DSM-5 Changes to PTSD Diagnostic Criteria

 In May, 2013, the American Psychiatric Association (APA) published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM provides classifications for mental health conditions, using set criteria and common language. With this new edition, the APA both refined and expanded its delineation of post-traumatic stress disorder (PTSD) and its symptoms, a condition first appearing in the DSM in 1980.

Previously classified as an anxiety disorder, PTSD is now considered a “trauma and stressor-related disorder." Disorders in this classification, such as PTSD, acute stress disorder (ASD), adjustment disorder (AD), reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) all require exposure to a significant life stress as the cause of the condition. In the case of PTSD and ASD, the stressor must be traumatic. For PTSD, this traumatic exposure may come from one of four sources: direct exposure to trauma; witnessing trauma in person; learning a close friend or relative experienced trauma (indirect exposure); and repeated or extreme indirect exposure to aversive details of the event – usually in the course of professional duties. The DSM specifically cites as examples of the fourth source those professionals who are continuously exposed to details of child abuse (such as social workers) and first responders responsible for body-part collection.

The DSM does not consider “indirect non-professional exposure through electronic media, television, movies or pictures” to be a source of trauma for PTSD. Exposure to trauma is Criterion A for PTSD in the DSM.

Criterion B pertains to symptoms of intrusion, including recurrent memories regarding the event; traumatic nightmares; and dissociative flashbacks.

Criterion C focuses on avoidance of thoughts or feelings related to the trauma; or the avoidance of people, places, activities or objects that serve as external reminders.

Criterion D relates to negative alteration in cognition and mood. Symptoms include dissociative amnesia; persistent and distorted negative beliefs about oneself; negative trauma-related emotions such as fear, anger and shame; diminished interest in significant pre-traumatic activities; feelings of alienation; and the inability to experience positive emotion.

Criterion E centers on alterations in arousal and reactivity, and includes irritable behavior; hypervigilance; exaggerated startle responses; problems concentrating; self-destructive or reckless behavior; and difficulty sleeping.

In order to be diagnosed with PTSD, the symptoms listed in criteria B through E must persist for at least a month; they must cause significant distress or impairment; and they must not be due to medication, substance abuse or other illness.

(Criteria F–H)

There are distinct criteria used to diagnose children age 6 and younger with PTSD; this form of PTSD is known as the preschool subtype. For example, in Criterion B the intrusion may instead present as repetitive play and the nightmares do not have to explicitly relate to the trauma. Their irritability may present as extreme temper tantrums. Children may also reenact the trauma through play. Conversely, they may become withdrawn and constriction of play may occur.

The PTSD diagnosis has been changed recognizing the developmental differences in how the disorder is expressed in different age groups. Therefore, the preschool diagnosis checklist also excludes certain symptoms that are not relevant to such young children, including dissociative amnesia and persistent self-blame. Generally, children this young do not display reckless behavior, which is frequently seen in adult sufferers of PTSD, nor do they experience thoughts of a foreshortened future due to their particular understanding of the concept of time itself.

Both children and adults both may be diagnosed with the dissociative subtype of PTSD, which is a new entry in the DSM-5. In addition to presenting with enough symptoms to receive a general diagnosis of PTSD, the patient also additionally displays depersonalization (being detached from oneself) and/or derealization (a distortion of reality or a sense of unreality) at levels significantly higher than the dissociation generally associated with PTSD flashbacks.

PTSD symptoms may be present immediately after the trauma, although the patient may not meet all the criteria initially. If the diagnosis is made more than six months after the original trauma, the diagnosis is considered to be “PTSD with delayed expression.”

PTSD effects nearly eight percent of Americans as some point in their life.


American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5. Washington, DC: American Psychiatric Publishing.

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