Trauma and Stressor-Related Disorders

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.

A college student at a film festival watching a series of violent movies that contain graphic rape scenes. Explanation: The examples given in Criterion A4 of posttraumatic stress dis- order are first responders collecting human remains and police officers repeat- edly exposed to details of child abuse. This criterion does not apply to exposure through electronic media, television, movies, or pictures, unless the exposure is work related.

A woman complains of sad mood and feeling hopeless 3 months after her hus- band files for divorce. She finds it difficult to take care of her home or make meals for her family but has continued to fulfill her responsibilities. She denies suicidal ideation, feels she was a good wife who "has nothing to feel guilty about," and wishes she could "forget about the whole thing." She cannot stop thinking about her situation. Which diagnosis best fits this symptom picture? A. Adjustment disorder, with depressed mood. B. Adjustment disorder, with disturbance of conduct. C. Adjustment disorder, with anxiety. D. Adjustment disorder, with mixed disturbance of emotions and conduct. E. Adjustment disorder, unspecified.

Adjustment disorder, with depressed mood. Explanation: Among the various specifiers included in the adjustment disorder diagnostic criteria, "with depressed mood" best fits this patient's symptoms. The full set of specifiers is as follows: 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 disorder.

Six months after the death of her husband, a 70-year-old woman is seen for symptoms of overwhelming sadness, anger regarding her husband's unexpected death from a heart attack, intense yearning for him to come back, and repeated unsuccessful attempts to begin moving out of her large home (which she can no longer afford) due to inability to sort through and dispose of her husband's belongings. What is the most appropriate diagnosis? a. Major depressive disorder. b. Posttraumatic stress disorder. c. Adjustment disorder, with depressed mood. d. Other specified trauma-and stressor-related disorder (persistent complex bereavement disorder). e. Normative stress reaction.

Adjustment disorder, with depressed mood. Explanation: The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature of adjustment disorders (Criterion A). The stressor may be a single event or there may be multiple stressors. There are several adjustment disorder specifiers, but "with depressed mood" best fits this patient's symptoms. Adjustment disorders may be diagnosed fol- lowing the death of a loved one when the intensity, quality, or persistence of grief reactions exceeds what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account. A more specific set of bereavement-related symptoms has been designated persistent complex bereavement disorder (see "Conditions for Further Study" in DSM-5 Section III). If this woman's symptoms persist for more than 12 months, a diagnosis of "other specified trauma- and stressor-related disorder (persistent complex bereavement disorder)" might be appropriate.

After a routine chest X ray, a 53-year-old man with a history of heavy cigarette use is told that he has a suspicious lesion in his lung. A bronchoscopy confirms the diagnosis of adenocarcinoma. The man delays scheduling a follow-up appointment with the oncologist for more than 2 weeks, describes feeling as if "all of this is not real," is having nightly dreams of seeing his own tombstone, and is experiencing intrusive flashbacks to the moment when he heard the physician saying, "The tests strongly suggest that you have cancer of the lung." He is tearful and is convinced he will die. He also feels intense guilt that his smoking caused the cancer and expresses the thought that he "deserves" to have cancer. What diagnosis best fits this clinical picture? A. Acute stress disorder. B. Posttraumatic stress disorder. C. Adjustment disorder. D. Major depressive disorder. E. Generalized anxiety disorder.

Adjustment disorder. Explanation: The essential feature of acute stress disorder (ASD) is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events. Traumatic events that are experienced directly include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual assault, physical attack, active combat, mugging, childhood physical and/or sexual abuse, being kidnapped, being taken hostage, terrorist attack, or torture), natural or human-made disasters (e.g., earthquake, hurricane, airplane crash), and severe accidents (e.g., severe motor vehicle or industrial accident). A life- threatening illness or debilitating condition is not necessarily considered a traumatic event. Stressful events that do not meet Criterion A definitions for a diagnosis of ASD may nonetheless be sufficient to qualify for an adjustment disorder diagnosis.

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.

