Criterion A: Traumatic Event(s)
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly experiencing the traumatic event(s)
- Witnessing, in person the event(s) as it occurred to others
- 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 event(s) must have been violent or accidental - Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
e. g. first responders collecting human remains
e. g. police officers repeatedly exposed to details of child abuse
* does not apply to exposure through media, television etc. unless exposure is work-related
*** Emotional reactions to the traumatic event (e.g. fear, helplessness, horror) are no longer part of Criterion A
Criterion B: Intrusive Symptoms
Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)
- Dissociative reactions (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
* such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings - Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
- Marked physiological reactions to internal or external cues that symbolize a resemble an aspect of the traumatic event(s)
Criterion C: Avoidance
Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
- Avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about were closely associated with the traumatic event(s)
- Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about her closely associated with the traumatic event(s)
Criterion D: Negative alterations in cognitions and mood
Negative alterations and cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
- Inability to remember an important aspect of the traumatic event(s)
* typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs - Persistent and exaggerated negative beliefs are expectations about oneself, others, or the world
* I am bad
* known can be trusted
* worlds completely dangerous
* my whole nervous system is permanently ruined - Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that be the individual to blame himself/herself or others
- Persistent negative emotional state
e. g. fear, horror, anger, guilt, or shame - Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions
E.g. inability to experience happiness, satisfaction, or loving feelings
Criterion E: Hyperarousal and Reactivity
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:
- Irritable behavior and angry outbursts (with little or no provocation)
* typically expressed as verbal or physical aggression toward people or objects - Reckless or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems with concentration
- Sleep disturbance
e. g. difficulty falling or staying asleep or restless sleep
Criterion F: Duration
Duration of the disturbance (Criteria B, C, D, and E) is MORE THAN 1 MONTH
Specifier: With dissociative symptoms
The individual’s symptoms meet the criteria for PTSD, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either:
Depersonalization
Derealization
Depersonalization
Persistent or recurrent experiences of feeling detached from one’s mental processes or body
Feeling as if one were an outside observer of one’s mental processes or body
e. g. feeling as though one were in a dream
e. g. feeling a sense of unreality of self or body or of time moving slowly
Derealization
Persistent or recurrent experiences of unreality of surroundings
The world around the individual is experienced as unreal, dreamlike, distant, or distorted
Specifier: With delayed expression
If the full diagnostic criteria are not met until at least 6 months after the event
Although the onset and expression of some symptoms may be immediate
PTSD clinical presentation
Highly variable
In some individuals, fear-based re–experiencing, emotional, and behavior symptoms may predominate
And others, anhedonic or dysphoric mood states and negative cognitions may be most distressing
In some others, arousal and reactive-externalizing symptoms are prominent, while in others dissociative symptoms predominate
Some individuals exhibit combinations of these symptom patterns
Traumatic events
Exposure to war as a combatant or civilian
Threatened or actual physical assault
Threatened or actual sexual violence
Kidnapping
Being taken hostage
Terrorist attack
Torture
Incarceration as a prisoner of war
Natural or man-made disasters
Severe motor vehicle accidents
Intrusive recollections versus depressive ruminations
Intrusive recollections in PTSD apply only to involuntary and intrusive distressing memories
The emphasis is on recurrent memories of the event that usually include sensory, emotional, or physiological behavioral components
PTSD: Prevalence
Projected lifetime risk 8.7%
12 month prevalence 3.5%
Highest rates (1/3 - 1/2 of those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide
Higher rates of PTSD among Latinos, African-Americans, and American Indians
Lower rates of PTSD among Asian Americans
PTSD: Development
PTSD can occur at any age, beginning after the first year of life
Symptoms usually begin within the first 3 months after the trauma, although there may be a delay of months, or even years before criteria for the diagnosis are met
Previously called “delayed onset” but is now called “delayed expression” with the recognition that some symptoms typically appear immediately and that the delay is in meaningful criteria
PTSD: Course
Duration varies, with complete recovery within 3 months occurring in approximately 1/2 of adults
Frequently, an individual’s reaction to a trauma initially meets criteria for acute stress disorder in the immediate aftermath of the trauma
Symptoms and predominance of different symptoms may vary over time
Some individuals remained symptomatic for longer than 12 months and sometimes for more than 50 years
Symptom recurrence and intensification may occur in response to reminders of the original trauma, ongoing life stressors, or newly experienced traumatic events
For older individuals, declining health, worsening cognitive functioning, and social isolation may exacerbate PTSD symptoms
Pre-traumatic Factors: Temperamental
Childhood emotional problems by age 6
e.g. prior traumatic exposure, externalizing or anxiety problems
Prior mental disorders
e.g. panic disorder, depressive disorder, PTSD, or OCD
Pre-traumatic factors: Environmental
Lower SES
Lower education
Exposure to prior trauma
*especially during childhood
Childhood adversity
e.g. economic deprivation, family dysfunction, parental separation or death
Cultural characteristics
e.g. fatalistic or self blaming coping strategies
Lower intelligence
Minority racial/ethnic status
Family psychiatric history
*Social support prior to event exposure is protected
Pre-traumatic Factors: genetic and physiological
Female gender and younger age at time of trauma exposure (for adults)
Certain genotypes may you to be protective or increase risk
Peritraumatic Factors
Severity of the trauma
Perceived life threat
Personal injury
Interpersonal violence
- particularly, perpetrated by a caregiver
- for children, involving a witnessed threat to a caregiver
For military personnel – being a perpetrator, witnessing atrocities, or killing the enemy
Dissociation that occurs during the trauma and persists afterward is also a risk factor
Posttraumatic Factors: Temperamental
Negative appraisals
Inappropriate coping strategies
Development of acute stress disorder
Posttraumatic Factors: Environmental
subsequent exposure to repeated upsetting reminders
Subsequent adverse life events
Financial or other trauma-related losses
*Social support is a protective factor that moderates outcome after trauma
Gender-Related Diagnostic Issues
PTSD is more prevalent among females across the lifespan
Females experience PTSD for longer duration
Some of the increased risk and females appears to be attributable to a greater likelihood of exposure to traumatic events
PTSD: Suicide Risk
Childhood abuse increases a person’s suicide risk
PTSD is associated with suicidal ideation and suicide attempts
Presence of PTSD may indicate which individuals with ideation eventually make a suicide plan or actually attempt suicide
