What is Reactive Attachment Disorder (RAD) F94.1?

By David Joel Miller.

Reactive Attachment Disorder begins early in life.

What is? Series

Reactive Attachment Disorder (RAD)
Photo courtesy of Pixabay.com

Reactive Attachment Disorder (RAD) is one of those disorders which was moved in the DSM-5.

It used to be included in the chapter on Disorders First Diagnosed in Infancy, Childhood, and Adolescence.

RAD now appears in the chapter on Trauma- and Stressor-Related Disorders.

Reactive Attachment Disorder is the result of deficiencies in early life care.

Reactive Attachment Disorder is an internalizing disorder. A related disorder called Disinhibited Social Engagement Disorder involves externalizing behaviors.  Both conditions are thought to be caused by poor caregiving early in life. RAD involves a consistent pattern of shutting down, withdrawing and inhibiting emotions. This disorder starts before age five and is rarely given after that age.

While this is a diagnosis primarily applied to very young children, in working with adults we often see conditions that probably began as Reactive Attachment Disorder.  A common statement is that they “just don’t get close to others.” This condition involves an inability to regulate emotion and unexplained anger, both issues we frequently see in adults who came from dysfunctional homes.

With children, we usually know that the symptoms are caused by neglect and poor parenting.  With adults, similar symptoms show up as depression, chronic sadness, anxiety disorders or even personality disorders.  Our understanding of reactive attachment disorder is pretty much an all or nothing condition.  I can’t help wonder about the effects which varying degrees of neglect or failure to meet the child’s emotional needs might be causing.

Reactive Attachment Disorder involves a consistent behavioral pattern.

Most of the Trauma- and Stressor-Related Disorders are related to anxiety and obsessive-compulsive disorders and are fear based. Reactive Attachment Disorder is about shutting down and internalizing. In Reactive Attachment Disorder, there is chronic sadness, depression, and loss of the pleasure.  There may also be accompanying anger, aggression, and dissociation. This involves a lot of withdrawal and inhibited emotion.

Reactive Attachment Disorder involves social and emotional problems.

Children with RAD are unresponsive to others.  They’re rarely happy or positive.  RAD involves frequent irritation, sadness and sometimes being afraid. Children with this disorder often react to adult caregivers in a negative way for no apparent reason. These patterns of poor relationships with adults continue even when caregivers change.

In adults, we see similar patterns with those people who get diagnosed with Persistent Depressive Disorder.  They often say they do not ever remember being happy.  What we often don’t know is if this person really had deficient care as a child or if they had a temperament which makes them difficult to parent.  Sick, or irritable temperamental children are harder to parent and more likely to be abused or neglected.

Extremely deficient care results in Reactive Attachment Disorder.

Characteristics of this less-than-adequate care include emotional needs not being met, frequent changes in caregivers, and being raised in impersonal institutionalize settings.  Mostly this deficient care results in poor relationships with caregivers and other adults, but it may also affect peer relationships.

Sometimes other things look like Reactive Attachment Disorder.

Sometimes children with Autism or developmental delays exhibit symptoms that can look like Reactive Attachment Disorder. In young children, it is important to be sure the problems were caused by poor caregiving.  In adults, we see behaviors that we suspect began as Reactive Attachment Disorder, but without a prior diagnosis, we can’t be sure. RAD may affect many other developmental areas.

Some cautions.

As with the other things we are calling a mental illness this RAD needs to interfere with the ability to work, or in children, go to school, relationships, or other enjoyable activities or cause personal distress. Otherwise, there may be issues, but the diagnoses will not be given. If the only time this happens is when someone is under the influence of drugs or medicines or because of some other physical or medical problem these problems would need to be more than the situation otherwise warrants. These other issues may need treating first, then if there are still symptoms, the diagnosis will be given.

Treatment for Reactive Attachment Disorder.

For children, getting into a situation with a caring, responsible, caregiver, can make all the difference.  For adults with problems now, which may or may not be the result of early childhood experiences, there are several therapies which may be helpful.

It is imperative that children who have Reactive Attachment Disorder get treatment early to prevent lifelong difficulties.  Adults who struggle with emotional difficulties may find that they still have early childhood issues that need to be addressed before their adult problems will resolve.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Amotivational Syndrome?

By David Joel Miller.

Have you lost your drive or your desire to do something?

unmotivated

Low Motivation.
Photo courtesy of Pixabay.com

Amotivational Syndrome is often connected with the smoking of marijuana.  This is something quite different from what we see in depression.  In depression, people lose the desire to do things they use to make them happy.  We call that loss of pleasure anhedonia.

