Posttraumatic Stress Disorder (PTSD) DSM-5 309.81 (F43.10)

Posttraumatic Stress Disorder (PTSD) DSM-5 309.81 (F43.10)

DSM-5 Category: Trauma and Stressor-Related Disorders

Introduction

DSM-5 has made a number of important changes to the criteria of post-traumatic stress disorder, the most significant being a more specific definition of the type and nature of the exposure to a threat. Under DSM-5, post-traumatic stress disorder (PTSD) is an anxiety disorder that develops in relation to an event which creates psychological trauma in response to actual or threatened death, serious injury, or sexual violation. The exposure must involve directly experiencing the event, witnessing the event in person, learning of an actual or threatened death of a close family member or friend, or repeated first-hand, extreme exposure to the details of the event. Traumas experienced may involve war, natural disasters, car accidents, sexual abuse and/or domestic violence. A formal diagnosis of PTSD is made when the symptoms cause clinically significant distress or impairment in social and/or occupational dysfunction for a period of at least one month. The symptoms cannot be due to a medical condition, medication, or drugs or alcohol.

PTSD Symptoms

PTSD symptoms may include nightmares, flashbacks, sleep disturbance, mood disorders, suicidal ideation, avoidance, and hyper-arousal in response to trauma-related stimuli. Hyper-arousal may include an increase in blood pressure and heart rate, hyperventilating, mood swings, fatigue, or insomnia when a memory of the event is triggered by some type of internal (cognition) or external (environmental) stimulus. Common symptoms related to PTSD would include insomnia, attention deficit problems, and anhedonia. Common comorbid disorders are depression, anxiety, and substance addiction.

Under DSM-5, for those older than six years of age, PTSD includes four clusters of symptoms (APA, 2013):

  • Re-experiencing the event — Recurrent memories of the event, traumatic nightmares, dissociative reactions, prolonged psychological distress
  • Alterations in arousal — Aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance
  • Avoidance — Distressing memories, thoughts, or reminders of the event.
  • Negative alterations in cognition and mood — Persistent negative beliefs, distorted blame, or trauma-related emotions; feelings of alienation and diminished interest in life

The duration of these symptoms (which cause clinically significant distress or impairment in social, occupational or other important areas of functioning) must occur for one month or longer. In addition, the disturbance cannot be attributed to a substance or medical condition.

DSM-5 has established two subtypes of PTSD:

1. PTSD Preschool subtype is used in the diagnosis of children younger than 6 years of age. The diagnostic thresholds are lowered for children and adolescents.

2. PTSD Dissociative Subtype is used when the person has prominent dissociative symptoms. These dissociative symptoms include depersonalization, in which the person feels like an outside observer or detached from oneself; and derealisation, in which the world seems unreal, distant or distorted. All other criteria of PTSD must also be met.

Post Traumatic Stress Disorder Treatment and Therapy

Common treatments for post-traumatic stress disorder include: Cognitive Behavior Therapy (CBT), psychotherapy, Exposure Therapy (ET), and eye movement desensitization and reprocessing (EMDR). Pharmacological interventions typically include anti-depressants such as serotonin reuptake inhibitors (SSRIs). In recent years, technology such as computer-aided exposure therapy has significantly improved the experience and effectiveness of exposure therapy (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010). The new age classification under DSM-5 reflects the different thresholds by age (lower for children) and therapeutic requirements.

A review of PTSD therapies, based on 14 studies with a total of 758 participants published by the Cochrane Collaboration, ranked CBT as the most effective PTSD therapy. The other therapies which were compared included ET, EMDR, psychodynamic and narrative therapy. All therapies produced improvements in the symptoms of PTSD, anxiety and depression (Gilles, Taylor, Gray, O’Brien, & D’Abrew, 2012). Eye movement desensitization and reprocessing therapy helps the patient analyze and formulate responses to traumatic events by exploring both physiological and neurological changes in relation to traumatic memories.

