Posttraumatic Stress Disorder (PTSD) is a serious mental health condition that can develop after a person has experienced or witnessed a traumatic event, such as a natural disaster, a serious accident, terrorism, war/combat, rape, or other violent personal assault. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), provides specific criteria to diagnose PTSD, ensuring accurate identification and appropriate treatment. This guide outlines the DSM-5 PTSD diagnosis criteria for adults, adolescents, and children older than 6 years, offering a detailed understanding for clinicians and individuals seeking clarity on PTSD diagnosis.
Criterion A: Stressor – Exposure to Traumatic Event
The first criterion for PTSD diagnosis in DSM-5 involves exposure to a traumatic event. According to Criterion A, the individual must have been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
1. Direct Experience
This refers to directly experiencing the traumatic event(s). For example, this could include being a victim of a physical assault, experiencing a car accident, or surviving a natural disaster.
2. Witnessing the Event
Witnessing, in person, the traumatic event(s) as it occurred to others also meets Criterion A. This could involve seeing someone else being attacked, witnessing a fatal accident, or observing the aftermath of a bombing.
3. Learning of Event Occurring to a Close Person
Learning that a traumatic event occurred to a close family member or close friend is another form of exposure. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. Learning about the sudden, unexpected death of a loved one can be profoundly traumatic.
4. Repeated or Extreme Exposure to Aversive Details
This criterion includes experiencing repeated or extreme exposure to aversive details of traumatic events. This is particularly relevant for first responders, such as police officers repeatedly exposed to details of child abuse cases or paramedics collecting human remains. It is important to note that exposure through electronic media, television, movies, or pictures, unless work-related, does not qualify under Criterion A4.
Criterion B: Intrusion Symptoms
Criterion B for PTSD diagnosis focuses on intrusion symptoms associated with the traumatic event(s), which must begin after the trauma occurred. Individuals must experience at least one of the following intrusion symptoms:
1. Intrusive Memories
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) are a hallmark of PTSD. These memories are not simply recollections; they are unwanted, distressing, and feel as if the event is happening again. In children older than 6 years, this may manifest as repetitive play where themes or aspects of the traumatic event(s) are expressed.
2. Distressing Dreams
Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s) are another intrusion symptom. These are more than just bad dreams; they are nightmares directly linked to the trauma. In children, there may be frightening dreams without recognizable content that are still related to the trauma.
3. Dissociative Reactions (Flashbacks)
Dissociative reactions, commonly known as flashbacks, are experiences where the individual feels or acts as if the traumatic event(s) were recurring. These reactions can range from a brief sense of reliving the event to a complete loss of awareness of present surroundings. In children, trauma-specific reenactment may occur in play.
4. Intense Psychological Distress to Trauma-Related Cues
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) is another intrusion symptom. These cues can be anything that reminds the person of the trauma, such as a sound, smell, sight, or even a date or time of year.
5. Marked Physiological Reactions to Trauma-Related Cues
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) can also occur. These reactions may include increased heart rate, sweating, trembling, or panic attacks when exposed to trauma reminders.
Criterion C: Avoidance Symptoms
Criterion C pertains to persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred. Individuals must exhibit at least one of the following avoidance symptoms:
1. Avoidance of Trauma-Related Memories, Thoughts, or Feelings
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) is a key avoidance symptom. This can involve actively trying not to think about the trauma or attempting to suppress any related emotions.
2. Avoidance of External Reminders
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) is another form of avoidance. This might include avoiding certain locations, people, or activities that trigger trauma memories.
Criterion D: Negative Alterations in Cognitions and Mood
Criterion D encompasses negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the trauma occurred. Individuals must experience at least two of the following:
1. Inability to Remember Key Aspects of the Trauma
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, is a cognitive alteration. This is not ordinary forgetting but a trauma-related memory gap.
2. Negative Beliefs About Self, Others, and the World
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”) are common cognitive changes. These negative beliefs are often distorted and generalized.
3. Distorted Cognitions About Cause or Consequences
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others are also included. This can involve feelings of guilt or shame about the trauma, even when the person was not at fault.
4. Persistent Negative Emotional State
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) is a mood alteration. This goes beyond normal sadness or anxiety; it is a pervasive and ongoing negative emotional experience.
5. Diminished Interest in Significant Activities
Markedly diminished interest or participation in significant activities that were previously enjoyed is another symptom. This can lead to social withdrawal and a loss of pleasure in life.
6. Feelings of Detachment or Estrangement
Feelings of detachment or estrangement from others can develop, making it difficult to feel close to or connected with other people.
7. Inability to Experience Positive Emotions
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings) is a significant mood alteration, often referred to as emotional numbing.
Criterion E: Marked Alterations in Arousal and Reactivity
Criterion E focuses on marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the trauma occurred. Individuals must exhibit at least two of the following:
1. Irritable Behavior and Angry Outbursts
Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects, are common arousal symptoms.
2. Reckless or Self-Destructive Behavior
Reckless or self-destructive behavior, such as substance abuse, risky driving, or other dangerous activities, can occur as a maladaptive coping mechanism.
3. Hypervigilance
Hypervigilance, an exaggerated state of watchfulness and scanning for threats, is a key arousal symptom in PTSD.
4. Exaggerated Startle Response
Exaggerated startle response, being easily startled by unexpected noises or movements, is another arousal symptom.
5. Problems with Concentration
Problems with concentration, making it difficult to focus on tasks or remember information, are common cognitive and arousal symptoms.
6. Sleep Disturbance
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep) is a frequent and distressing symptom of PTSD.
Criterion F: Duration
Criterion F specifies that the duration of the disturbance (Criteria B, C, D and E) is more than 1 month. Symptoms must persist for longer than a month to meet the criteria for PTSD diagnosis, differentiating it from acute stress disorder.
Criterion G: Functional Significance
Criterion G states that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must significantly interfere with the person’s daily life and well-being.
Criterion H: Exclusion
Criterion H ensures that the disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Symptoms must be directly related to the traumatic event and not better explained by substance use or another medical issue.
Specifiers for PTSD Diagnosis
The DSM-5 also includes specifiers to further refine the PTSD diagnosis:
With Dissociative Symptoms
This specifier is used when the individual’s symptoms meet the criteria for PTSD, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either:
1. Depersonalization
Depersonalization involves 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
Derealization involves persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). It is crucial to ensure these dissociative symptoms are not due to substance use or another medical condition.
With Delayed Expression
The “with delayed expression” specifier is used 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). This acknowledges that PTSD can sometimes emerge months after the traumatic event.
Conclusion
Understanding the DSM-5 PTSD diagnosis criteria is crucial for accurate diagnosis and effective treatment. This comprehensive guide provides a detailed overview of each criterion, helping clinicians and individuals alike better understand the complexities of PTSD. If you believe you or someone you know may be experiencing PTSD, seeking professional evaluation and support is essential for recovery and improved quality of life.
