Criteria
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)[1]
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly experiencing the traumatic event(s)
Witnessing, in person, the event(s) as it occurred to others
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
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 related to work.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing memories of the event
Recurrent distressing dreams in which the content and/or affect of the dream are related to the event
Dissociative reactions, such as flashbacks, in which the individual feels or acts as if the event were recurring (such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings)
Intense or prolonged psychological distress on exposure to internal or external cues symbolizing or resembling an aspect of the event
Marked physiologic reactions on exposure to internal or external cues symbolizing or resembling an aspect of the event.
Persistent avoidance of stimuli associated with the trauma beginning after the traumatic event, as indicated by at least one of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with 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 trauma.
Negative alterations in cognitions and mood associated with the trauma, which began or worsened after the event, as evidenced by at least 2 of the following:
Inability to remember important aspects of the event (not due to factors such as head injury or alcohol or drugs)
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")
Persistent, distorted cognitions about the cause or consequences of the trauma that lead the individual to blame himself/herself or others
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
Markedly diminished interest or participation in significant activities
Feelings of detachment or estrangement from others
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) as indicated by 2 or more of following:
Irritable behavior or anger outbursts, with little or no provocation, typically expressed as verbal or physical aggression toward people or objects
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Duration of disturbances in criteria B, C, D, and E is >1 month.
Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Disturbance is not due to medication, substance use, or other illness.
The individual may also be diagnosed as having a dissociative subtype of PTSD as indicated by 1 of the following:
Depersonalization (experience of being an outside observer of or detached from oneself)
Derealization (experience of unreality, distance, or distortion).
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).
PTSD with delayed expression may be diagnosed 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).
International Classification of Diseases 11th revision (ICD-11)[2]
ICD-11 defines PTSD as a disorder that may develop following exposure to an extremely threatening or horrific event or series of events.
Essential features:
Exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Such events include, but are not limited to, directly experiencing natural or human-made disasters, combat, serious accidents, torture, sexual violence, terrorism, assault, or acute life-threatening illness (e.g., a heart attack); witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and learning about the sudden, unexpected, or violent death of a loved one.
Following the traumatic event or situation, the development of a characteristic syndrome lasting for at least several weeks, consisting of all three core elements:
Re-experiencing the traumatic event in the present, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive memories or images; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings); or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, without a prominent cognitive aspect, and may occur in response to reminders of the event. Reflecting on or ruminating about the event(s) and remembering the feelings that one experienced at that time are not sufficient to meet the re-experiencing requirement.
Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change their environment (e.g., move to a different city or change jobs) to avoid reminders.
Persistent perceptions of heightened current threat; for example, as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. Hypervigilant people constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviors designed to ensure safety (e.g., not sitting with ones' back to the door, repeated checking in vehicles' rear-view mirrors).
The disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
Complex PTSD (CPTSD) is the name given to another, related mental health condition that can occur after any type of traumatic event, but tends to occur more commonly after chronic, repeated, or prolonged traumas that are nearly impossible to escape from. These include childhood abuse, childhood emotional neglect, domestic violence, or exposure to sustained civil war, torture, or community violence.
People with CPTSD have all the characteristic features of PTSD, as well as additional difficulties in how they experience their emotions, negative thoughts and feelings about themselves, and how they form relationships with other people.
Essential features:
Exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible. Such events include, but are not limited to, torture, concentration camps, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse.
Following the traumatic event, the development of all three core elements of PTSD lasting for at least several weeks:
Re-experiencing the traumatic event after the traumatic event has occurred, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive memories or images; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings); or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, without a prominent cognitive aspect, and may occur in response to reminders of the event. Reflecting on or ruminating about the event(s) and remembering the feelings that one experienced at that time are not sufficient to meet the re-experiencing requirement.
Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of thoughts and memories related to the event(s), or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change their environment (e.g., move house or change jobs) to avoid reminders.
Persistent perceptions of heightened current threat; for example, as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises. Hypervigilant people constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviors designed to ensure safety (not sitting with ones' back to the door, repeated checking in vehicles' rear-view mirror). In CPTSD, unlike in PTSD, the startle reaction may in some cases be diminished rather than enhanced.
Severe and pervasive problems in affect regulation. Examples include heightened emotional reactivity to minor stressors, violent outbursts, reckless or self-destructive behavior, dissociative symptoms when under stress, and emotional numbing, particularly the inability to experience pleasure or positive emotions.
Persistent beliefs about oneself as diminished, defeated, or worthless, accompanied by deep and pervasive feelings of shame, guilt, or failure related to the stressor. For example, the individual may feel guilty about not having escaped from or succumbing to the adverse circumstance, or not having been able to prevent the suffering of others.
Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride, or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them.
The disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
Complex PTSD remains beyond the scope of this topic.
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