CHAPTER 1: ABNORMAL BEHAVIOR IN
scientific approach to their clinical work and
HISTORICAL CONTEXT
 There is no single definition for psychological
abnormality; the same goes for psychological
normality.
 PSYCHOLOGICAL DISORDER - a psychological
dysfunction within an individual associated
with distress or impairment in functioning and
a response that is not typical or culturally
expected.
 PSYCHOLOGICAL DYSFUNCTION – breakdown in
cognitive, emotional, or behavioral functioning.
 PERSONAL DISTRESS – difficulty performing
appropriate and expected roles.
 ATYPICAL RESPONSE – reaction is outside
cultural norms.
3 COMPONENTS OF A PYSCHOLOGICAL DISORDER:
 Psychological Dysfunction
 Personal Distress
 Atypical Response
5D’s OF ABNORMAL BEHAVIOR
1. DEVIANCE – any deviation from accepted norms
in a society of culture is considered abnormal.
2. DANGER – whenever an individual poses a risk
of danger to themselves or others, then it’s
most likely that they are abnormal.
3. DURATION – the time in which the change in
mental state of the person persists.
4. DISTRESS – do the symptoms cause suffering to
the person and to the people around them?
5. DYSFUNCTION – does the behavior cause a
dysfunction in the person’s everyday routine
and activities?
THE DIAGNOSTIC AND STATISTICAL MANUAL
 Widely accepted system used to classify
psychological disorders.
 It contains diagnostic criteria for behavior
patterns.
THE SCIENCE OF PSYCHOPATHOLOGY
 PSYCHOPATHOLOGY - is the scientific study of
psychological disorders.
 Within this field are specially trained
professionals, including clinical and counseling
psychologists, psychiatrists, psychiatric social
workers, and psychiatric nurses, as well as
marriage and family therapists and mental
health counselors.
 PhD or Doctors of Philosophy – clinical and
counseling psychologists
 PsyD or Doctors of Psychology – clinical and
counseling; inclined to clinical practice
 MD or Doctors of Medicine – psychiatrists;
specializes in therapy, medicine, and
pharmaceutical needs
 MSW – psychiatric and non-psychiatric social
workers
 LPC/MHSP – licensed professional counselors,
mental health service providers
 MN/RN – psychiatric nurses
 Lay Public and Community Groups
 Many mental health professionals take a
therefore are called scientist-practitioners.
3 FUNCTIONS AS A SCIENTIST-PRACTITIONER:
1. CONSUMER OF SCIENCE – enhancing the
practice
2. EVALUATOR OF SCIENCE – determining
the effectiveness of the practice
3. CREATOR OF SCIENCE – conducting
research that leads to new procedures
useful in practice
3 CATEGORIES IN THE STUDY AND DISCUSSION
OF PSYCHOLOGICAL DISORDERS:
 Clinical Description
 Causation (Etiology)
 Treatment and Outcome
CLINICAL DESCRIPTION
 Begins with a presenting problem.
 CLINICAL DESCRIPTION – distinguish clinically
significant dysfunction from common human
experience.
 PREVALENCE – how many people in the
population as a whole have the disorder?
 INCIDENCE – how many new cases occur during
a given period?
 ONSET - the time span from the beginning of
the first symptom to the time of developing a
full blown diagnosable psychiatric syndrome.
TRICIA a. ACUTE – sudden and severe
b. INSIDIOUS – develops gradually without
being noticed
 COURSE – individual pattern or development of
the disorder in a patient, including the
sequence and speed of the stages and forms
they take.
a. EPISODIC - the symptoms disappear
completely for varied periods of time,
only to reappear again
b. CHRONIC – symptoms persist or progress
over a long period of time, sometimes
even last for a lifetime
c. TIME LIMITED - the disorder will
improve without treatment in a
relatively short period
 PROGNOSIS – the anticipated course of a
disorder.
a. GOOD – individual will probably recover
b. GUARDED – probable outcome doesn’t
look good
CAUSATION, TREATMENT, & ETIOLOGY OUTCOMES
 ETIOLOGY – study of origins
 TREATMENT – includes pharmacologic,
psychosocial, and/or combined treatments.
 TREATMENT OUTCOME RESEARCH – limited in
specifying actual causes of disorders.
HISTORICAL CONCEPTIONS OF ABNORMAL BEHAVIOR
 Major psychological disorders have existed
across all time periods, in all cultures, and vary
 depending on prevailing paradigms of world
views.
3 DOMINANT TRADITIONS:
1. Supernatural
2. Biological
3. Psychological
SUPERNATURAL TRADITION
 For much of our recorded history, deviant
behavior has been considered a reflection of
the battle between good and evil.
 Abnormal behavior is caused by demonic
possession, witchcraft, and sorcery.
 Treatments for abnormal behavior included
exorcism, torture, beatings, and crude
surgeries (e.g. trephination).
 Mass hysteria may simply demonstrate the
phenomenon of emotion contagion, in which
the experience of an emotion seems to spread
to those around us.
 PARACELSUS – suggested that the movements of
the moon and stars had profound effect on
people’s psychological functioning and
