Diagnosis Primer: Post Traumatic Stress Disorder (PTSD)

Post Traumatic Disorder (PTSD) is a relatively common disorder in those who have experienced trauma. It includes much of the cultural assumptions of what trauma causes like flashbacks and reactions to reminders of the trauma. The depictions are often done with some real misinformation so hopefully, this will help flesh out how PTSD is understood and for those who struggle with trauma and PTSD to have a better understanding and hopefully give them language to communicate their struggles.

It’s also good to know as psychiatrists can sometimes give a diagnosis without explaining why or even what it is to patients this could help those people as well.

Criterion for Post Traumatic Stress Disorder

Criteria for PTSD as given in the Diagnostic and Statistical Manual Fifth Edition (DSM-5) [as of the 2018 revisions]

Criterion A: stressor (1 Required)

The person was exposed to death, threatened death, actual, threatened serious injury, or actual or threatened sexual violence, in the following way(s):

  • Direct exposure
  • Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
  • Learning that a relative or close friend was exposed to a trauma
  • Witnessing the trauma

Criterion B: Intrusion Symptoms (1 Required)

The traumatic event is persistently re-experienced in the following way(s):Emotional distress after exposure to traumatic reminders

  • Flashbacks
  • Nightmares
  • Physical reactivity after exposure to traumatic reminders
  • Unwanted upsetting memories

Criterion C: Avoidance (1 Required)

Avoidance of trauma-related stimuli after the trauma, in the following way(s):

  • Trauma-related external reminders
  • Trauma-related thoughts or feelings

Criterion D: Negative Alterations in Cognitions and Mood (2 Required)

Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

  • Decreased interest in activities
  • Difficulty experiencing positive affect
  • Exaggerated blame of self or others for causing the trauma
  • Feeling isolated
  • Inability to recall key features of the trauma
  • Negative affect
  • Overly negative thoughts and assumptions about oneself or the world

Criterion E: Alterations in Arousal and Reactivity

Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

  • Difficulty concentrating
  • Difficulty sleeping
  • Heightened startle reaction
  • Hypervigilance
  • Irritability or aggression
  • Risky or destructive behaviour

Criterion F: Duration (Required):

Symptoms last for more than 1 month.

Criterion G: Functional Significance (Required)

Symptoms create distress or functional impairment (e.g., social, occupational).

Criterion H: Exclusion (Required)

Symptoms are not due to medication, substance use, or other illness.

International Classification of Diseases (ICD-10) PTSD Criteria:

  1. The patient must have been exposed to a stressful event or situation (either brief or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive distress in almost anyone.
  2. There must be persistent remembering or “reliving” of the stressor in intrusive “flashbacks,” vivid memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor.
  3. The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure to the stressor.
  4. Either of the following must be present:
    1. Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor.
    2. Persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), shown by any two of the following:
      1. Difficulty in falling or staying asleep.
      2. Irritability or outbursts of anger.
      3. Difficulty in concentrating.
      4. Exaggerated startle response.
  5. Criteria B, C, and D must all be met within 6 months of the stressful event or at the end of a period of stress. (For some purposes, onset delayed more than 6 months can be included, but this should be clearly specified.)

PTSD Subtypes:

A subtype is a more specific label to help differentiate presentations of conditions to allow for better treatment. These subtypes are found in the DSM-V.

Preschool Subtype: A diagnosis applied to children under the age of six who have experienced severe trauma and its effects. It was added to accommodate the changes in presentation in extremely young children.

Criteria Associated with Preschool Type PTSD:

  1. Avoiding activities or places that remind the child of the trauma.
  2. Exhibiting fear, guilt, and sadness, or withdrawing from friends and activities.
  3. Recreating trauma in play/recurrent dreams of the trauma .
  4. Ongoing nightmares with or without recognizable content about the traumatic event.

Dissociative Subtype: This disorder refers to someone who meets PTSD diagnostic criteria and experiences depersonalization and/or derealization. This disorder is commonly seen in those who experienced childhood sexual abuse (CSA).

