Diagnostic Criteria for Post-Traumatic Stress Disorder (PTSD)
PTSD requires exposure to trauma followed by four specific symptom clusters persisting for more than one month with significant functional impairment. 1, 2
Trauma Exposure Criterion
The patient must have experienced exposure to actual or threatened death, serious injury, or sexual violence through: 1, 3
- Direct personal experience of the traumatic event 1
- Witnessing the traumatic event happen to others, especially caregivers 1
- Learning that the traumatic event occurred to a close family member or friend 1
- Repeated exposure to aversive details of traumatic events 2
Required Symptom Clusters (All Four Must Be Present)
1. Intrusion Symptoms (At Least One Required)
- Recurrent, involuntary distressing memories of the traumatic event 1, 2
- Traumatic nightmares (children do not need to remember dream content) 1, 2
- Dissociative reactions (flashbacks) where the person acts or feels as if the trauma is recurring 1, 4
- Intense psychological distress at exposure to trauma reminders 1, 2
- Physiologic reactions to internal or external cues resembling the trauma 1
- Repetitive play involving trauma themes (in children) 1
2. Avoidance Symptoms (At Least One Required)
- Avoidance of distressing memories, thoughts, or feelings about the traumatic event 1, 2
- Avoidance of external reminders including people, places, conversations, activities, objects, or situations that trigger trauma memories 1, 2
3. Negative Alterations in Cognition and Mood (At Least Two Required)
- Inability to remember important aspects of the traumatic event 1, 2
- Persistent negative beliefs or expectations about oneself, others, or the world 1, 2
- Persistent distorted thoughts about the cause or consequences leading to self-blame or blaming others 1, 2
- Persistent negative emotional states (fear, horror, anger, guilt, shame, depression) 1, 2
- Markedly diminished interest or participation in significant activities, including play 1
- Feelings of detachment or estrangement from others, leading to social withdrawal 1, 2
- Persistent inability to experience positive emotions (happiness, satisfaction, loving feelings) 1
4. Alterations in Arousal and Reactivity (At Least Two Required)
- Irritable behavior and angry outbursts with little or no provocation, including extreme temper tantrums 1, 2
- Reckless or self-destructive behavior 1, 2
- Hypervigilance 1, 2
- Exaggerated startle response 1, 2
- Problems with concentration 1, 2
- Sleep disturbance (difficulty falling or staying asleep, restless sleep) 1, 2
Temporal and Functional Requirements
Symptoms must persist for more than one month after the traumatic exposure to distinguish PTSD from Acute Stress Disorder (which occurs 3 days to 1 month post-trauma). 1, 2, 4, 5, 6
Significant distress or functional impairment must be present, affecting social, occupational, or other important areas of functioning. 4, 6
Critical Diagnostic Pitfalls to Avoid
Most PTSD symptoms are internal and not observable through behavior alone—direct questioning about specific symptoms is essential rather than relying on behavioral observations. 2
Two-thirds of individuals with PTSD symptoms do not voluntarily seek care, making active screening necessary rather than waiting for patients to report symptoms. 1, 2
Children and adolescents may not spontaneously report symptoms, and parents often underestimate their distress, requiring direct age-appropriate screening of the child. 2
Partial PTSD (subthreshold symptoms) still warrants treatment, as these patients benefit from intervention even without meeting full diagnostic criteria. 2
Differential Diagnosis Considerations
Acute Stress Disorder is ruled out if symptoms persist beyond one month, as ASD specifically captures the 3-day to 1-month post-trauma window. 4, 5
Panic Disorder is excluded when symptoms are clearly trauma-linked and include dissociative and intrusive reexperiencing phenomena, not just discrete panic attacks. 1, 4