In Amotivational Syndrome people seem to spend more time looking inward and contemplating things and less time actively doing them.  This syndrome was originally recognized in younger, marijuana smokers who were heavier daily users.

Does marijuana smoking cause loss of motivation?

Things that are, or were, associated with Amotivational Syndrome include the development of apathy and loss of ambition.  Heavy smokers just seem to become indifferent and stop caring about anything except smoking.  They seem to have fewer goals and decreased effectiveness.  Problems with attention and concentration have also been attributed to heavy marijuana smoking and Amotivational Syndrome.

Many of these characteristics are seen in daily, heavy, marijuana smokers.  What is unclear is whether the marijuana smoking causes this cluster of symptoms or whether those people who are low in motivation like to smoke marijuana.  At one point it was commonly accepted that some marijuana smokers are likely to suffer from Amotivational Syndrome.

Not all marijuana smokers are low in motivation.

Because of the many famous, popular people, who have been reported to be regular marijuana smokers, the connection between smoking marijuana and low motivation has come into question. It is unclear how common this condition is, or even if this is a valid syndrome.  Amotivational Syndrome has not been reported in countries other than the United States.  There’s some question whether Amotivational Syndrome is, in fact, a cultural rather than a mental condition.

Animals on marijuana don’t lose motivation.

Laboratory studies of both humans and animals have not found evidence of the Amotivational Syndrome for those using marijuana.  Amotivational Syndrome or loss of goals and direction has been found in many groups of young people who are not using marijuana on a regular basis.  This has led some writers to conclude that Amotivational Syndrome is a personality characteristic rather than the result of smoking marijuana.  It may be that those people with low motivation are attracted to using marijuana and other intoxicating substances.

One other possibility that has been suggested is that those people who are under the influence of drugs and alcohol or other substances may have low motivations to do anything while under the influence.  What we may be seeing in those people who were described as having Amotivational Syndrome may, in fact, be the effects of intoxication and withdrawal from marijuana or other substances.

As with the other things we are calling a mental illness or symptoms of a mental illness Amotivational Syndrome would need to interfere with your ability to work or go to school, your relationships, your enjoyable activities or cause you personal distress for it to be the focus of clinical attention. Otherwise, while you may have lost some motivation you will not be identified as someone needing clinical assistance.  If the only time you have low motivation is when you are under the influence of marijuana or another drug this would be diagnosed as drug intoxication.

For more on this and related topics see the other posts on counselorssoapbox.com under        Drug Use, Abuse, and Addiction

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Polydrug or Polysubstance use?

By David Joel Miller.

Polydrug use is common.

Drugs

What is Polydrug or Polysubstance use?
Photo courtesy of Pixabay.com

Polydrug use, sometimes referred to as multiple drug use, is an increasingly common pattern. Diagnosis of Substance Use Disorders used to be divided along the lines of the particular substance that someone used or abused. Treatment systems separated the alcoholics from the Heroin users and so on. There was a lot of validity to that model but it is becoming less and less possible as more people are using combinations of many drugs.

Most drug users have a preferred “High.” Stimulant users like being way up. Depressant users like the falling asleep, passing out kind of high. Hallucinogen users are chasing an altered reality. Some people dabble in all three types and their pattern of addiction is more to the process of using drugs than to any one particular substance.

I have heard people with a history of polysubstance use describe themselves as “trashcan junkies” just open the lid and throw something in. When asked what drugs they do, the standard answer is “What have you got?”

Drugs of abuse have cultures.

Alcohol users and abusers tend to hang out together. They have their preferred beverage of choice and their favorite method of consumption. If you drink the way others in your social circle drink then you can maintain the illusion that your drinking is under control. Some drinking groups divide up a 12 or 24 pack, some pass around a bottle of wine or a paper bag containing the hard stuff. Other groups order fancy mixed drinks from the cocktail waitress. Alcohol is everywhere and most people develop some familiarity with this culture.

Weed smokers have their culture also. They pass around the blunt, smoke a bowl or roll a joint. They have particular names for the varieties of marijuana they smoke or those they disdain. Most drink alcohol from time to time. Many weed smokers also have cultural decorations, tribal music and cultural heroes who smoked a lot of weed. But in a group of consistent marijuana users, it is likely that most primarily smoke marijuana.

Heroin users develop their own special culture. They know the process of making a rig. Users learn the concepts of going to the cotton and cotton fever. They also know the struggles of kicking and going cold turkey.

