PTSD DSM V criteria A
A. 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 traumatic event(s) as they 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 events 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); does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work-
related.
Criteria B
B. Presence of one or more intrusion symptoms
associated with the traumatic event:
– Recurrent, involuntary & intrusive distressing memories of the event
– Recurrent distressing dreams in which the content or affect of the
dream are related to the traumatic event(s)
– Dissociative reactions (e.g. flashbacks) – feeling or acting as though
the traumatic event was recurring
– Psychological or physiological distress with reminders of trauma
criteria C
C. Persistent avoidance of reminders of the trauma,
including one or both of:
– Avoidance of distressing memories, thoughts or feelings
– Avoidance of external reminders (eg people, places, objects)
criteria D
D. Negative changes in cognition and mood,
including two or more of the following:
- inability to remember important aspects of the trauma
- exaggerated negative beliefs about oneself, others or the world
- distorted cognitions about the causes or consequences of the trauma
(e.g. self-blame)
- persisting negative emotions: e.g. fear, horror, anger, guilt, shame
- markedly diminished interest or participation in significant activities
- feeling detached or estranged from others
- inability to experience positive emotions
criteria E
E. Marked changes in arousal and reactivity
including two or more of:
- irritable behavior and angry outbursts
- reckless or self-destructive behavior
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbance (insomnia or restless sleep)
(Yellow highlights reflect symptoms overlapping with MDD
E. Duration more than one month
PTSD VERSUS OTHER TRAUMA AND
STRESSOR RELATED DISORDERS
- Acute stress disorder (PTSD-like condition, but less
than one month duration) - Adjustment disorder (maladaptive reaction to an
identifiable stressor; condition remits within 6 months
when the stressor resolves; different kind of stressor) - Other Specified Trauma and Stressor Related
Disorder - examples:
– PTSD-like condition that falls short of the required criteria
– PTSD-like condition that follows a “non-Criterion A” stressor
– A prolonged duration adjustment disorder
PTSD symptoms
- avoidance (internal and external)
- negative cognitions and mood)
- reexperiencing (intrusion symptoms)
- hyperarousal
+ moral injury
moral injury
- Moral injury is the damage done to one’s
conscience when that person perpetrates,
witnesses, or fails to prevent acts that transgress
their own moral values - Using deadly force in combat and causing the harm or death of civilians, knowingly but without alternatives, or accidentally
- Giving orders in combat that result in the injury or death
- Failing to provide medical aid to an injured civilian or service member
- Failing to report knowledge of a sexual assault or rape committed against oneself, a fellow service member, or civilians
- Following orders that were illegal, immoral, or personally abhorrent
- Change in belief about the justification for war, during or after service
complex PTSD
- Complex PTSD is not a DSM-5-TR diagnosis
- ICD-11 (WHO, 2019) includes this diagnosis
- Complex PTSD may develop:
- following extremely threatening or horrific trauma(s)
- commonly when trauma is prolonged and/or repetitive
- and when escape is difficult or impossible
- e.g. torture, genocide campaigns, prolonged domestic
violence, repeated childhood sexual or physical abuse - All general PTSD criteria are met plus additional severe
and persistent symptoms: - problems in affect regulation
- beliefs about oneself as diminished, defeated or worthless
- difficulties in sustaining relationships and feeling close to others
What is the lifetime prevalence of Criterion A in
the general population?
60-80%
PTSD prevelance
- Canadian general population
- Lifetime approximately 9%
- US general population
- Lifetime approx. 7%
- Female:Male ~ 2:1
- Prevalence higher in some US subpopulations:
- 2 to 3X in Native Americans on reservations
- Combat veterans 30-50%
psychiatric comorbities
- bipolar
- depression
- substance use disorder
- physical injury / chronic pain
- cluster B personality disorder
- psychotic
PTSD symptom overlap with MDD
- SHARED DSM-5-TR DIAGNOSTIC CRITERIA:
- Dysphoric mood
- Loss of interest, loss of positive emotion
- Negative cognitions such as guilt and pessimism
- Impaired concentration
- Insomnia
- Using DSM-5-TR diagnostic criteria symptoms can be applied toward both diagnoses
who gets PTSD?
