ARCHIVED: Appendix D: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Diagnostic criteria for stress disorders

 

Appendix D: Diagnostic Criteria for Stress Disorders

Acute Stress Disorder (ASD)

Reprinted from The Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision)11p.471-472 with permission of the American Psychiatric Association.

  1. 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
  2. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
    • a subjective sense of numbing, detachment, or absence of emotional responsiveness
    • a reduction in awareness of his or her surroundings (e.g., "being in a daze")
    • derealization
    • depersonalization
    • dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
  3. The traumatic event is persistently re- experienced in at least one of the following ways:
    • recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience
    • distress on exposure to reminders of the traumatic event
  4. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
  5. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
  6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
  7. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
  8. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.

Posttraumatic Stress Disorder (PTSD)

Reprinted from The Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision)11p.467-468 with permission of the American Psychiatric Association.

  1. The person has been exposed to a traumatic event in which both of the following were present:
    1. 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.
    2. the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour.
  2. The traumatic event is persistently reexperienced in one (or more) of the following ways:
    1. recurrent 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.
    2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
    3. 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.
    4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
    5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  3. 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:
    1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
    2. efforts to avoid activities, places, or people that arouse recollections of the trauma
    3. inability to recall an important aspect of the trauma
    4. markedly diminished interest or participation in significant activities
    5. feeling of detachment or estrangement from others
    6. restricted range of affect
    7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
  4. 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
  5. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
  6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more

    Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Disorders of Extreme Stress not Otherwise Specified (DESNOS)

Judith Herman81 has challenged the ability of the diagnosis of posttraumatic stress disorder (PTSD)9,10,11 to capture the full range of human response to trauma. She and others (e.g.,173) suggest that it is more accurate to think about human responses to trauma as a spectrum anchored at one end by an acute stress reaction that resolves on its own without treatment, and on the other by what Herman calls "complex posttraumatic stress disorder," with "classic or simple" PTSD residing somewhere between the two.81p.119

When the DSM IV10 was being developed, a field trial was completed to explore whether the construct of complex PTSD, also termed disorders of extreme stress, not otherwise specified (DESNOS) should be included as a diagnosis separate from PTSD. Although many argue that the field trial and other more recent studies support the legitimacy of the DESNOS diagnosis,174 DESNOS was not included in the DSM IV. However, the categories of symptoms included in the conceptualization of DESNOS were listed under the "Associated and Descriptive Features of PTSD."171

In the most recent version of DSM-IV-TR, the authors state that the following constellation of symptoms may be associated with PTSD, and are generally seen when the stressor involves interpersonal trauma such as childhood sexual or physical abuse or domestic battering:

  • impaired affect modulation;
  • self-destructive and impulsive behaviour;
  • dissociative symptoms;
  • somatic complaints;
  • feelings of ineffectiveness;
  • shame, despair, or hopelessness;
  • feeling permanently damaged;
  • a loss of previously sustained beliefs;
  • hostility;
  • social withdrawal;
  • feeling constantly threatened;
  • impaired relationships with others;
  • a change from the individual's previous personality characteristics.11p.465
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