Flashcards in Trauma- and Stressor-Related Disorders (Reactive Attachment Disorder/Disinhibited Social Engagement Disorder/PTSD) Deck (19)
Which of the following reactions to a traumatic event was required for the DSM-IV diagnosis of posttraumatic stress disorder (PTSD) but is not required for the DSM-5 diagnosis?
A. Intense fear, helplessness, or horror.
B. Insomnia or hypersomnia.
D. A foreshortened sense of the future.
Correct Answer: A. Intense fear, helplessness, or horror.
Explanation: DSM-5 criteria for PTSD differ significantly from the DSM-IV criteria. The stressor criterion (Criterion A) is more explicit with regard to events that qualify as “traumatic” experiences. Also, DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (experiencing “intense fear, helplessness, or horror”) has been eliminated in DSM-5.
Which of the following statements about reactive attachment disorder (RAD) is true?
A. RAD occurs only in children who lack healthy attachments.
B. RAD occurs only in children who have secure attachments.
C. RAD occurs only in children who have impaired communication.
D. RAD occurs in children without a history of severe social neglect.
E. RAD is a common condition, with a prevalence of 25% of children seen in clinical settings.
Correct Answer: A. RAD occurs only in children who lack healthy attachments.
Explanation: Reactive attachment disorder of infancy or early childhood 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. Serious social neglect is a diagnostic requirement for reactive attachment disorder and is also the only known risk factor for the disorder. Children with reactive attachment disorder show social communicative functioning comparable to their overall level of intellectual functioning. The prevalence of RAD is unknown, but the disorder is seen relatively rarely in clinical settings. Even in populations of severely neglected children, the disorder is uncommon, occurring in less than 10% of such children.
A 4-year-old boy in day care often displays fear that does not seem to be related to any of his activities. Although frequently distressed, he does not seek contact with any of the staff and does not respond when a staff member tries to comfort him. What additional caregiver-obtained information about this child would be important in deciding whether his symptoms represent reactive attachment disorder (RAD) or autism spectrum disorder (ASD)?
A. Age at first appearance of the behavior.
B. Family history about his siblings.
C. History of language delay.
D. Indications that he has experienced severe social neglect.
E. Presence of selective attachment behaviors.
Correct Answer: D. Indications that he has experienced severe social neglect.
Explanation: Aberrant social behaviors manifest in young children with RAD, but they also are key features of ASD. Specifically, young children with either condition can manifest dampened expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. As a result, RAD must be differentiated from ASD. These two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors. Children with RAD have experienced a history of severe social neglect, although it is not always possible to obtain detailed histories about the precise nature of their experiences, especially in initial evaluations. Children with ASD will only rarely have a history of social neglect. Children with ASD regularly show attachment behavior typical for their developmental level. In contrast, children with RAD do so only rarely or inconsistently, if at all.
For a child diagnosed with reactive attachment disorder, which of the following situations would qualify for a disorder specifier of “severe”?
A. The child has been in five foster homes.
B. The child never expresses positive emotions when interacting with caregivers.
C. The disorder has been present for 18 months.
D. The child meets all symptoms of the disorder, with each symptom manifesting at relatively high levels.
E. There is a documented history of physical abuse of the child.
Correct Answer: D. The child meets all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Explanation: Reactive attachment disorder is specified as severe when a child meets all symptoms of the disorder, with each symptom manifesting at relatively high levels.
A 6-year-old girl has repeatedly approached strangers while in the park with her class. The teacher requests an evaluation of the behavior. The girl has a history of being placed in several different foster homes over the past 3 years. Which diagnosis is suggested from this history?
A. Attention-deficit/hyperactivity disorder (ADHD).
B. Disinhibited social engagement disorder (DSED).
C. Autism spectrum disorder (ASD).
D. Bipolar I disorder.
E. Borderline personality disorder.
Correct Answer: B. Disinhibited social engagement disorder (DSED).
A 25-year-old woman, new to your practice, tells you that a little more than 3 months ago she was accosted on her way home. The attacker told her he had a gun, was going to rape her, and would shoot her if she resisted. He walked her toward an alley. She was sure he would kill her afterward no matter what she did, and therefore she pushed away from him, aware that she might be shot. She was able to escape unharmed. She describes not being able to fall asleep for the first 2 nights after the attack and of avoiding that particular street in her neighborhood for 2 days following the event. She thinks that the attacker might have touched her breasts but cannot remember for sure. She has recently started feeling anxious all of the time and is tearful, and she has stopped going to work. She fears that something about her makes her “look like a victim.” What is the most likely diagnosis?
A. Posttraumatic stress disorder.
B. Acute stress disorder.
C. Adjustment disorder.
D. Dissociative amnesia.
E. Personality disorder.
Correct Anwer: C. Adjustment disorder.