Complex Post-Traumatic Stress Disorder (C-PTSD)

Complex Post-Traumatic Stress Disorder (C-PTSD) is a disorder that is proposed for the DSM but not accepted and a disorder that is being added to the ICD-11. It differs from general PTSD principally in that it is only applicable to people who have experienced severe repeated and long term traumatic experiences. Child abuse, living in a war zone, domestic violence and prisoners of war are examples of long term trauma. Complex trauma is also denoted by the overlapping traumatic experiences causing multiple kinds of traumatic experiences to affect the body and mind before any recovery can happen.

All of those with C-PTSD must also meet the criteria for post traumatic stress disorder. In the ICD-11 it will fall in the Disorders Specifically Associated with Stress category along with PTSD.

The suggested C-PTSD criterion include:

  1. Consciousness Instability: includes dissociation, intrusive thoughts, rumination and loss of memory.
  2. Distorted Views of the Perpetrator: Being preoccupied with a perpetrator, giving power to them, developing a preoccupation with them or clinging onto the idea of being special to the perpetrator.
  3. Emotional Dysregulation: Includes more than depressed moods and anxiety. Mood swings are more prominent and include a wider range of emotions. Compulsivity around handling emotions is also persistent.
  4. Loss or Change in System of Meanings: Beliefs someone held before trauma changing or going away completely, such as religious faith and even just a sense of hope.
  5. Self-Perception Issues: C-PTD can cause a skewed perception of self. One might feel helpless, full of shame and guilt, like a constant victim or a horrible person.
  6. Struggle With Interpersonal Relationships: Avoidance, distrust, paranoia, and a sense of inability to connect with others are common. One with C-PTSD might also be constantly searching for a ‘saviour’ and go to great lengths to protect themselves from other people.

Common symptoms associated with C-PTSD that are not in the currently suggested criterion:

  • Dissociation: Transient and chronic dissociative episodes are common. C-PTSD can fall in the secondary dissociative structural state with BPD & OSDD whereas PTSD is first.
  • Feelings of isolation loneliness: Those with C-PTSD often feel completely separated from others and society. It can be hard as complex trauma can create distance even from those with uncomplicated trauma.
  • Helplessness: Feelings of helplessness often occur at the core belief level that nothing will ever change and at mercy of surroundings.
  • Muscle Armoring: Many complex trauma survivors, who have experienced ongoing abuse, develop body hyper-vigilance. This is where the body is continually tensed, as though the body is “braced” for potential trauma. Muscle Armoring is linked to chronic pain.
  • A Profound Loss of Trust: Struggles with feeling on edge and having trust violated is common with all trauma survivors but like the shame, it can become ingrained at the core belief level. As those with C-PTSD are often at the mercy of someone in power which can break trust in systems. Trust in children with C-PTSD was often never even built.
  • Suicidality: While this is found in those with PTSD it’s more pronounced in C-PTSD patients and can be chronic.
  • Toxic Shame: Survivor of abuse often are made to feel they deserved to be abused and/or they were the reason for it. Often survivors are made to feel they don’t deserve better. The core beliefs about the self of sexual abuse survivors who are repeatedly abused can develop feelings of being dirty, damaged and disgusting as a result of the violation.

Diagnostic Class and Related Disorders:

PTSD is classed as a Trauma- and Stressor-Related Disorder in the DSM-V. This class of disorders all have trauma or stressors as a diagnostic criterion, this is why they were separated out from anxiety disorders because they do not have to have a traumatic event as a root cause.

The disorders in classification include:

  1. Acute Stress Disorder
  2. Adjustment Disorder
  3. Disinhibited Social Engagement Disorder (DESD)
  4. Other Trauma and Stressor-Related Disorders
  5. Post Traumatic Stress Disorder (PTSD)
  6. Reactive Attachment Disorder (RAD)
  7. Unspecified Trauma and Stressor-Related Disorder

The label Other Trauma and Stressor-Related Disorders is used when one does not meet full criteria for another discrete disorder and it is important to remember as it can help catch those with atypical trauma responses.

