Posttraumatic Stress Disorder DSM-IV Diagnoses and Criteria

Posttraumatic Stress Disorder DSM-IV Diagnoses and Criteria

Posttraumatic Stress Disorder DSM-IV™ Diagnosis            & Criteria

Proposed Revision 309.81  Posttraumatic Stress Disorder

A. The person was exposed to one or more of the  following event(s): death or threatened death, actual or threatened serious  injury, or actual or threatened sexual violation, in one or more of the  following ways: **

  1. Experiencing the event(s)  him/herself
  2. Witnessing,  in person, the event(s) as they occurred to others
  3. Learning that the event(s) occurred to a  close relative or close friend; in such cases, the actual or  threatened death must have been violent or accidental
  4. Experiencing repeated or extreme  exposure to aversive details of the event(s) (e.g.,  first responders collecting body parts; police officers repeatedly exposed to  details of child abuse); this does not apply to exposure through electronic  media, television, movies, or pictures, unless this exposure is work  related.

More revisions at the above link


309.81                Posttraumatic Stress Disorder

Diagnostic Features

The essential feature of Posttraumatic Stress Disorder            is the development of characteristic symptoms following exposure to            an extreme traumatic stressor involving direct personal experience of            an event that involves actual or threatened death or serious injury,            or other threat to one’s physical integrity; or witnessing an event            that involves death, injury, or a threat to the physical integrity of            another person; or learning about unexpected or violent death, serious            harm, or threat of death or injury experienced by a family member or            other close associate (Criterion A1). The person’s response to the event            must involve intense fear, helplessness, or horror (or in children,            the response must involve disorganized or agitated behavior) (Criterion            A2). The characteristic symptoms resulting from the exposure to the            extreme trauma include persistent reexperiencing of the traumatic event            (Criterion B), persistent avoidance of stimuli associated with the trauma            and numbing of general responsiveness (Criterion C), and persistent            symptoms of increased arousal (Criterion D). The full symptom picture            must be present for more than 1 month (Criterion E), and the disturbance            must cause clinically significant distress or impairment in social,            occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include,            but are not limited to, military combat, violent personal assault (sexual            assault, physical attack, robbery, mugging), being kidnapped, being            taken hostage, terrorist attack, torture, incarceration as a prisoner            of war or in a concentration camp, natural or manmade disasters, severe            automobile accidents, or being diagnosed with a life-threatening illness.            For children, sexually traumatic events may include developmentally            inappropriate sexual experiences without threatened or actual violence            or injury. Witnessed events include, but are not limited to, observing            the serious injury or unnatural death of another person due to violent            assault, accident, war, or disaster or unexpectedly witnessing a dead            body or body parts. Events experienced by others that are learned about            include, but are not limited to, violent personal assault, serious accident,            or serious injury experienced by a family member or a close friend;            learning about the sudden, unexpected death of a family member or a            close friend; or learning that one’s child has a life-threatening disease.            The disorder may be especially severe or long lasting when the stressor            is of human design (e.g., torture, rape). The likelihood of developing            this disorder may increase as the intensity of and physical proximity            to the stressor increase.

The traumatic event can be reexperienced in various ways.            Commonly the person has recurrent and intrusive recollections of the            event (Criterion B1) or recurrent distressing dreams during which the            event is replayed (Criterion B2). In rare instances, the person experiences            dissociative states that last from a few seconds to several hours, or            even days, during which components of the event are relived and the            person behaves as though experiencing the event at that moment (Criterion            B3). Intense psychological distress (Criterion B4) or physiological            reactivity (Criterion B5) often occurs when the person is exposed to            triggering events that resemble or symbolize an aspect of the traumatic            event (e.g. anniversaries of the traumatic event; cold, snowy weather            or uniformed guards for survivors of death camps in cold climates; hot,            humid weather for combat veterans of the South Pacific; entering any            elevator for a woman who was raped in an elevator).

Stimuli associated with the trauma are persistently avoided.            The person commonly makes deliberate efforts to avoid thoughts, feelings,            or conversations about the traumatic event (Criterion C1) and to avoid            activities, situation, or people who arouse recollections of it (Criterion            C2). This avoidance of reminders may include amnesia for an important            aspect of the traumatic event (Criterion C3). Diminished responsiveness            to the external world, referred to as “psychic numbing” or            “emotional anesthesia,” usually begins soon after the traumatic            event. The individual may complain of having markedly diminished interest            or participation in previously enjoyed activities (Criterion C4), of            feeling detached or estranged from other people (Criterion C5), or of            having markedly reduced ability to feel emotions (especially those associated            with intimacy, tenderness, and sexuality) (Criterion C6). The individual            may have a sense of a foreshortened future (e.g., not expecting to have            a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety or increased            arousal that were not present before the trauma. These symptoms may            include difficulty falling or staying asleep that may be due to recurrent            nightmares during which the traumatic event is relived (Criterion D1),            hypervigilance (Criterion D4), and exaggerated startle response (Criterion            D5). Some individuals report irritability or outbursts of anger (Criterion            D2) or difficulty concentrating or completing tasks (Criterion D3).


