**2.6 Potential diagnostic statistical manual – v changes**

It is apparent that the definition of posttraumatic stress disorder has evolved throughout the years. As such, it is to be expected that the Diagnostic Statistical Manual criteria will continue to be adapted as we learn more about the disorder. Some of the proposed changes for the Diagnostic Statistical Manual - V criteria will be presented in this section. Currently, none of the changes presented here have been officially accepted. Upon publication of the Diagnostic Statistical Manual - V, readers should reevaluate the proposed changes that have been presented in this chapter. It is not expected that the current proposal will severely alter the prevalence rates of posttraumatic stress disorder or severely impact how clinicians evaluate or treat the disorder (Frueh et. al., 2010).

The Diagnostic Statistical Manuel – IV – TR criterion for posttraumatic stress disorder specifies three symptom clusters: re-experiencing, avoidance or emotional numbing, and hyperarousal (American Psychiatric Association, 2000). These symptoms arise from primary or secondary exposure to a traumatic event that evokes feelings of extreme horror, fear, or helplessness. Re-experiencing is described as having nightmares, intrusive memories, feeling as if the event were reoccurring, and experiencing psychological and/or physiological distress when encountering internal or external reminders of the trauma. Avoidance or emotional numbing is defined as trying to avoid thoughts or feelings about the trauma, trying to avoid people or places that serve as reminders of the trauma, impaired memory for the trauma, feeling detached from others, having a sense of a foreshortened future, restricted affect, and anhedonia. Finally, hyper-arousal is defined as difficulty sleeping, irritability or anger, difficulty concentrating, hyper-vigilance, and exhibiting an exaggerated startle response. In order to receive a diagnosis of posttraumatic stress disorder, an individual must exhibit one re-experiencing symptom, three avoidance or emotional numbing symptoms, and two hyper-arousal symptoms. The symptoms must be present for over one month following the traumatic event and must cause impaired functioning or distress. If the symptoms have been apparent for less than three months the posttraumatic stress disorder is labeled as acute, but if present for over three months, the label is then changed to chronic posttraumatic stress disorder. The criteria for the Diagnostic Statistical Manual – IV – TR (current edition) and the proposed changes for the Diagnostic Statistical Manual – V can be seen in the table below (figure 1).

Combat Related Posttraumatic Stress Disorder –

traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) **Note:**  In children, trauma-specific reenactment may

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the

5. Marked physiological reactions to reminders

C. Persistent avoidance of stimuli associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by efforts

to avoid 1 or more of the following:

1. Avoids internal reminders (thoughts, feelings, or physical sensations) that arouse recollections of the traumatic event(s)

2. Avoids external reminders (people, places, conversations, activities, objects, situations) that arouse recollections of the traumatic event(s).

D. Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more

of the following: **Note**: In children, as evidenced by 2 or more of the following:

2. Persistent and exaggerated negative expectations about one's self, others, or the world (e.g., "I am bad," "no one can be trusted," "I've lost my soul forever," "my whole nervous system is permanently ruined,"

"the world is completely dangerous").

3. Persistent distorted blame of self or others about the cause or consequences of the

drugs).

traumatic event(s)

1. Inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia; not due to head injury, alcohol, or

occur in play.

traumatic event(s)

of the traumatic event(s)

History, Prevalence, Etiology, Treatment, and Comorbidity 31

the experience, illusions, hallucinations, and dissociative flashback episodes,

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the

C. Persistent avoidance of stimuli

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more)

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the

3. Inability to recall an important aspect of

5. Feeling of detachment or estrangement

4. Markedly diminished interest or participation in significant activities

traumatic event

of the following:

trauma

the trauma

from others

including those that occur on awakening or when intoxicated). **Note:** In young children, trauma-specific reenactment may occur.


A. The person has been exposed to a traumatic event in which both of the

was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical

2. The person's response involved intense fear, helplessness, or horror. **Note:** In children, this may be expressed instead by

disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) of the

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. **Note:** In young children, repetitive play may occur in which themes or aspects of the trauma are

2. Recurrent distressing dreams of the event. **Note:** In children, there may be frightening dreams without recognizable

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving

following ways:

expressed.

content.

following were present:

integrity of self or others

**Diagnostic Statistical Manual – V Diagnostic Statistical Manual – IV – TR** 

1. Experiencing the event(s) him/herself 1. The person experienced, witnessed, or

A. The person was exposed to one or more of the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or

2. Witnessing, in person, the event(s) as they

3. Learning that the event(s) occurred to a close relative or close friend; in such cases, the actual or threatened death must have been violent or

4. Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work

B. Intrusion symptoms that are associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by 1 or more

1. Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). **Note:** In children, repetitive play may occur in which themes or aspects of

2. Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). **Note:** In children, there may be frightening dreams without recognizable

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the

the traumatic event(s) are expressed.

more of the following ways:

occurred to others

accidental

related.

content.

of the following:


Combat Related Posttraumatic Stress Disorder –

posttraumatic stress disorder.

numbing are distinct concepts.

