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Posttraumatic Stress Disorder (description, assessment and diagnosis)

Diagnostic Changes

The DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV and are as follows:

• Stressor criterion (Criterion A) is more specific regarding the individual experience of "traumatic events";
• Criterion A2 (subjective reaction) no longer exists;
• The three major symptoms clusters in DSM-IV (reexperiencing, avoidance/numbing, and arousal) are now four symptom clusters in DSM-5.
  • The avoidance/numbing cluster is now divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood;
  • The persistent negative alterations in cognitions and mood cluster contains most of the DSM-IV arousal symptoms and includes irritable or aggressive behavior and reckless or self-destructive behavior;
• Diagnostic thresholds have been lowered for children and adolescents to be more sensitive to development;
• There are additional separate criteria for children 6 years of age or younger

Diagnostic Criteria

DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV.

Two main DSM-IV criteria have been altered:

• Criterion A is now more explicit regarding how an individual experienced the "traumatic" event(s).
• Criterion A2 (subjective reaction to the event) no longer exists.

Symptom Clusters
The DSM-IV had 3 major symptom clusters (reexperiencing, avoidance/numbing, arousal) but now has 4:

• Reexperiencing
• Avoidance
• Persistent negative alterations in cognitions and mood
  • Includes the majority of DSM-IV numbing symptoms;
  • Also contains new and reconceptualized symptoms such as persistent negative emotional states;
• Alterations in arousal and reactivity
  • Includes most DSM-IV symptoms for arousal;
  • Also contains irritable, aggressive, and/or self-destructive behavior;

Developmental Sensitivities

• Diagnostic thresholds have been lowered for children and adolescents to account for development.
• Separate and additional criteria have been added for children age 6 or younger.

Posttraumatic stress disorder is now more sensitive to development in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate and additional criteria have been added for children age 6 years of age or younger.

Demographic Information

Base Rates of Posttraumatic Stress Disorder in different clinical settings

Setting	Reference	Base Rate*	Demography	Diagnostic Method
Non-clinical: Population based	Kessler et al., 2005	6.8%	United States, nationally representative, age 18 and older	National Comorbidity Survey - Replication
Non-clinical: Population based	de Vries & Olff, 2009	7.4%	Netherlands, nationally representative, age 18-80	Composite International Diagnostic Interview (CIDI)
Non-clinical: Population based	Pietrzak et al., 2011	6.4%	United States, nationally representative, age 18 and older	Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions
Non-clinical: Population based	Bunting et al., 2013	8.8%	Northern Ireland, representative sample, age 18 and older	Northern Ireland Study of Health and Stress
Non-clinical: Population based	23819543 Atwoli et al., 2013	2.3%	South Africa, nationally representative sample, age 18 and older	South African Stress and Health Study, using the Composite International Diagnostic Interview (CIDI)
U.S. Service Members	Hoge et al., 2004	♦11.5%-19.5%	U.S. Army and Marine Soldiers Deployed to Iraq and Afghanistan	PTSD Checklist

• Base rates are lifetime prevalence unless otherwise specified

♦ Note: These rates were using broad PTSD Checklist scoring criteria of being scored positive if subjects reported at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptom that were categorized as at the moderate level. The 11.5% is for soldiers returning from deployment in Iraq, 19.5% is for soldiers returning from Afghanistan. Note: Another common practice is to use a strict cutoff of 50 on the PCL, above which someone screens positive for PTSD. With this cutoff, rates are 6.2% and 12.9% for Service Members returned from Afghanistan and Iraqi, respectively.

Diagnosis

DSM 5 Criteria for Posttraumatic Stress Disorder♦

♦The following criteria apply to adults, adolescents and children older than 6 years.

1. 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).
      1. Note: Criterion #4 does not apply to exposure through electronic media, television, movies, pr pictures, unless this exposure s work related.
2. 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).
      1. 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).
      1. 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.)
      1. 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).
3. 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 wight 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).
4. Negative Alterations i 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).
5. 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.
   6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
6. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
7. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms:The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, 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).
   1. Note: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).

Specify if:

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).

Empirically Supported Treatment

Sources: ¹Department of Veterans Affairs and Department of Defense. . (2010). VA/DoD clinical practice guidelines: management of post-traumatic stress. Washington, D.C.: Veterans Health Administration, Department of Defense. ²Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., . . . McIntyre, J. S. (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder: American Psychiatric Publ.

Behavioral Interventions

• Recommended:
  • ¹Brief Cognitive Behavioral Therapy (CBT; 4-5 sessions) has significant benefit.
    • This includes stress inoculation training, trauma-focused therapy including components of cognitive restructuring, Cognitive Processing Therapy (CPT), imaginal, virtual, and in-vivo exposure as in Prolonged Exposure psychotherapy (PE)²
    • Patient education is recommended as part of psychotherapy for patients and family members
  • ²EMDR may help both acute and chronic PTSD, especially individuals who have trouble with prolonged exposure or

have trouble verbalizing their trauma. Long term gains require further study.

• Treatments with weaker evidence:
  • ¹Patient education, imagery rehearsal therapy, psychodynamic therapy, hypnosis, relaxation techniques, and group

therapy may have some benefit.

• • ¹Web-based CBT, Acceptance and commitment therapy, and Dialectical Behavioral Therapy have unknown benefit.

Medication

• ²SSRIs are more effective than placebo in treating PTSD
• ¹There is no evidence to support a medication to prevent the development of PTSD
  • ¹Imipramine, propranolol, prazosin, other antidepressants, anticonvulsants, and atypical antipsychotics have unknown benefit.
  • ¹Strongly recommend against the use of benzodiazepines² and typical antipsychotics since they have no benefit and potential harm.

Process and Outcome Measures

Measure	Cut-off scores				Critical Change (unstandardized scores)
Benchmarks Based on Published Norms
		A	B	C	95%	90%	SEdifference
Primary Care PTSD Screen		1.0	3.1	2.0	1.0	.8	.5
PTSD Checklist Scores		28.8	40.8	34.9	4.6	3.8	2.3
Clinician Administered PTSD Scale		28.8	40.8	34.9	8.3	7.0	4.2