Posttraumatic Stress Disorder

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The DSM-5 gives the following criteria for a diagnosis of posttraumatic stress disorder (PTSD):

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

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) (American Psychiatric Association, 2013)¹.

Criterion A specifies that PTSD forms only as a direct response to trauma. This trauma must involve exposure to actual or threatened death, serious injury, or bodily harm. This trauma can be experienced, personally witnessed,  known to have occurred to a close family member or friend (though this must involve more than a peaceful death or death from illness), or repeated or extreme exposure to  details of trauma through one's line of work. Media exposure does not count as a trauma that can result in PTSD. Events that do count include physical attack, robbery, mugging, childhood abuse, rape, noncontact sexual abuse, human trafficking, being kidnapped, being held hostage, a terrorist attack, torture, being a prisoner of war, natural or human-made disasters, severe motor vehicle accidents, or, for children, developmentally inappropriate sexual experiences. Life threatening medical illnesses on their own may not be traumatic, but medically traumatic experiences can include sudden and catastrophic events such as waking up during a surgery or experiencing anaphylactic shock. Seeing one's child experience a life-threatening medical catastrophe could also cause the disorder. If symptoms are present in the absence of a qualifying trauma, an adjustment disorder is a more appropriate diagnosis.

Criterion B lists intrusion symptoms that can qualify one for a diagnosis of PTSD. These intrusions must relate to the traumatic event and can include: being preoccupied with or  unable to block thoughts related to the trauma; having nightmares related to the trauma; having dissociative flashbacks that range from experiencing sensations, thoughts, or feelings as if one was still being traumatized up to actually reliving the trauma; becoming intensely distressed or being unable to calm down after exposure to reminders of the trauma; experiencing physiological symptoms (a racing heartbeat, difficulty breathing, stomach pains, etc) after exposure to reminders of the trauma. In children, repetitive play that involves traumatic aspects, reenactment of trauma through play, or generally frightening dreams qualify.

Criterion C states that avoidance of memories, thoughts, or feelings about or closely related to the trauma or of people, places, conversations, activities, objects, or situations that are associated with or remind one of the trauma must occur for a diagnosis of PTSD.

Criterion D lists negative alterations in cognition and mood that can follow or worsen after a traumatic event and so qualify one for a diagnosis of PTSD. These can involve: dissociative amnesia for part or all of the trauma; unreasonable or uncontrollable negative beliefs about oneself, others, or the world; wrongly blaming oneself or others for the trauma; persistent negative emotions such as fear, horror, anger, guilt, or shame; having less interest in previously enjoyed activities; feeling detached or different from others; being unable to feel positive emotions such as happiness, satisfaction, or love.

Criterion E lists symptoms related to increased reactivity and arousal of the nervous system that can follow or worsen after a traumatic event and so qualify one for a diagnosis of PTSD. These can include: unproportionate or unreasonable irritated or angry outbursts that may involve verbal or physical aggression; engaging in reckless or self-destructive behavior; always being on the lookout for harm or danger; having an exaggerated startle response or reacting to sudden and unexpected stimuli with "jumpiness"; being unable to concentrate and having problems remembering daily events or keeping track of conversations; having trouble falling asleep, staying asleep, or sleeping well.

Criterion F specifies that the symptoms must last longer than one month (otherwise, the diagnosis is acute stress disorder).

Criterion G specifies that the symptoms must cause significant distress or impairment.

Criterion H specifies that the symptoms are not due to a substance or medical condition.

A dissociative subtype of PTSD involves depersonalization or derealization not associated with a substance or medical condition.

PTSD can have delayed expression if some qualifying symptoms arise six or more months after the trauma.

Other possible symptoms of PTSD include developmental regression (reverting to having the skills of an individual of a younger age), auditory pseudo-hallucinations (hearing one's thoughts as being spoken by one or more voices; may be due to structural dissociation), paranoia, or difficulties with emotional regulation and sustaining interpersonal relationships. Reckless behavior can accidently injure the individual or others. In adolescents, PTSD is associated with reluctance to pursue developmentally appropriate opportunities (such as dating or driving), judging oneself as cowardly, being afraid of never being able to fit in with peers, and loss of aspirations for the future. In older individuals, PTSD is associated with crying spells, negative health perceptions, primary care utilization, and suicidal ideation. PTSD from childhood abuse is especially correlated with suicidal ideation, and those with suicidal ideation and PTSD may be more likely to attempt than are those without PTSD. PTSD is associated with disability and impairment in many areas and has high economic costs (American Psychiatric Association, 2013)¹.