History, Prevalence, Etiology, Treatment, and Comorbidity 33

The first change that was proposed is meant to give more clarity to what qualifies as a traumatic event. The current criteria states that the person must have both "experienced, witnessed, or [been] confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and "the person's response involved intense fear, helplessness, or horror" (American Psychiatric Association, 2000). In order to provide more clarity, it has been proposed that a traumatic event should be constituted by actual or threatened: death, serious injury, or sexual violation. In addition, the individual must have either personally experienced the traumatic event, witnessed it in person, heard about it happening to a close friend or relative (where death or threatened death must be either violent or accidental), or have had one extreme exposure or repeated exposures to the unpleasant details of the event (American Psychiatric Association, 2010). A criticism of the current definition is that it could be interpreted that witnessing the media's portrayal of a situation would qualify as a traumatic event, although not all clinicians would endorse this interpretation. Therefore, it has been proposed that the Diagnostic Statistical Manuel - V prohibit that a media portrayal of an event qualify as traumatic unless the exposure is work related. The new definition also removes the qualifier that the person must react with intense fear, helplessness, or horror. One of the arguments for this change is that the current definition does not allow for individual differences in how people respond to trauma. A contrary argument for removing this qualifier is that most

people respond to trauma in a manner that is consistent with the criteria.

In a worldwide sample of 28,490 participants who experienced a potentially traumatic event, only 1.4% of participants did not respond to the event with intense fear, helplessness or horror while meeting all other criteria for a diagnosis of posttraumatic stress disorder (Karam et. al., 2010). This study bolsters the argument that those who experience an event which results in them meeting all of the other criteria for the disorder will almost always respond with intense horror, fear, or helplessness. For that reason, including this additional criterion does not provide meaningful information. Those that do not meet the criteria may for some reason respond differently to trauma, but this would be something to be explored in therapy rather than addressed in their diagnosis. In addition, excluding this qualifier from the diagnostic criteria could reduce the amount of time it takes to assess for

Another relatively significant change that is being proposed is to use four symptom clusters to diagnose posttraumatic stress disorder instead of three. More specifically, it has been proposed to divide the avoidance and emotional numbing cluster into an avoidance cluster and separate cluster focusing on distorted thinking and negative emotions. In order to obtain a diagnosis using the divided clusters, an individual would need to avoid either internal or external reminders of the trauma. In addition they would need three symptoms from the distorted thinking and negative emotions cluster. This cluster would be comprised of seven symptoms which include: inability to remember the trauma, anhedonia, feeling detached, restricted affect, pervasive experience of negative emotions, distorted blame of self or others for the trauma, and persistent distorted negative thoughts about one's self, others, and the world. This change is being proposed because factor analysis has suggested that the current model does not account for all of the dimensions of posttraumatic stress disorder (Frueh et. al., 2010). More specifically this means that avoidance and emotional

A problem that has emerged with the current diagnosis is that posttraumatic stress disorder symptoms overlap with many of the symptoms from major depressive disorder. Some of the


Fig. 1. DSM IV – TR (American Psychiatric Association, 2000) and Proposed Criteria for the DSM – V (American Psychiatric Association, 2010 obtained 7.6.11 from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#)

1. Irritable or aggressive behavior 1. Difficulty falling or staying asleep 2. Reckless or self-destructive behavior 2. Irritability or outbursts of anger

3. Hypervigilance 3. Difficulty concentrating

5. Problems with concentration 5. Exaggerated startle response

4. Exaggerated startle response 4. Hypervigilance

6. Restricted range of affect (e.g., unable to

7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage,

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

significant distress or impairment in social, occupational, or other important areas of

*Acute***:** if duration of symptoms is less than

*With Delayed Onset:* if onset of symptoms is

*Chronic***:** if duration of symptoms is 3

at least 6 months after the stressor

F. The disturbance causes clinically

functioning.

