Posttraumatic Stress Disorder (PTSD) is a mental health condition that can develop in individuals who have experienced or witnessed a traumatic event. Diagnosing PTSD requires a careful evaluation based on specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). This guide breaks down the DSM-5 criteria for PTSD in adults, adolescents, and children older than 6 years, providing a clear understanding of what constitutes a PTSD diagnosis.
Criterion A: Exposure to Traumatic Event
The first criterion for PTSD diagnosis involves exposure to a traumatic event. According to DSM-5, this exposure must involve actual or threatened death, serious injury, or sexual violence and occur in one or more of the following ways:
- Directly experiencing the traumatic event(s). This could range from being in a car accident to experiencing a natural disaster or assault.
- Witnessing, in person, the traumatic event(s) as it happened to others. Seeing someone else injured or threatened can be deeply traumatic.
- Learning that a traumatic event occurred to a close family member or close friend. This is particularly relevant when the event was violent or accidental, such as learning about the sudden death of a loved one in a car crash.
- Experiencing repeated or extreme exposure to aversive details of traumatic events. This is often relevant for professionals like first responders or police officers who are repeatedly exposed to the graphic details of traumatic events in their work. It’s important to note that media exposure (TV, movies, internet) doesn’t count unless it is work-related.
Criterion B: Intrusion Symptoms
After experiencing a traumatic event, individuals with PTSD often re-experience the trauma through intrusive symptoms. At least one of the following intrusion symptoms must be present:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). These memories are not just typical recollections; they are unwanted, feel very real, and cause significant distress. In children, this may manifest as repetitive play where themes of the trauma are expressed.
- Recurrent distressing dreams where the content or feeling of the dream is related to the traumatic event(s). Nightmares that replay the trauma or related themes are common. Children might have frightening dreams without a clear traumatic content.
- Dissociative reactions (flashbacks) where the individual feels or acts as if the traumatic event(s) were happening again. Flashbacks can range from brief moments to complete loss of awareness of the present surroundings. In children, this can be seen in trauma-specific reenactment during play.
- Intense or prolonged psychological distress when exposed to cues that remind them of the traumatic event(s). Triggers can be internal (thoughts, feelings) or external (places, people, sounds) that symbolize or resemble aspects of the trauma.
- Marked physiological reactions to cues that symbolize or resemble the traumatic event(s). These are physical responses like increased heart rate, sweating, or panic attacks when encountering reminders of the trauma.
Criterion C: Avoidance Symptoms
Avoidance is another core feature of PTSD. Individuals will attempt to avoid reminders of the trauma. At least one of the following must be present:
- Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). This could involve trying to suppress thoughts or feelings related to the trauma.
- 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 might include avoiding certain locations, people, or activities that bring back memories of the trauma.
Criterion D: Negative Alterations in Cognitions and Mood
PTSD can also lead to negative changes in thoughts and feelings, beginning or worsening after the traumatic event. At least two of the following are required:
- Inability to remember an important aspect of the traumatic event(s) (usually due to dissociative amnesia and not other factors like head injury or substance use). This is more than just forgetting details; it’s a significant gap in memory directly related to the trauma.
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world. Examples include “I am bad,” “No one can be trusted,” or “The world is completely dangerous.”
- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame themselves or others. This involves distorted thinking about who is at fault for the trauma.
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). Feeling stuck in negative emotions related to the trauma is a key symptom.
- Markedly diminished interest or participation in significant activities. Loss of interest in hobbies and activities that were once enjoyable is common.
- Feelings of detachment or estrangement from others. Feeling disconnected from loved ones and socially isolated.
- Persistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings). Difficulty feeling joy or positive emotions.
Criterion E: Marked Alterations in Arousal and Reactivity
Changes in arousal and reactivity are also characteristic of PTSD, starting or worsening after the traumatic event. At least two of the following are needed:
- Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression. Becoming easily angered and reacting aggressively.
- Reckless or self-destructive behavior. Engaging in risky behaviors without considering the consequences.
- Hypervigilance. Being constantly on guard and overly aware of surroundings, feeling like danger is always present.
- Exaggerated startle response. Being easily startled by unexpected noises or movements.
- Problems with concentration. Difficulty focusing and paying attention.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Insomnia or disturbed sleep patterns are common.
Criterion F, G, and H: Duration, Distress, and Exclusion
Beyond the symptom clusters, there are additional criteria for a PTSD diagnosis:
- Criterion F: Duration. The disturbance (Criteria B, C, D, and E) must last for more than 1 month.
- Criterion G: Clinically Significant Distress or Impairment. The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must negatively impact daily life.
- 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 a medical issue.
Specifiers: With Dissociative Symptoms and With Delayed Expression
DSM-5 also includes specifiers to further describe the nature of PTSD:
- With dissociative symptoms: This specifier is used when an individual experiences persistent or recurrent symptoms of depersonalization (feeling detached from oneself and one’s body) or derealization (feeling of unreality of surroundings) in response to the stressor.
- With delayed expression: This specifier applies if the full diagnostic criteria are not met until at least 6 months after the traumatic event, although some symptoms may appear immediately.
Understanding these DSM-5 diagnostic criteria is crucial for accurately identifying PTSD and ensuring individuals receive appropriate support and treatment. If you or someone you know is struggling with symptoms following a traumatic event, seeking professional evaluation from a mental health professional is an important step towards recovery.
Source: APA. (2013a). Exhibit 1.3-4DSM-5 Diagnostic Criteria for PTSD. https://www.ncbi.nlm.nih.gov/books/NBK555835/box/NBK555835-box-ex1-3/