speculated that the gravitational effects of the
moon on bodily fluids might be a possible cause
of mental disorders.
BIOLOGICAL TRADITION
 HIPPOCRATES – classified abnormal behavior as
a physical disease. He considered the brain to
be the seat of wisdom, consciousness,
intelligence, and emotion. Therefore, disorders
TRICIA
involving these functions would logically be
located in the brain.
 HIPPOCRATIC CORPUS – deduced that
psychological disorders could be treated like
any other disease.
 GALEN – extended Hippocrates’ work
 HUMORAL THEORY OF MENTAL ILLNESS -
assumed that normal brain functioning was
related to four bodily fluids or humors: blood
(heart), black bile (spleen), yellow bile (liver),
and phlegm (brain).
 During the 19th century, the biological tradition
was reinvigorated because of the discovery of
the nature and cause of syphilis and strong
support from the well-respected American
psychiatrist John P. Grey.
 SYPHILIS - a sexually transmitted disease
caused by a bacterial microorganism entering
the brain.
 GENERAL PARESIS - a form of neurosyphilis
which brings parenchymatous changes in the
central nervous system.
 LOUIS PASTEUR – discovered the bacterial
microorganism that causes syphilis.
 JOHN GREY – championed the biological
tradition in the United States.
 Biological treatments such as insulin shock
therapy, electroconvulsive therapy (ECT), and
brain surgeries (lobotomy) were standard
practice.
 Medications such as neuroleptics and major
tranquilizers were becoming increasingly
available.
PSYCHOLOGICAL TRADITION
 MORAL THERAPY - a strong psychosocial
approach to mental disorders that included
treating institutionalized patients as normally
as possible in a setting that encouraged and
reinforced normal social interaction, thus
providing them with many opportunities for
appropriate social and interpersonal contact.
 PHILIPPE PINEL AND JEAN BAPTISTE PUSSIN –
proponents of moral therapy.
 BENJAMIN RUSH – led reforms in the US by
introducing moral therapy in hospitals.
 WILLIAM TUKE – followed Pinel’s lead in
England
 DOROTHEA DIX – led the mental hygiene
movement.
PSYCHOANALYTIC THEORY
 Freudian theory of the structure and function
of the mind.
3 STRUCTURES OF THE MIND:
1. ID – pleasure principle, illogical, emotional,
irrational
2. EGO – reality principle, logical, rational
3. SUPEREGO – morality principle
 DEFENSE MECHANISM – occurs when the Ego
loses the battle with the Id and Superego.
 Denial
 Displacement
 Rationalization
 Reaction Formation
 Projection
 Repression
 Sublimation
PSYCHOSEXUAL STAGES OF DEVELOPMENT:
- Oral, Anal, Phallic, Latency, Genital
LATER DEVELOPMENTS IN PSYCHOANALYTIC
THOUGHT
 ANNA FREUD – emphasized influence of the ego
in defining behavior.
 MELANIE KLEIN, OTTO KERNBERG, & OBJECT
RELATIONS THEORY – emphasized how children
incorporate (introject) objects.
 CARL JUNG, ALFRED ADLER, KAREN HORNEY,
ERIC FROMM, ERIK ERIKSON – “Neo-Freudians”;
departure from the Freudian thought and de-
emphasized the sexual core of Freud’s theory.
 TALK THERAPY – used to unearth the hidden
intrapsychic conflicts.
 Aside from talk therapy, psychoanalytic therapy
uses techniques such as dream analysis and
free association.
HUMANISTIC THEORY
 People are innately good and strive towards
self-actualization.
 Known theorists include: Abraham Maslow, Carl
Rogers, and Fritz Perls.
 HUMANISTIC THERAPY – conveys empathy and
unconditional positive regard (UPR).
BEHAVIORISM
 BEHAVIORAL MODEL – derived from a scientific
approach to the study of psychopathology.
2 BEHAVIORAL MODELS:
1. CLASSICAL CONDITIONING – conditioning
was extended due to the acquisition of
fear; there is a contingency between
neutral and unconditioned stimuli.
 Pavlov and Watson
2. OPERANT CONDITIONING – voluntary
behavior is controlled by consequences.
 Skinner and Thorndike
 REACTIONARY MOVEMENT – challenged
psychoanalysis and non-scientific approaches.
 BEHAVIOR THERAPY – uses techniques derived
from behaviorism and tends to be direct and
time-limited.
PIONEERS OF BEHAVIOR THERAPY:
1. JOSEPH WOLPE – systematic desensitization
2. AARON BECK – cognitive therapy
3. ALBERT BANDURA – social learning
 PHENOTYPE – the combination of an
individual’s observable characteristics and
traits.
 GENOTYPE – unique set of genes an individual
carry.
NATURE OF GENES
 DEOXYRIBONUCLEIC ACID – double helix strand
that carries the genetic information of an
individual.
 There are normally 23 pairs of chromosomes
in each person.
 DOMINANT GENE - is one of a pair of genes that
strongly influences a particular trait, and we
need only one of them to determine, e.g. eye
or hair color.
 RECESSIVE GENE - must be paired with another
(recessive) gene to determine a trait,
otherwise, it won’t have any effect.
 EPIGENETICS – the environment influences the
gene development.
THE INTERACTION OF GENETIC AND ENVIRONMENTAL
EFFECTS

