulsion tendencies when correctly done.
Also, when tackling OCD, the therapist can identify and challenge cognitive distortions that relate to the patient’s OCD and make the patient aware of them. This would be a first step in helping the patient counter such thoughts. The therapy is aimed at changing the behavior, reducing dysfunction and improving the client’s life.
Medical Management
The patient should get her consultations from her Personal Care Physician (PCP). The patient has diabetes type 2 and needs continuous screening and monitoring by the primary care team. The PCP should be involved to ascertain if the patient develops any side effects to the medication. Prozac has been linked with hypoglycemia and poor glycemic control in diabetic patients. TCA have been associated with adverse effects such as orthostatic hypotension which may lead to dizziness and fall (Ulrich et al., 2020).
The patient should be aware of these side effects and should visit the PCP as soon as she notices any anomaly. Suicide risk is also increased in this patient and therefore the PCP who is the first contact for this patient plays a significant role in identifying and appropriately referring this patient.
Community resources
Patients with OCD experience impairment in occupational functioning and struggle to maintain employment. They can easily go into financial hardship because of this. Such patients can benefit from community resources referral. Organizations such as the National Alliance on Mental Illness (NAMI) provide free information about the disorder, medication and support groups.
Follow-up Plan and Collaboration
The patient should report back after one week for follow up and make sure she is compliant to her medications. A follow-up plan should be made every visit. The objective of the follow-up plan is to monitor for signs of self-harmful behaviors, any urges and the need to give in to such urges. These drugs come with certain adverse effects. The dose should be adjusted if the patient is not tolerating the drug well.
The patient should then be monitored every 4 weeks for medication management. Baseline lab tests should also be done monthly. These include the complete blood count, tests on kidney function, as well as liver function tests. The patient should make consultations with the therapist on a weekly basis for updates, questions, and concerns. SSRIs have been associated with the risk of patients being suicidal. The therapist and PCP should therefore be instructed on this possibility and collaborate to watch out for any unusual behaviors that may point towards suicidal tendencies.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.
- DiVall, M. V., & Woolley, A. B. (2019). CHAPTER Pharmacologic Agents. Acute Care Handbook for Physical Therapists E-Book, 431.
- Greenberg, W. M. (2018, May 17). Obsessive-Compulsive Disorder Treatment & Management: Approach Considerations, Pharmacotherapy, Behavior Therapy. Medscape. Retrieved from https://emedicine.medscape.com/article/1934139-treatment#d8.
- Kayser R. R. (2020). Pharmacotherapy for Treatment-Resistant Obsessive-Compulsive Disorder. The Journal of Clinical Psychiatry, 81(5), 19ac13182. https://doi.org/10.4088/JCP.19ac13182
- Salehi, M., Hadizadeh, H., Chang, A., & Grados, M. A. (2019). Recommendations for prescribing SSRIs. Contemporary Pediatrics, 36(11), 24-27.
- Ulrich, S., Ricken, R., Buspavanich, P., Schlattmann, Peter; Adli, Mazda (2020). Efficacy and Adverse Effects of Tranylcypromine and Tricyclic Antidepressants in the Treatment of Depression. Journal of Clinical Psychopharmacology, 40(1), 63–74. doi:10.1097/JCP.0000000000001153
