Understanding Trauma Diagnosis: DSM-5 Criteria for PTSD

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 in adults, adolescents, and children older than 6 years. Accurate trauma diagnosis using DSM-5 is crucial for effective treatment and support for individuals struggling with the aftermath of trauma.

This article outlines the DSM-5 diagnostic criteria for PTSD, providing a clear and concise understanding of each criterion. This information is essential for mental health professionals, individuals seeking to understand PTSD, and anyone wanting to learn more about trauma diagnosis using the DSM-5 framework.

Criterion A: Stressor – Exposure to Trauma

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. Directly experiencing the traumatic event(s). This could involve being the victim of violence, experiencing a natural disaster firsthand, or being in a serious accident.
2. Witnessing, in person, the traumatic event(s) as it occurred to others. Observing a violent crime, accident, or disaster happening to someone else can be traumatic.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. This criterion applies when learning about a violent or accidental death or threat of death to a loved one.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s). This is particularly relevant for first responders, law enforcement, and other professionals who are repeatedly exposed to graphic details of traumatic events in the course of their work. It’s important to note that exposure through media (television, movies, or pictures) does not qualify under this criterion unless it is work-related.

Criterion B: Intrusion Symptoms

Criterion B focuses on intrusion symptoms, which are recurrent and involuntary experiences related to the traumatic event. Individuals must experience one or more of the following intrusion symptoms:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). These memories are not simply recollections but feel as if the event is happening again, causing significant distress. In children older than 6 years, this may manifest as repetitive play where themes of the trauma are present.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Nightmares that directly replay or are thematically linked to the trauma are characteristic of this criterion. In children, these dreams may be frightening but lack recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. Flashbacks can range from brief moments of reliving the event to complete loss of awareness of the present surroundings. In children, trauma-specific reenactment may occur during 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). These cues can trigger strong emotional reactions, reminding the individual of the trauma.
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Physical responses like increased heart rate, sweating, or panic attacks can occur when exposed to trauma-related cues.

Criterion C: Avoidance

Criterion C involves persistent avoidance of stimuli associated with the traumatic event(s). This avoidance begins after the traumatic event(s) and is 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). This involves actively trying to suppress thoughts, feelings, or memories related to the trauma.
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). This can include avoiding places or people that trigger memories of the trauma or situations that are reminiscent of the traumatic event.

Criterion D: Negative Alterations in Cognitions and Mood

Criterion D encompasses negative changes in thoughts and feelings related to the traumatic event(s). These negative alterations begin or worsen after the traumatic event(s) and are 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). This is not ordinary forgetting, but a significant gap in memory specifically related to the traumatic period.
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”). These are pervasive negative beliefs that develop or worsen after the trauma.
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. This involves distorted thinking that leads to inappropriate self-blame or blaming of others for the trauma.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Experiencing chronic negative emotions is a key feature of this criterion.
5. Markedly diminished interest or participation in significant activities. Loss of interest in activities that were previously enjoyed is a common symptom.
6. Feelings of detachment or estrangement from others. Feeling emotionally disconnected from others and struggling to form close relationships can occur.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). Difficulty experiencing joy, happiness, or other positive emotions is another symptom.

Criterion E: Marked Alterations in Arousal and Reactivity

Criterion E focuses on marked changes in arousal and reactivity associated with the traumatic event(s). These alterations begin or worsen after the traumatic event(s) and are 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. Increased irritability and anger, often disproportionate to the situation, are common.
2. Reckless or self-destructive behavior. Engaging in risky or harmful behaviors, such as substance abuse, reckless driving, or self-harm, can be a symptom.
3. Hypervigilance. Being in a state of constant alertness and scanning the environment for threats is characteristic of hypervigilance.
4. Exaggerated startle response. An excessive reaction to unexpected noises or movements is a common symptom.
5. Problems with concentration. Difficulty focusing attention and concentrating on tasks is often reported.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Insomnia, nightmares, and restless sleep are frequent sleep-related problems.

Criterion F, G, and H: Duration, Distress, and Exclusion

In addition to the above criteria, there are three further criteria that must be met for a PTSD diagnosis:

• Criterion F: Duration. The disturbance (Criteria B, C, D, and E) must last for more than 1 month. PTSD is not diagnosed immediately after a trauma; symptoms must persist for over a month.
• Criterion G: Clinically Significant Distress or Impairment. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must significantly interfere with the individual’s daily life and well-being.
• Criterion H: Exclusion. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. The symptoms must be directly related to the traumatic event and not caused by substance use or another medical condition.

Specifiers for PTSD

The DSM-5 also includes specifiers to further refine the PTSD diagnosis:

• With dissociative symptoms: This specifier is used when an individual meets the criteria for PTSD and, in addition, experiences persistent or recurrent symptoms of depersonalization (feeling detached from oneself or one’s body) or derealization (experiences of unreality of surroundings). These dissociative symptoms must not be attributable to substance use or another medical condition.
• With delayed expression: This specifier applies if the full diagnostic criteria for PTSD are not met until at least 6 months after the event (although some symptoms may be immediate). This recognizes that PTSD symptoms can sometimes emerge later.

Source: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), American Psychiatric Association.

Understanding these DSM-5 criteria for trauma diagnosis is the first step towards recognizing PTSD and seeking appropriate support and treatment. If you or someone you know is struggling with symptoms after a traumatic event, seeking professional help from a mental health expert is crucial.