DSM-5 PTSD Criteria: Diagnosing Post Traumatic Stress Disorder in Veterans
Post traumatic stress disorder (PTSD) is a recognized psychiatric disorder that a person may develop after exposure to a traumatic event. For many years, PTSD went widely undiagnosed or was not recognized as the serious condition it is. Thanks to advancements in research and the breakdown of social stigmas, we have more information about the mental health condition than ever before. We know that the majority of people who are exposed to traumatic events do not develop PTSD, and we know that veterans of the U.S. military are disproportionately affected by PTSD when compared to American civilians.
This blog post provides a brief breakdown of the required criteria for a diagnosis of PTSD, as well as PTSD specifications, as defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), published by the American Psychiatric Association. It’s important to note that this edition made changes to the previous DSM-IV)
What PTSD Criteria Does The DSM-5 Include?
The DSM-5 outlines specific criteria that must be present. These include:
- A stressor
- Intrusive symptoms
- Avoidance symptoms
- Negative alterations in cognition and mood
- Alternations in arousal and reactivity
- Duration of symptoms
- Functional significance
We will break down each of these PTSD DSM-5 criteria below.
Criterion A: Stressor
In the context of PTSD, the stressor is the traumatic event that leads to the development of PTSD. The precise definition of “traumatic event” is contested, but the DSM V requires exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. These types of events can cause psychological distress and trigger a number of stressor-related disorders, but PTSD is among the most serious.
Exposure to this stressor must have occurred in one of the following ways: direct exposure; witnessing the trauma; learning that a relative or close friend was exposed to the trauma; or indirect exposure to details of the trauma, often in the course of professional duties (for example, a paramedic treating victims of a serious motor vehicle accident would be indirectly exposed to the traumatic event of the motor vehicle accident even if she did not witness the accident herself).
Military service is a risk factor for PTSD due to frequent exposure to traumatic events, such as witnessing the death of fellow soldiers, witnessing injuries, discharging a weapon, participating in active combat, and experiencing general stress of deployment. Experiences during active duty may lead to extreme exposure to these types of stressors.
Criterion B: Intrusive symptoms
Not everyone who is exposed to a traumatic event will develop PTSD. In order for a person to receive a diagnosis of PTSD, the DSM-V requires the person to show at least one intrusive symptom. Intrusive symptoms can manifest in sudden upsetting memories; nightmares or bad dreams; flashbacks to the traumatic event (mentally re-experiencing the trauma); emotional distress after reminders of the traumatic event; or physical reactivity following reminders of the traumatic event (for example, an increased heart rate after exposure to reminders of the traumatic event). While the intrusive symptoms of PTSD can vary, these are some of the most common.
Criterion C: Avoidance symptoms
The third criterion for a PTSD diagnosis is avoidance of reminders of the trauma. This could be an avoidance of thoughts or feelings about the event or avoidance of trauma-related reminders altogether. A person who suffered sexual assault may display avoidance of thoughts and feelings of the assault and do their best to never think about the event. Someone who witnessed a person drowning may avoid trauma-related reminders and stay away from pools or bodies of water. In the case of military veterans, they may avoid any depictions of violence to avoid reminders of their own trauma. For a diagnosis of PTSD, the presence of at least one of these symptoms is required.
Criterion D: Negative alterations in cognition and mood
A person who receives a diagnosis of PTSD must display at least two of the following symptoms following the stressor: inability to recall key features of the stressor; overly negative thoughts or assumptions about oneself or the world; exaggerated blaming of self or of others for causing the trauma; negative affect (having a flat or depressed mood); decreased interest in regular activities; feelings of isolation; or difficulty experiencing a positive effect (having a hard time feeling happy).
Criterion E: Alterations in arousal and reactivity
For a diagnosis of PTSD, at least two of the following symptoms that began or worsened after the stressor must be present: Irritability or aggression (such as having angry outbursts); risky or destructive behavior (for example, driving recklessly); hypervigilance (for example, not being able to relax for fear that something bad will happen); increased startle reaction; difficulty concentrating; or sleep disturbances. These alterations in arousal and reactivity are a defense mechanism for preventing further trauma.
Criterion F: Duration of symptoms
Even if a person fulfills all the required criteria, a diagnosis of PTSD requires persistence of the symptoms for more than one month. A person may fulfill all criteria immediately following a traumatic event but display fewer or none of the required symptoms two weeks after the event. Although the criteria were present for a time, the person would not meet the duration requirement.
Criterion G: Functional significance
The PTSD symptoms experienced by the person with the diagnosis must create distress or functional impairment in a person’s life. For example, a veteran who suffers from PTSD and currently works in an office setting may find that he has difficulty concentrating and is irritable toward his coworkers. These symptoms may harm his job performance. A college student who experienced sexual assault at a party may find that their friendships are affected by their negative affect, hypervigilance, and avoidance of other social events.
Criterion H: Exclusion
In order to meet the criteria for a PTSD diagnosis, the symptoms must not be caused by medication, substance abuse, or any other illness.
This is an extremely simplified discussion of PTSD intended to provide clarity to a frequently-discussed condition. Follow-up blogs will address specifications of the diagnosis, as well as how veterans can approach service connection for PTSD when seeking disability benefits from the Department of Veterans Affairs. Veterans and their family members can also learn more about this psychiatric disorder on the VA’s National Center for PTSD website.
What PTSD Specifications Does The DSM-5 Include?
It’s important to note that the DSM-5 also outlines two specifications for PTSD diagnoses. These specifications can apply to veterans who meet the eight PTSD criteria outlined above and have unique circumstances. These specifications may not apply to every PTSD diagnosis.
“Depersonalization is the experience of being detached from oneself and one’s surroundings.”
This specification applies to individuals who meet all PTSD criteria and who also experience dissociative symptoms when exposed to reminders of the traumatic event. One dissociative symptom is depersonalization, which is the experience of being detached from oneself and one’s surroundings or feeling like an outside observer or as if one is only dreaming. Some individuals may compares this sensation to a numbing feeling. Someone experiencing depersonalization may have an “out of body” experience.
Another symptom characteristic of a dissociative specification is derealization. With derealization, the individual may experience reminders of the trauma as though the reminders are not really happening, or believing the event or the reminders to be “unreal.” Similarly to depersonalization, derealization is a way for the individual to mentally distance themselves from the traumatic event.
This specification applies when the full diagnostic criteria are not met until at least six months after the initial traumatic event. In this specification, an individual may experience some symptoms immediately after the trauma but not the full range of symptoms required for a diagnosis. In other cases, an individual may seem to be functioning perfectly normally with no symptoms at all until some time passes or a significant event, such as the loss of a loved one or a life change such as a divorce or retirement, brings on worsening symptoms. Regardless of when the symptoms appear, the individual must meet the full diagnostic criteria in order to receive a diagnosis of PTSD.
PSTD can cause significant distress, and a diagnosis is important for receiving the mental health care and financial help you need. In a follow-up to this blog post, will will discuss how veterans can obtain service connection for PTSD and how the VA rates this condition for disability compensation.