DSM-5: Post-Traumatic Stress Disorder (PTSD).

This is another post from my DSM-5 e-mail list. If you find the infor­ma­tion below use­ful or inter­est­ing, you are wel­come to join.

(747 words = 5 min read)

The essen­tial fea­ture of PTSD is the devel­op­ment of reac­tive symp­toms fol­low­ing expo­sure to a trau­matic event. The diag­no­sis of PTSD has notable changes in DSM-5.

One dif­fer­ence is that, accord­ing to DSM-5, a per­son no longer needs to expe­ri­ence emo­tional reac­tions (“intense fear, help­less­ness, or hor­ror” described in DSM-IV) to the trauma.

The authors pro­vide a long list to describe cri­te­rion A (“expo­sure to actual or threat­ened death, seri­ous injury, or sex­ual vio­lence in one (or more) of the fol­low­ing ways”). Note that sex­ual vio­lence is now included in the definition.

Cri­te­rion A also allows for the diag­no­sis of PTSD for indi­vid­u­als who have had only indi­rect expo­sure to the trauma, though the trauma must have occurred to “close rel­a­tives or friends”. There is also a clause for repeated and extreme expo­sures, such as what para­medics and other first respon­ders wit­ness. The events of Sep­tem­ber 11, 2001, have influ­enced this diagnosis.

Cri­te­rion B, pre­vi­ously the “re-experiencing” sphere, is now the “intru­sion” sphere. These symp­toms include mem­o­ries, night­mares, dis­so­ci­a­tion, and dis­tress­ing reac­tions to inter­nal and exter­nal cues related to the trauma.

Cri­te­rion C remains the “avoid­ance” sphere (avoid­ance of both inter­nal and exter­nal reminders), though patients only need to meet one of two cri­te­ria in DSM-5 (ver­sus three of seven in DSM-IV).

Cri­te­rion D encom­passes “neg­a­tive alter­ations in cog­ni­tions and mood”, which includes mem­ory prob­lems, neg­a­tive thoughts (think Beck’s cog­ni­tive the­ory of depression), and result­ing dis­tress­ing emo­tions. This cri­te­rion helps cap­ture the “comor­bid­ity” of depres­sion seen in PTSD.

Cri­te­rion E is the “hyper­arousal” sphere that describes the irri­tabil­ity, “jumpi­ness”, and para­noia often seen in PTSD.

The authors note that these symp­toms must per­sist for at least one month and cause “clin­i­cally sig­nif­i­cant dis­tress or impair­ment”. As usual, they ask that the reader ensure that these symp­toms are not due to a med­ical prob­lems or a sub­stance use dis­or­der. There are only two specifiers:

  • with dis­so­cia­tive symp­toms (deper­son­al­iza­tion or derealization)
  • with delayed expres­sion (full cri­te­ria are not met until at least six months after the event… the authors state that there is “abun­dant evi­dence” to sup­port the delay in symp­tom appear­ance, but do not offer any expla­na­tions as to why)

The authors also include PTSD cri­te­ria for chil­dren ages six and under (which I will not review here, since I only work with adults… child psy­chi­a­trists, I direct you to page 272).

The authors note “audi­tory pseudo-hallucinations, such as hav­ing the sen­sory expe­ri­ence of hear­ing one’s thoughts spo­ken in one or more voices”, as well as para­noid ideation, can be present in PTSD. I find this use­ful because, pre­vi­ously, I’d give a pri­mary diag­no­sis of PTSD and a sec­ondary diag­no­sis of “psy­chosis NOS”, though it was clear that these were not “organic” psy­chotic symptoms.

The authors also note that pro­longed expo­sure to trauma can result in emo­tion dys­reg­u­la­tion, prob­lems with sta­ble inter­per­sonal rela­tion­ships, and dis­so­cia­tive symp­toms… which sounds a lot like bor­der­line per­son­al­ity disorder.

DSM-5 states that the pro­jected life­time risk for PTSD is only about 9%. This speaks to the resilience peo­ple pos­sess, as much more than 9% of the pop­u­la­tion expe­ri­ences trauma described in cri­te­rion A. Com­plete recov­ery is within three months for about half of adults. This again is a tes­ta­ment to the resilience peo­ple have.

PTSD is also diag­nosed much more in the US than in other West­ern coun­tries. (Paul McHugh has writ­ten a lot about the ampli­fi­ca­tion of PTSD in the US.) Women are more likely than men to receive a diag­no­sis of PTSD. Those at high­est risk of devel­op­ing PTSD include sur­vivors of rape, mil­i­tary com­bat and cap­tiv­ity, and eth­ni­cally or polit­i­cally moti­vated intern­ment and genocide.

The authors divide risk fac­tors for PTSD into three groups:

  1. pre­trau­matic fac­tors (tem­pera­ment; child­hood adver­sity; racial minor­ity; etc.)
  2. per­i­trau­matic fac­tors (severity/dose of trauma; inter­per­sonal vio­lence; etc.)
  3. post­trau­matic fac­tors (“neg­a­tive appraisals”; expo­sure to upset­ting reminders; etc.)

The dif­fer­en­tial diag­no­sis for PTSD is one of the largest in psy­chi­a­try; it includes other stress dis­or­ders, mood dis­or­ders, per­son­al­ity dis­or­ders, psy­chotic dis­or­ders, and neu­rocog­ni­tive dis­or­ders. PTSD also has many “comor­bid” con­di­tions as already noted above; DSM-5 states that 80% of peo­ple diag­nosed with PTSD are likely to have symp­toms that meet cri­te­ria for another mood, anx­i­ety, or sub­stance use disorder.

Anec­do­tally speak­ing, peo­ple wrestling with home­less­ness and poverty often have a sig­nif­i­cant his­tory of trauma. We might assume that the home­less caused their own prob­lems. When you start ask­ing clar­i­fy­ing ques­tions, how­ever, you often learn that they had hor­ri­fy­ing child­hoods. Just some food for thought.

Next time: Prob­a­bly bipo­lar disorder.