Highlights of Changes from DSM-IV to DSM-5: Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is now in a separate chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the center of public as well as professional discussion.
The diagnostic criteria for DSM-5 (Table 1) identifies the trigger to PTSD as exposure to actual or threatened death, serious injury, or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:
| 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. 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). Note: 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). Note: 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). Note: 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. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in 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 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 event(s) 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 (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) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). |
| 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g. “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). |
| 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, or 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, 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 (e.g. difficulty falling or staying asleep or restless sleep). |
| 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: |
| 1. 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). |
| 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g. the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g. blackouts, behavior during alcohol intoxication) or another medical condition (e.g. complex partial seizures). |
| 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). |
a
The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see Table 2. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC, APA 2013. Copyright © 2013, American Psychiatric Association. Used with permission.
•.
directly experiences the traumatic event;
•.
witnesses the traumatic event in person;
•.
learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
•.
experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).
The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individual’s social interactions, capacity to work, or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs, or alcohol.
Compared with DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individual’s response to the event—intense fear, helplessness, or horror, according to DSM-IV—has been deleted because that criterion proved to have no utility in predicting the onset of PTSD.
DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and includes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal.
Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress. Avoidance refers to distressing memories, thoughts, feelings, or external reminders of the event.
Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.
Finally, arousal is marked by aggressive, reckless, or self-destructive behavior, sleep disturbances, hypervigilance, or related problems. The current manual emphasizes the “flight” aspect associated with PTSD; the criteria of DSM-5 also account for the “fight” reaction often seen.
The number of symptoms that must be identified depends on the cluster. DSM-5 only requires that a disturbance continue for more than a month and eliminates the distinction between acute and chronic phases of PTSD.
DSM-5 also includes two key additions to PTSD criteria: a separate criteria set for PTSD in children younger than 6 years (Table 2) and a subtype of PTSD with prominent dissociative symptoms (either experiences of feeling detached from one’s own mind or body, or experiences in which the world seems unreal, dreamlike, or distorted).
| A. In children 6 years and younger, 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, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures. |
| 3. Learning that the traumatic event(s) occurred to a parent or caregiving figure. |
| 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). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. |
| 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may not be possible to ascertain that the frightening content is related to the traumatic event. |
| 3. Dissociative reactions (e.g. flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in 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 reminders of the traumatic event(s). |
| C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s). |
| Persistent Avoidance of Stimuli |
| 1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). |
| 2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). |
| Negative Alterations in Cognitions |
| 3. Substantially increased frequency of negative emotional states (e.g. fear, guilt, sadness, shame, confusion). |
| 4. Markedly diminished interest or participation in significant activities, including constriction of play. |
| 5. Socially withdrawn behavior. |
| 6. Persistent reduction in expression of positive emotions. |
| D. 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 (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). |
| 2. Hypervigilance. |
| 3. Exaggerated startle response. |
| 4. Problems with concentration. |
| 5. Sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep). |
| E. The duration of the disturbance is more than 1 month. |
| F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior. |
| Specify whether: |
| • With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following: |
| 1. 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). |
| 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g. the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g. blackouts) or another medical condition (e.g. complex partial seizures). |
| 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). |
a
Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC, APA 2013. Copyright © 2013, American Psychiatric Association. Used with permission.
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