DSM-5 Criteria for Chronic PTSD Diagnosis
According to the DSM-5, chronic PTSD is diagnosed when symptoms persist for more than 3 months following exposure to a traumatic event, with specific criteria across five domains that must be met for diagnosis.
Criterion A: Stressor
- Exposure to actual or threatened death, serious injury, or sexual violence through:
- Direct experience
- Witnessing the event
- Learning about traumatic event occurring to a close family member/friend
- Experiencing repeated or extreme exposure to aversive details of traumatic events
Criterion B: Intrusion Symptoms (≥1 required)
- Recurrent, involuntary, and intrusive distressing memories
- Recurrent distressing dreams related to the event
- Dissociative reactions (flashbacks) where the person feels or acts as if the event were recurring
- Intense or prolonged psychological distress at exposure to cues
- Marked physiological reactions to cues that symbolize or resemble the event 1, 2
Criterion C: Avoidance (≥1 required)
- Persistent avoidance of stimuli associated with the traumatic event:
Criterion D: Negative Alterations in Cognitions and Mood (≥2 required)
- Inability to remember important aspects of the event
- Persistent negative beliefs about oneself, others, or the world
- Distorted cognitions about the cause or consequences leading to blame
- Persistent negative emotional state
- Markedly diminished interest in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions 1, 2
Criterion E: Alterations in Arousal and Reactivity (≥2 required)
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbance 1, 2
Duration and Functional Impairment
- Criterion F: Duration - Symptoms persist for more than 3 months (for chronic specification)
- Criterion G: Functional Significance - Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
- Criterion H: Exclusion - Disturbance is not attributable to physiological effects of a substance or another medical condition 2
Specifiers
- With dissociative symptoms: Either depersonalization or derealization
- With delayed expression: Full criteria not met until at least 6 months after the event 3
Key Diagnostic Changes in DSM-5
- PTSD was moved from anxiety disorders to a new category called "Trauma and Stressor-related Disorders" 3
- The subjective reaction criterion (former A2 criterion requiring fear, helplessness, or horror) was eliminated 4, 3
- The symptom clusters were expanded from three to four, with the addition of "negative alterations in cognitions and mood" as a separate cluster 5, 3
- The scope of symptoms was expanded beyond fear-based reactions to include dysphoric, anhedonic, aggressive/externalizing, guilt/shame, and dissociative symptoms 5
Common Diagnostic Pitfalls
- Failing to distinguish between acute PTSD (symptoms lasting 1-3 months) and chronic PTSD (symptoms lasting >3 months)
- Overlooking avoidance symptoms, which are required but may be subtle
- Missing the functional impairment criterion, which is essential for diagnosis
- Not considering cultural factors that may influence symptom presentation 6
- Confusing Complex PTSD (recognized in ICD-11 but not in DSM-5) with chronic PTSD 1
Differential Diagnosis
- Adjustment disorder (less severe stressor or different symptom profile)
- Acute stress disorder (similar symptoms but duration less than 1 month)
- Other trauma-related disorders (reactive attachment disorder, disinhibited social engagement disorder)
- Major depressive disorder
- Anxiety disorders
- Substance-induced disorders 1, 2