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DSM – POSTTRAUMATIC STRESS DISORDER (PTSD)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. 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.
4. 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 work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
2. 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 traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due
to dissociative amnesia and not to other factors such as head injury, alcohol, or
drugs).
2. 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”).
, 3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
1. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
Specify whether:
- With dissociative symptoms: The individual's symptoms meet the criteria for post-
traumatic stress disorder, and the individual experiences persistent or recurrent
symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one's mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant,
or distorted).
- With delayed expression: 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).
ARTICLE BY BREWIN ET AL. (2009) – REFORMULATING PTSD FOR DSM-V:
LIFE AFTER CRITERION A
Criticisms on the PTSD-diagnosis and the research on them (after the arrow):
1. PTSD pathologises normal distress
- Reactions to extreme stress are time-limited, and PTSD symptoms will resolve
naturally of their own accord with no lasting harm to the person → Studies
show that extreme stress sometimes leads to severe and long-lasting
psychopathology
- The ‘symptoms’ of PTSD are ubiquitous reactions to stressful events found in
people suffering from normal distress → Raises the question what normal is,
and this has not yet been answered
- PTSD is not biologically distinguishable from normal distress → Unique
patterns of functional neuroimaging of emotions have been found in PTSD
, 2. Inadequacy of Criterion A
- Other disorders are linked to traumatic events → Traumatic events do not
increase the risk for other disorders independently of the increased risk for
PTSD
- Insufficient specificity of Criterion A (too broad) → Very few individuals meet
the full diagnostic criteria in non-Criterion A-events
- Excessive specificity of Criterion A (too narrow) → Individual differences in
genetics, environment and vulnerability suggest that focusing on a single
triggering event is misguided
3. Symptoms overlap with other disorders → Flashbacks and traumatic nightmares are
considered highly distinctive and specific to PTSD
Improving the PTSD-diagnosis:
1. Eliminating Criterion A:
- Research shows that altering Criterion A has
little impact on PTSD prevalence or
diagnostic precision – Criterion A primarily
describes the context of PTSD rather than
contributing to diagnostic accuracy
- Other anxiety disorders use simpler criteria
focused on core symptoms – PTSD diagnosis
should centre on reexperiencing symptoms
such as vivid, multisensory intrusive
memories accompanied by fear or horror
2. Reducing the symptoms distinctive to PTSD
(Criterion B-E)
- Other anxiety disorders use simpler criteria
focused on core symptoms – PTSD diagnosis
should centre on re-experiencing symptoms
such as vivid, multisensory intrusive memories accompanied by fear or horror
- Removing dysphoria-related symptoms would reduce overlap with other
disorders, creating more homogeneity among PTSD cases
- The number of diagnostic symptoms would reduce from 17 to 6 core
symptoms, emphasising specificity to PTSD
ARTICLE BY OZER ET AL. (2003) – PREDICTORS OF POSTTRAUMATIC
STRESS DISORDER AND SYMPTOMS IN ADULTS: A META-ANALYSIS
Over 50% of people (60.7% of men, 51.2% of women) experience a traumatic event in their
lifetime → Despite widespread exposure, only 5% (women) to 10% (men) of individuals
develop PTSD, highlighting significant variability in psychological responses
↓
The contrast between the high prevalence of trauma exposure and lower PTSD rates
underscores the importance of identifying systematic risk factors and individual differences in
psychological resilience to trauma
Seven predictors analysed:
DSM – POSTTRAUMATIC STRESS DISORDER (PTSD)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. 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.
4. 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 work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
2. 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 traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due
to dissociative amnesia and not to other factors such as head injury, alcohol, or
drugs).
2. 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”).
, 3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically
expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
1. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
Specify whether:
- With dissociative symptoms: The individual's symptoms meet the criteria for post-
traumatic stress disorder, and the individual experiences persistent or recurrent
symptoms of either of the following:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one's mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant,
or distorted).
- With delayed expression: 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).
ARTICLE BY BREWIN ET AL. (2009) – REFORMULATING PTSD FOR DSM-V:
LIFE AFTER CRITERION A
Criticisms on the PTSD-diagnosis and the research on them (after the arrow):
1. PTSD pathologises normal distress
- Reactions to extreme stress are time-limited, and PTSD symptoms will resolve
naturally of their own accord with no lasting harm to the person → Studies
show that extreme stress sometimes leads to severe and long-lasting
psychopathology
- The ‘symptoms’ of PTSD are ubiquitous reactions to stressful events found in
people suffering from normal distress → Raises the question what normal is,
and this has not yet been answered
- PTSD is not biologically distinguishable from normal distress → Unique
patterns of functional neuroimaging of emotions have been found in PTSD
, 2. Inadequacy of Criterion A
- Other disorders are linked to traumatic events → Traumatic events do not
increase the risk for other disorders independently of the increased risk for
PTSD
- Insufficient specificity of Criterion A (too broad) → Very few individuals meet
the full diagnostic criteria in non-Criterion A-events
- Excessive specificity of Criterion A (too narrow) → Individual differences in
genetics, environment and vulnerability suggest that focusing on a single
triggering event is misguided
3. Symptoms overlap with other disorders → Flashbacks and traumatic nightmares are
considered highly distinctive and specific to PTSD
Improving the PTSD-diagnosis:
1. Eliminating Criterion A:
- Research shows that altering Criterion A has
little impact on PTSD prevalence or
diagnostic precision – Criterion A primarily
describes the context of PTSD rather than
contributing to diagnostic accuracy
- Other anxiety disorders use simpler criteria
focused on core symptoms – PTSD diagnosis
should centre on reexperiencing symptoms
such as vivid, multisensory intrusive
memories accompanied by fear or horror
2. Reducing the symptoms distinctive to PTSD
(Criterion B-E)
- Other anxiety disorders use simpler criteria
focused on core symptoms – PTSD diagnosis
should centre on re-experiencing symptoms
such as vivid, multisensory intrusive memories accompanied by fear or horror
- Removing dysphoria-related symptoms would reduce overlap with other
disorders, creating more homogeneity among PTSD cases
- The number of diagnostic symptoms would reduce from 17 to 6 core
symptoms, emphasising specificity to PTSD
ARTICLE BY OZER ET AL. (2003) – PREDICTORS OF POSTTRAUMATIC
STRESS DISORDER AND SYMPTOMS IN ADULTS: A META-ANALYSIS
Over 50% of people (60.7% of men, 51.2% of women) experience a traumatic event in their
lifetime → Despite widespread exposure, only 5% (women) to 10% (men) of individuals
develop PTSD, highlighting significant variability in psychological responses
↓
The contrast between the high prevalence of trauma exposure and lower PTSD rates
underscores the importance of identifying systematic risk factors and individual differences in
psychological resilience to trauma
Seven predictors analysed:
