Post-traumatic stress disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a traumatic event. It can develop after events such as natural disasters, serious accidents, terrorist attacks, war, rape, or other violent personal assaults. At Neuralia TMS, we understand how the symptoms of PTSD can be severe and long-lasting, and affect a person’s daily life.
The DSM-5, published by the American Psychiatric Association, plays a valuable role in the diagnosis of PTSD. It provides standardised criteria used by clinicians to ensure accurate and consistent diagnosis.
According to the DSM-5, PTSD diagnosis requires exposure to a traumatic event and the presence of specific symptoms from four categories: intrusive thoughts, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. The DSM-5 also introduces a subtype for children under age 6 and includes a dissociative subtype.
By using the DSM-5 PTSD criteria, healthcare professionals in Australia can reliably identify PTSD, helping those who need it to receive appropriate treatment and support.
Diagnostic Criteria for PTSD in DSM-5
To be diagnosed with PTSD, an individual needs to meet the following criteria, as laid out in the DSM-5. These criteria are used for adults and children above the age of 6 years – children under 6 fall under a specific subtype of PTSD.
Criterion A: Trauma Exposure
To receive a PTSD diagnosis, a person must have been witness to threatened or actual death, serious injury, or sexual violence. This exposure could occur in one (or more) of the following ways:
- Directly experiencing the traumatic event
- Witnessing the traumatic event as it happens to others
- Learning that the traumatic event happened to a close family member or friend
- Experiencing repeated exposure to details of the traumatic event
- Experiencing a single extreme exposure to details of the traumatic event (for example, first responders collecting human remains)
Criterion B: Intrusion Symptoms
As well as being exposed to the original event, the person must experience one (or more) of the following intrusive symptoms related to the traumatic event:
- Recurrent, involuntary, distressing memories of the specific event
- Recurring dreams of a distressing nature, related to the traumatic event
- Dissociative reactions (for instance, flashbacks) where they feel or act like the traumatic event is happening all over again
- Prolonged or intense psychological distress from cues (internal or external) that symbolise or resemble something about the traumatic event
- Distinct physiological responses to triggers or reminders of the traumatic event
Criterion C: Avoidance
For a PTSD diagnosis, the person must be actively and persistently avoiding anything that stimulates thoughts, feelings, or memories about the event. This may also extend to avoiding people, places, activities, and conversations that may bring up memories of the trauma.
Criterion D: Negative Alterations in Cognition and Mood
Negative shifts in mood and thoughts that began or worsened after the traumatic event must be present for a diagnosis. These are indicated by two (or more) of the following:
- Difficulty or inability to recall an important aspect of the traumatic event
- Constant, prolonged, and exaggerated negative beliefs or expectations (for example, “I’m a bad person” or “Nobody can be trusted”)
- Persistent, distorted ideas about the cause or consequences of the traumatic event that result in the person blaming themselves or others
- A persistent and/or prolonged negative emotional state (such as shame, guilt fear, horror, or anger)
- Noticeably reduced interest or participation in activities they used to enjoy
- Feelings of detachment or estrangement from others
- Constant and prolonged inability to feel or experience positive emotions
Criterion E: Alterations in Arousal and Reactivity
PTSD will also present with noticeable changes in reactivity. Two (or more) signs must be present for a diagnosis. These changes could present as:
- Irritable behaviour and angry outbursts (for no apparent reason) expressed as verbal or physical aggression
- Self-destructive or reckless behaviour
- Hypervigilance bordering on paranoia
- An exaggerated or overactive startle response
- Trouble with ability to focus
- Sleep disturbance (for example, difficulty falling or staying asleep, restless sleep)
Criterion F: Duration of Symptoms
Criteria B, C, D, and E should be present for more than a month. If it’s been less than a month, the condition could be a different stressor-related disorder (like acute stress disorder) rather than PTSD, so duration is an important factor in accurately diagnosing a patient.
Criterion G: Functional Significance
The previous criteria must be causing clinically significant impairment in life or distress to the person experiencing it. If the symptoms aren’t severe enough to affect how the person functions in everyday life, it could be put down to something other than PTSD.
Criterion H: Exclusion of Other Factors
The person in question should have no other medical or cognitive conditions, and shouldn’t be under the influence of drugs or alcohol. There must be nothing else that could account for the symptoms – only then will a qualified healthcare professional be able to diagnose PTSD definitively.
Subtypes and Specifiers in DSM-5 PTSD
Dissociative Subtype
The dissociative subtype of PTSD includes symptoms of depersonalisation and derealisation.
- Depersonalisation is when an individual feels detached from their own bodies or mental processes, as if they are outside observers of themselves and their life.
- Derealisation involves feelings of unreality or detachment from the environment, making it seem false, dreamlike, or distorted.
This subtype is particularly common among people who have experienced severe, chronic trauma, like childhood abuse. Identifying this subtype correctly is important because it can affect treatment approaches.
Delayed Expression
This subtype is characterised by a delay in the onset of symptoms. In these cases, full diagnostic criteria aren’t met until at least 6 months after the event. This delay can occur because people may initially suppress or manage their symptoms through coping mechanisms that eventually become ineffective.
Recognising delayed expression is key to making sure those who develop PTSD later on still receive the appropriate diagnosis and treatment.