Some of the younger opiate abusers believe they are from a different tribe. They do their opiates as pills and liquids, obtained from doctors, pharmacies and diverted medical supplies. They may even hold fast to the myth that they are not addicts because they do not use needles. That myth gets shattered when their supply is interrupted and they have to kick along with the heroin addicts.

Polysubstance users move between cultures.

Increasingly we are seeing those whose allegiance is not to one drug of choice but to the process of doing drugs of any and every kind. The use of multiple substances is the norm rather than the exception. Most people in drug treatment and a major part of our jail and prison populations have long histories of using a wide variety of substances.

Polysubstance dependence is a problem without a diagnosis.

The most recent edition of the DSM eliminated the diagnosis of polysubstance dependence. We never did use polysubstance abuse. From here on the plan is to list each drug someone may have developed a problem with and then rate each use disorder as mild, moderate or severe.

For those working in the Substance Use Disorder field, this is problematic. While a client may have a mild problem with each of eight or ten different drugs, overall they can have a significant problem living life without using drugs or destructive behaviors.

My own experience has been that when someone has this “polysubstance dependence” problem, there are usually some other significant mental health issues going on.  The best treatment when polysubstance abuse or dependence are encountered is treatment of the mental health issues and the substance use issues at the same time.

Terms and their meaning can differ with the profession using them. The literature from the Rehab or AOD (Alcohol and Other Drug) field may be very different from that in the mental health field. There is still a large gap between recovery programs and AOD professionals and the terms and descriptions used in the DSM.

FYI. These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Disruptive Mood Dysregulation Disorder?

By David Joel Miller.

Maybe that child does not have Bipolar Disorder?

What is? Series

Disruptive Mood Dysregulation Disorder
Photo courtesy of Pixabay.com

Disruptive Mood Dysregulation Disorder F34.8 was added to the new DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) partially because way too many children were getting diagnoses of Bipolar Disorder. Most of these children grew up and never had an episode of mania or hypomania, the one thing that is required for a Bipolar Diagnosis.

The research supports the idea that a particular type of childhood depression was not getting the treatment it deserved. As a result, a lot of children were getting diagnoses they should not have had. Bipolar is only one of these possible incorrect diagnoses.

Some of the prominent symptoms of Disruptive Mood Dysregulation Disorder (DMDD) are temper tantrums and chronic irritability. These symptoms are quite different from the pressured uncontrollable behavior seen in Bipolar. DMDD has also been misdiagnosed as several other psychiatric disorders in the past.

One reason this has been getting noticed is that children who have the particular group of symptoms now recognized as DMDD rarely grow up to have Bipolar Disorder or behavioral disorders. What they develop as they grow are significant levels of depression and anxiety.

Disruptive Mood Dysregulation Disorder (DMDD) is similar to depression.

DMDD shares some characteristics with other forms of Depression. In both DMDD and the other depressions, there are mood issues, sadness, feeling empty or being chronically irritable. These mood issues result in changes to the body, physical symptoms, as well as changes in thinking and behavior. The result is that the person with DMDD or depression can’t function well even when they want to. DMDD is now found in the DSM chapter on depression. For many with adult depression, their issues all started in childhood with DMDD.

What are the symptoms of Disruptive Mood Dysregulation Disorder (DMDD?)

Disruptive Mood Dysregulation Disorder (DMDD) results in temper tantrums.

Children with Disruptive Mood Dysregulation can’t respond to frustration appropriately. The result of this lack of frustration tolerance is frequent temper tantrums or outbursts. These outbursts may be expressed verbally, or behaviorally. The defining characteristic of these temper outbursts is that they are excessive for the child’s developmental stage.

Even when this child is not having temper tantrums they are almost always in an angry or irritable mood. This angry irritable mood should be something that others can readily see by observing the child.

Age of onset of Disruptive Mood Dysregulation Disorder (DMDD.)

DMDD is only diagnosed if the symptoms first appear between the age of 6 and 18. The expectation is that the symptoms of depression seen with DMDD are inconsistent with the person’s developmental level. This is an issue of not being able to regulate your emotions.

Before age six we expect young or school-age children to have difficulty regulating emotions and to react with sadness, irritability or temper tantrums when frustrated. Young children may become frustrated and not able to exercise self-control no matter what the encouragement or punishment they receive.

Even if this disorder does not get recognized and diagnosed until later teen years the child must have had these symptoms before age ten. This separates DMDD from things that may be typical of adolescents during the teenage years.