THE PRESENT: AN INTEGRATIVE APPROACH  ERIC KANDEL - suggested that the very genetic
structure of cells may change as a result of
 Psychopathology is multiply determined. learning if genes that were inactive or dormant
 Unidimensional accounts of psychopathology interact with the environment in such a way
are incomplete. that they become active.
 BIOPSYCHOSOCIAL MODEL – shows reciprocal  GENE-ENVIRONMENT INTERACTIONS - the
relations between biological, psychological, environment may occasionally turn on certain
social, and experiential factors. genes and may lead to changes in the number
TRICIA
of receptors at the end of a neuron, which, in
turn, would affect biochemical functioning in
the brain.
 DIATHESIS-STRESS MODEL - individuals inherit
tendencies to express certain traits or
behaviors, which may then be activated under
conditions of stress.
 DIATHESIS - a condition that makes someone
susceptible to developing a disorder.
 GENE-ENVIRONMENT CORRELATION MODEL -
indicates that genetic endowment may increase
the probability that an individual will
CHAPTER 2: INTEGRATIVE APPROACH TO experience stressful life events.
PSYCHOPATHOLOGY  NONGENOMIC INHERITANCE OF BEHAVIOR –
genes are not the whole story.
 ONE-DIMENSIONAL MODEL – could mean a
paradigm, school, or conceptual approach; CHAPTER 5: ANXIETY DISORDERS
could also mean an emphasis on a specific
cause of abnormal behavior.  Anxiety is a common dimension of day-to-day
 MULTIDIMENSIONAL MODEL – interdisciplinary, human experiences.
eclectic, and integrative; draws upon  ANXIETY - is an unpleasant emotion
information from several sources and views characterized by a feeling of vague,
abnormal behavior as multiple determined. unspecified harm.
 ANXIETY DISORDERS – marked by experience of
MULTIDIMENSIONAL MODELS OF ABNORMAL physiological arousal, apprehension or feeling
BEHAVIOR: of dread, hypervigilance, avoidance, and
sometimes, a specific fear or phobia.
 Biological influences
 Behavioral influences FEAR
 Emotional influences
 Social influences  Fear is a present-oriented mood.
 Developmental influences  It is an immediate alarm reaction to danger.
 Involves abrupt activation of the sympathetic
GENETIC CONTRIBUTIONS TO PSYCHOPATHOLOGY nervous system.
  Fear is a response to a known, immediate,
external, definite or non-conflictual threat.