In the US, the lifetime risk of PTSD using DSM-IV criteria was 8.7%, and the 12-month prevalence is 3.5%. Prevalence rates of 0.5-1.0% are more common in other countries. PTSD is more common among veterans and those whose jobs frequently expose them to traumatic situations (firefighters, police, emergency responders). However, the highest rates are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide (American Psychiatric Association, 2013)¹. In one study of 244 Australian adults with PTSD, the individuals reported a mean of 5.2 types of trauma; almost three-fourths of the participants (71%) had experienced 4 or more unique types of trauma, and 29% reported having experienced 7 or more types of trauma. This is comparable to other studies, in which up to 77% of individuals with PTSD report having experienced multiple types of trauma. The five most common types of trauma reported in this study were physical assault (70%), unwanted or uncomfortable sexual experiences (64%), traumatic experiences not categorized by the survey (62%), sexual assault (57%), and the sudden unexpected death of a loved one (43%). Also common were transportation accidents (40%), illness or injury (34%), and assault with a weapon (32%). Less common traumas included having caused injury to someone else (10%), exposure to a toxic substance (8%), and combat or war experiences (6%). Having experienced an increased number of types of trauma is associated with increased PTSD severity (Spence et al., 2011)².

PTSD can occur at any age, and though symptoms usually begin within the first three months after the trauma, symptoms can be delayed by years. The duration of symptoms can range from resolving within three months to remaining present for over half of a century (American Psychiatric Association, 2013)¹. When a traumatic event is not deliberate, almost one-third of those exposed will develop PTSD symptoms within the first month, but only 17.8% will meet the criteria for PTSD 3 months after the trauma. By 12 months, only 14.8% will still meet the criteria for PTSD. In contrast, 11.8% of individuals who were exposed to an intentional trauma will show PTSD symptoms within the first month, but 23.3%   will meet the criteria for PTSD 12 months post-trauma, and 37.1% will at some point meet the criteria for PTSD. These differences may be partially attributable to intentionally caused traumas being experienced as more severe, being more likely to affect populations with pre-existing vulnerabilities, and being less likely to be followed by sufficient support. Overall, 34.8% of cases of PTSD will resolve within 3 months, but 39.1% of cases will prove chronic. In many cases, PTSD may fluctuate, with periods of symptom remission and relapse (Santiago et al., 2013)³.

Personal risk factors include emotional problems and prior mental health disorders, being of a lower socioeconomic class, having less access to education or having a lower intelligence, having been exposed to previous trauma or childhood adversity, belonging to a culture that emphasizes self-blame, and having little social support. Trauma is more likely to lead to PTSD if it is more perceived as more severe and life threatening, involves interpersonal violence, involves violence from a caregiver, or involves forced perpetration (such as military personnel having to kill the enemy). Individuals who attempt to cope with trauma using dissociation are more likely to develop PTSD, as are those who are repeatedly exposed to reminders of the trauma. Older adults are less likely to develop PTSD following trauma; in contrast, being exposed to trauma at a younger age is associated with an increased risk of developing PTSD. Higher rates of PTSD are present among US Latino, African American, and American Indian populations and lower rates among Asian Americans even after adjustment for traumatic exposure demographic variables. Females are more likely to develop PTSD and to have PTSD for longer lengths of time, but these differences are negligible within populations of those exposed to trauma, particularly interpersonal violence. This suggests that differences in the rates and types of trauma exposure account for gender difference in the prevalence and course of PTSD (American Psychiatric Association, 2013)¹.

Unfortunately, barriers to treatment may also contribute to unremitting PTSD. In the Australian survey study, almost half (49%) of participants had not received treatment for PTSD. 63% was unsure how to access a local professional who was trained to treat PTSD, 43% were not financially stable enough to afford treatment, 21% doubted that their symptoms were severe enough to warrant treatment, and 19% were afraid of being seen as weak if they sought professional help. Additionally, 30% reported that previous attempts to seek treatment for their PTSD had lead to failure (Spence et al., 2011)². That said, when treatment is obtained, it can be very effective even for individuals with severe and chronic PTSD. There is strong evidence that prolonged exposure therapy in particular leads to improvements in PTSD, depressive, and anxiety symptoms. Cognitive, cognitive behavioral, and eye movement desensitization and reprocessing therapies may also prove helpful. A combination of treatment types may be especially helpful for individuals who also require assistance with substance use disorders or other comorbid conditions (Cusack et al., 2016)⁴.

Differential diagnoses for PTSD include adjustment disorders, anxiety disorders, obsessive compulsive disorder, major depressive disorder, personality disorders, dissociative disorders, conversion disorders, psychotic disorders, and traumatic brain injury. However, it should be kept in mind that those with PTSD are 80% more likely than those without PTSD to meet the diagnostic criteria for at least one other mental disorder (such as depressive, bipolar, or anxiety disorders). Comorbid substance abuse disorders or conduct disorder are more common in males, and oppositional defiant disorder and separation anxiety disorder are more common in children. As well, PTSD often occurs with traumatic brain injury in veterans (American Psychiatric Association, 2013)¹.

¹ American Psychiatric Association. (2013). Trauma- and Stressor-Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm07

² Spence, J., Titov, N., Solley, K., Dear, B. F., Johnston, L., Wootton, B., ... Choi, I. (2011). Characteristics and treatment preferences of people with symptoms of posttraumatic stress disorder: An internet survey. PLoS One, 6(7).

³ Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., ... Fullerton, C. S. (2013). A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic events. PLoS One, 8(4).

⁴ Cusack, K., Jonas, D. E., Forneris, C. A., Winesc, C., Sonise, J., Middleton, J. C., ... Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141.