Adjustment disorder. Explanation: The patient developed emotional symptoms within 3 months of the stressor. The symptoms qualify as clinically significant, because although her distress is not out of proportion to the severity of the stressor precipitating the symptoms, she does demonstrate significant impairment in important areas of functioning. This symptom pattern is diagnostic for adjustment disorder. The essential feature of acute stress disorder is the development of acute posttraumatic symptoms within 1 month of exposure to extreme traumatic stressors. The full symptom picture of 9 or more (of a possible 12) symptoms must be present at least 3 days after the traumatic event and can be diagnosed up to 1 month after the event; symptoms that occur immediately after the event but resolve in less than 3 days would not qualify for a trauma-or stressor-related disorder diagnosis. The patient does not have dissociative experiences, flashbacks, dreams, or avoidance symptoms and does not meet the criteria for acute stress disorder or posttraumatic stress disorder. There is nothing to suggest that she has a personality disorder or that she has dissociative amnesia.

Which of the following stressful situations would meet Criterion A for the diagnosis of acute stress disorder (ASD)? A. Finding out that one's spouse has been fired. B. Failing an important final examination. C. Receiving a serious medical diagnosis. D. Being in the cross fire of a police shootout but not being harmed. E. Being in a subway train that gets stuck between stations.

Being in the cross fire of a police shootout but not being harmed. Explanation: The essential feature of ASD is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events. Traumatic events that are experienced directly include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual assault, physical attack, active combat, mugging, childhood physical and/or sexual abuse, being kidnapped, being taken hostage, terrorist attack, or torture), natural or human-made disasters (e.g., earthquake, hurricane, airplane crash), and severe accidents (e.g., severe motor vehicle or industrial accident). Stressful events that do not meet Criterion A definitions for a diagnosis of ASD may nonetheless be sufficient to qualify for an adjustment disorder. In adjustment disorder, the stressor can be of any severity. The diagnosis of adjustment disorder is used when the response to an extreme stressor does not meet the full criteria for ASD (or another specific mental disorder) and for situations in which the stressor is not considered extreme (e.g., spouse leaving, being fired.)

Criterion B for acute stress disorder requires the presence of nine (or more) symptoms from any of five categories of response. Which of the following is not one of these five categories? A. Intrusion. B. Dissociation. C. Confusion. D. Avoidance. E. Arousal.

Confusion. Explanation: Criterion B for acute stress disorder requires the presence of 9 (or more) of a total of 12 symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred.

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.

Disinhibited social engagement disorder (DSED). Explanation: The essential feature of DSED is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers (Criterion A). The behaviors must include socially disinhibited behavior, not just ADHD-like impulsivity (Criterion B), and the child must have experienced a pattern of extremes of insufficient care (Criterion C) as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults. 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).

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 build- ing 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."

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.

Following discharge from the hospital, a 22-year-old man describes vivid and intrusive memories of his stay in the intensive care unit (ICU), where he received treatment for smoke inhalation. Now at home, he states that he has memories of people being tortured and hearing their screams. He dreams of this every night, waking from sleep in a terror. He talks about not feeling like himself after the experience, finding little pleasure in life after what happened to him, and being easily angered by his family; in addition, he avoids his physician out of fear that he will be told he needs to return to the ICU. What is the most likely explanation for this patient's symptoms? a. He has acute stress disorder because his life was in danger during the ICU stay. b. He has posttraumatic stress disorder because his life was in danger during the ICU stay. c. He has a delirium persisting from the ICU stay. d. He had a delirium in the ICU and now has an adjustment disorder. e. He has a psychotic disorder.

He had a delirium in the ICU and now has an adjustment disorder. Explanation: Flashbacks in acute stress disorder must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, other psychotic disorders, depressive or bipolar disorder with psychotic features, a delirium, substance/medication-induced disorders, and psychotic disorders due to another medical condition. Acute stress disorder flashbacks are distinguished from these other perceptual disturbances by being directly related to the traumatic experience and occurring in the absence of other psychotic or substance/medication-induced features.

Which of the following experiences would not qualify as exposure to a traumatic event (Criterion A) in the diagnosis of acute stress disorder or posttraumatic stress disorder? a. Hearing that one's brother was killed in combat. b. Hearing that one's close childhood friend survived a motor vehicle accident but is paralyzed. c. Hearing that one's child has been kidnapped. d. Hearing that one's company had suddenly closed. e. Hearing that one's spouse has been shot.

Hearing that one's company had suddenly closed. Explanation: The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents. A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking during surgery, anaphylactic shock). Witnessed events include, but are not limited to, observing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war or disaster, or a medical catastrophe in one's child (e.g., a life-threatening hemorrhage). Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental (e.g., death due to natural causes does not qualify). Such events include violent personal assault, suicide, serious accident, and serious injury. The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence).

