PTSD Diagnosis, DSM-5 Criteria, and Treatment Approaches

Introduction to PTSD and DSM-5 Diagnostic Criteria

The diagnostic criteria for post-traumatic stress disorder (PTSD) were revised in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. The criteria for a PTSD diagnosis include an exposure history to qualifying traumatic events and signs from a cluster of four symptom domains: intrusion, avoidance, negative alterations in mood and cognitions, and alterations in arousal and reactivity. The sixth criterion concerns the duration of symptoms, the seventh addresses functional impairment, and the eighth specifies that symptoms must not be attributable to substances or a co-occurring medical condition (American Psychiatric Association, 2013).

Effective diagnosis of PTSD requires the evaluation of several criteria. The clinician must establish that the patient was indeed exposed to a traumatic experience and that the patient manifests symptoms linked to that trauma from the following four symptom clusters:

• Intrusion
• Avoidance
• Alterations in arousal and reactivity
• Alterations in cognitions and mood

The sixth criterion requires that symptoms have persisted for a minimum of one month following the traumatic experience. The seventh criterion states that the symptoms must impair the individual's daily functioning. The eighth criterion specifies that the symptoms must not be attributable to a co-occurring medical condition. The DSM-5 further states that a qualifying traumatic stressor must involve exposure to actual or threatened death, serious injury, or sexual violence. Such exposure may occur in four ways: (i) directly; (ii) by directly witnessing the event; (iii) by learning that a close friend or family member experienced actual or threatened trauma; or (iv) through extreme or repeated exposure to aversive details of traumatic events (Greenberg, Brooks, & Dunn, 2015).

A clinical interview must reveal information meeting all specified criteria before a formal diagnosis can be made. PTSD diagnosis may also be subclinical, meaning the criteria are closely but not fully met.

DSM-5 Criteria in Detail

PTSD diagnosis follows eight criteria derived from the DSM-5. The first criterion — trauma exposure — encompasses four qualifying forms of exposure:

• Experiencing the traumatic event directly
• Witnessing the event in person
• Learning that the traumatic experience affected a close relative, such as a parent
• Being subjected to repeated or extreme exposure to aversive details of traumatic events (excluding media exposure such as photographs, television, or films)

The second criterion requires at least one persistent intrusion symptom associated with the traumatic event, which may include:

• Intrusive recollections, perceptions, or thoughts
• Hallucinations or illusions
• Dissociative flashback episodes
• Distressing images
• Intense psychological distress or physiological reactions to cues related to the event

In children, re-experiencing may occur through repetitive play, which differs from the way adults typically re-experience trauma.

The third criterion requires persistent avoidance of stimuli associated with the trauma, as evidenced by at least one of the following:

• Avoiding thoughts or feelings linked to the event
• Avoiding people, places, activities, or conversations that serve as reminders of the event

The fourth criterion requires at least two negative alterations in mood and cognitions related to the traumatic event, such as:

• Persistent and distorted negative beliefs about oneself, others, or the world
• Persistent negative emotional states
• Markedly diminished interest or participation in significant activities
• Feelings of detachment or estrangement from others
• Persistent inability to experience positive emotions

The fifth criterion requires at least two marked alterations in arousal and reactivity, including:

• Irritable behaviour and angry outbursts
• Reckless or self-destructive behaviour
• Hypervigilance

The final three criteria state that: (vi) the symptoms must have lasted for more than one month; (vii) the disturbance must cause clinically significant distress or functional impairment; and (viii) the disturbance must not be attributable to the physiological effects of a substance or another medical condition (American Psychiatric Association, 2013).

Vignette Analysis and Case Background

The patient is a 45-year-old African-American woman who recalls her father frequently beating her mother. She describes it as feeling like a daily occurrence, though she acknowledges it was simply very frequent. Her father left the family when she was eight years old after beginning a relationship with another woman. Her mother subsequently married another man, whose son sexually abused the patient and her friends when she was thirteen years old. Although she attempted to disclose her experiences to her mother, her mother told her to remain silent. In response to the pain she experienced, the patient began cutting herself as a means of coping. Currently, she is in her second marriage, which has lasted six years. She acknowledges a history of turbulent and abusive relationships. Based on the clinical vignette, the patient clearly presents with PTSD, though her case is assessed as subclinical — the diagnostic criteria are closely, but not entirely, met.

Couple and Family Therapy as Treatment

Several therapeutic options are available for treating PTSD. For this 45-year-old wife and mother, couple and family therapy is the most appropriate approach. PTSD distress does not affect only the individual who experienced the trauma; it also negatively impacts the family. Partners and spouses are often caught in this distress. The patient acknowledges that she does not fully understand why her husband remains committed to her. She describes him as the caring father figure she never had. She feels that she deserves love and wishes to reciprocate it, but she fears allowing him emotional and physical closeness because she is afraid he will eventually leave. Family members may be incorporated into what is broadly termed generic couple therapy.

This approach seeks to improve relationship functioning and is the method most commonly applied in family therapy for mentally ill adults. Improving relationship functioning helps reduce a patient's PTSD symptoms and enhances the well-being of family members by reducing the recurring stress that has been affecting their relationships.

Because the approach aims to improve the relationship generally rather than targeting the specific mechanisms maintaining the disorder, family therapy functions here as an adjunctive therapy. Other therapeutic modalities should be applied alongside this approach to directly address PTSD symptoms. Partner-assisted interventions may also be employed, in which family members serve as surrogate coaches for the therapist. This educates family members about the rationale behind therapy so that they can actively support the patient and reinforce individually tailored therapeutic work. These interventions do not focus primarily on relational matters; rather, the manner in which the interventions are delivered is of primary importance.

Family members may also participate in disorder-specific family therapies, which carry dual and simultaneous objectives: enhancing positive relational functioning and reducing PTSD symptoms. To maximise effectiveness, interventions are tailored to target the specific mechanisms driving the development of PTSD and relational distress (Friedman, Keane, & Resick, 2014).

References

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

Center for Substance Abuse Treatment. (2014). Trauma-informed care in behavioral health services.

Courtois, C. A., & Ford, J. D. (2013). Treatment of complex trauma: A sequenced, relationship-based approach.

Friedman, M. J., Keane, T. M., & Resick, P. A. (2014). Handbook of PTSD: Science and practice.

Greenberg, N., Brooks, S., & Dunn, R. (2015). Latest developments in post-traumatic stress disorder: Diagnosis and treatment. British Medical Bulletin, ldv014.

Margolies, L. (2010). Understanding the effects of trauma: Post-traumatic stress disorder (PTSD). Psych Central.

Nielsen, M. B., Tangen, T., Idsoe, T., Matthiesen, S. B., & Mageroy, N. (2015). Post-traumatic stress disorder as a consequence of bullying at work and at school: A literature review and meta-analysis. Aggression and Violent Behavior, 21, 17–24.

Walker, P. (n.d.). Emotional neglect and complex PTSD. Retrieved January 15, 2016, from http://pete-walker.com/pdf/emotionalNeglectComplexPTSD.pdf