ANXIETY

 Anxiety is a future-oriented mood.

 It is a negative mood state characterized by
bodily symptoms of physical tension and by
apprehension about the future.
 Anxiety is a response to an unknown, internal, COMORBIDITIES
vague or conflictual threat.
 It is an apprehension about a future threat.  COMORBIDITY – co-occurrence of two or more
disorders in an individual i.e., anxiety disorders
ANXIETY DISORDERS with depression/major depression.
 Diagnoses with depression or alcohol or drug
 Can develop in childhood and persist into abuse makes it less likely to recover from
adulthood if not treated. anxiety disorder and more likely to relapse.
 Most likely to occur in females than males with  Physical comorbidities such as anxiety disorder
a 2:1 ratio. with thyroid disease can also occur.
 Primary determination of whether the fear or
anxiety is excessive or out of proportion is SUICIDE
made by the clinician, taking cultural
contextual factors into account.  Anxiety or related disorder increases the
chances of having thoughts about suicide
CAUSES OF ANXIETY DISORDERS (suicidal ideation) or making suicidal attempts.
 Strongest with panic disorder and
a. BIOLOGICAL posttraumatic stress disorder.
- genetic vulnerability  According to Weissman study, 20% of patients
- anxiety and brain circuits with panic disorder had attempted suicide.
- depleted levels of GABA
b. SOCIAL CLASSIFICATIONS OF ANXIETY DISORDERS
- stressful life events trigger vulnerabilities
c. PSYCHOLOGICAL  Separation Anxiety Disorder
- anxiety and fears are learned responses  Selective Mutism
- catastrophic thinking and appraisal plays a role  Specific Phobia
 Social Anxiety Disorders
BIOLOGICAL CONTRIBUTIONS TO ANXIETY
TRICIA

 Panic Disorder
 Agoraphobia
 We inherit a tendency to be tense, uptight, and  Generalized Anxiety Disorder
anxious.  Substance/Medication Induced Anxiety
 BEHAVIORAL INHIBITION SYSTEM – activated by Disorders
signals from the brain stem of unexpected
events that might signal danger. SEPARATION ANXIETY DISORDER
 FIGHT/FLIGHT SYSTEM – immediate alarm-and-
escape response like panic. A. Inappropriate and excessive fear or anxiety
concerning separation from those to whom the
PSYCHOLOGICAL CONTRIBUTIONS TO ANXIETY individual is attached.

 According to Freud, anxiety is a psychic CAN BE CLASSIFIED AS SEPARATION ANXIETY IF