Frequency and duration of Disruptive Mood Dysregulation Disorder (DMDD.)

On average, a child with DMDD should be having three or more episodes of mood dysregulation per week. This separates out the child who has occasional difficulties in response to a stressor from those who just can’t regulate emotions and are triggered more easily than they should be given their age.

These temper outbursts and mood dysregulation should go on most of the time for a year or more. This is no passing phase. Even if there are brief periods when the irritable angry mood is not present these periods of better mood should not last for more than three months.

Mood dysregulation happens in more than one place.

For us to think this child’s issue is a disorder we would expect the symptoms to appear in more than one setting, school, home, organized activates and so forth. In at least one of these setting, probably more, the outbursts are expected to be severe.

If there is mania it is not Disruptive Mood Dysregulation Disorder (DMDD.)

For a small group of children, there will be symptoms of mania or hypomania. If that is present then yes Bipolar Disorder is more appropriate and they are likely to develop more severe bipolar symptoms over time. Early treatment for childhood Bipolar Disorder can reduce the severity and impact of the disease but only if we are getting the diagnosis correctly.

One other difference between of Disruptive Mood Dysregulation Disorder (DMDD) and Bipolar is the way symptoms fluctuate. DMDD fluctuates in response to frustration. Bipolar symptoms come and go as a function of time.

Other Disruptive Mood Dysregulation Disorder (DMDD) issues.

DMDD has a lot of co-morbidity with other disorders. Children with DMDD are at increased risk of abusing substance and developing a substance use disorder (SUD.) And yes, we see SUD in elementary school children.

Because girls tend to internalize problems, while boys externalize, there is likely to be a bias in the diagnosis of Disruptive Mood Dysregulation Disorder (DMDD.) Only time will tell if this turns out to be another label for young boys.

Symptoms of Disruptive Mood Dysregulation Disorder (DMDD) are likely to change as the child grows and matures. It will be interesting to see if children who receive the DMDD diagnosis go on to experience Major Depression or some other adult mental health issues. Hopefully, treatment for this disorder while the child is young can prevent lifelong problems.

As with the other things we are calling a mental illness DMDD needs to interfere with the child’s ability to go to school, their relationships, and enjoyable activities or cause them personal distress. Otherwise, they may have the issues but not get the diagnoses. If the only time this happens is when under the influence of drugs or medicines or because of some other physical or medical problem these symptoms need to be more than the situation would warrant. Other issues may need treating first, then if the child still has symptoms they could get this diagnosis.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Sleep Walking?

By David Joel Miller.

Can people really do all that stuff while asleep?

Sleep Walking?

Sleep Walking?
Photo courtesy of Pixabay.com

Turns out that people can do a number of things while mostly asleep. Sleep Walking (Was DSM-IV 307.46 Now DSM-5 F51.3) and Sleep Terrors (DSM-IV 307.47 now DSM-5 F51.4)) use to be considered separate disorders. In the New DSM-5, they have been combined into one category, Non-Rapid Eye Movement Sleep Arousal Disorders. Despite now being one disorder with subtypes they get coded with two different numbers. (DSM is a registered trademark of the APA.) In the new lists, ICD-9, ICD-10 and oh my ICD-11, these numbers may all keep changing, sorry about that.

The Sleep Walking part also covers some other behaviors that can take place while the person is mostly asleep. It is also possible to engage in Sleep Eating and Sleep Sex. Sex while mostly asleep has also been called sexsomnia. Sleep Eating and Sleep Sex are specifiers added to the Sleep Walking diagnosis. These specifiers do not get their own numbers.

For someone to get this diagnosis these things must happen repeatedly not just occasionally.

And yes these things are considered real diseases not just excuses for things people do that may bother others.

Sleepwalking along with sleep eating and sleep sex are all things people do early in the sleep cycle before REM sleep, hence the name Non-Rapid Eye Movement Sleep Arousal Disorders.

One characteristic of Sleepwalkers is the blank look on their faces. Other clues that this person is not awake and is functioning on autopilot are the difficulty you will have in waking the sleepwalker up.

There was a belief that you should never wake someone up who was sleepwalking. I see no evidence that this is particularly harmful other than the sudden jolt that comes from waking up in a place other than where you went to bed. On the other hand as hard as it is to wake sleep walkers most of us will elect to just lead them back to bed and try to get them in the correct posture for sleep.

Sleepwalkers are also unresponsive to efforts to communicate with them. You can talk to them all you want but they just keep wandering around. Picture the actors you see in those zombie movies and you have a close approximation to the characteristic sleep-walker.

