DSM criteria for PTSD

PTSD was first included as a mental disorder in the third edition of the in 1980 Diagnostic and Statistical Manual of Mental Disorders (DSM-III). The diagnostic criteria have been slightly adjusted over the years.

The DSM is a classification system used in healthcare in the Netherlands and the United States, among other places, to classify mental disorders. The DSM contains the diagnostic criteria for now over 300 disorders. These criteria must be ‘met’ in order to officially establish a disorder.

PTSD in the DSM

In the DSM-III, PTSD was described at the time as a disorder that develops after someone has a demonstrable traumatic event has experienced or witnessed this, and who is characterized by long-term symptoms of continually reliving the event, avoidance of reminders of the event, and symptoms of anxiety and tension.

Since the DSM-III edition, the diagnostic criteria for PTSD have been adjusted several times. For example, they have now been expanded to include additional symptoms, including negative changes in mood and cognition, and the definition of a traumatic event (the ‘A-criterion') has also been tightened in the current DSM-5 edition.

What these changes show with each new edition is that thinking about trauma and post-traumatic stress is an ongoing process that has evolved tremendously over the past decades and continues to evolve.

Diagnostic criteria for PTSD

The PTSD classification is determined by a psychologist or psychiatrist based on a number of criteria. The first criterion, also known as the ‘A-criterion’, is crucial. The A-criterion is about establishing the traumatic event. In the DSM-5, this is concisely described as:

‘Exposure to actual or threatened death, serious injury, or sexual violence.

It is further described that the A-criterion can be experienced in four different ways:

• Experiencing the traumatic event(s) firsthand.
• Having been a direct witness to the event(s) that affected another/others.
• Hearing that a traumatic event(s) happened to a close family member or good friend. This must involve a violent event or accident.
• Experiencing repeated or extreme exposure to aversive details of traumatic events, for example as a first responder or police officer.

In addition to the presence of the A criterion, the following symptoms are also present, which must be present for more than a month:

• Intrusions and flashbacksrecurrent memories of the event(s) in the form of flashbacks, reliving the experience, or nightmares. This is often accompanied by intense emotional and physical reactions.
• Avoidance: or efforts to avoid painful memories, thoughts, or feelings about the traumatic event(s).
• Negative feelings and thoughtsbegun and/or worsened after the traumatic event. This may include, among other things, depressed mood and feelings of guilt and shame, and problems with attention, concentration, and memory.
• Hyperarousalsomeone constantly feels tense, alert, irritable and/or startles easily. Sleep and concentration problems are also very common.

   –> Read more about PTSD symptoms here

PTSD with delayed expression

PTSD can develop immediately after a traumatic event, but it can also arise after a longer period of time. Sometimes even years after a traumatic event has taken place. This is also known as ‘PTSD with delayed expression.’ Situations later in life can revive memories of earlier trauma, after which PTSD can still develop. 

Criticism of the A-criterion

The ‘A-criterion’ is a complex criterion: it has been described in slightly different ways across various editions of the DSM, and there is much debate about how strictly a traumatic event should be defined.

In practice, this means that people who have experienced a traumatic event that does not meet the so-called Criterion A sometimes do not receive a PTSD classification, even though they suffer severely from all other post-traumatic stress symptoms. This can subsequently pose a problem for access to (reimbursed) care: without a DSM classification, care is not reimbursed or is only partially reimbursed in the Netherlands. 

Complex PTSD (not yet) in the DSM

Despite the great efforts of many scientists and aid workers to have complex PTSD included as a separate classification in the DSM, this has not happened to date. In the Netherlands, complex PTSD (according to the DSM) cannot yet be officially diagnosed on paper, but in practice it is Complex PTSD worked. For instance, there are various treatments specifically for complex PTSD, and a lot of research is also being conducted on it.

In International Statistical Classification of Diseases and Related Health Problems (abbreviated as ICD), an alternative classification system used in Germany and the United Kingdom, among other places, does describe ‘complex post-traumatic stress disorder’.