pre trauma factors:
- females
- low IQ
- prior trauma
- prior mental disorder
- personality factors
- genetics
trauma factors:
- perceived risk of death
- assaultive trauma
- severity of trauma
- physical injury
post trauma factors:
- increased HR
- low social support
- pain severity
- ICU stay
- traumatic brain injury
- peritraumatic dissociation
- acute stress disorder
-disability
fear conditioning
- Mammals have innate, highly adaptive responses to life-
threatening events – ie “fight or flight” response - “Fear conditioning” is a form of classical conditioning: the
innate (unconditioned) physiological fear response gets
paired with a previously neutral (conditioned) stimulus - Long after the precipitating traumatic event, cues in the
environment can trigger the same physiological response - The triggering events may be consciously recognized, or
subtle and not consciously registered (e.g. fleeting
peripheral movement, unexpected object at the roadside) - Individuals exposed to trauma avoid situations that remind
them of the trauma, and then experience “negative
reinforcement” of avoidance behavior
fear conditioning - clinical and therapeutic implications
- Trauma-focused therapies directly address FC; conditioned
stimulus exposure in a safe environment can lead to
extinction; understanding negative reinforcement related
to avoidance - Plasticity enhancing Rx: D-cycloserine (NMDA agonist) to
enhance learning in exposure therapy; SSRIs may also
increase plasticity by increasing BDNF - Prevention of full-blown PTSD may be possible by interfering
early in the process of memory consolidation: - E.g. early psychotherapeutic treatment;
Pharmacologic trials of prevention – morphine, propranolol
dysregulated circuits
- People with PTSD show abnormalities in sympathetic
nervous system and HPA-axis regulation, both suggesting
that stress-response systems are hyper-reactive - Normally, reciprocal inhibition exists between medial
prefrontal cortex (mPFC) and the amygdala: - during stress, limbic activation inhibits PFC function
- PFC activity, in turn inhibits the amygdala, decreasing stress
response - In PTSD, amygdala activation is exaggerated while PFC
function is diminished - Neural pathways downstream from the amygdala mediate
hyper-arousal, increased heart rate, and enhanced startle.
dysregulated circuits - clinical and therapeutic implications
- SSRIs are associated with reduced amygdala activation;
Therapy may yield increased PFC “top down” regulation - Early exposures to manageable stress can yield resilience;
this is termed “stress inoculation” - Better stress response regulation is associated with resilience;
neuropeptide Y may be involved in the pathway - Neurostimulation therapies (e.g. Transcranial magnetic
stimulation or transcranial direct current stimulation) are a
potentially promising direction
memory reconsolidation
- Personal memories begin with encoding of experience in
working and short-term memory and then proceed to
consolidation into long-term memory - Research following 9/11 has shown that long-term memories
are not fixed or indelible: - Every time a long-term memory is recalled, it is temporarily
“labile” and needs to be “reconsolidated” – in this process
a memory can be updated or changed - In a sense any long-term memory is only as old as the last
time it was recalled! - Repeated unwanted recall of traumatic memories may
reinforce maladaptive beliefs and interpretations (e.g.
relating to guilt, personal responsibility, helplessness)
memory reconsolidation - clinical and therapeutic implications
- In exposure-based therapies, memories may be “updated”
with new perspectives, or different emotional salience
because memory reconsolidation takes place in a safe and
reassuring environment - Propranolol administered before re-activation of traumatic
memories in therapy may enhance the therapeutic benefit
of exposure therapy
epigenetic factors
- “Epigenetics” = enduring change in expression of genes
induced by environmental exposures (e.g. by DNA
methylation or histone acetylation) - Childhood neglect/abuse experiences can epigenetically
program stress systems leading to disturbed regulation of
HPA axis AND prolonged responses to later life stresses - E.g. inhibition of expression of glucocorticoid receptors in the
hippocampus by DNA methylation - Epigenetic mechanisms may be able to act across
generations
epigenetic factors - clinical and therapeutic implications
- Epigenetic mechanisms may explain the observation that
childhood trauma is a predisposing factor for adult PTSD - Future possibilities: epigenetic “biological markers” may be
able to identify risk for PTSD - Another future possibility: pharmacologic treatments might
be used to modify epigenetic changes (e.g. animal studies
on histone deacetylase inhibitors)
genetic factors
- Exposure to trauma is a “required” criterion for a diagnosis
of PTSD, but is clearly not the “only” causal factor - PTSD is highly heritable, estimated h = 0.4 – 0.5
- Specific risk genes have not been consistently identified
- Implicated genes with a plausible link include:
- BDNF (neural plasticity)
- GABA (neural inhibition)
- Glucocorticoid (stress response)
which biological tx might prevent PTSD within 24h of injury?
morphine
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Anxiety Disorders18
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Bipolar Disorders19
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Stroke48
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Coma15
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Depressive Disorderws38
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Neuron Death43
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Neuro Infections52
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Neuromuscular Diseases33
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NMD continued35
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Adult Epilepsy56
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Pediatric Epilepsy23
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Personality Disorders21
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Hypotonia26
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PTSD32
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Schizophrenia44
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ICP and TBI26
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Spinal Cord Disease0
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Substance Use Disorders46
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Psychotherapy24
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Epilepsy Treatment16
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Headache46
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Sleep Disorders53
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Perinatal Neuro Complications34
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Eating Disorders24
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OCD11
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Acute Painless Vision Loss35
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Chronic Vision Loss31
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Red or Painful Eye25
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Ocular Trauma22
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Psych Pharmacology34
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MCI and Dementia45
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Neurodegenerative Dementias40
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FASD47
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Gait Disorders16
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Mood/Anxiety Disorders in Peds48
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Autism Spectrum Disorders25
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Eye Movement Abnormalities, Diplopia and Pupillary Disorders54
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PEDIATRIC OPHTHALMOLOGY AND STRABISMUS36
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Ocular Pharmacology11
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Ocular Manifestations of Systemic Disease7
