PTSD and Trauma: What Is In the Criteria and What Isn’t
/We are seeing a lot more about Posttraumatic Stress Disorder (PTSD) in the media in recent years, particularly as more and more military personnel are returning from combat and as our culture is recognizing the traumatic impacts of physical, emotional, and sexual violence. This increase in awareness and the available treatments for PTSD is largely positive and will help lower the stigma or messages that one should “just get over” a traumatic event, allowing more people to receive treatment and alleviate suffering. But the criteria and nuances are not always discussed, and so I wanted to outline the criteria in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as well as the limitations of that criteria.
Criteria
The DSM-5 went further than previous editions in defining the criteria for PTSD by being more specific in what constitutes a traumatic event. For starters, the diagnostic criteria now are more explicit about sexual violence as a traumatic event, and they acknowledge that one can develop PTSD from repeated exposure to the details of traumatic events (as in the case of first responders) or if someone close to them experienced a traumatic event.
There are now four areas of diagnostic symptom criteria instead of three. So, to have PTSD, one must have experienced trauma and have symptoms in these four areas:
Re-experiencing. This category includes the intrusive ways one relives the trauma or what it felt like to be exposed to the traumatic event. Symptoms may look like recurrent nightmares, flashbacks, intrusive thoughts about the trauma, or feeling distressed when reminded of the event. The re-experiencing symptoms are challenging because they can take a survivor out of their present life and sense of safety and send them into the past.
Avoidance. While it is normal and adaptive to not want to be around one’s perpetrator, avoidance symptoms are broader and more persistent than that. In PTSD, the survivor is trying to avoid memories of the trauma or any reminders that may lead to memories of the trauma. This could look like avoiding TV or movies that might contain associations with the trauma or avoiding a road that one used to drive on with their abusive partner.
Arousal and Reactivity. Survivors with PTSD have some form of change in how they react to the world. In the attempt to be “on guard” for potential threats, their nervous system activity easily comes “on” such that they may be hypervigilant, have an exaggerated startle response, be more irritable, have problems with memory and concentration, or find that their ability to sleep or have restful sleep is disturbed. Survivors may also have more reckless behaviors such as abusing substances or increased thoughts about suicide.
Negative Cognitions and Mood. Following the development of PTSD, survivors may feel as if their outlook on the world has changed. They may develop new negative core beliefs about their worth, responsibility for the trauma, their safety, and their sense of power. They may also lose interest in activities in their lives or connections to their support systems. In addition, their emotional state can change
The symptoms have to be present for more than one month. And, as always with the DSM, the person has to experience significant difficulty in areas of functioning such as school, work, or relationships.
The DSM-5 also includes criteria for PTSD in children under six years old and adds specifications for when a survivor experiences dissociative symptoms such as feeling detached from themselves or their surroundings.
What Isn’t Covered In This Criteria
While the DSM’s definition of PTSD has broadened, there are some areas of trauma and its impacts that aren’t covered. For instance, the definition of trauma in the DSM is still relatively narrow and focused on the type of trauma rather than how it impacts the person. For this reason, the PTSD diagnosis does not include these types of traumas:
Developmental traumas. This refers to dysregulation that occurs over time and at an early age, usually caused by difficulties with a child’s caregivers. For example, this type of trauma can come out of being raised by a caregiver who was emotionally erratic or neglectful as a pattern but did not endanger the child such that they were at risk of death or serious injury, as described in the DSM.
Non-Life Threatening Traumas. The traumatic event may look more like repeated exclusion by peers or repeated events of not feeling good enough.
Non-violent or Accidental Losses. If one loses a partner to a heart attack, this may not technically meet the criteria of a “violent” or “accidental” death, as defined in the DSM, but the person may still experience all of the categories of symptoms from PTSD.
The symptoms that the survivor experiences after a trauma may not meet all of the criteria for PTSD, and so the DSM includes other types of Trauma- and Stressor-Related Disorders, such as:
Acute Stress Disorder. This is very similar to the description for PTSD, but the duration of the symptoms is between 3 days and 1 month.
Adjustment Disorder. An adjustment disorder occurs after a person experiences a stressor (but not the type of immediate, catastrophic, life-threatening event as in PTSD criteria) and has marked changes in mood or behavior in response to that stressor. I often see this occurring after a divorce, job loss, or move.
Other or Unspecified Trauma- and Stressor-Related Disorders These diagnoses can be used when a survivor is clearly having symptoms related to an event that has happened to them but does not meet the exact criteria for one of the other disorders.
While this blog post is heavy on diagnosis from the DSM-5, it is important to remember that definitions of how we see a diagnosis change over time and with new information and understanding in our culture. For instance, soldiers returning from World War I were labeled as “shell-shocked” and were perceived as deficient or more fragile than others. Today, we are shifting to understanding that soldier’s bodies and brains are reacting to the abnormal dysregulation that has happened to them.
It is also important to note that there are many forms of treatment that help survivors recover from their traumatic experiences, regardless of whether or not they have PTSD as defined by the DSM. If you or a family member or friend have experienced distress due to trauma, I recommend seeking treatment from a trauma-informed therapist.