What are the DSM V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) diagnostic criteria and treatment options for Post-Traumatic Stress Disorder (PTSD)?

DSM-5 Diagnostic Criteria for PTSD

PTSD diagnosis requires exposure to trauma (direct experience, witnessing, learning about trauma to close others, or repeated exposure to traumatic details), plus specific symptom clusters persisting for more than one month and causing significant functional impairment. 1

Criterion A: Trauma Exposure

• Exposure must involve actual or threatened death, serious injury, or sexual violence 1, 2
• Exposure can occur through:
  • Direct personal experience 1
  • Witnessing trauma happening to others 1
  • Learning that trauma occurred to a close family member or friend 1
  • Repeated or extreme exposure to aversive details of traumatic events (e.g., first responders) 1

Criterion B: Intrusion Symptoms (≥1 Required)

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event 1
• Traumatic nightmares with content related to the event 1
• Dissociative reactions (flashbacks) where the person feels or acts as if the trauma is recurring 1
• Intense psychological distress when exposed to trauma-related cues 1
• Marked physiological reactions to trauma reminders 3

Criterion C: Avoidance (≥1 Required)

• Avoidance of trauma-related thoughts, memories, or feelings 1
• Avoidance of external reminders (people, places, conversations, activities, objects, situations) that arouse trauma-related distress 1
• Cognitive avoidance is a key determinant in DSM-5 diagnosis and was a major change from DSM-IV 4

Criterion D: Negative Alterations in Cognition and Mood (≥2 Required)

• Inability to remember important aspects of the traumatic event (dissociative amnesia, not due to head injury or substances) 1
• Persistent and exaggerated negative beliefs about oneself, others, or the world 1
• Persistent distorted cognitions about the cause or consequences of the trauma leading to self-blame or blame of others 1
• Persistent negative emotional state (fear, horror, anger, guilt, shame) 3
• Markedly diminished interest or participation in significant activities 3
• Feelings of detachment or estrangement from others 3
• Persistent inability to experience positive emotions 3

Criterion E: Alterations in Arousal and Reactivity (≥2 Required)

• Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression 1
• Reckless or self-destructive behavior 1
• Hypervigilance 1
• Exaggerated startle response 1
• Problems with concentration 3
• Sleep disturbance (difficulty falling or staying asleep, restless sleep) 1

Criterion F: Duration

• Symptoms must persist for more than one month 1, 5
• Symptoms occurring earlier than one month may represent acute stress disorder rather than PTSD 5

Criterion G: Functional Impairment

• The disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1

Criterion H: Exclusion

• The disturbance is not attributable to the physiological effects of a substance or another medical condition 3

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Key Differences Between DSM-IV and DSM-5

• DSM-5 expanded the avoidance criterion to require only one symptom instead of three, but made cognitive avoidance more prominent 4
• DSM-5 created a new symptom cluster (Criterion D) for negative alterations in cognitions and mood, separating these from the numbing symptoms previously grouped with avoidance 4
• DSM-5 removed the requirement that the person's response involve "intense fear, helplessness, or horror" at the time of trauma 2
• The within-subjects concordance between DSM-IV and DSM-5 diagnoses shows high agreement overall, but individuals diagnosed under DSM-IV but not DSM-5 were primarily indirect victims, while those diagnosed under DSM-5 but not DSM-IV presented with cognitive avoidance and negative cognitions not captured by DSM-IV 4

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Assessment Tools

• The Clinician-Administered PTSD Scale (CAPS) is the gold standard diagnostic interview for PTSD 1
• The PTSD Checklist for DSM-5 (PCL-5) uses DSM-5 diagnostic criteria to help diagnose PTSD and determine symptom severity 5
• For pediatric populations, use the PTSD Reaction Index Brief Form for known trauma exposures 1
• In primary care settings, use the Pediatric Traumatic Stress Screening Tool 1

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Critical Clinical Considerations

• Most PTSD symptoms are internal and not observable through behavior alone—direct questioning about symptoms is essential 1
• Patients with PTSD often do not voluntarily report symptoms, requiring active screening 1
• Flashbacks are dissociative episodes, not psychotic phenomena, and should not be confused with psychosis 6
• Sleep disturbances are extremely common and may require specific assessment for obstructive sleep apnea 1, 5
• Comorbidities (depression, anxiety disorders, substance use) are present in the majority of PTSD cases and require concurrent treatment 1, 5