A 31-year-old man narrowly escapes (without injury) from a house fire caused when he dropped the lighter while trying to light his crack pipe. Six weeks later, while smoking crack, he thinks he smells smoke and runs from the building in a panic, shouting, “It’s on fire!” Which of the following symptoms or circumstances would rule out a diagnosis of posttraumatic stress disorder (PTSD) for this patient?
A. Having difficulty falling asleep.
B. Being uninterested in going back to work.
C. Inappropriately getting angry at family members.
D. Experiencing symptoms only when smoking crack cocaine.
E. Concluding that “the world is completely dangerous.”
Correct Answer: D. Experiencing symptoms only when smoking crack cocaine.
Explanation: Although the stressor and symptoms described would qualify this man for a diagnosis of PTSD, Criterion H states that “The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.” If this man’s symptoms occur only when he smokes crack cocaine, he would not meet criteria for PTSD.
Criterion A4 of posttraumatic stress disorder requires “Experiencing repeated or extreme exposure to aversive details of the traumatic event.” Which of the following would not qualify as an experiencing trauma under this criterion?
A. A police officer reviewing surveillance videotapes of homicides to identify perpetrators.
B. A social worker interviewing children who have been sexually abused and obtaining the details of the abuse.
C. A soldier sifting through the rubble of a collapsed building to retrieve remains of comrades.
D. A college student at a film festival watching a series of violent movies that contain graphic rape scenes.
E. A psychologist working with victims of torture who are seeking political asylum in the United States.
Correct Answer: D. A college student at a film festival watching a series of violent movies that contain graphic rape scenes.
Which of the following statements about gender differences in the risk of developing posttraumatic stress disorder (PTSD) is true?
A. The risk is lower in females in preschool-age populations.
B. The risk is higher in females across the life span.
C. The risk is higher in males in elderly populations.
D. The risk is lower in middle-aged females than in middle-aged males.
E. The risk is higher in males across the life span.
Correct Answer: B. The risk is higher in females across the life span.
Explanation: PTSD is more prevalent among females than among males across the lifespan. Females in the general population experience PTSD for a longer duration than do males. At least some of the increased risk for PTSD in females appears to be attributable to a greater likelihood of exposure to traumatic events, such as rape, and other forms of interpersonal violence. Within populations exposed specifically to such stressors, gender differences in risk for PTSD are attenuated or nonsignificant.
A 5-year-old child was present when her babysitter was sexually assaulted. Which of the following symptoms would be most suggestive of posttraumatic stress disorder (PTSD) in this child?
A. Playing normally with toys.
B. Having dreams about princesses and castles.
C. Taking the clothing off her dolls while playing.
D. Expressing no fear when talking about the event.
E. Talking about the event with her parents.
Correct Answer: C. Taking the clothing off her dolls while playing.
Explanation: The clinical expression of reexperiencing can vary across development. Young children may report new onset of frightening dreams without content specific to the traumatic event. Before age 6 years (see criteria for PTSD in children 6 years and younger), young children are more likely to express reexperiencing symptoms through play that refers directly or symbolically to the trauma. They may not manifest fearful reactions at the time of the exposure or during reexperiencing. Parents may report a wide range of emotional or behavioral changes in young children. Children may focus on imagined interventions in their play or storytelling. In addition to avoidance, children may become preoccupied with reminders. Because of young children’s limitations in expressing thoughts or labeling emotions, negative alterations in mood or cognition tend to involve primarily mood changes.
Which of the following statements about risk factors for developing posttraumatic stress disorder (PTSD) is true?
A. Sustaining personal injury does not affect the risk of developing PTSD.
B. Severity of the trauma influences the risk of developing PTSD.
C. Dissociation has no impact on the risk of developing PTSD.
D. Perceived life threat is the only risk factor for developing PTSD.
E. Prior mental disorders have little influence on the risk of developing PTSD.
Correct Answer: B. Severity of the trauma influences the risk of developing PTSD.
How does the 12-month prevalence of posttraumatic stress disorder (PTSD) in the United States compare with that in European and Latin American countries?
A. It is much lower than that in other countries.
B. It is much higher than that in other countries.
C. It is equal to that in other countries.
D. It is somewhat higher than that in other countries.
E. It is somewhat lower than that in other countries.
Correct Answer: D. It is somewhat higher than that in other countries.
Explanation: The 12-month prevalence of PTSD among U.S. adults is about 3.5%. Lower estimates are seen in Europe and most Asian, African, and Latin American countries, clustering around 0.5%–1.0%. Although different groups have different levels of exposure to traumatic events, the conditional probability of developing PTSD following a similar level of exposure may also vary across cultural groups.
A 25-year-old woman with asthma becomes extremely anxious when she gets an upper respiratory infection. She presents to the emergency department with complaints of being unable to breathe. While there, she begins to hyperventilate and then reports feeling extremely dizzy. Her hyperventilation causes her to become fatigued, and when the medical evaluation indicates that she is retaining carbon dioxide (CO 2 ), it becomes necessary to admit her. The woman denies any other symptoms beyond anxiety. What is the most appropriate diagnosis?
