PTSD:  Diagnosis

Chose a topic in this section:
1. Criteria
2. Differential Diagnosis
3. Common Symptoms of & Responses to Trauma
4. Other Mental Disorders That May Result from Trauma

1. Criteria:

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR),
an individual needs to meet these criteria (A-F) to qualify for a diagnosis of PTSD:

A. The individual was exposed to a traumatic event in which both of the following were present:
       (1) the person experienced, witnessed, or was 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
       (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 following ways:
       (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
       (2) recurrent distressing dreams of the event
       (3) acting or feeling as if the traumatic event were recurring (illusions, hallucinations, dissociative flashbacks, sense of reliving)
       (4) intense psychological distress at exposure to internal and external cues that symbolize or resemble an aspect of the trauma
       (5) physiological reactivity on exposure to internal and external cues that symbolize or resemble an aspect of the trauma

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before trauma),
         as indicated by 3 of the following:
       (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 trauma
       (3) inability to recall an important aspect of the trauma
       (4) markedly diminished interest or participation in significant activities
       (5) feeling of detachment or estrangement from others
       (6) restricted range of affect (e.g., unable to having loving feelings)
       (7) sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or normal life span)

D. Persistent symptoms of increased arousal (not present before trauma), as indicated by 2 or more of the following:
       (1) difficulty falling or staying asleep
       (2) irritability or outbursts of anger
       (3) difficulty concentrating
       (4) hypervigilance
       (5) exaggerated startle response

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

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

       »Specifiers allow clinicians to define more uniform groups within the disorder based on certain features
Acute:  if duration of symptoms is less than 3 months
Chronic:  if duration of symptoms is 3 months or more
With Delayed Onset:  if onset of symptoms is at least 6 months after the stressor

Above is adapted from DSM-IV-TR (p. 467-468).

                        Trauma Diagram

2. Differential Diagnosis:
    » If it is unclear which diagnosis is appropriate, this section may help you discern which is more appropriate.

PTSD vs. Adjustment Disorder
Adjustment Disorder is diagnosed either when: (1) the stessor is not extreme (i.e., not life-threatening) or
       (2) the stressor is extreme but the reaction to it does not meet criteria for PTSD.

PTSD vs. Acute Stress Disorder
Acute Stress Disorder is diagnosed if the PTSD-like symptoms occur within 4 weeks of the trauma and resolve
       within that same period.  If the symptoms carry on for more than a month after the event and meet PTSD criteria,
       the diagnosis is changed to PTSD.

PTSD vs. Malingering
       Identifying motivation for feigning PTSD-like symptoms is essential to the diagnosis of Malingering. Those who are diagnosed
       with Malingering are faking symptoms for some outside purpose or gain, such as insurance payment or escaping punishment,
       whereas PTSD sufferers are truly experiencing the distressing symptoms. 

(DSM-IV-TR, 2000)

3. Symptoms & Responses to Trauma  
(Briere, 2004; DSM-IV-TR, 2000)

Posttraumatic Symptoms
● Intrusive experiences including flashbacks, nightmares, unwanted thoughts or memories, and reliving sensations
● Avoidance of thinking about or associating with stimuli that remind the victim of the trauma, emotional numbing
● Increased arousal demonstrated by decreased or poor sleep, muscle tension, irritability, difficulty concentrating,
      and abnormal startle response

Dissociative Symptoms
● Depersonalization (a feeling of detachment from one's self or body)
● Derealization (a feeling of a lost sense of or detachment from reality)
Identity confusion
● "Spacing out"
● Amnesia (memory loss)
Fugue state (sudden, unexpected travel away from one's home with loss of memory of
                       some/all of one's personal history)

Physical Symptoms
● Motor/Sensory reactions (e.g., paralysis, blindness)
● Psychogenic pain (pain originating from a psychological source)

Sexual Symptoms (especially relevant if trauma is sexual in nature)
● Sexual distress (including sexual dysfunction)
● Sexual fears

Cognitive Symptoms
● Low self-esteem
● Helplessness/hopelessness
● Inflated perception of danger
● Irrational guilt

Common Activities Used to Decrease Distress from Trauma
● Binging-Purging
● Reckless sexual behavior
● Self-mutilation
● Compulsive stealing
● Aggression

4. Other Mental Disorders That May Result from Trauma  (Briere, 2004; DSM-IV-TR, 2000)

Conversion Disorder
This disorder involves the presence of sensory and/or motor function symptoms that appear to be biological in nature.  Closer
examination reveals that these deficits are due to psychological factors.  These symptoms are often created or worsened by extreme trauma,
(e.g., combat experience, losing a loved one).

Somatization Disorder
This disorder consists of a host of bodily symptoms of varying nature that cannot be fully explained biologically.  Specifically, a person with
this disorder must possess at least:  4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual symptom, and 1 pseudoneurological symptom
(e.g., paralysis). This disorder is often the product of repeated childhood abuse, especially of the sexual nature.  The link between trauma and
psychologically manifested physical symptoms is unclear, though possibly a result of the chronic autonomic arousal involved in multiple traumas.

Major Depressive Disorder (with Psychotic features) - This disorder is characterized by a depressed mood, loss of interest in activities,
and several other adverse symptoms.  In addition,psychotic hallucinations (perceptual disturbances) or delusions (false beliefs) are also present. 
Depressive symptoms often accompany the distressing aftermath of a trauma as the individual copes with prevalent posttraumatic symptoms
(reexperiencing, increased arousal, avoidance).  The psychotic features are thought to be associated with the dissociative effects of the trauma that
strain the person's link with reality. 

Panic DisorderRecurrent, unexpected panic attacks are a necessary feature of this disorder as well as continual worry about additional attacks
or the consequences of such attacks.  This disorder is most clearly associated with the hyperarousal symptoms involved in PTSD.  In their study of the
relationship between panic and trauma, Falsetti and Resnick (1997) discovered that 69% of those seeking treatment for trauma symptomology reported
trauma-focused panic attacks. 

Borderline Personality Disorder - Described as a profound "pattern of instability of interpersonal relationships, self-image, and affects, and marked
implusivity", this disorder is traditionally thought to have its origins in childhood.  It is believed that the rewarding of dependent behaviors and punishing of
independent behaviors during development often leads to this skewed sense of self and relations to others.  Extreme childhood trauma (e.g., neglect, abuse)
retards the development process and distorts the child's ability to relate to self and others.

Dissociative Disorders - This group of disorders involves a disruption of consciousness, memory, identity, or perception.  The sufferer experiences
a break from reality or self.  This "dissociation" is the mind's way of coping with trauma.  Especially in childhood, trauma can cause a fracturing of the
self which can lead to severe impairment in later life.