Post Intensive Care Syndrome

PTSD and DSM-5

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In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 1). PTSD is included in a new category in DSM-5, Trauma- and Stressor-Related Disorders. All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. For a review of the DSM-5 changes to the criteria for PTSD, see the American Psychiatric Association website on Posttraumatic Stress Disorder.

DSM-5 Criteria for PTSD

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Full copyrighted criteria are available from the American Psychiatric Association (1). All of the criteria are required for the diagnosis of PTSD. The following text summarizes the diagnostic criteria:

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Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

• Direct exposure

• Witnessing the trauma

• Learning that a relative or close friend was exposed to a trauma

• Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

 

Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):

• Intrusive thoughts

• Nightmares

• Flashbacks

• Emotional distress after exposure to traumatic reminders

• Physical reactivity after exposure to traumatic reminders

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Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):

• Trauma-related thoughts or feelings

• Trauma-related reminders

 

Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

• Inability to recall key features of the trauma

• Overly negative thoughts and assumptions about oneself or the world

• Exaggerated blame of self or others for causing the trauma

• Negative affect

• Decreased interest in activities

• Feeling isolated

• Difficulty experiencing positive affect

 

Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

• Irritability or aggression

• Risky or destructive behavior

• Hypervigilance

• Heightened startle reaction

• Difficulty concentrating

• Difficulty sleeping

 

Criterion F (required): Symptoms last for more than 1 month.

 

Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).

 

Criterion H (required): Symptoms are not due to medication, substance use, or other illness.

Two specifications:

• Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:

  • Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).

  • Derealization. Experience of unreality, distance, or distortion (e.g., "things are not real").

• Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

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Note: DSM-5 introduced a preschool subtype of PTSD for children ages six years and younger.

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How Do the DSM-5 PTSD Symptoms Compare to DSM-IV Symptoms?

Overall, the symptoms of PTSD are generally comparable between DSM-5 and DSM-IV. A few key alterations include:

• The revision of Criterion A1 in DSM-5 narrowed qualifying traumatic events such that the unexpected death of family or a close friend due to natural causes is no longer included.

• Criterion A2, requiring that the response to a traumatic event involved intense fear, hopelessness, or horror, was removed from DSM-5. Research suggests that Criterion A2 did not improve diagnostic accuracy (2).

• The avoidance and numbing cluster (Criterion C) in DSM-IV was separated into two criteria in DSM-5: Criterion C (avoidance) and Criterion D (negative alterations in cognitions and mood). This results in a requirement that a PTSD diagnosis includes at least one avoidance symptom.

• Three new symptoms were added:

  • Criterion D (Negative thoughts or feelings that began or worsened after the trauma): Overly negative thoughts and assumptions about oneself or the world; and, negative affect

  • Criterion E (Trauma-related arousal and reactivity that began or worsened after the trauma): Reckless or destructive behavior

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What Are the Implications of the DSM-5 Revisions on PTSD Prevalence?

Changes in the diagnostic criteria have minimal impact on prevalence. National estimates of PTSD prevalence suggest that DSM-5 rates were only slightly lower (typically about 1%) than DSM-IV for both lifetime and past-12 month (3). When cases met criteria for DSM-IV, but not DSM-5, this was primarily due the revision excluding sudden unexpected death of a loved one from Criterion A in the DSM-5. The other reason was a failure to have one avoidance symptom. When cases met criteria for DSM-5, but not DSM-IV, this was primarily due to not meeting DSM-IV avoidance/numbing and/or arousal criteria (3). Research also suggests that similarly to DSM-IV, prevalence of PTSD for DSM-5 was higher among women than men, and increased with multiple traumatic event exposure (3).

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References

1. American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders, (5th ed.). Washington, DC: Author.

2. Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM-5. Depression & Anxiety, 28, 750-769. doi:10.1002/da.20767

3. Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26, 537-547. doi:10.1002/jts.21848