reaction to danger surrounding the reactivation AN INDIVIDUAL EXPERIENCES 3 OF THESE:
of an infantile fearful situation.
 Parents’ positive and predictable responses: 1. Excessive distress when anticipating or
less anxious experiencing separation from home or from
 Parents’ negative and overprotective major attachment figures.
responses: more anxious 2. Worry about losing major attachment figures.
 Locus of control: higher, more anxious 3. Worry about experiencing an untoward event
from a major attachment figure.
SOCIAL CONTRIBUTIONS 4. Reluctance or refusal to go out because of fear
of separation.
 marriage, divorce, difficulties at work, death of 5. Excessive fear or reluctance about being alone
a loved one, pressured to excel at school without attachment figures at home or in other
settings.
TRIPLE VULNERABILITY THEORY
6. Reluctance or refusal to sleep away from home
 Describes a theory of the development of or to go to sleep without being near a major
anxiety where all the factors are put together attachment figure.
in an integrated way. 7. Repeated nightmares involving theme of
separation.
8. Repeated complaints of physical symptoms
when separation from major attachment figures
occurs or is anticipated.
 B. Fear, anxiety, or avoidance is persistent lasting
for 4 weeks for children and 6 months or
more for adults.
C. Disturbance causes distress.
D. Disturbance is not caused by other disorder.
RISK FACTORS INCLUDE:
 Develops after life stresses, especially loss
(e.g. death of a relative or a pet)
 Parental overprotection and intrusiveness
SELECTIVE MUTISM
A. Consistent failure to speak in specific social
situations in which there is an expectation for
speaking (e.g. school) despite speaking in other
situations.
B. Disturbance interferes with educational or
occupational achievement or with social
communication.
C. Duration of the disturbance is at least 1 month
(not limited to the first month of school).
D. Failure to speak is not attributable to a lack of
knowledge of, or comfort with, the spoken
language required in the social situation.
E. The disturbance is not better explained by a
communication disorder.
ASSOCIATED FEATURES INCLUDE:
 Excessive shyness
 Fear of embarrassment
 Social isolation and withdrawal
 Clinging
 Temper tantrums
SPECIFIC PHOBIA
A. Marked fear or anxiety about a specific object
or situation.
B. Exposure to the stimulus provokes an
immediate anxiety.
C. Phobic object or situation is actively avoided or
endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the
actual danger.
E. Fear or anxiety or avoidance is persistent
lasting for 6 months.
F. Fear or anxiety causes distress.
G. The anxiety is not better explained by another
mental disorder.
TYPES OF SPECIFIC PHOBIA:
 Animal type
 Natural environment type
 Blood-injection-injury type
 Situational type
 Other types (loud sounds)
SPECIFIC PHOBIA CAN SOMETIMES DEVELOP:
 After a traumatic event
 Observation of others going through a
traumatic event
 An unexpected panic attack in the feared
situation
 Informal transmission
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
 Starts in mid-teens and duration is lifelong.
 Frequently appears among first degree
biological relatives.
CRITERIA FOR SOCIAL PHOBIA:
A. Marked fear or anxiety about one or more
social situations in which the individual is
exposed to possible scrutiny by others
(exposure to the feared situation provokes
anxiety).
B. The individual fears that he or she will act in a
way or show anxiety symptoms that will be
negatively evaluated.
C. Social situations almost always provoke social
anxiety.
D. The social situations are avoided or endured
with intense fear or anxiety.
E. Fear or anxiety is out of proportion to the
actual threat posed by the social situation and
to the sociocultural context.
F. Persistent and lasting for 6 months or more.
G. The fear, causes clinically significant distress or
impairment in important areas of functioning.
H. Not caused by physiological effects of a
substance.
I. The fear, anxiety, or avoidance is not better
explained by the symptoms of another mental
disorder.
J. If another mental condition is present, the
fear, anxiety, or avoidance is clearly unrelated
or is excessive.
SPECIFIERS:
TRICIA
 Performance only – they have performance
fears that impairs in their professional life
but they do not fear or avoid non-
performance situations.
ASSOCIATED FEATURES INCLUDE:
 Pauresis or “shy bladder syndrome”
 May be inadequately assertive or
excessively submissive.
 May overly show rigid body posture
 May be shy or withdrawn
 Seek employment that does not require
social contact.
 Men may be delayed in marrying whereas
women prefer to be homemakers.
PSYCHOLOGICAL TREATMENT OF PHOBIAS:
 Social Phobia – exposure, role playing or small
group interactions, social skills training
 Cognitive Therapy – enhances treatment for
social but not specific phobias
 Medication – SSRIS, Zoloft, Paxil
PANIC ATTACK
 An abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes.
 A panic attack is NOT A MENTAL DISORDER.
 Can occur in the context of any anxiety
disorder as well as other mental disorders.
 When the presence of a panic attack is
identified, it should be noted as a specifier
(e.g. PTSD with panic attacks).
  UNCUED/UNEXPECTED ATTACKS – occur - Cognitive-behavior therapies are highly
unexpectedly without warning; more likely a effective.
panic disorder.
 CUED/EXPECTED ATTACKS – triggered by AGORAPHOBIA
specific situations; more likely a phobia.
A. Fear or anxiety in two or more of the following:
PANIC DISORDER 1. Public transportations
2. Open spaces
 Higher risk on women than men (2:1 ratio). 3. Enclosed spaces
 Commonly develops in young adults (20-24 4. Standing in line or being in a crowd
years old). 5. Being outside of the home alone
 Prognosis is worse when agoraphobia is present. B. Fears/anxiety are due to thoughts that escape
might be difficult.
PSYCHOSOCIAL FACTORS: C. Provoke anxiety
D. Avoided or endured with anxiety
a. Cognitive-Behavioral Theories – classical
E. Fear/anxiety is out of proportion
conditioning
F. Fear/anxiety is persistent lasting 6 months
b. Psychoanalytic Theories – arise from an
G. Fear/anxiety causes distress
unsuccessful defense against anxiety-provoking
H. If a medical condition is present, the
impulses.
fear/anxiety is in excess
CRITERIA FOR PANIC DISORDER: I. Fear/anxiety is not caused by another disorder

