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The Diagnostic and Statistical Manual of Mental Disorders provides standard criteria and common language for the classification of mental disorders. It is published by the American Psychiatric Association. The fifth revision (DSM-5) was released in May 2013. This revision includes changes to the diagnostic criteria for PTSD and Acute Stress Disorder.
The reason the PTSD diagnostic criteria were revised is to take into account things we have learned from scientific research and clinical experience.
What are the major revisions to the PTSD diagnosis?
PTSD (as well as Acute Stress Disorder) moved from the class of anxiety disorders into a new class of "trauma and stressor-related disorders." All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. The rationale for the creation of this new class is based upon clinical recognition of variable expressions of distress as a result of traumatic experience. The necessary criteria of exposure to trauma links the conditions included in this class; the homogeneous expression of anxiety or fear-based symptoms, anhedonic and dysphoric symptoms, externalizing anger or aggressive symptoms, dissociative symptoms, or some combination of those listed differentiates the diagnoses within the class (1).
Overall, the symptoms of PTSD are mostly the same in DSM-5 as compared to DSM-IV. A few key alterations include:
The three clusters of DSM-IV symptoms are divided into four clusters in DSM-5: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. DSM-IV Criterion C, avoidance and numbing, was separated into two criteria: Criteria C (avoidance) and Criteria D (negative alterations in cognitions and mood). The rationale for this change was based upon factor analytic studies, and now requires at least one avoidance symptom for PTSD diagnosis.
Three new symptoms were added:
Criteria D (negative alterations in cognitions and mood): persistent and distorted blame of self or others, and persistent negative emotional state
Criteria E (alterations in arousal and reactivity): reckless or destructive behavior
Other symptoms were revised to clarify symptom expression.
Criterion A2 (requiring fear, helplessness, or horror happen right after the trauma) was removed in DSM-5. Research suggests that Criterion A2 did not improve diagnostic accuracy (2).
A clinical subtype "with dissociative symptoms" was added. The dissociative subtype is applicable to individuals who meet the criteria for PTSD and experience additional depersonalization and derealization symptoms (3).
PTSD assessment measures, such as the PC-PTSD, CAPS, and PCL, are being revised by the National Center for PTSD to be made available upon validation of the instruments. Please see our Assessments section for more information.
Based on initial analyses of the DSM-5 criteria, the prevalence of PTSD will be similar to what it is currently in DSM-IV (5,6). Research also suggests that similarly to DSM-IV, prevalence of PTSD for DSM-5 was higher among women than men, and prevalence increased with multiple traumatic event exposure (6).
National estimates of PTSD prevalence suggest that DSM-5 rates were slightly lower than DSM-IV (6). Discordant findings in diagnostic prevalence were attributable to three major changes in the DSM-5 criteria for PTSD:
The revision of Criterion A1 in DSM-5 narrowed qualifying traumatic events such that the unexpected death of family or a close friend due to natural causes is no longer included. Research suggests this is the greatest contributor (>50%) to discrepancy for meeting DSM-IV but not DSM-5 PTSD criteria.
Splitting DSM-IV Criterion C into two criteria in DSM-5 now requires that a PTSD diagnosis must include at least one avoidance symptom.
Criterion A2, response to traumatic event involved intense fear, hopelessness, or horror, was removed from DSM-5.
Lanius, R., Brand, B., Vermetten, E., Freewn, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety, 29, 701-708. doi: 10.1002/da.21889
Scheeringa, M. S., Zeanah, C. H., & Cohen, J. A. (2011). PTSD in children and adolescents: toward an empirically based algorithm. Depression and Anxiety, 28, 770-782. doi:10.1002/da20736
Miller, Mark W; Wolf, Erika Jane; Kilpatrick, Dean G; Resnick, Heidi S; Marx, Brian P; et al. (Sep 3, 2012). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychological Trauma: Theory, Research, Practice, and Policy./PTSD/professional/articles/article-pdf/id39382.pdf
Kilpatrick, D., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and Proposed DSM-5 Criteria [Manuscript submitted for publication].
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