How does DSM-5 differ from DSM-IV in its classification of posttraumatic stress disorder (PTSD)? a. In DSM-5, PTSD has been placed with the dissociative disorders. b. InDSM-5, PTSD has been placed with the depressive disorders. c. In DSM-5, PTSD has been placed in a newly created chapter. d. In DSM-5, PTSD has been placed with "Other Conditions That May Be a Focus of Clinical Attention." e. In DSM-5, PTSD has been placed with "Conditions for Further Study" in Section III.

In DSM-5 PTSD has been placed in a newly created chapter. Explanation: The establishment of a separate chapter for trauma and stressor-related disorders is based on strong evidence that the clinical expression of psychological distress following exposure to a traumatic or stressful event is quite variable. In some cases, symptoms can be understood within an anxiety-based or fear-based context. This was the rationale for designating acute stress disorder and posttraumatic stress disorder as anxiety disorders in DSM-IV. Many individuals 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. These individuals are better grouped under a separate category: trauma and stressor-related disorders.

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.

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.

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. C. Avoidance. D. A foreshortened sense of the future. E. Flashbacks.

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.

Criterion B in the DSM-5 diagnostic criteria for acute stress disorder (ASD) requires the presence of symptoms from five different categories: Intrusion, Negative Mood, Dissociative, Avoidance, and Arousal. Match each of the following symptoms to the appropriate category (each symptom may be placed into only one category). a. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). b. Problems with concentration. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). c. 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). d. 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). e. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects. f. 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). g. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). i. Hypervigilance. j. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. k. Exaggerated startle response. l. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). m. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). n. 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).

Intrusion: a. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s), h. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s), j. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring, and n. 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). Negative Mood: c. Persistent inability to experience positive emotions (e.g., inability to expe- rience happiness, satisfaction, or loving feelings). Dissociative: d. 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) and g. 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). Avoidance: e. 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) and l. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Arousal: b. Problems with concentration, f. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects, i. Hypervigilance, k. Exaggerated startle response, and m. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). See explanation in book.

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"). i. Hypervigilance. 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. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s), g. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s), j. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring, p. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s), and s. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Avoidance: b. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) and 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). Negative Alterations in Cognitions and Mood: 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), 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"), k. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others, m. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame), o. Markedly diminished interest or participation in significant activities, r. Feelings of detachment or estrangement from others, and t. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Arousal: a. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects, f. Reckless or self-destructive behavior, i. Hypervigilance, l. Exaggerated startle response, n. Problems with concentration and q. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). See explanation in book.

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.

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 probabil- ity of developing PTSD following a similar level of exposure may also vary across cultural groups.

How many Criterion B symptoms are required to be present for the diagnosis of acute stress disorder? A. One. B. Three. C. Five. D. Seven. E. Nine.

Nine. Explanation: Criterion B for acute stress disorder requires the presence of 9 (or more) of a total of 12 symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred.

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 trauma-and stressor-related disorder. D. Normal grief. E. Adjustment disorder.

Other specified trauma- and 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.

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 (CO2), 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.

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).

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.

RAD occurs only in children who lack 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.

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.

Severity of the trauma influences the risk of developing PTSD. Explanation: Risk factors related to the traumatic event (i.e., peritraumatic factors) include severity (dose) of the trauma (the greater the magnitude of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, interpersonal violence (particularly trauma perpetrated by a caregiver or involving a witnessed threat to a caregiver in children), and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma and persists afterward is a risk fac- tor. Risk factors related to temperament include childhood emotional problems by age 6 years (e.g., prior traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g., panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder).

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.

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.

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.

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.

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.

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. Explanation: The preschool criteria for PTSD include all of the types of traumatic exposure listed in the criteria for older individuals except for Criterion A4 ("Experiencing repeated or extreme exposure to aversive details of the traumatic event"); in addition, Criterion A3 for preschool children specifies "parent or caregiving figure" instead of "a close family member or a close friend." The preschool criteria require one or more symptoms in Criterion B (intrusion), one or more symptoms in Criterion C (avoidance or negative alterations in cognitions or mood), and two or more symptoms in Criterion D (arousal and reactivity). By contrast, the criteria for individuals older than 6 years require one or more symptoms in Criterion B (intrusion), one or both symptoms in Criterion C (avoidance), two or more symptoms in Criterion D (negative alterations in cognitions or mood), and two or more symptoms in Criterion E (arousal and reactivity).

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 lifespan. 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 lifespan.

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.