A. Acute stress disorder.
B. Generalized anxiety disorder.
C. Adjustment disorder with anxiety.
D. Psychological factors affecting other medical conditions.
E. Factitious disorder.
Correct Answer: D. Psychological factors affecting other medical conditions.
Explanation: In psychological factors affecting other medical conditions, specific psychological entities (e.g., psychological symptoms, behaviors, other factors) exacerbate a medical condition. These psychological factors can precipitate, exacerbate, or put an individual at risk for medical illness, or they can worsen an existing condition. In contrast, an adjustment disorder is a reaction to the stressor (e.g., having a medical illness).
How do the diagnostic criteria for posttraumatic stress disorder (PTSD) in preschool children differ from those for PTSD in individuals older than 6 years?
A. The preschool criteria incorporate simpler language that can be understood by children 6 years or younger.
B. The preschool criteria require one or more intrusion symptoms, one symptom representing either avoidance or negative alterations in cognitions and mood, and two or more arousal/reactivity symptoms, whereas the criteria for older individuals require symptoms in all four categories.
C. The criteria for individuals older than 6 years require one or more intrusion symptoms, one symptom representing either avoidance or negative alterations in cognitions and mood, and two or more arousal/reactivity symptoms, whereas the preschool criteria require symptoms in all four categories.
D. The preschool criteria require that the child directly experience the trauma, whereas the criteria for older individuals do not have this requirement.
E. The preschool criteria include only one type of traumatic exposure— witnessing of a traumatic event occurring to a parent or caregiving figure— as a qualifying traumatic event.
Correct Answer: B. The preschool criteria require one or more intrusion symptoms, one symptom representing either avoidance or negative alterations in cognitions and mood, and two or more arousal/reactivity symptoms, whereas the criteria for older individuals require symptoms in all four categories.
The DSM-5 diagnostic criteria for posttraumatic stress disorder (PTSD) require the presence of symptoms from four different categories: Intrusion (Criterion B), Avoidance (Criterion C), Negative Alterations in Cognitions and Mood (Criterion D), and Arousal (Criterion E). Match each of the following symptoms to the appropriate category (each symptom may be placed into only one category).
a. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
b. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
c. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
d. 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).
e. 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).
f. Reckless or self-destructive behavior.
g. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s).
h. 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”).
j. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
k. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
l. Exaggerated startle response.
m. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
n. Problems with concentration.
o. Markedly diminished interest or participation in significant activities.
p. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
q. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
r. Feelings of detachment or estrangement from others.
s. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
t. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Intrusion: c, g, j, p, s;
Avoidance: b, e;
Negative Alterations in Cognitions and Mood: d, h, k, m, o, r, t;
Arousal: a, f, i, l, n, q.
Eighteen months following the death of her son, a 49-year-old woman consults you for psychotherapy. She reports that her son died following a skiing accident on a trip that she gave him as a gift for his 17th birthday. She is preoccupied with the death and blames herself for providing the gift of the trip. Although she denies any overt suicidal plans, she describes longing for her son and an intense wish to be with him. She has not entered her son’s room since his death, has difficulty relating to her husband and feels anger toward him for agreeing to allow their son to go on the ski trip, and reports arguments between them regarding her social isolation and her lack of interest in maintaining their home and preparing meals for their other children. She was treated with a selective serotonin reuptake inhibitor at full dose for 6 months after her son’s death but reports that the medication had no impact on her symptoms. What is the most appropriate diagnosis?
A. Major depressive disorder.
B. Posttraumatic stress disorder.
C. Other specified traumaand stressor-related disorder.
D. Normal grief.
E. Adjustment disorder.
Correct Answer: C. Other specified traumaand stressor-related disorder.
Explanation: The severe and persistent grief and mourning reactions that characterize this woman’s symptom presentation meet criteria for the proposed diagnosis persistent complex bereavement disorder, which appears in Section III (“Conditions for Further Study”) of DSM-5. However, because the proposed criteria sets in Section III are not intended for clinical use, the appropriate diagnosis in this case would be other specified trauma- and stressor-related disorder (persistent complex bereavement disorder). This woman’s symptoms do not meet criteria for major depressive disorder, posttraumatic stress disorder, or an adjustment disorder. The “other specified trauma- and stressor-related disorder” category applies to presentations in which symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic class.
In children who have experienced severe neglect, how many will experience reactive attachment disorder:
A. At least 25%
C. Less than 10%
Correct Answer: C.
What is true about disinhibited social engagement disorder:
A. Prevalence is unknown
B. In high risk populations, children severely neglected and placed in institutions, about 20% will experience disorder
C. Rates are 29% in other clinical settings
D. Not much is known about this disorder at all
Correct Answer: A, B