Physical aggression:

Physical aggression is the same as physical abuse. This dissertation will use the term physical aggression instead of physical abuse to be consistent with the other types of aggressive behavior noted.

154 15. Psychological distress:

Psychological distress is the pain caused by any type of aggression which is long-lasting and is often relived by the individual time after time. Psychological distress can include symptoms related to shame, depression, anxiety,

posttraumatic stress disorder, suicidality, and substance abuse. For the purposes of this dissertation, the author measured the psychological distress variables of depression and PTSD.

16. Depression:

Depression refers to feeling blue or sad for an extended period of time.

The DSM-5 (APA, 2013) identifies several categories or types of depression. For purposes of this dissertation, this writer used Major Depressive Disorder. The DSM-5 (APA, 2013) defines Major Depressive Disorder as:

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day.

2. Markedly diminished interest or pleasure in all, or almost all activities.

3. Significant unintentional weight loss when not dieting or weight gain.

4. Insomnia or hypersomnia.

5. Psychomotor agitation or retardation (observable by others).

6. Fatigue or loss of energy.

7. Feelings of worthlessness or excessive or inappropriate guilt.

8. Diminished ability to think or concentrate, or indecisiveness.

9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

155 17. Posttraumatic Stress Disorder:

The DSM-5 (APA, 2013) defines Posttraumatic Stress Disorder as:

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 close friend.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).

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).

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).

5. Marked physiological reactions to internal or 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 experience occurred, 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 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.

156 4. Persistent negative emotional state.

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. Marked alterations in arousal and reactivity 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. Irritable behavior and angry outbursts.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance.

F. Duration of the disturbance (symptoms in Criteria B, C, D, and E) is more than one 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 or another medical condition.

18. Suicidality:

Webster's Concise English Dictionary (1992) refers to suicide as the act of

"killing yourself." Suicide is defined as "death caused by injurious behavior with any intent to die as a result of the behavior" (CDC, 2013). The CDC (2013) includes the definition for suicidal ideation, which includes "thinking about, considering, or planning for suicide."

157 19. Substance abuse/Substance Use Disorder:

The DSM-5 (APA, 2013) explains that substance use disorder encompasses 11 criteria:

1. The individual may take the substance in larger amounts or over a longer period that was originally intended.

2. The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use.

3. The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects.

4. Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used.

5. Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home.

6. The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

7. Important social, occupational, or recreational activities may be given up or reduced because of substance use.

8. Recurrent substance use in situations in which it is physically hazardous.

9. The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.

11. Withdrawal is a syndrome that occurs when blood or tissue

concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance.