Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

overview

Trauma- and stressor-related disorders include a group of conditions where exposure to a traumatic or stressful event is a required diagnostic criterion. These disorders are characterized by a wide range of emotional, behavioral, and physiological responses to significant stress or trauma. While anxiety and fear are common reactions, individuals may also display symptoms such as mood disturbances, aggression, dissociation, or social withdrawal.
Posttraumatic Stress Disorder (PTSD) is considered the prototypical disorder in this category and involves a specific set of symptoms following exposure to a life-threatening or horrifying event. Symptoms often include intrusive memories, avoidance behaviors, negative alterations in mood and cognition, and heightened arousal.

Other disorders in this category reflect differing developmental contexts or symptom presentations, such as disrupted attachment in early childhood, intense short-term reactions, maladaptive adjustment to life changes, or prolonged grief responses. Although the disorders share a unifying feature of trauma or stress exposure, they differ significantly in how individuals process and respond to these experiences.

DSM Chapter Sections:

• Reactive Attachment Disorder (RAD)

• Disinhibited Social Engagement Disorder (DSED)

• Posttraumatic Stress Disorder (PTSD)

• Acute Stress Disorder (ASD)

• Adjustment Disorders

• Prolonged Grief Disorder

• Other Specified Trauma- and Stressor-Related Disorder

• Unspecified Trauma- and Stressor-Related Disorder

Reactive attachment disorder

Reactive Attachment Disorder (RAD) is marked by a consistent pattern of emotionally withdrawn behavior in young children toward adult caregivers. The core issue is a lack of developmentally appropriate attachment, usually due to severe neglect or insufficient caregiving early in life.

Criteria:

A. Child consistently shows emotionally withdrawn behavior toward adult caregivers, shown by both:

• Rarely seeks comfort when upset
• Rarely responds to comfort when offered

B. Social and emotional impairments.
C. History of severe neglect or disrupted care.
D. The attachment issues (A) are directly linked to the inadequate care (C)
E. Does not meet criteria for Autism Spectrum Disorder
F. Symptoms must begin before age 5
G. Child must have a developmental age of at least 9 months

Disinhibited social engagement disorder

Disinhibited social engagement disorder (DSED) is characterized by culturally inappropriate, overly familiar behavior with unfamiliar adults. Children with this disorder show a lack of typical caution around strangers, frequently engaging in overly familiar verbal or physical interactions without checking back with caregivers. Unlike reactive attachment disorder, children with DSED may form attachments, ranging from secure to disturbed, but still show disinhibited social behavior. The child must have a developmental age of at least 9 months to receive this diagnosis.

DSED is strongly associated with a history of social neglect or deprivation, including frequent changes in caregivers or institutional care with high child-to-caregiver ratios. However, signs of the disorder often persist even after the child is no longer in a neglectful environment and may appear in children without current signs of neglect.

Criteria:

A. Socially disinhibited behavior with unfamiliar adults, with at least two of the following:

• Little or no hesitation in approaching strangers.
• Overly familiar verbal or physical behavior beyond cultural norms.
• Rarely checks back with caregiver after separating.
• Willingly goes off with strangers with minimal/no hesitation.

B. Behavior is not solely due to impulsivity (e.g., ADHD).
C. History of extreme insufficient care.
D. The behavior in A is directly linked to the care issues in C.
E. Developmental age of at least nine months required.

Posttraumatic Stress disorder

Posttraumatic stress disorder (PTSD) is characterized by the development of specific symptoms following exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. This exposure may occur through direct experience, witnessing trauma, learning of a trauma affecting a loved one, or repeated exposure to traumatic details through one’s professional duties.

The clinical presentation of PTSD is diverse. Symptoms may involve fear-based reactions, anhedonia, mood disturbances, dissociation, or externalizing behaviors. These can appear alone or in combination, and presentation may vary across individuals.

Criteria for individuals six years and older:

A. Trauma Exposure: The person must be exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:

• Directly experiencing the trauma.
• Witnessing it happen to others in person.
• Learning that it occurred to a close family member or friend (must be violent or accidental).
• Repeated or extreme exposure to aversive details of traumatic events (e.g., first responders).

B. Intrusion Symptoms (at least 1):

• Intrusive memories.
• Distressing dreams.
• Dissociative reactions (e.g., flashbacks).
• Intense psychological distress to trauma cues.
• Physiological reactions to trauma cues.

C. Avoidance (at least 1):

• Avoiding distressing thoughts, feelings, or memories of the trauma.
• Avoiding external reminders (people, places, conversations, etc.).

D. Negative Changes in Cognition or Mood (at least 2):

• Memory gaps related to the trauma.
• Negative beliefs about self, others, or the world.
• Distorted blame of self or others.
• Persistent negative emotional state.
• Decreased interest in activities.
• Detachment or estrangement from others.
• Inability to experience positive emotions.

E. Arousal and Reactivity (at least 2):

• Irritable or aggressive behavior.
• Reckless or self-destructive behavior.
• Hypervigilance.
• Exaggerated startle response.
• Difficulty concentrating.
• Sleep disturbances.

F. Duration: Symptoms from Criteria B–E last more than 1 month

G. Functional Impact: Causes significant distress or impairment in functioning.

H. Rule Out: Substance use or medical condition.

Acute stress disorder

Acute Stress Disorder (ASD) is characterized by the development of significant psychological symptoms occurring within the first month after exposure to a traumatic event. These events must involve actual or threatened death, serious injury, or sexual violence, and can be experienced directly, witnessed, or learned about if the trauma happened to a close family member or friend. Professionals, such as first responders, may also develop ASD due to repeated or extreme exposure to aversive details of traumatic events.