A. Recurrent unexpected panic attacks (4 or GENERALIZED ANXIETY DISORDER (GAD)

more).
A. Excessive anxiety or worry occurring more days
B. Experience physical symptoms such as:
than not for 6 months in a number of events or
- palpitations
activities.
- accelerated heart rate
B. Controlling the worry is difficult
- sweating
C. Experience 3 or more of the following (1 for
- trembling or shaking
children):
- shortness of breath or sensations of smothering
1. Restlessness
- feeling of choking
2. Easily fatigued
- chest pain
3. Difficulty concentrating
- nausea, abdominal distress
4. Irritability
- feeling dizzy, lightheaded or faint
5. Muscle tension
- chills or heat sensations TRICIA

6. Sleep disturbance
- paresthesias (numbing/tingling sensation)
 Common worries include relationships, health,
- derealization or depersonalization
finances, daily hassles.
- fear of losing control or going crazy
 Often begins in adolescence or earlier, onset
- fear of dying
insidious.
C. At least one of the attacks has been followed
 Women are twice as likely as men to
by 1 month (or more) of one or both of the
experience GAD.
following:
1. Persistent concern or worry about
CHAPTER 5: TRAUMA AND STRESSOR RELATED
additional attacks or the consequences.
DISORDERS
2. Significant change in behavior related
to the attacks.  TRAUMA – is the physical or medical injury or a
3. Not caused by a substance. blow in the head (shock) or other parts of the
4. Not caused by a GMC. body.
 PSYCHOTRAUMA – is an extremely distressing
RISK FACTORS OF PANIC DISORDERS:
experience that causes severe emotional shock
 Negative affectivity and may have a long lasting psychological
 Anxiety sensitivity effects on the person.
 History of fearful spells  TRAUMATIC EVENTS – an event or an incident
 Separation anxiety that is outside the range of usual human
 Childhood sexual and physical abuses experience and that would be markedly
 Smoking distressing to almost anyone.
 Identifiable stressors before the panic
CHARACTERISTICS OF TRAUMATIC EVENTS:
attack
 Offspring of parents with anxiety disorder  Life-threatening
 Respiratory disturbance (asthma)  Unpredictable
 Uncontrollable
TREATMENT FOR PANIC DISORDER:
 Meaningless
 Medication Treatment
EXAMPLES OF TRAUMATIC EVENTS:
- SSRIS (e.g. Prozac and Paxil)
- Relapse rates are high following medication - Seeing another person who has been injured or
discontinuation killed.
 Psychological and Combined Treatments
 - Victims/survivors or witnesses of tragic 1. Reduced or absent reticence in approaching
vehicular accidents. and interacting with unfamiliar adults.
- War/arm conflict 2. Overly familiar verbal or physical behavior
- Natural disasters (that is not consistent with culturally
- Tragic or sudden death sanctioned and with age-appropriate social
- Chronic or terminal illness boundaries).
- Exposure to domestic violence 3. Diminished or absent checking back with
- Sexual abuse adult caregiver after venturing away, even
- Fires in unfamiliar settings.
- School shooting 4. Willingness to go off with an unfamiliar
- Plane crash adult with minimal or no hesitation.
B. The behaviors in Criterion A are not limited to
REACTIVE ATTACHMENT DISORDER impulsivity (as in
attention-deficit/hyperactivity disorder) but
A. A consistent pattern of inhibited, emotionally
include socially disinhibited behavior.
withdrawn behavior toward adult caregivers,
C. The child has experienced a pattern of
manifested by both of the following:
extremes of insufficient care as evidenced by
1. The child rarely or minimally seeks comfort
at least one of the following:
when distressed.
1. Social neglect or deprivation in the form of
2. The child rarely or minimally responds to
persistent lack of having basic emotional
comfort when distressed.
needs for comfort, stimulation, and
B. A persistent social and emotional disturbance
affection met by caregiving adults.
characterized by at least two of the following:
2. Repeated changes of primary caregivers
1. Minimal social and emotional
that limit opportunities to form stable
responsiveness to others.
attachments (e.g. frequent changes in
2. Limited positive affect.
foster care).
3. Episodes of unexplained irritability,
3. Rearing in usual settings that severely limit
sadness, or fearfulness that are evident
opportunities to form selective
even during nonthreatening interactions
attachments (e.g. institutions with high
with adult caregivers.
child-caregiver ratios).
C. The child has experienced a pattern of
D. The care for Criterion C is presumed to be
extremes of insufficient care as evidenced by
responsible for the disturbed behavior in
at least one of the following:
Criterion A.
1. Social neglect or deprivation in the form of
E. The child has a developmental age of at least 9
persistent lack of having basic emotional TRICIA