In the ICD-10 PTSD falls under the Mental disorders section, then Neurotic, Stress-Related and Somatoform Disorders. In the subsection of Stress-Related and Adjustment Disorders. The top classification includes anxiety disorders, trauma disorders and dissociative disorders. In the ICD-11 it is proposed to be it’s own class of disorders Disorders specifically associated with stress much like the DSM V moving it out of the same class as anxiety disorders.

Comon Disorders that Happen with PTSD

Often called Comorbid disorders these conditions happen with PTSD in many cases or require PTSD in their development.

  • Anxiety Disorders: Including Agoraphobia, Generalized Anxiety Disorder (GAD), Panic Disorder, Phobias, Selective Mutism, Separation Anxiety Disorder, and Social Anxiety Disorder. The effects on the regulation of stress can add to anxiety experiences and many things that precipitate anxiety are common with those with PTSD.
  • Borderline Personality Disorder (BPD): BPD it’self has been linked to trauma and attachment issues (common in PTSD). C-PTSD and BPD also share many overlapping symptomologies.
  • Chronic Pain: Due to somatic symptoms, brain structure changes, and/or the effects of the dysregulated stress systems.
  • Depression: Including Major Depression and persistent depressive disorder. It’s understandable why the horrible trauma and continuous negative experiences can make someone depressed. The effects on the regulation of negative emotions also can exacerbate depressive episodes.
  • Dissociative Identity Disorder (DID): DID is caused by severe chronic and complex trauma before the age of 9. So everyone with DID also has PTSD, specifically C-PTSD.
  • Other Specified Dissociative Disorders (OSDD): Like DID they OSDD forms from chronic childhood trauma and because of this all those with OSDD have PTSD.
  • Substance Abuse Disorders (SUD): Substance abuse is high in those with PTSD to self manage the symptoms of PTSD and often can form into a health problem.

PTSD in The Brain

PTSD forms after a significantly traumatic event happen in someone’s life. PTSD to some extent acts as a wound to the brain, the event causing a disruption in the normal processes of a healthy brain. Long term trauma has been shown to have more persistent and diverse effects on the mind and body, developmental trauma (trauma before the brain has fully formed in early adulthood) likewise is shown to have more systematic changes to brain function and long term cases can lack that acute stage when it is often caught to PTSD.

The PTSD always forms during the trauma as one of the key factors is the error in memory processing during the trauma along with the autonomic nervous system disruption. The memory error is key as this forms the flashbacks and trauma triggers. The autonomic nervous system disruption is related to the “fight, flight, freeze & fawn” response is triggered to the point it stays dysregulated and/or becomes more easily agitated.

The brain regions that play an important role in PTSD include the hippocampus, amygdala, and ventromedial prefrontal cortex. Cortisol and norepinephrine are two neurochemical systems that are critical in the function of stress responses and PTSD. The structure of these affected areas can be altered to make the shape and size markedly different to non-traumatized individuals. The connections between areas in traumatized brains can become distorted as well so information and stimuli can become warped during the brains normal functions.

  • The ventromedial prefrontal cortex is dysregulated and decreases in size. this region of the brain is used in regulating negative emotions & fear. Dysfunction in the ventromedial prefrontal cortex is key in the hyperarousal symptoms experienced by those with PTSD.
  • The amygdala is seen to be larger and more active than in non-traumatized people. This change in the size denotes that it will be in overdrive. With an amygdala in this hyperaroused state, it lowers the ability to control emotions and triggers the stress responses.
  • The hippocampus is smaller than average and it plays a huge role in the above-discussed memory error as well as further problems with short and long term memory. Short term working memory is held in this region of the brain, which is why trauma also affects short term memory, but the hippocampus also works to process the memory to move it to the long term memory. One of the things happening in this process is linking all the sensory inputs, actions and emotions into a cohesive retrievable package. With this dysfunction, it can influence why flashbacks happen as it does not process it as a fully integrated memory and you re-experience it. It also plays a role in why some memories are disaggregated (think body memories).