The symptoms of ASD begin within 3 days of the trauma and must last for at least 3 days but no longer than 1 month. Individuals must exhibit nine or more symptoms from five distinct clusters: intrusion, negative mood, dissociation, avoidance, and arousal. Intrusion symptoms include recurrent, involuntary memories or dreams, flashbacks, and intense distress or physiological reactivity to reminders of the trauma. Dissociative symptoms can involve feeling detached from one’s body (depersonalization), a sense of unreality about the environment (derealization), or memory gaps related to the event. Negative mood is often expressed through an inability to feel positive emotions, while avoidance behaviors may include efforts to avoid trauma-related thoughts, feelings, or external reminders. Arousal symptoms often manifest as sleep disturbance, irritability, hypervigilance, difficulty concentrating, and exaggerated startle responses.

Criteria:

A. Trauma Exposure
Exposure to actual or threatened death, serious injury, or sexual violence through:

• Direct experience.

• Witnessing trauma.

• Learning about trauma to a close family member or friend (must be violent or accidental).

• Repeated/extreme exposure to trauma details (e.g., first responders).

B. Nine or more symptoms from any combination of the following five categories, beginning or worsening after the trauma:

• Intrusion: Distressing memories, dreams, flashbacks, or intense distress/reactivity to trauma reminders.

• Negative Mood: Inability to feel positive emotions.

• Dissociation: Altered sense of reality or memory gaps.

• Avoidance: Avoidance of trauma-related thoughts or reminders.

• Arousal: Sleep problems, irritability, hypervigilance, poor concentration, exaggerated startle.

C. Duration: Symptoms last from 3 days to 1 month following the trauma.
D. Impairment: Causes significant distress or impairment in functioning.
E. Rule Out: Not due to substances, medical conditions, or better explained by another mental disorder (e.g., brief psychotic disorder).

Adjustment disorder

Adjustment disorder is characterized by emotional or behavioral symptoms that arise in response to an identifiable stressor. The symptoms must begin within three months of the stressor and represent a marked distress that is out of proportion to the severity or intensity of the situation, considering the individual’s cultural and contextual factors. The stressor can be a single event (e.g., job loss, breakup) or multiple stressors (e.g., financial strain and relationship conflict). It can be acute, recurrent, or chronic, and may affect an individual, family, or broader group. Developmental transitions, such as moving away for college, becoming a parent, or retiring, are common triggers.

Adjustment disorder is distinct from normal stress reactions in that the individual’s response causes significant impairment in social, occupational, or other areas of functioning. The symptoms may include depression, anxiety, or disturbances in conduct, and are not due to another mental disorder or the effects of a substance.

Criteria:

A. Emotional or behavioral symptoms develop in response to an identifiable stressor, occurring within 3 months of the onset of the stressor.
B. Symptoms are clinically significant, shown by one or both:

• Distress out of proportion to the severity or context of the stressor.
• Impairment in social, occupational, or other important areas of functioning.

C. The disturbance does not meet criteria for another mental disorder and is not simply a worsening of a preexisting condition.
D. The reaction is not normal bereavement and does not meet criteria for prolonged grief disorder.
E. Once the stressor or its consequences end, symptoms do not persist beyond six months.

prolonged grief disorder

Prolonged Grief Disorder (PGD) is a newly recognized diagnosis that describes a persistent and impairing grief reaction following the death of a close loved one. The diagnosis can be made after 12 months in adults, or 6 months in children and adolescents, post-loss (Criterion A).

The core symptom is intense yearning or longing for the deceased or a preoccupation with thoughts or memories of the person. In children and adolescents, this may focus more on the circumstances of the death. This symptom must occur most days and be clinically significant for at least the past month (Criterion B).

In addition to the core symptom, the individual must also exhibit at least three of the following symptoms, occurring nearly every day for at least one month (Criterion C):

• Feeling part of oneself has died (identity disruption)

• Disbelief about the death

• Avoidance of reminders of the loss

• Intense emotional pain (e.g., anger, guilt)

• Difficulty reconnecting with others or activities

• Emotional numbness

• Sense that life is meaningless

• Intense loneliness

The disturbance must cause clinically significant distress or impairment (Criterion D) and must exceed culturally expected norms of bereavement (Criterion E).

Other specified trauma-and-stressor-related disorder

Other specified trauma- and stressor-related disorder is used when a person exhibits significant distress or impairment due to trauma- or stressor-related symptoms, but does not meet full criteria for any specific disorder within this diagnostic category (e.g., PTSD, Acute Stress Disorder, Adjustment Disorder).

This diagnosis allows the clinician to specify the reason the presentation doesn’t meet full criteria for another disorder. It is recorded as “Other Specified Trauma- and Stressor-Related Disorder” followed by the description (e.g., “persistent response to trauma with PTSD-like symptoms”).

Examples include:

• Delayed-onset adjustment-like disorder (symptoms begin more than 3 months after the stressor)

• Prolonged adjustment-like disorder (lasting more than 6 months without an ongoing stressor)

• Subthreshold PTSD (PTSD-like symptoms that persist longer than 6 months but do not meet full criteria)

• Cultural syndromes like ataque de nervios or other culturally specific trauma reactions

Unspecified trauma-and-stressor-related disorder

This diagnosis is used when a person shows significant trauma- or stressor-related symptoms that cause distress or impairment but do not meet full criteria for any specific disorder in the category. It is applied when the clinician chooses not to specify why the criteria are unmet, often due to insufficient information, such as in emergency or initial assessment settings.

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