months.
needs for comfort, stimulation, and
affection met by caregiving adults.
 Specify the following:
2. Repeated changes of primary caregivers
 Persistence
that limit opportunities to form stable
 Current Severity
attachments (e.g. frequent changes in
foster care). POSTTRAUMATIC STRESS DISORDER (PSTD)
3. Rearing in usual settings that severely limit
opportunities to form selective  Extreme response to a severe stressor (anxiety,
attachments (e.g. institutions with high avoidance of stimuli associated with trauma,
child-caregiver ratios). emotional numbing).
D. The care for Criterion C is presumed to be  Exposure to a traumatic event that involves
responsible for the disturbed behavior in actual or threatened death or injury (e.g. war,
Criterion A. rape, natural disaster).
E. The criteria are not met for autism spectrum  Trauma leads to intense fear or helplessness.
disorder.  Symptoms are present for more than a month.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least 9 3 CATEGORIES OF SYMPTOMS:
months.
1. Re-experiencing the traumatic event in the
form of nightmares, intrusive thoughts, or
 Specify the following:
images.
 Persistence – The disorder has been present for
2. Avoidance of stimuli (e.g. refusing to walk on
112 months.
street where rape occurred, numbing,
 Current Severity – Reactive attachment
decreased interest in others, distant or
disorder is specified as severe when a child
estranged from others, unable to experience
exhibits all symptoms of the disorder, with
positive emotions).
each symptom manifesting at relatively high
3. Increased arousal (insomnia, irritability,
levels.
hypervigilance, exaggerated startle response).
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
DIAGNOSTIC CRITERIA:
A. A pattern of behavior in which a child actively
 The following criteria apply to adults,
approaches and interacts with unfamiliar adults
adolescents, and children older than 6 years.
and exhibits at least two of the following:
A. Exposure to actual or threatened death, serious
injury, or sexual violence in one (or more) of
the following ways.
1. Directly experiencing the traumatic
event(s).
2. Witnessing, in person, the event(s) as it
occurred to others.
3. Learning that the traumatic event(s)
occurred to a close family member or
friend.
4. Experiencing repeated or extreme exposure
to aversive details of the traumatic
event(s) (e.g. first responders, police
officers).
* Criterion A4 does not apply to exposure
through electronic media, television, movies,
or pictures, unless this exposure is work
related.
B. Presence of one (or more) of the following
intrusion symptoms associated with the
traumatic event(s), beginning after the
traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s).
*In children older than 6 years, repetitive play
may occur in which themes or aspects of the
traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the
content and/or affect of the dream are
related to the traumatic event(s).
TRICIA
*In children, there may be frightening dreams
without recognizable content.
3. Dissociative reactions (e.g. flashbacks) in
which the individual feels or acts as if the
traumatic event(s) were recurring.
* In children, trauma-specific reenactment may
occur in role-play.
4. Intense or prolonged psychological distress
at exposure to internal or external cues that
symbolize or resemble an aspect of the
traumatic event(s).
5. Marked physiological reactions to internal
and external cues that symbolize or resemble
an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with
the traumatic event(s), beginning after the
traumatic event(s) occurred, and as evidenced
by one or both of the following:
1. Avoidance of or efforts to avoid distressing
memories, thoughts, or feelings about or
closely associated with the traumatic
event(s).
2. 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).
D. Negative alterations in cognitions and mood
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect
of the traumatic event(s).
2. Persistent and exaggerated negative beliefs
or expectations about oneself, others, or
the world.
3. Persistent, distorted cognitions about the
cause or consequences of the traumatic
event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state (e.g.
fear, horror, anger, guilt, shame).
5. Markedly diminished interest or
participation in significant activities.
6. Feelings of detachment or estrangement
from others.
7. Persistent inability to experience positive
emotions (e.g. inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, and as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with
little or no provocation) typically expressed
as verbal or physical aggression toward
people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
