Post-Traumatic Stress Disorder
The diagnosis of PTSD was created in the late 1970s to care for U.S. military veterans returning from Vietnam, for whom little was being done to understand and address the trauma they had experienced during the war.
PTSD necessarily involves trauma but is a medical diagnosis with specific criteria that constitutes a phenomenon narrower in scope than what is commonly referred to as “having trauma”, or post-traumatic symptoms.
Note
Due to the nature of this topic, some may find this module activating. We encourage you to take breaks as much as you need as you work through this content. Please reach out to training@numinus.com if you need support.
DSM-Classified Trauma and Stressor-Related Disorders
As mentioned in the last module, the DSM-5 categorizes five Trauma and Stressor Related Disorders for which the common link is stress-response syndromes in reaction to specific triggering events (Virginia Commission on Youth, 2017).
Populations with a High Burden of PTSD Diagnoses
The following populations are commonly diagnosed with PTSD:
- Military veterans
- First responders
- Women
- People of a lower socioeconomic status
- Black, Indigenous, and Peoples of Colour
- People who are LGBTQ2SI+
- Other marginalized populations
Question
What are the diagnostic criteria for post-traumatic stress disorder?
The following are the DSM-5 diagnostic criteria for PTSD:
- Criterion A: in-person direct or indirect exposure to death, threatened death, actual or threatened serious injury or sexual violence
- Criterion B: intrusion symptoms (must experience at least one)
- Unwanted memories
- Nightmares
- Flashbacks or other dissociative reactions
- Emotional or physical distress after traumatic reminders
- Criterion C: avoidance symptoms (must experience at least one)
- Thoughts
- Feelings
- External reminders
- Criterion D: negative alterations in cognitions or mood (must experience two or more of the following):
- Memory gaps
- Negative thoughts or assumptions about oneself or the world
- Exaggerated blame of self or others for causing trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
- Criterion E: alterations in arousal and reactivity after the trauma (must experience two or more of the following):
- Irritability/aggression
- Risky or destructive behaviour
- Hypervigilance
- Heightened startle
- Difficulty concentrating
- Difficulty sleeping
- Criterion F (required): duration of B, C, D, and E is more than one month
- Criterion G (required): the condition significantly impacts social, work, or other important areas of functioning
- Criterion H (required): exclusion (symptoms not due to medication, substance use, other illness)
PTSD Diagnostic Specifications
In the diagnosis of PTSD, it is important to also consider the potential for a dissociative or delayed specification.
Dissociative Specification
Individuals who experience dissociative symptoms may experience high levels of depersonalization or derealization. These experiences must not be due to substance use.
Delayed Specification
In some cases, PTSD criteria may not be met until at least six months following the trauma. It is not uncommon for the onset of some symptoms to be immediate.
Screening and Monitoring Instruments
The PCL-5 is the most commonly used screening and monitoring instrument for post-traumatic stress disorder in primary care. The scores of 0 (“not at all”) to 4 (“extremely”) are used for diagnosis.
Learn More
For an example of the PCL-5 used by Veteran Affairs in the United States to screen clients for post traumatic stress disorder, please download their PTSD checklist.
Treatment
There are several evidence-based treatment approaches for PTSD including prolonged exposure therapy, cognitive processing therapy, anxiety management training, stress inoculation training, and eye movement desensitization and reprocessing (Watkins et al., 2018; Pantalon & Motta, 1998).
Unfortunately, existing treatments with exposure components have high dropout rates, whereas transdiagnostic treatments may lower treatment dropout (Imel et al., 2013; Gutner & Presseau, 2019). Exposure-based treatments involve repetitive revisiting of details of traumatic events in an attempt to desensitize. Fear is prioritized in these treatments and anger, guilt, shame, grief, and other emotions are not targeted.
The US FDA has approved two medications for the treatment of PTSD, the SSRIs sertraline hydrochloride (Zoloft) and paroxetine hydrochloride (Paxil). Despite their approval for the indication of PTSD, effect sizes are small, and a meta-analysis showed that average dropout rate from treatment is 29%, demonstrating that many individuals fail to respond or tolerate treatment with these SSRIs. By comparison, the average dropout rate from MDMA-AT from pooled phase 2 data was 6.8% (5 out of 74) (Feduccia et al., 2019).
References
Feduccia, A. A., Jerome, L., Yazar-Klosinski, B., Emerson, A., Mithoefer, M. C., & Doblin, R. (2019). Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline. Frontiers in psychiatry, 10, 650.
Gutner, C. A., & Presseau, C. (2019). Dealing with complexity and comorbidity: Opportunity for transdiagnostic treatment for PTSD. Current treatment options in psychiatry, 6(2), 119–131.
Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of consulting and clinical psychology, 81(3), 394–404.
Pantalon, M. V., & Motta, R. W. (1998). Effectiveness of anxiety management training in the treatment of posttraumatic stress disorder: a preliminary report. Journal of behavior therapy and experimental psychiatry, 29(1), 21–29.
Virginia Commission on Youth (2017). Trauma and Stress-Related Disorders [PDF]. Government of Virginia.
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in behavioral neuroscience, 12, 258.