The following specifiers may be used to specify onset            and duration of the symptoms of Posttraumatic Stress Disorder:

Acute.  This specifier should be used when              the duration of symptoms is less than 3 months. Chronic.  This specifier should be used when the symptoms              last 3 months or longer. With Delayed Onset.  This specifier indicates that at              least 6 months have passed between the traumatic event and the onset              of the symptoms.

Associated Features and Disorders

Associated descriptive features and mental disorders. Individuals with Posttraumatic Stress Disorder may describe painful            guilt feelings about surviving when others did not survive or about            the things they had to do to survive. Phobic avoidance of situations            or activities that resemble or symbolize the original trauma may interfere            with interpersonal relationships and lead to marital conflict, divorce,            or loss of job. The following associated constellation of symptoms may            occur and are more commonly seen in association with an interpersonal            stressor (e.g., childhood sexual or physical abuse, domestic battering,            being taken hostage, incarceration as a prisoner of war or in a concentration            camp, torture): impaired complaints; feelings of ineffectiveness, shame,            despair, or hopelessness; feeling permanently damaged; a loss of previously            sustained beliefs, hostility; social withdrawal; feeling constantly            threatened; impaired relationships with others; or a change from the            individual’s previous personality characteristics.

There may be increased risk of Panic Disorder, Agoraphobia,            Obsessive-Compulsive Disorder, Social Phobia, Specific Phobia, Major            Depressive Disorder, Somatization  Disorder, and Substance-Related            Disorders. It is not known to what extent these disorders precede or            follow the onset of Posttraumatic Stress Disorder.

Associated laboratory findings. Increased arousal            may be measured through studies of autonomic functioning (e.g., heart            rate, electromyography, sweat gland activity).

Associated physical examination findings and general            medical conditions. General medical conditions may occur as a consequence            of the trauma (e.g., head injury, burns).

Specific Culture and Age Features

Individuals who have recently emigrated from areas of            considerable social unrest and civil conflict may have elevated rates            of Posttraumatic Stress Disorder. Such individuals may be especially            reluctant to divulge experiences of torture and trauma due to their            vulnerable political immigrant status. Specific assessments of traumatic            experiences and concomitant symptoms are needed for such individuals.

In younger children, distressing dreams of the event may,            within several weeks, change into generalized nightmares of monsters,            of rescuing others, or of threats to self or others. Young children            usually do not have the sense that they are reliving the past; rather,            the reliving of the trauma may occur through repetitive play (e.g.,            a child who was involved in a serious automobile accident repeatedly            reenacts car crashes with toy cars). Because it may be difficult for            children to report diminished interest in significant activities and            constriction of affect, these symptoms should be carefully evaluated            with reports from parents, teachers, and other observers. In children,            the sense of a foreshortened future may be evidenced by the belief that            life will be too short to include becoming an adult. There may also            be “omen formation” – that is, belief in an ability to foresee            future untoward events. Children may also exhibit various physical symptoms            such as stomachaches and headaches.


Community-based studies reveal a lifetime prevalence for            Posttraumatic Stress Disorder ranging from 1% to 14%, with the variability            related to methods of ascertainment and the population sampled. Studies            of at-risk individuals (e.g., combat veterans, victims of volcanic eruptions            or criminal violence) have yielded prevalence rates ranging from 3%            to 58%.


Posttraumatic Stress Disorder can occur at any age, including            childhood. Symptoms usually begin within the first 3 months after the            trauma, although there may be a delay of months, or even years, before            symptoms appear. Frequently, the disturbance initially meets criteria            for Acute Stress Disorder (see p. 429) in the immediate aftermath of            the trauma. The symptoms of the disorder and the relative predominance            of reexperiencing, avoidance, and hyperarousal symptoms may vary over            time. Duration of the symptoms varies, with complete recovery occurring            within 3 months in approximately half of cases, with many others having            persisting symptoms for longer than 12 months after the trauma.

The severity, duration, and proximity of an individual’s            exposure to the traumatic event are the most important factors affecting            the likelihood of developing this disorder. There is some evidence that            social supports, family history, childhood experiences, personality            variables, and preexisting mental disorders may influence the development            of Posttraumatic Stress Disorder. This disorder can develop in individuals            without any predisposing conditions, particularly if the stressor is            especially extreme.

Differential Diagnosis

In Posttraumatic Stress Disorder, the stressor must be            of an extreme (i.e., life-threatening) nature. In contrast, in Adjustment            Disorder, the stressor can be of any severity. The diagnosis of            Adjustment Disorder is appropriate both for situations in which the            response to an extreme stressor does not meet the criteria for Posttraumatic            Stress Disorder (or another specific mental disorder) and for situations            in which the symptom pattern of Posttraumatic Stress Disorder occurs            in response to a stressor that is not extreme (e.g., spouse leaving,            being fired).