PTSD for Children 6 Years and Younger
PTSD in children aged 6 years and younger presents differently than in older children and adults. The DSM-5 outlines specific criteria for this age group, recognising that young children may not be able to express their distress verbally. Symptoms often manifest through play that re-enacts the trauma, changes in behaviour like increased clinginess, and physical symptoms like stomach aches.
Diagnosing PTSD in young children involves careful observation of their play and behaviour patterns, as well as input from parents and caregivers. Early intervention is key for this age group to support healthy development and mitigate any long-term effects of trauma.
Changes from DSM-IV to DSM-5
The APA’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is a significant update from the DSM-IV. It was released in May 2013 and introduced several important changes to the classification and diagnosis of mental disorders. These updates aim to improve diagnostic accuracy, reflect current research, and enhance the clinical utility of the manual.
Structural Changes
One of the notable changes in DSM-5 is the reorganisation of chapters and disorders. Unlike the DSM-IV, which categorised disorders into discrete sections, DSM-5 groups them based on developmental and lifespan considerations.
This new structure begins with diagnoses that typically manifest early in life, like neurodevelopmental disorders, and progresses through those more common in adolescence and adulthood, like anxiety and depressive disorders.
Changes to Specific Disorders
Attention-Deficit/Hyperactivity Disorder (ADHD): The criteria for diagnosing ADHD were adjusted to better account for adult presentations. DSM-5 includes examples to illustrate how symptoms might manifest across different ages and environments. The age of onset criterion was changed from before 7 years of age to before 12 years of age, recognising that symptoms may be more noticeable later in childhood.
Introduction of New Disorders
Disruptive Mood Dysregulation Disorder (DMDD): This new diagnosis aims to address concerns about the potential overdiagnosis and overtreatment of bipolar disorder in children. DMDD is characterised by severe temper outbursts and persistent irritability, which are distinct from the episodic nature of bipolar disorder.
Hoarding Disorder: Previously considered a subtype of Obsessive-Compulsive Disorder (OCD), hoarding is now recognised as a distinct disorder. This change reflects research indicating that hoarding behaviours have different clinical features and treatment responses compared to OCD.
Elimination of Multiaxial System
The DSM-IV used a multiaxial system to provide a comprehensive diagnosis, including clinical syndromes, personality disorders, medical conditions, psychosocial and environmental problems, and overall functioning.
DSM-5 got rid of this system and integrated all relevant information into a single diagnostic record. This change simplifies the diagnostic process and emphasises the importance of considering the whole person rather than categorising issues into separate axes.
Cultural Considerations
DSM-5 places greater emphasis on cultural issues, recognising that cultural context can influence the expression and interpretation of symptoms. It includes a cultural formulation interview to help clinicians understand patients’ cultural backgrounds and how these may impact their mental health.
Prevalence and Impact of PTSD
PTSD is a mental health condition that can affect people of all ages. According to the DSM-5, about 8% of the population will experience PTSD at some point in their lives.
In Australia, it’s estimated that around 11% of the population will suffer from PTSD during their lifetime. This disorder is often seen in people who have experienced or witnessed traumatic events such as natural disasters, serious accidents, terrorist attacks, war/combat, or personal assaults.
PTSD can have a profound impact on daily life. Symptoms include intrusive memories, avoidance behaviours, negative changes in thinking and mood, and alterations in arousal and reactivity. These symptoms can disrupt relationships, work, and social activities.
People with PTSD may also struggle with other mental health issues like depression, anxiety, and substance abuse. Early intervention and support are very important for mitigating the long-term effects of PTSD on individuals and their families.
Treatment and Management
Effective treatment for PTSD involves a combination of therapeutic approaches and, in some cases, medication. According to the DSM-5, trauma-focused psychotherapies are the most recommended treatment. These include cognitive behavioural therapy (CBT), specifically cognitive processing therapy (CPT) and prolonged exposure (PE) therapy. These therapies help people process and reframe their traumatic experiences, reducing the power these memories hold over them.
Eye Movement Desensitisation and Reprocessing (EMDR) is another evidence-based therapy that has shown effectiveness in treating PTSD. This therapy involves recalling distressing events while engaging in bilateral sensory input, such as side-to-side eye movements. This can help reduce the emotional impact of traumatic memories.
Medications like selective serotonin reuptake inhibitors (SSRIs) can also be prescribed to help manage symptoms, especially when psychotherapy alone hasn’t been enough. These medications can alleviate symptoms of depression and anxiety that often accompany PTSD.
Support from family and friends, along with self-care practices like regular exercise, healthy eating, and mindfulness, can also play an important role in the management of PTSD. Access to mental health services and community support groups can provide assistance and much-needed encouragement.
Support and Awareness
PTSD is a prevalent and impactful mental health condition that needs comprehensive and personalised treatment. With the right interventions, people with PTSD can experience significant improvement in their symptoms and overall quality of life.
Increased awareness, early diagnosis, and accessible mental health services are essential for supporting those affected by PTSD in Australia. By providing a supportive environment and encouraging open discussions about mental health, we can help reduce the stigma associated with PTSD and promote better outcomes for those affected by this challenging condition.
If you’re looking for any further information on PTSD or TMS treatments for PTSD, get in touch. Our compassionate team at Neuralia TMS is here to help!
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