These changes can have wide-ranging effects on the cognitive process, memory formation and recall, mood regulation and social reactions, along with the diagnostic criteria around anxiety and intrusive symptoms.

Physical health can also be affected, especially in childhood trauma. The likely hood of developing conditions including cardiac problems, nervous system disorders, autoimmune conditions, chronic pain and cancer all rise.

Notes on The Definition of Trauma:

  • Perception is taken into account by most trauma specialists when looking at threatened harmed, children will often have a lower threshold considered.
  • Child abuse, domestic abuse, rape/sexual assault (compounded by young age), severe medical issues, loss of a child, severe accidents, torture and combat exposure (not just soldiers) are the most common causes of PTSD.
  • New work to understand the topic of emotional abuse and the psychological scars it can leave has levels of discussion to understand how to count for this without leaving trauma as too broad a term to be functional.
  • There is importance to have some limits to what trauma is and isn’t, it’s not an act of gatekeeping or invalidation most of the time. There just is a scale of something that is a high stressor and what constitutes trauma. A bad break up VS an abusive relationship is one commonly mentioned.
  • Not everyone who experiences the same event will develop a trauma disorder. This is connected to resilience, this is not a marker of any character or lack thereof, but is connected to protective/risk factors. This includes health, attachment, past trauma and many others.
  • Subjects like societal trauma (eg countries during a war, effects of violent oppression or after terrorism and mass shootings) and some forms of intergenerational trauma have overlap with the psychological and physiological understandings of trauma but they are sometimes used in a sociological sense where not every person affected experiences PTSD/C-PTSD level traumatization. Sociological understandings look at the shifts on a wider level. Also, take into account that toxic stress and trauma are not totally delineated terms in many settings.

Posts To Learn More:

  1. Trauma-Informed Care in Behavioral Health Services.Treatment Improvement Protocol (TIP) Series, No. 57.Center for Substance Abuse Treatment (US).Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014
  2. DSM-5 Criteria for PTSD. (2019, April 10). Retrieved July 10, 2019, from https://www.brainline.org/article/dsm-5-criteria-ptsd
  3. A. (2018). Trauma- and Stressor-Related Disorders. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition,17-22. doi:10.1176/appi.books.9780890425596.529303
  4. “6B40 Post Traumatic Stress Disorder.” World Health Organization, World Health Organization, http://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1829103493
  5. Bremner JD. Traumatic stress: effects on the brain. Dialogues Clin Neurosci. 2006;8(4):445–461.
  6. Kati Morton LMFT (2013, July, 13), PTSD – Post-Traumatic Stress Disorder – Mental Health with Kati Morton | Kati Morton, [Video File]. Retrieved from https://www.youtube.com/watch?v=QnfRGQp6ZPA
  7. DissociaDID (2019, Apr, 21) The SCIENCE of PTSD and DISSOCIATION | Debunking DID: Ep 12
  8. PTSD, N. (2018). Types of PTSD. Psych Central. Retrieved on July 10, 2019, from https://psychcentral.com/lib/types-of-ptsd/
  9. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.
  10. American Psychiatric Association (APA). (2015). Understanding mental disorders: Your guide to the DSM-5. Washington, DC: Author.
  11. Ginzburg, K., Koopman, C., Butler, L. D., Palesh, O., Kraemer, H. C., Classen, C. C., & Spiegel, D. (2006). Evidence for a dissociative subtype of post-traumatic stress disorder among help-seeking childhood sexual abuse survivors. Journal of Trauma Dissociation, 7, 7-27.
  12. “Trauma and Stressor Related Disorders.” Collection of Evidence-Based Practices for Children and Adolescents with Mental Health Treatment Needs, 2017.
  13. Staff. “Causes – Post-Traumatic Stress Disorder (PTSD).” NHS Choices, NHS, 27 Sept. 2018, http://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/causes/
  14. Lucario , Lily H. “12 Life-Impacting Symptoms Complex PTSD Survivors Endure.” The Mighty, 17 Aug. 2017, Http://themighty.com/2017/08/life-impacting-symptoms-of-complex-post-traumatic-stress-disorder-ptsd/

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