Staff Voices: Diagnostic Changes DSM V – PTSD & ASD
After nearly 25 years, the DSM-V has finally been released! The diagnoses of PTSD and ASD have been significantly revised based upon recent research. Most notably, PTSD and ASD have been moved from anxiety disorders to new category “Trauma- and Stressor-Related Disorders.” In addition, in DSM-IV and DSM IV-TR, PTSD and ASD were distinct. ASD was not a diluted version of PTSD, but an early response characterized primarily by an emphasis on dissociative qualities. In the new edition, ASD bears much more resemblance to PTSD. I have summarized these changes below:
Criterion A1 has expanded and the controversial A2 criterion “experience fear, helplessness and horror” has been removed due to lack of empirical support.
A1 trauma exposure now includes:
- Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
- Direct experience of traumatic event
- Witnessing, in person, the event
- Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or an accident
- Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse
The symptom clusters have been revised and expanded to four symptom clusters as noted below:
- Intrusion symptoms (one or more). This category includes markedly intense responses to trauma cues whether emotional, dissociative or physiological. Recurrent distressing memories as well as distressing dreams with trauma-focused content complete this category. Please note that the intrusion symptoms must be associated with the traumatic event and begin after the trauma. This category is most similar to the re-experiencing symptom cluster of DSM-IV.
- Avoidance symptoms (one or both). This category is streamlined version of the avoidance symptom cluster of DSM-IV. Avoidance includes efforts to avoid distressing trauma-related memories, thoughts or feelings and reminders that arouse distressing memories, thoughts and feelings.
- The new category is titled “Negative alterations in cognitions and mood” associated with the trauma (two or more). This category is broader, as it includes persistent, distorted cognitions about the causes or consequences of the trauma, persistent negative emotions and a persistent inability to experience positive emotions. This category goes on to describe persistent negative beliefs and expectations about the world and others, diminished social activities and feelings of detachment from others.
- Marked alterations in arousal and reactivity associated with the traumatic event (two or more). This category is fairly broad, including symptoms previously considered to be part of the Hyperarousal category (i.e., sleep disturbance and hypervigilance) as well as irritability, angry outbursts and reckless or self-destructive behavior.
Finally, the criteria must persist for more than 1 month, result in significant impairment and not be attributable to physiological effects of a substance or other medical condition.
The new diagnostic criteria also includes new specifiers:
With Dissociative symptoms:
- Depersonalization (disconnected from the self or body)
- Derealization (disconnect from the world, or world seems distorted or unreal)
Specify if With Delayed Expression: full diagnostic criteria are not met until at least 6 months after the event
The ASD criteria have also changed significantly:
- The changes to criterion A are consistent with PTSD.
- The presence of nine or more (of any of the following) from the five categories below:
- Intrusion Symptoms- as described above
- Negative Mood (persistent inability to experience positive emotions)
- Dissociative symptoms – An altered sense of reality or inability to remember an important aspect of the trauma
- Avoidance symptoms – as described above
- Arousal symptoms – as described above with the exception of reckless or self-destructive behavior.
Duration of these symptoms should be at least 3 days, but no more than 1 month following trauma. These symptoms should cause clinically significant impairment or distress and should not be attributable to another medical condition or substance.
Given these changes…
How will this impact how you assess PTSD as all of the current PTSD measures are based on DSM-IV diagnostic criteria?
Do you have concerns about the new diagnostic criteria? Do you agree with the new categories or believe that all categories should require two or more criteria?
Will this impact how you train new clinicians in PTSD?
What impact on clinical work will it have if the emphasis on dissociative symptoms is removed from ASD?
Dr. Holly O’Reilly is a Cognitive-Behavioral Therapy trainer at the CDP.
After nearly 25 years, the DSM-V has finally been released! The diagnoses of PTSD and ASD have been significantly revised based upon recent research. Most notably, PTSD and ASD have been moved from anxiety disorders to new category “Trauma- and Stressor-Related Disorders.” In addition, in DSM-IV and DSM IV-TR, PTSD and ASD were distinct. ASD was not a diluted version of PTSD, but an early response characterized primarily by an emphasis on dissociative qualities. In the new edition, ASD bears much more resemblance to PTSD. I have summarized these changes below:
Criterion A1 has expanded and the controversial A2 criterion “experience fear, helplessness and horror” has been removed due to lack of empirical support.
A1 trauma exposure now includes:
- Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
- Direct experience of traumatic event
- Witnessing, in person, the event
- Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or an accident
- Experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse
The symptom clusters have been revised and expanded to four symptom clusters as noted below:
- Intrusion symptoms (one or more). This category includes markedly intense responses to trauma cues whether emotional, dissociative or physiological. Recurrent distressing memories as well as distressing dreams with trauma-focused content complete this category. Please note that the intrusion symptoms must be associated with the traumatic event and begin after the trauma. This category is most similar to the re-experiencing symptom cluster of DSM-IV.
- Avoidance symptoms (one or both). This category is streamlined version of the avoidance symptom cluster of DSM-IV. Avoidance includes efforts to avoid distressing trauma-related memories, thoughts or feelings and reminders that arouse distressing memories, thoughts and feelings.
- The new category is titled “Negative alterations in cognitions and mood” associated with the trauma (two or more). This category is broader, as it includes persistent, distorted cognitions about the causes or consequences of the trauma, persistent negative emotions and a persistent inability to experience positive emotions. This category goes on to describe persistent negative beliefs and expectations about the world and others, diminished social activities and feelings of detachment from others.
- Marked alterations in arousal and reactivity associated with the traumatic event (two or more). This category is fairly broad, including symptoms previously considered to be part of the Hyperarousal category (i.e., sleep disturbance and hypervigilance) as well as irritability, angry outbursts and reckless or self-destructive behavior.
Finally, the criteria must persist for more than 1 month, result in significant impairment and not be attributable to physiological effects of a substance or other medical condition.
The new diagnostic criteria also includes new specifiers:
With Dissociative symptoms:
- Depersonalization (disconnected from the self or body)
- Derealization (disconnect from the world, or world seems distorted or unreal)
Specify if With Delayed Expression: full diagnostic criteria are not met until at least 6 months after the event
The ASD criteria have also changed significantly:
- The changes to criterion A are consistent with PTSD.
- The presence of nine or more (of any of the following) from the five categories below:
- Intrusion Symptoms- as described above
- Negative Mood (persistent inability to experience positive emotions)
- Dissociative symptoms – An altered sense of reality or inability to remember an important aspect of the trauma
- Avoidance symptoms – as described above
- Arousal symptoms – as described above with the exception of reckless or self-destructive behavior.
Duration of these symptoms should be at least 3 days, but no more than 1 month following trauma. These symptoms should cause clinically significant impairment or distress and should not be attributable to another medical condition or substance.
Given these changes…
How will this impact how you assess PTSD as all of the current PTSD measures are based on DSM-IV diagnostic criteria?
Do you have concerns about the new diagnostic criteria? Do you agree with the new categories or believe that all categories should require two or more criteria?
Will this impact how you train new clinicians in PTSD?
What impact on clinical work will it have if the emphasis on dissociative symptoms is removed from ASD?
Dr. Holly O’Reilly is a Cognitive-Behavioral Therapy trainer at the CDP.