What are the DSM‑5 diagnostic criteria for post‑traumatic stress disorder?

DSM-5 Diagnostic Criteria for Post-Traumatic Stress Disorder

PTSD diagnosis requires exposure to trauma plus four distinct symptom clusters (intrusion, avoidance, negative cognition/mood alterations, and arousal/reactivity changes) persisting for more than one month and causing significant functional impairment. 1

Criterion A: Trauma Exposure (Required)

The patient must have experienced, witnessed, learned about, or had repeated exposure to details of traumatic events involving actual or threatened death, serious injury, or sexual violence. 1, 2 This includes:

• Direct experience of the traumatic event 1
• Witnessing trauma happening to others 1
• Learning that trauma occurred to a close family member or friend (limited to violent or accidental events) 3
• Repeated exposure to aversive details of traumatic events (e.g., first responders collecting human remains) 1

Important note: The DSM-5 removed the former A2 criterion requiring an intense emotional reaction (fear, helplessness, horror) at the time of trauma, narrowing the focus to the objective nature of the traumatic event itself. 3

Criterion B: Intrusion Symptoms (≥1 Required)

At least one of the following re-experiencing symptoms must be present: 1

• Recurrent, involuntary distressing memories of the traumatic event 1
• Traumatic nightmares with content related to the trauma (children need not recall dream content) 1
• Dissociative flashbacks where the patient feels or acts as if the trauma is recurring 1
• Intense psychological distress when exposed to internal or external trauma reminders 1
• Physiologic reactions (e.g., increased heart rate, sweating) to trauma cues 1
• Repetitive play incorporating trauma themes (specific to children) 1

Criterion C: Avoidance (≥1 Required)

At least one avoidance behavior must be present: 1

• Avoidance of distressing memories, thoughts, or feelings about the trauma 1
• Avoidance of external reminders including people, places, conversations, activities, objects, or situations that trigger trauma memories 1

The DSM-5 restructured this criterion to emphasize that the phobic object or situation is "actively avoided or endured with intense fear." 1

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

At least two of the following must be present: 1

• Inability to recall important aspects of the traumatic event (dissociative amnesia, not due to head injury or substances) 1
• Persistent negative beliefs or expectations about self, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous") 1
• Persistent distorted thoughts leading to self-blame or blaming others for causing the trauma or its consequences 1
• Persistent negative emotional states including fear, horror, anger, guilt, shame, or depression 1
• Markedly diminished interest or participation in significant activities, including play in children 1
• Feelings of detachment or estrangement from others, resulting in social withdrawal 1
• Persistent inability to experience positive emotions such as happiness, satisfaction, or loving feelings 1

Critical distinction: This cluster represents a major DSM-5 innovation, creating an empirically driven category that was previously embedded within the numbing/avoidance cluster in DSM-IV. 3

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

At least two of the following hyperarousal symptoms must be present: 1

• Irritable behavior and angry outbursts with little or no provocation, including extreme temper tantrums in children 1
• Reckless or self-destructive behavior 1
• Hypervigilance (excessive alertness to potential threats) 1
• Exaggerated startle response 1
• Problems with concentration 1
• Sleep disturbance including difficulty falling or staying asleep, or restless sleep 1

Criterion F: Duration (Required)

Symptoms must persist for more than one month after trauma exposure to distinguish PTSD from Acute Stress Disorder, which lasts 3 days to 1 month. 1, 2 This temporal criterion is essential for diagnosis. 2

Pediatric consideration: For individuals under 18 years, the 6-month duration requirement used in some anxiety disorders does not apply to PTSD; the one-month threshold is consistent across all ages. 1

Criterion G: Functional Impairment (Required)

The disturbance must cause clinically significant distress or impairment in social, occupational, academic, or other important areas of functioning. 1, 2 This criterion ensures that symptoms are not merely present but are causing meaningful disruption to the patient's life. 4

Criterion H: Exclusion (Required)

The disturbance must not be attributable to the physiological effects of a substance (medication, alcohol, drugs) or another medical condition. 2, 4

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Key Diagnostic Considerations

Screening Imperative

Approximately two-thirds of individuals with PTSD symptoms do not voluntarily seek care, making proactive screening essential rather than waiting for patients to self-report. 1 Direct inquiry about trauma exposure and symptoms is necessary because most PTSD symptoms are internal and not observable through behavior alone. 1

Assessment Tools

• The Clinician-Administered PTSD Scale (CAPS) is the gold standard diagnostic interview, assessing frequency and intensity of all DSM-5 symptoms 1
• The PTSD Checklist for DSM-5 (PCL-5) uses diagnostic criteria to determine severity, with a cutoff score of 23 suggesting probable PTSD diagnosis 4, 5
• The PTSD Symptom Scale Interview for DSM-5 (PSSI-5) demonstrates excellent interrater reliability (κ = 0.84 for diagnosis) and internal consistency (α = 0.89) 5

Common Diagnostic Pitfalls

• Underdiagnosis occurs when clinicians rely solely on observable behaviors rather than directly asking about internal symptoms 1
• Overlooking partial PTSD can result in untreated patients who still benefit from intervention 1
• Focusing only on overt behaviors leads to underestimation of distress, particularly in children 1
• Delayed screening is problematic because 10% of trauma-exposed individuals develop PTSD by 3-5 months, highlighting the need for early monitoring rather than waiting passively for one month 1

Comorbidity Screening

Depression, anxiety disorders, and substance use disorders are extremely common in PTSD and require concurrent assessment and treatment. 1, 4 Sleep disturbances warrant specific evaluation, including screening for obstructive sleep apnea, which frequently co-occurs with PTSD-related sleep problems. 1, 4