PTSD: A systematic approach to diagnosis and treatment: Accurate diagnosis and management depends on proper application of DSM-5 criteria
Posttraumatic stress disorder (PTSD) has increasingly become a part of American culture since its introduction in the American Psychiatric Association's third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. (1) Since then, a proliferation of material about this disorder--both academic and popular--has been generated, yet much confusion persists surrounding the definition of the disorder, its prevalence, and its management. This review addresses the essential elements for diagnosis and treatment of PTSD.
Diagnosis: A closer look at the criteria
Criteria for the diagnosis of PTSD have evolved since 1980, with changes in the definition of trauma and the addition of symptoms and symptom groups. (2) Table l (3) (page 36) summarizes the current DSM-5 criteria for PTSD.
Trauma exposure. An essential first step in the diagnosis of PTSD is to determine whether the individual has experienced exposure to trauma. This concept is defined in Criterion A (trauma exposure). (3) PTSD is nonconformist among the psychiatric diagnoses in that it requires a specific external event as part of its definition. Misapplication of the trauma exposure criterion by many clinicians and researchers has led to misdiagnosis and erroneously high prevalence estimates of PTSD. (4,5)
A traumatic event is one that represents a threat to life or limb, specifically defined as "actual or threatened death, serious injury, or sexual violence." (3) DSM-5 does not allow for just any stressful event to be considered trauma. For example, no matter how distressing, failing an important test at school or being served with divorce proceedings do not represent a requisite trauma (6) because these examples do not entail a threat to life or limb.
DSM-5 PTSD Criterion A also requires a qualifying exposure to the traumatic event. There are 4 types of qualifying exposures:
* direct experience of immediate serious physical danger
* eyewitness of trauma to others
* indirect exposure via violent or accidental trauma experienced by a close family member or close friend
* repeated or extreme exposure to aversive details of trauma, such as first responders collecting human remains or law enforcement officers being repeatedly exposed to horrific details of child abuse. (3)
Witnessed trauma must be in person; thus, viewing trauma in media reports would not constitute a qualifying exposure. Indirect trauma exposure can occur through learning of the experience of a qualifying trauma exposure by a close family member or personal friend.
It is critical to differentiate exposure to trauma (an objective construct) from the subjective distress that may be associated with it. If trauma has not occurred or a qualifying exposure is not established, no amount of distress associated with it can establish the experience as meeting Criterion A for PTSD. This does not mean that nonqualifying experiences of stressful events are not distressing; in fact, such experiences can result in substantial psychological angst. Conversely, exposure to trauma is not tantamount to a diagnosis of PTSD, as most trauma exposures do not result in PTSD. (7,8)
Symptom groups. DSM-5 symptom criteria for PTSD include 4 symptom groups, Criteria B to...