Over the past 15 years, between increases in school and dsm 5 depression criteria pdf violence in the United States and unrelenting wars overseas, overt exposure to traumatic events has become an epidemic. Changing definitions and the rationale for such shifts have significant implications for counselors. The highly debated and variable definition of trauma and the diagnostic criteria for psychological responses to traumatic events may contribute to low counselor efficacy in trauma practice.
Without a clear understanding of the latest views and requirements for trauma diagnosis using DSM-5, counselors may feel tentative about assessing for trauma and selecting efficacious interventions. Only in the late 19th century did Pierre Janet and Sigmund Freud provide the first writings on the characterizations and clinical implications of traumatic events. Varied events as a car accident, a natural disaster, learning about a death of a loved one, and even a particularly difficult divorce were considered variations of traumatic experience. PTSD was historically characterized as an anxiety disorder within the DSM. Also termed the stressor criterion, PTSD criterion A stipulated two requirements.
The debate over what constitutes a traumatic event emerged with the first inclusion of the diagnosis into the DSM-III, and has persisted. PTSD resulting from less threatening events. Having a double-barreled criterion engendered considerable disagreement in trauma research and clinical practice. The integrated conceptualization of numbing and avoidance had marked significance on clinical practice. Several of the aforementioned considerations denote concern around subthreshold or subsyndromal survivors, namely individuals whose trauma did not match the A1 or A2 events or whose symptoms did not fulfill the restrictive criterion C. In the DSM-5, PTSD now serves as the cornerstone of a new category of diagnoses, TSRD. Within the new category, the definition of trauma is more explicit, and the symptomatic profile was expanded from a three- to four-factor structure.
Subjective responses following a traumatic event are no longer required, and a separate preschool diagnosis for children 6 years old and younger is now available. The modifications to the PTSD diagnosis in the DSM-5 are delineated in Table 1. The foremost change in the DSM-5 diagnosis of PTSD is its assignment to an innovative diagnostic category, TSRDs. Emphasis on the precipitating traumatic event called for reconsideration of the definition of trauma. Despite the argument by Brewin et al. DSM-5 retained criterion A1, with modifications to the breadth of the definition.
Actual or threatened death must have been violent or accidental. Such exposure through media, television, movies or pictures does not qualify unless for work. Several changes in the DSM-5 definition stand out immediately, such as the inclusion of sexual violence within the core premise of trauma. Experiencing sexual violence may precipitate PTSD, as can witnessing it, learning about it and experiencing repeated exposure to stories of such acts. Furthermore, loss of a loved one to natural causes is no longer considered a causal factor. For example, now a client whose partner unexpectedly died of a heart attack no longer fits PTSD criteria.
Along with changes to the definition of trauma, the DSM-5 now excludes the A2 subjective response. The PTSD diagnosis now represents survivors who experience reactions other than fear, helplessness or horror, or who exhibit no pronounced emotional response. For example, a client who witnessed a fatal car accident and predominantly feels pervasive guilt for not offering support could be diagnosable. DSM-IV, and requires only one of five symptoms. The new criterion E, persistent alterations in arousal, reflects the previous criterion D and includes one additional symptom, reckless or self-destructive behaviors.
Two of the now six symptoms of altered arousal are required. In addition to delayed expression, the DSM-5 includes specifiers for dissociative symptoms in PTSD, with either depersonalization or derealization constituting the primary presentation. In recognizing the gross oversights in previous iterations of the DSM regarding developmental considerations in PTSD, the DSM-5 explicitly provides a preschool subtype for children 6 years and younger. This new diagnosis honors the unique trauma experiences and responses of children, with symptoms that are behaviorally based and thus not reliant upon the cognitive or linguistic complexity absent in young survivors. Understanding these changes and the rationale behind them is essential to thorough client conceptualization and efficacious counseling.
Otherwise, counselors may feel tentative about key areas of care, such as assessing for trauma exposure, making accurate diagnoses, selecting efficacious interventions and filing reimbursement claims. A consideration of specific ways the new that the DSM-5 PTSD diagnosis impacts counselors, clients and clinical practice follows. The expanded PTSD symptom set in the DSM-5 set leads to extensive variations in possible trauma responses. Two clients may present in drastically different manners, but receive the same diagnosis.
Counselors will encounter many questions with the changing and heterogeneous face of PTSD. For instance, would a counselor work differently with the client with a PTSD diagnosis than with a client having an analogous presentation, but no PTSD diagnosis? Do neurological ramifications differ dramatically now given the shifting labels, and thus call for varied interventions? Changes precipitated by the DSM-5 require counselors be acutely aware of the modified PTSD diagnostic criteria for careful assessment of survivors. Thorough assessment includes applying both informal and formal approaches, using multiple sources of information, and conducting initial and ongoing screenings. During the present transition, informal assessment becomes especially important as efforts to revise and validate formal assessment tools continue.