PTSD new diagnostic info: Classification and subtypes
The risk of exposure to trauma has been a part of the human condition since we evolved as a species. Attacks by saber tooth tigers or twenty-first century terrorists have probably produced similar psychological sequelae in the survivors of such violence. Shakespeare’s Henry IV appears to meet many, if not all, of the diagnostic criteria for Posttraumatic Stress Disorder (PTSD), as have other heroes and heroines throughout the world’s literature.
Because of studies of Vietnam Vets suffering, finally in 1980, the American Psychiatric Association (APA) added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme (2). Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of “trauma.”
Now, in the new DSM book, there is a PTSD Preschool Subtype which applies to children six years old and younger; it has fewer symptoms (especially in the “D” cluster because it is difficult for young children to report on their inner thoughts and feelings) and also has lower symptom thresholds to meet full PTSD criteria.
Importance of traumatic events
In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions), and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events to be clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness, financial reverses, and the like. (By this logic, adverse psychological responses to such “ordinary stressors” would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that, although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.
PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the “stressor criterion,” which means that he or she has been exposed to an event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress. Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Although there is currently a renewed interest in subjective aspects of traumatic exposure, it must be emphasized that events such as rape, torture, genocide, and severe war zone stress are experienced as traumatic events by nearly everyone.
Revisions to PTSD diagnostic criteria
The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000) (2-5). A very similar syndrome is classified in ICD-10 (The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines) (6). One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common. Recent data from the National Comorbidity Survey Replication indicates lifetime PTSD prevalence rates are 3.6% and 9.7% respectively among American men and women (7). Rates of PTSD are much higher in post-conflict settings such as Algeria (37%), Cambodia (28%), Ethiopia (16%), and Gaza (18%) .
DSM-IV Diagnostic criteria for PTSD included a history of exposure to a traumatic event and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerned duration of symptoms; and, a sixth criterion stipulated that PTSD symptoms must cause significant distress or functional impairment.
The latest revision, the DSM-5 (2013), has made a number of notable evidence-based revisions to PTSD diagnostic criteria, with both important conceptual and clinical implications (9). First, because it has become apparent that PTSD is not just a fear-based anxiety disorder (as explicated in both DSM-III and DSM-IV), PTSD in DSM-5 has expanded to include anhedonic/dysphoric presentations, which are most prominent. Such presentations are marked by negative cognitions and mood states as well as disruptive (e.g. angry, impulsive, reckless and self-destructive) behavioral symptoms. Furthermore, as a result of research-based changes to the diagnosis, PTSD is no longer categorized as an Anxiety Disorder. PTSD is now classified in a new category, Trauma- and Stressor-Related Disorders, in which the onset of every disorder has been preceded by exposure to a traumatic or otherwise adverse environmental event.
PTSD is no longer considered an Anxiety Disorder but has been reclassified as a Trauma and Stressor-Related Disorder because it has a number of clinical presentations, as discussed previously. In addition, two new subtypes have been included in the DSM-5. The Dissociative Subtype includes individuals who meet full PTSD criteria but also exhibit either depersonalization or derealization (e.g. alterations in the experience of one’s self and the world, respectively).The Preschool Subtype applies to children six years old and younger; it has fewer symptoms (especially in the “D” cluster because it is difficult for young children to report on their inner thoughts and feelings) and also has lower symptom thresholds to meet full PTSD criteria.
PTSD and Vietnam, combat trauma, the American Psychiatric Association
“Since 1980, there has been a great deal of attention devoted to the development of instruments for assessing PTSD. Keane and associates working with Vietnam war-zone Veterans, first developed both psychometric and psychophysiological assessment techniques that have proven to be both valid and reliable. Other investigators have modified such assessment instruments and used them with natural disaster survivors, rape/incest survivors, and other traumatized individuals” (Friedman, 2013, n.p.).
Research partner, Jeremy Bourret. This treatise was sent to me in an email with author unknown.
