Recent Changes in the Definition of Reactive Attachment Disorder
The Diagnostic and Statistical Manual, commonly referred to as the DSM, contains definitions for a vast range of mental illnesses, as well as detailed criteria that doctors can use when diagnosing these illnesses in their patients. In addition to its primary function as a guidebook for practicing mental health professionals, the DSM also serves as the main frame of reference on mental health issues in the United States (and some other countries) for insurance companies, public policymakers, and pharmaceutical companies.
The definitions and criteria in the DSM are not set in stone. The American Psychiatric Association maintains committees of specialists who review the current state of scientific and medical knowledge, then compare that knowledge to the current content of the Diagnostic and Statistical Manual. When these specialists feel that the DSM no longer matches the latest research and clinical findings, they recommend changes that can be included in a revised or fully updated edition of the manual. In May 2013, the APA replaced the previously revised fourth edition of the manual (DSM IV) with a new fifth edition (DSM 5).
Reactive Attachment Disorder Basics
Reactive attachment disorder typically begins in infancy, but can also appear at any other point before a child reaches age 5. As a rule, children develop the disorder because they don’t receive the type of care and attention needed to establish bonds to other people in early life. Most kids who develop the condition have histories that include neglect, physical or emotional abuse, or orphaning. The U.S. National Library of Medicine lists childhood reactive attachment disorder symptoms that include a marked tendency to stay away from physical contact, a marked tendency to stay away from the person responsible for providing care, an active dislike of interacting with other people, a preference for social isolation, and a lack of responsiveness to efforts on the part of others to provide comfort.
If left unaddressed, reactive attachment disorder can produce a range of long-term problems that continue to make an impact for decades or longer. Examples of these problems include depression, substance abuse or addiction, post-traumatic stress disorder (PTSD) or other forms of medically serious anxiety, disordered eating (sometimes accompanied by serious malnutrition), sexual misconduct, poor academic performance and other school-related difficulties, problems with anger or self-control, disruptions in the development of physical attributes or learning skills, difficulty maintaining adult relationships, and difficulty finding or keeping employment.
In DSM IV, reactive attachment disorder belongs to a group of conditions called disorders of infancy, childhood, or adolescence. DSM 5 removes the disorder from this category and places it in a new category of conditions known as trauma- and stressor-related disorders. Other conditions in this group include PTSD, a PTSD-like ailment called acute distress disorder, and another stress-related ailment called adjustment disorder. The American Psychiatric Association created the trauma- and stressor-related disorders category in order to emphasize a similarity in the underlying causes of these conditions, namely some sort of exposure to singular traumatic events or stresses that occur gradually over time.
According to the criteria set forth in DSM IV, a person with reactive attachment disorder can have symptoms that fall into one of two basic subtypes, known as “emotionally withdrawn/inhibited” and “socially indiscriminate/uninhibited.” Individuals with the emotionally withdrawn/inhibited subtype have the classic symptoms associated with reactive attachment and fail to make full connections with others. On the other hand, individuals with the socially indiscriminate/uninhibited subtype fail to distinguish between their primary caregivers and other people, and therefore develop the same level of attachment to close family members and complete strangers.
DSM 5 acknowledges the fact that the two subtypes of reactive attachment disorder listed in DSM IV are actually quite different on a fundamental level. In this new edition of the guidebook, the emotionally withdrawn/inhibited subtype from DSM IV now constitutes the only type of reactive attachment disorder. People affected by the socially indiscriminate/uninhibited subtype from DSM IV will now be diagnosed with disinhibited social engagement disorder. Apart from the differences in their core symptoms, disinhibited social engagement disorder and the newly redefined reactive attachment disorder differ in key aspects that include their course of development over time and the treatments needed to counteract their damaging effects.