The Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group, chaired by Dr. Katharine A. Phillips of Brown University,
consisted of 14 members [21]. The work group first met in October 2008, tasked with assessing the rather large DSM-IV chapter containing the Anxiety Disorders. Given the size of the Anxiety Disorders chapter, they elected to break into three subgroups. Ultimately, the main group decided to split the Anxiety Disorders chapter of DSM-IV into three separate chapters, each more narrowly focused [22]. The three resulting chapters in DSM-5 are titled: Anxiety Disorders; Obsessive-Compulsive and Related Disorders; and Trauma- and Stressor-Related Disorders. The most substantial changes are noted in the Trauma- and Stressor-Related Disorders section of DSM-5 and represent the focus of this section.
In addition to posttraumatic stress disorder (PTSD) and acute stress disorder, the Trauma and Stressor-Related Disorders chapter also includes adjustment disorder and reactive attachment disorder. The decision to sepa- rate PTSD away from the Anxiety Disorders was hotly debated. Opponents of this change opined that moving PTSD out of the Anxiety Disorders chapter was unsupported by existing data and that classically conditioned fear (i.e., anxiety) was central to its development [23].
PTSD and acute stress disorder also experienced significant diagnostic changes in addition to their separation from the Anxiety Disorders chapter. The stressor criterion (Criterion A) for both conditions changed. In DSM-IV, Criterion A required that 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 physi- cal integrity of self or others;” and “the person’s response involved intense fear, helplessness, or horror” [1 (p467)]. DSM-5 instead requires “exposure to actual or threatened death, serious injury, or sexual violence” [2 (p271)] in one (or more) of the following ways: directly experiencing the traumatic event; witnessing, in person, the event(s) as it occurred to others; learn- ing that the traumatic event(s) occurred to a close family member or close friend (actual or threatened death must have been violent or accidental); or experiencing repeated or extreme exposure to aversive details of the trau- matic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse, etc). The work group also elimi- nated DSM-IV’s requirement that the individual experience “intense fear, helplessness, or horror” [1 (p467)].
DSM-5 also redefined the symptom clusters that must follow a trau- matic event to diagnose PTSD. In DSM-IV, the three major symptom clusters include re-experiencing, avoidance/numbing, and arousal. In DSM-5, the re-experiencing and arousal clusters remain. However, the avoidance/numb- ing cluster is now divided into two separate clusters, “avoidance” and persis- tent “negative alterations in cognitions and mood” [2 (p271)]. The newly formed persistent negative alterations cluster retained most of the numbing symp- toms (with some rewording) and added additional symptoms including the
following: persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; 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); and persistent inability to experience positive emotions. The group also attempted to account for different reactions based on develop- mental age by providing a separate set of criteria for children age 6 or younger.
Reactive attachment disorder and adjustment disorder are the other DSM-IV conditions now included in the Trauma- and Stressor-Related Disorder chapter. In DSM-IV, reactive attachment disorder featured two subtypes, emotionally withdrawn/inhibited and indiscriminately social/dis- inhibited. In DSM-5, each subtype is named as a separate disorder, namely reactive attachment disorder and disinhibited social engagement disorder. In DSM-5, adjustment disorder is described as a collection of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of onset of the stressor(s).
The following vignette demonstrates a possible implication of the changes to the Trauma- and Stressor-Related Disorders:
Dr. C is a 53-year-old forensic psychiatrist who has been in practice for over 20 years. His oldest daughter left home recently to enroll as a freshman at an out-of-state university. Dr. C finds that he seems to be having a harder time “letting work go” when he gets home in the evening. He feels particu- larly shaken by a recent case involving a freshman coed who was kidnapped, tortured, repeatedly raped, and murdered. He finds himself frequently pictur- ing the gruesome autopsy photos, worrying about his daughter’s safety, and ruminating about how the crime impacted the victim’s family. Dr. C starts avoiding new cases and his production decreases considerably. He begins find- ing reasons to avoid the office altogether and starts calling in sick frequently. Worried about Dr. C, a colleague suggests that he make a therapy appoint- ment. During the intake appointment, the clinician finds that Dr. C meets suf- ficient criteria in each of the four symptom clusters for PTSD.
According to DSM-IV, Dr. C would not meet criteria for PTSD because he was not directly exposed to a traumatic event that caused a significant nega- tive emotional reaction at the time the event occurred. In DSM-5, he likely meets criteria for PTSD based on his experiencing work-related recurrent and significant exposure to negative traumatic situations with emotion- ally upsetting characteristics. His distress seems particularly related to the case involving the freshman coed, although repeated exposure to disturbing details of other cases could also be relevant.
How these changes impact the overall prevalence of PTSD in clinical sam- ples and forensic referrals remains unclear. Some authors have suggested
that the overall prevalence will change minimally, if at all [24]. Other authors have suggested that the prevalence may actually decrease due to the new requirement that at least one avoidance symptom be present [25]. Given the largely subjective nature of establishing criteria for PTSD, the risk of feign- ing in civil and criminal forensic cases remains a concern.