These episodes of sleepwalking happening in Non-REM sleep come without memories. This is described as having an “amnesia” for the events that happened during the sleepwalking.

The full diagnostic criteria are in the DSM-5. As with most other disorders, this one does not get used if the cause of this event is drugs or medications or if it seems to be caused by some other medical or psychological condition.

Sleep Walking Disorder is separate from Nightmares for several reasons. Nightmares and Bad dreams happen later in the sleep cycle predominantly during REM sleep. People remember what happened during nightmares and bad dreams. Nightmares often are connected to real life events as in PTSD. Sleepwalking just happens out of nowhere.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5, some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

You might want to take a look at other posts on Sleep   Dreams and Nightmares

More “What is” posts will be found at What is.

T

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is Acute Stress Disorder?

By David Joel Miller.

Stress can knock you down and leave you in the mud.

What is? Series

What is Acute Stress Disorder?
Photo courtesy of Pixabay.com

Most people have heard of the granddaddy of all the Trauma- and Stressor-Related Disorders, Posttraumatic Stress Disorder, far fewer people have heard of the smaller member of this family, Acute Stress Disorder.

Acute Stress Disorder is a condition in which something bad happens and it knocks you for a loop but eventually, it goes away. We do not want to make the normal problems of living into a mental disorder so we only begin counting things as possible disorders when the stressor is still affecting your life at least 3 days after the incident.

A great many people experience some stressor which does not end up becoming PTSD. If you are still having symptoms a month after the event we start thinking this may become long-term and then you get the designation of Posttraumatic Stress Disorder.

We want to keep normal life events out of this equation, so expected events like having an elderly person in your family die an expected death do not count as a trauma disorder, either Acute Stress Disorder or Posttraumatic Stress Disorder.

The full text of the DSM-5 includes a detailed description of how to recognize Acute Stress Disorder but here is a short description of the condition.

Four conditions need to be met for this trauma to be Acute Stress Disorder.

  1. You get exposed to something that could kill or seriously injure you or someone close to you.
  2. It happens in the real world. Movies, TV or your imagination do not count.
  3. This is unexpected.
  4. You can’t escape the results of this experience. You re-experience the events in more ways than one. Think of people who investigate child abuse or first responders at shootings or those who recover body parts in the war zone in addition to those who were the direct victim.

This experiencing and re-experiencing causes you problems.

The DSM-5 lists 14 symptoms. I will not repeat them all here. For the full text see the DSM-5. These 14 symptoms are clustered in 5 categories. To get the Acute Stress Disorder you need to have at least 9 of the 14 symptoms but they can be from any category.

1.The experience keeps coming back.

You may have nightmares, intrusive thoughts, flashbacks, spacing out and this may be triggered by either internal thoughts or external triggers.

2. This experience bums you out.

Basically, you get into and stay in a really negative mood.

3.The trauma spaces you out.

You may get overwhelmed and just “bounce” mentally. In more clinical language we would call this dissociation.

4.The result of the experience is it keeps you away from things.

You may find yourself avoiding people, places or things that remind you of the trauma. Some people do not like to be alone or they may use drugs and alcohol to knock themselves out rather than just falling asleep.

5.You are on edge and stay that way.

This could come out as poor sleep, being irritable or angry all the time, be losing your ability to concentrate, or being easily triggered by any little thing. People in this condition are always on high alert for something that might go wrong. The door slams down the block and those with Acute Stress Disorder will jump at a sound others will not notice.

As with the other things we are calling a mental illness, this needs to interfere with your ability to work or go to school, your relationships, your enjoyable activities, or cause you personal distress. Otherwise, you may have the issues but you will not get the diagnoses if this is a preference, not a problem. If the only time this happens is when you are under the influence of drugs or medicines or because of some other physical or medical problem this problem needs to be more than your situation would warrant. These other issues need treating first, then if you still have symptoms you could get this diagnosis.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What is “Conditions for Further Study?”

By David Joel Miller.

Are there more mental illnesses than we know about?

What is? Series

What is “Conditions for Further Study?”
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“Conditions for Further Study” is a chapter in the DSM-5 which describes some possible mental illnesses that have not yet gotten full official recognition. These are not something a clinician can diagnose, or one which insurance companies will pay to treat, not by these descriptions anyway.

You would think that by now we would have identified every possible mental, emotional or behavioral disorder, and come up with sure-fire treatments for each of them. Unfortunately, it doesn’t work that way.