PTSD is often comorbid with substance abuse and mood disorders such as depression and anxiety, requiring a more complex treatment approach. The traumatic event can be the underlying cause of more serious comorbid conditions such as the inability to speak, or auditory hallucinations. Multicomponent therapies are also being explored. For example, improvements in PTSD and substance abuse symptoms have been shown through the combined use of CBT along with structured writing therapy (van Dam, Ehring, Vedel, & Emmelkamp, 2013) as well as integrated exposure therapy (Mills et al., 2012). Other combined therapies with CBT include emotion regulation training (Bryant et al., 2013) and music and dance therapy.

Virtual reality exposure therapy (VRET) is one of the most promising areas of PTSD therapy. VRET has been used with war veterans from Iraq and Afghanistan (McLay et al., 2011) and all forms of phobias. VRET has a high success rate of coaxing reluctant participants into exposure therapy. One survey of 150 people with phobias showed only a 3% refusal rate to participate in VRET versus 27% for other forms of therapy (Gerardi, Cukor, Difede, Rizzo, & Rothbaum, 2010). VRET places the patient in a computer-generated environment that simulates situations related to the cause of the disorder. Anxiety and fear related to the negative events are reduced over time. As a result of this study, it suggests that computer-aided therapies are proving to be as effective as face-to-face therapies while saving time and providing faster access to care.

Living With PTSD

Post-traumatic stress disorder causes impairments in daily life through the persistent re-experiencing of the negative event via recollections such as intrusive negative thoughts and dreams, flashbacks, and dissociative states. Under DSM-5, emotional reactions to the traumatic event such as fear and helplessness are no longer part of the criteria for PTSD.

The effect of PTSD on daily life and overall prognosis are related to the severity of the exposure. PTSD is associated with “high-risk” professions such as the military, policing, firefighting and emergency medical work. PTSD has significantly limited daily functioning in those exposed to extreme and prolonged trauma such as war veterans. Depression is a common experience of war veterans with PTSD. The comorbidity of PTSD and depression produces lower quality of life scores in physical and mental well-being than those for a single disorder.

Substance abuse is more prevalent among individuals who have PTSD, and the severity of symptoms is more pronounced for those with alcohol and other drug problems than for non-users and past users (Wiechelt, Miller, Smyth, & Maguin, 2011). Persons with comorbid addictions also experience significantly more health problems, poorer social functioning, and higher rates of violence and suicide.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bryant, R. A., Mastrodomenico, J., Hopwood, S., Kenny, L., Cahill, C., Kandris, E., & Taylor, K. (2013). Augmenting cognitive behaviour therapy for post-traumatic stress disorder with emotion tolerance training: a randomized controlled trial. FOCUS: The Journal of Lifelong Learning in Psychiatry, 11(3), 379-386.

Gerardi, M., Cukor, J., Difede, J., Rizzo, A., & Rothbaum, B. O. (2010). Virtual reality exposure therapy for post-traumatic stress disorder and other anxiety disorders. Current psychiatry reports, 12(4), 298-305.

Gillies, D., Taylor, F., Gray, C., O'Brien, L., & D'Abrew, N. (2012). Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database Syst Rev, 12.

McLay, R. N., Wood, D. P., Webb-Murphy, J. A., Spira, J. L., Wiederhold, M. D., Pyne, J. M., & Wiederhold, B. K. (2011). A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder. Cyberpsychology, behavior, and social networking, 14(4), 223-229.

Mills, K. L., Teesson, M., Back, S. E., Brady, K. T., Baker, A. L., Hopwood, S., ... & Ewer, P. L. (2012). Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. JAMA, 308(7), 690-699.

van Dam, D., Ehring, T., Vedel, E., & Emmelkamp, P. M. (2013). Trauma-focused treatment for posttraumatic stress disorder combined with CBT for severe substance use disorder: a randomized controlled trial. BMC psychiatry, 13(1), 172.

Wiechelt, S. A., Miller, B. A., Smyth, N. J., & Maguin, E. (2011). Associations between post-traumatic stress disorder symptoms and alcohol and other drug problems: Implications for social work practice. Practice, 23(4), 183-199.

 


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