*Specify* if:

3 months

Fig. 1. DSM IV – TR (American Psychiatric Association, 2000) and Proposed Criteria for the

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#)

DSM – V (American Psychiatric Association, 2010 obtained 7.6.11 from

months or more

children, or a normal life span)

have loving feelings)

4. Pervasive negative emotional state -- for example: fear, horror, anger, guilt, or shame

6. Feeling of detachment or estrangement from

E. Alterations in arousal and reactivity that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: **Note**: In children, as evidenced by 2

6. Sleep disturbance -- for example, difficulty falling or staying asleep, or restless sleep. F. Duration of the disturbance (symptoms in Criteria B, C, D and E) is more than one month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not due to the direct physiological effects of a substance (e.g., medication or alcohol) or a general medical condition (e.g., traumatic brain injury, coma).

*With Delayed Onset:* if diagnostic threshold is not exceeded until 6 months or more after the event(s) (although onset of some symptoms

may occur sooner than this).

7. Persistent inability to experience positive emotions (e.g., unable to have loving feelings,

5. Markedly diminished interest or participation in significant activities.

others.

*Specify if:*

psychic numbing)

or more of the following:

The first change that was proposed is meant to give more clarity to what qualifies as a traumatic event. The current criteria states that the person must have both "experienced, witnessed, or [been] confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and "the person's response involved intense fear, helplessness, or horror" (American Psychiatric Association, 2000). In order to provide more clarity, it has been proposed that a traumatic event should be constituted by actual or threatened: death, serious injury, or sexual violation. In addition, the individual must have either personally experienced the traumatic event, witnessed it in person, heard about it happening to a close friend or relative (where death or threatened death must be either violent or accidental), or have had one extreme exposure or repeated exposures to the unpleasant details of the event (American Psychiatric Association, 2010). A criticism of the current definition is that it could be interpreted that witnessing the media's portrayal of a situation would qualify as a traumatic event, although not all clinicians would endorse this interpretation. Therefore, it has been proposed that the Diagnostic Statistical Manuel - V prohibit that a media portrayal of an event qualify as traumatic unless the exposure is work related. The new definition also removes the qualifier that the person must react with intense fear, helplessness, or horror. One of the arguments for this change is that the current definition does not allow for individual differences in how people respond to trauma. A contrary argument for removing this qualifier is that most people respond to trauma in a manner that is consistent with the criteria.

In a worldwide sample of 28,490 participants who experienced a potentially traumatic event, only 1.4% of participants did not respond to the event with intense fear, helplessness or horror while meeting all other criteria for a diagnosis of posttraumatic stress disorder (Karam et. al., 2010). This study bolsters the argument that those who experience an event which results in them meeting all of the other criteria for the disorder will almost always respond with intense horror, fear, or helplessness. For that reason, including this additional criterion does not provide meaningful information. Those that do not meet the criteria may for some reason respond differently to trauma, but this would be something to be explored in therapy rather than addressed in their diagnosis. In addition, excluding this qualifier from the diagnostic criteria could reduce the amount of time it takes to assess for posttraumatic stress disorder.

Another relatively significant change that is being proposed is to use four symptom clusters to diagnose posttraumatic stress disorder instead of three. More specifically, it has been proposed to divide the avoidance and emotional numbing cluster into an avoidance cluster and separate cluster focusing on distorted thinking and negative emotions. In order to obtain a diagnosis using the divided clusters, an individual would need to avoid either internal or external reminders of the trauma. In addition they would need three symptoms from the distorted thinking and negative emotions cluster. This cluster would be comprised of seven symptoms which include: inability to remember the trauma, anhedonia, feeling detached, restricted affect, pervasive experience of negative emotions, distorted blame of self or others for the trauma, and persistent distorted negative thoughts about one's self, others, and the world. This change is being proposed because factor analysis has suggested that the current model does not account for all of the dimensions of posttraumatic stress disorder (Frueh et. al., 2010). More specifically this means that avoidance and emotional numbing are distinct concepts.