Not all psychopathology that occurs in individuals exposed            to an extreme stressor should necessarily be attributed to Posttraumatic            Stress Disorder. Symptoms of avoidance, numbing, and increased arousal            that are present before exposure to the stressor do not meet criteria            for the diagnosis of Posttraumatic Stress Disorder and require consideration            of other diagnoses (e.g., Brief Psychotic Disorder, Conversion Disorder,            Major Depressive Disorder), these diagnoses should be given instead            of, or in addition to, Posttraumatic Stress Disorder.

Acute Stress Disorder is distinguished from Posttraumatic            Stress Disorder because the symptom pattern in Acute Stress Disorder            must occur within 4 weeks of the traumatic event and resolve within            that 4-week period. If the symptoms persist for more than 1 month and            meet criteria for Posttraumatic Stress Disorder, the diagnosis is changed            from Acute Stress Disorder to Posttraumatic Stress Disorder

In Obsessive-Compulsive Disorder, there are recurrent            intrusive thoughts, but these are experienced as inappropriate and are            not related to an experienced traumatic event. Flashbacks in Posttraumatic            Stress Disorder must be distinguished from illusions, hallucinations,            and other perceptual disturbances that may occur in Schizophrenia,            other Psychotic Disorders, Mood Disorder With Psychotic Features,            a delirium, Substance-Induced Disorders, and Psychotic Disorders            Due to a General Medical Condition.

Malingering should be ruled out in those situations            in which financial remuneration, benefit eligibility, and forensic determinations            play a role.

309.81    DSM-IV Criteria for Posttraumatic                  Stress Disorder 

A. The person has been exposed to a traumatic event in which                  both of the following have been present:

(1) the person experienced, witnessed, or was confronted with                  an event or events that involved actual or threatened death or                  serious injury, or a threat to the physical integrity of self                  or others (2) the person’s response involved intense fear, helplessness,                  or horror. Note: In children, this may be expressed instead                  by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or                  more) of the following ways:

(1) recurrent and intrusive distressing recollections of the                  event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or                  aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable                  content.

(3) acting or feeling as if the traumatic event were recurring                  (includes a sense of reliving the experience, illusions, hallucinations,                  and dissociative flashback episodes, including those that occur                  upon awakening or when intoxicated). Note: In young children,                  trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or                  external cues that symbolize or resemble an aspect of the traumatic                  event.

(5) physiological reactivity on exposure to internal or external                  cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma                  and numbing of general responsiveness (not present before the                  trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated                  with the trauma

(2) efforts to avoid activities, places, or people that arouse                  recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant                  activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving                  feelings)

(7) sense of a foreshortened future (e.g., does not expect to                  have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before                  the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and                  D) is more than one month.

F. The disturbance causes clinically significant distress or                  impairment in social, occupational, or other important areas of                  functioning.

Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more

Specify if: With Delayed Onset: if onset of symptoms is at least 6                  months after the stressor

5 Responses to “Posttraumatic Stress Disorder DSM-IV Diagnoses and Criteria”

  1. March 13, 2010 at 1:37 pm Need e mail from a PTSD doctor on the connection between Sleep Apnea and Combat related PTSD

  2. Brittany said

    June 4, 2011 at 6:33 pm My husband came home from 6 months in Kandahar as a civilian contractor, and he is not the same person that I married.  Is there anyone out there that can help me? My husband refuses to admit that he needs help, but I cannot go on living this way…I believe he is suffering from PTSD.  Are there any resources out there for people like us?  He is no longer employed by the contractor. Thanks

    • Mark said

      April 23, 2012 at 6:10 am Brittany, I know what you are feeling and what your husband could be feeling.  I was a DoD Contractor in the Western region of Afghanistan from 2009-10 and I had 2 close calls while I was at Bagram Air Base (one being a suicide bomber and the other was a mortar landing near me).  When I came home, I really didn’t think that I was a candidate for PTSD, but I spoke with a mental health specialist.  He did say that due to some of my reactions and my constant thoughts about these events, I do have a “slight”  case of PTSD.  This was something that I needed to do on my own.  When I see the mental health doctor, I don’t want my wife to be there.  It is a battle that I feel that I need to overcome and once I admitted that I needed to talk to someone, I started my healing.  But I was afraid that I would be “labeled” and that my family just wouldn’t understand.  I wished I had better news, but sometimes, it’s just a battle that he needs to overcome and find just anyone to talk to.  Not saying he needs a mental health specialist, but someone that has been there and can relate to what he is going through.  Good luck Brittany and God bless!

  3. ellen callnan said

    November 12, 2011 at 6:19 pm Could some of you experts research and find data that supports PTSD is often the result of BULLYING.  Continued, shaming, assaults, name calling, peer neglect, teacher and other figures of empowerment ignoring signs of indirect and direct hostility or tactics separating the target from relief or expected rescue, by those who suspect and turn their backs, creating another BETRAYAL…THUS BETRAYAL TRAUMA….

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