F. Duration of the disturbance (Criteria B, C, D,
and E) is more than 1 month.
G. The disturbance causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
H. The disturbance is not attributable to the
physiological effects of a substance (e.g.
medication, alcohol) or another medical
condition.
 Specify whether:
 With dissociative symptoms – The
individual’s symptoms meet the criteria for
posttraumatic stress disorder, and in
addition, in response to the stressor, the
individual experiences persistent or
recurrent symptoms of either of the
following:
a. Depersonalization – Persistent or recurrent
experiences of feeling detached from, and
as if one were an outside observer of, one’s
mental processes or body (e.g. feeling as
though one were in a dream, feeling a
sense of unreality of self or body or of time
moving slowly).
b. Derealization – Persistent or recurrent
experiences of unreality of surroundings
(e.g. the world around the individual is
experienced as unreal, dreamlike, distant,
or distorted).
 Specify if:
  With delayed expression – If the full
diagnostic criteria are not met until at least
6 months after the event (although the
onset and expression of some symptoms
may be immediate).
ACUTE STRESS DISORDER
A. Exposure to actual or threatened death, serious
injury, or sexual violation in one (or more) of
the following ways:
1. Directly experiencing the traumatic
event(s).
2. Witnessing, in person, the event(s) as it
occurred to others.
3. Learning that the traumatic event(s)
occurred to a close family member or
friend.
*In cases of actual or threatened death of a
family member or friend the event(s) must
have been violent or accidental.
4. Experiencing repeated or extreme exposure
to aversive details of the traumatic
event(s) (e.g. first responders collecting
human remains, police officers repeatedly
exposed to details of child abuse).
*This does not apply to exposure through
electronic media, television, movies, or
pictures, unless this exposure is work related.
*Duration lasts from 3 days to 1 month.
B. Presence of nine (or more) of the following
symptoms from any of the five categories of
TRICIA
intrusion, negative mood, disassociation,
avoidance, and arousal, beginning or worsening
after the traumatic event(s) occurred:
 INTRUSION SYMPTOMS:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s).
2. Recurrent distressing dreams in which the
content and/or affect of the dream are
related to the traumatic event(s).
3. Dissociative reactions (e.g. flashbacks) in
which the individual feels or acts as if the
traumatic event(s) were recurring.
4. Intense or prolonged psychological distress
at exposure to internal or external cues
that symbolize or resemble an aspect of the
traumatic event(s).
 NEGATIVE MOOD:
5. Persistent inability to experience positive
emotions (e.g. inability to experience
happiness, satisfaction, or loving feelings).
 DISSOCIATIVE SYMPTOMS:
6. 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).
7. 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 SYMPTOMS:
8. Efforts to avoid distressing memories,
thoughts, or feelings about or closely
associated with the traumatic event(s).
9. 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).
 AROUSAL SYMPTOMS:
10. Sleep disturbance
11. Irritable behavior and angry outbursts (with
little or no provocation) typically expressed
as verbal or physical aggression toward
people or objects.
12. Hypervigilance
13. Problems with concentration
14. Exaggerated startle response
ADJUSTMENT DISORDERS
A. The development of emotional or behavioral
symptoms in response to an identifiable
stressor(s) occurring within 3 months of the
onset of the stressor(s).
B. These symptoms or behaviors are clinically
significant, as evidenced by one or both of the
following:
1. Marked distress that is out of proportion to
the severity or intensity of the stressor,
taking into account the external context
and the cultural factors that might
influence symptom severity and
presentation.
2. Significant impairment in social,
occupational, or other important areas of
functioning.
C. The stress-related disturbance does not meet
the criteria for another mental disorder and is
not merely an exacerbation of a preexisting
mental disorder.
D. The symptoms do not represent normal
bereavement.
E. Once the stressor or its consequences have
terminated, the symptoms do not persist for
more than an additional 6 months.
 Specify whether:
 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.

STAGES OF TRAUMA

1. Sudden occurrence of traumatic event

2. Physical effects
3. Shock or disbelief
4. Destabilization
5. Psychological effects
6. Coping/Normalizing
7. Recovery

TRAUMA IMPACT MODEL:

TRICIA