A problem that has emerged with the current diagnosis is that posttraumatic stress disorder symptoms overlap with many of the symptoms from major depressive disorder. Some of the

Combat Related Posttraumatic Stress Disorder –

**3.2.1 Men in the military** 

**3.2.2 Women in the military** 

History, Prevalence, Etiology, Treatment, and Comorbidity 35

Gulf War (Sundin et. al., 2009). Prevalence figures vary widely in the military based upon a number of variables, such as how posttraumatic stress disorder was assessed, how much time has elapsed since the trauma, the level of combat exposure, the number of completed

Posttraumatic stress disorder has been known to develop following a broad range of traumatic situations. Due to this chapter's focus on combat related posttraumatic stress disorder this section will only present traumatic situations that are commonly experienced by those in the military. Some of the more common trauma experiences include: combat situations where the soldier felt as though their life was in danger or witnessed the death or threatened death of another person, seeing dead bodies or mutilated body parts during an assignment, or sexual assault while in the military. Men experience posttraumatic stress disorder as a result of combat situations more frequently than women because women are not permitted to have infantry positions. Women are more likely to experience sexual assault, which is unfortunately

Men in the military are vulnerable to an array of traumatic situations during combat. Individual differences exist and dictate whether a person has a heightened likelihood for developing posttraumatic stress disorder and how severe the stressor must be in order for them to develop the disorder (See the section on etiology for a more in depth discussion of individual differences in vulnerability for developing posttraumatic stress disorder). Some soldiers may be traumatized by just hearing the sounds of explosions due to a fear of being harmed by an explosive device. More resilient soldiers may obtain posttraumatic stress disorder from being involved an automobile accident while deployed or by being exposed to an explosive device that detonated near them or injured someone around them. Furthermore, they could be traumatized from engaging in hand-to-hand combat or in a firefight with the enemy. Finally, soldiers could be traumatized while retrieving severely injured soldiers or collecting bodies or body parts of soldiers who were killed in combat. Women in the military are also at risk for being involved in the previously mentioned traumatic situations, but have a decreased likelihood because their job assignments are intended to keep them away from direct combat. The list of potential combat scenarios provided is not meant to be all-inclusive, as there are a number of unpredictable situations

Women in the military are thought to have an increased probability of experiencing a traumatic event during their service because of their ability to be sexually assaulted. Female soldiers and male soldiers placed in non-combat positions experience the same level of risk for encountering a traumatic event during deployment. Female soldiers are additionally at risk for being sexually assaulted by other soldiers (Williams & Bernstein, 2011). Although men are also sexually assaulted while in the military, women are more frequently assaulted. Lipari and Lancaster (2003) found that in active duty personnel, 3% of women have been sexually assaulted while in the military as compared to 1% of men. Furthermore, Sadler and colleagues (2003) found in a sample of 558 female veterans, 28% had experienced a rape or

tours, gender, and the unit the individual was assigned to during deployment.

**3.2 Gender differences in posttraumatic stress disorder in the military** 

a frequent occurrence in the military (Williams & Bernstein, 2011).

in war that can cause a soldier to develop posttraumatic stress disorder.

symptoms that overlap include: anhedonia, sleep problems, irritability, and difficulty concentrating. Due to the high comorbidity of posttraumatic stress disorder and major depressive disorder, some have suspected that counting the same symptom for both disorders accounts for much of the comorbidity rather than the disorders actually cooccurring. A study by Elhia and colleagues (2008) demonstrated that the disorders do in fact frequently co-occur because when the symptoms that overlap with depression and anxiety are removed, the lifetime prevalence figure for posttraumatic stress disorder only decreases from 6.81% to 6.42%. Removing the overlapping symptoms would cause some individuals to reach a subclinical level, but it is valuable to be aware that the disorders are in fact distinct. Concern about the overlap in criteria may become even more common because the proposed changes will make posttraumatic stress disorder less distinct from depression. It is being proposed that the current symptoms, which are very similar to those of major depressive disorder remain in the criteria. Furthermore, it has been proposed that additional criterion that also overlaps with major depressive disorder be added to the diagnostic criteria. It is unclear how this change will impact future comorbidity of posttraumatic stress disorder and major depressive disorder, which may prove to be a problem.

Additional changes that are being proposed include adding an extra symptom to the hyperarousal cluster and removing the distinction between chronic and acute posttraumatic stress disorder (American Psychological Association, 2010). Other minor changes are being proposed to reword some of the criteria in order to provide clarity. Removing the distinction between chronic and acute posttraumatic stress disorder is being proposed because there is not enough evidence to show that they are separate concepts rather than just two separate time points on the same continuum. The additional symptom that may be added to the hyper-arousal cluster includes engaging self-destructive or reckless behavior. With the additional symptom, individuals would need to have three of six symptoms from the hyperarousal cluster to receive a diagnosis.

We have clearly come a long way in our understanding of posttraumatic stress disorder throughout the years, but there are many aspects of the disorder that we still do not understand. As we learn more about the mechanisms of the disorder, the definition will continue to be adapted within the Diagnostic Statistical Manual.