Periodically a new disease comes along. It wasn’t all that long ago that no one had ever heard of AIDS or even HIV. The same thing, sort of, is happening in mental health. Researchers would like to be sure that when they tell you about the characteristics of and the treatment for a mental illness that everyone who was a subject in the research had the same disease.

Clinicians know that not everyone who has the same “diagnostic label” has the same symptoms. So you get a group of people who supposedly all have the same thing, say PTSD, and then you give them tests and assessments. For some things, personality characteristics like say introversion and extraversion, people will be on a continuum.

For other things like Posttraumatic Stress Disorder there will be clusters of people who all have similar symptoms and then clusters of other people who have different symptoms.

Lumpers and splitters.

Some people want only a few categories, like dogs and cats. The trouble with this is that Poodles are very different from Rottweilers. The house cat sitting on my desk is nowhere near like a Lion. So while we want to be specific about a mental, emotional or behavioral disorder someone might have, we also want to avoid creating several billion mental illness descriptions, one for each person.

Researchers and clinicians who notice these different clusters may become convinced that there are differences in symptoms that should be categorized as separate illnesses. For example, not all PTSD is alike. The PTSD that results from combat may show different features than the PTSD we see in battered women or abused children. Currently, they may all get a diagnosis of PTSD but there are different treatment approaches. Some clinicians have taken to referring to the form of PTSD that is the result of repeated abuse as “complex trauma” even though this is not officially a DSM diagnosis.

Are behavioral disorders a mental illness?

We see some similarities between drug and alcohol use disorders and some behaviors. Children and adolescents get some behavioral disorder diagnoses, things I sometimes refer to as “bad kid” diagnosis. But in adults not much in the way of behavior currently, meets criteria for a mental illness.

So far the only behavior that has gotten included in the Substance-Related and Addictive Disorders chapter is Gambling. Other behaviors, internet usage, compulsive gaming and pornography all have features that look like the loss of impulse control seen in Gambling.

Some of the major things that counselors treat are not diagnoses.

Anger is a huge reason for referrals to therapy, yet anger currently is not a specific diagnosis. While anger may be the reason for referral, currently it is seen as a symptom of some other problem, not a specific diagnosis. Despite the common practice of court-ordered Anger Management classes, Anger is not a diagnosis.

Suicidal behavior is not an official mental illness either.

Same problem with non-suicidal self-injury sometimes called cutting. Currently, the only place this fits is under Borderline Personality Disorder where it may be a symptom. This seems problematic. Does adding Non-Suicidal self-injury inflate the number of people with a diagnosis of Borderline Personality Disorder? Can you have one without the other? Shouldn’t someone who is thinking about killing themselves qualify for a diagnosis for that reason alone?

Disorders of special populations.

Several group-specific problems may be the focus of treatment but so far are not recognized as mental illnesses. This is a particularly acute problem for treatment of military personnel. Moral Injury is a situation in which you are required to do something that violates your sense of right and wrong. In civilian life, you may find ways to avoid this dilemma but in the military, there are few choices. Sometimes to do one good thing, following orders, you have to do something else that troubles your conscience.

Military sexual trauma is another non-DSM issue. In combat, you count on your comrades to keep you safe. Being raped by someone in your unit is a very traumatic incident. Having to continue to have good relationships with your abuser in order to stay alive is a tough situation.

Certainly, there are other problems, cultural or situational, that have not yet reached official disorder status but that require more research.

Do Conditions for further study make it to become a full diagnosis?

In each edition of the DSM, there are a number of proposed new diagnosis. Most do not make it as separate mental illness. After much research, they may get lumped in with existing disorders. Many of these proposed new disorders have long specific names. My observation is that the fewer words in the name the more likely it will get its own place in the DSM. Binge Eating Disorder made it. I have my doubts that Neurobiological Disorder Associated with Prenatal Alcohol Exposure will make it unless it gets a short name.  (More on Fetal Alcohol Exposure Problems is coming up in future posts.)

Currently, there are 8 “Conditions for Further Study” listed in the DSM-5. The DSM-IV-TR had 16, most of which disappeared in this revision.

What are those Conditions for Further Study in the DSM-5?

  1. Attenuated Psychosis Syndrome.
  2. Depressive Episodes with Short-Duration Hypomania
  3. Persistent Complex Bereavement.
  4. Caffeine Use Disorder.
  5. Internet Gaming Disorder.
  6. Neurobiological Disorder Associated with Prenatal Alcohol Exposure.
  7. Suicidal Behavior Disorder.
  8. Non-Suicidal Self-Injury.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

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For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.