Changes in PTSD Diagnostic Criteria Between DSM-IV-TR and DSM-V
The Diagnostic and Statistical Manual of Mental Disorders is the most accepted collection of classifications and diagnostic criteria used by clinicians, mental health professionals, and researchers around the world. Post-Traumatic Stress Disorder was introduced into the third edition of the DSM in 1980. Since then, there have been many changes over the course of two more editions of the DSM. The textbook, Abnormal Psychology in a Changing World, defines PTSD as “a prolonged maladaptive reaction to a trauma that lasts longer than one month after the traumatic experience” (Nevid, Rathus, & Greene, 2018). While many people experience traumatic events, not everyone experiences symptoms of PTSD. Some factors that may predispose a person to PTSD include: history of child sexual abuse, lack of social support, feeling shame, lack of active coping responses in dealing with the traumatic stressor, genetic predisposition, and prior psychiatric history (Nevid, Rathus, & Greene, 2018). The type of trauma as well as the duration can also add to a persons’ chances of developing PTSD.
Based off of the diagnostic criteria in the DSM-IV-TR, the majority of the United States population has experienced a traumatic event that is of the PTSD level; however, only a small portion experience symptoms of PTSD. The lifetime prevelance of PTSD in the U.S., according to a national study conducted in 2000, was 6.8% (Beck & Sloan, 2012). There are also gender differences when it comes to the prevelance of PTSD in U.S. adults. Researchers have found that men experince higher amounts of traumatic events, women have a higher risk of developing the disorder ((Beck & Sloan, 2012).
Breslau et al concluded that, “Persons with PTSD were at incresased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence (Breslau et al., 1991). The DSM-V discusses risk and prognostic factors and divides them into three groups: pretraumatic, peritraumatic, and posttraumatic. It also discusses the incresed risk of suicide among PTSD patients. It does state that, “traumatic events such as childhood abuse increase a person’s suicide risk” (American Psychiatric Association, 2013). The DSM-IV-TR inlcuded changes from the DSM-III; however, the DSM-V finally allowed for a separate category for trauma and stress related disorders, which moved PTSD out of the anxiety disorders section. This paper will explore the changes in diagnostic criteria between the DSM-IV-TR and the DSM-V, as well as explore the literature backing those changes. It will also briefly touch upon cultural considerations.
The changes that were made surrounding PTSD in the DSM-V included both major and more minor difference. In the DSM-IV-TR, PTSD was listed under Anxiety Disorders. However, in the DSM-V, there is a new category titled, Trauma and Stress Related Disorders, which now includes PTSD. Before the diagnostic criteria begins being listed there is an added note in the DSM-V that states that the following criteria applies only to people over the age of six, and that there are corresponding criteria for those children under the age of six. The first change noted between the two editions’ diagnostic criteria would be that the DSM-IV-TR lists criteria’s A through F, where-as the DSM-V includes two more sections making it A through H. Some of the sections from the DSM-IV-TR were separated into multiple sections which accounts for the two added categories. In DSM-IV-TR, criteria A only includes A1 and A2, whereas the criteria in the DSM-V includes A1 through A4 providing a more elaborate description of the circumstances under which a person experienced a traumatic event. Criteria B is very similar between the two editions, however, the DSM-V uses the term “intrusion symptoms” rather than saying that the traumatic event is persistently re-experienced. The DSM-V also specifies that the symptoms must begin after the traumatic event is experienced.
The heaviest amount of differences in diagnostic criteria between the two editions, exists between criteria C and criteria H. In the DSM-IV-TR, criteria C includes the “numbing of general responsiveness as indicated by three or more of the following,” and then proceeds to list seven different symptoms. In the fifth edition, there is no numbing of responses and there are only two symptoms listed, with the patient only needing to meet one of them. Another major difference in this section is that in the DSM-IV-TR, some of the symptoms listed included more symptoms involving feelings and emotions, whereas the DSM-V only lists two symptoms that are strictly discussing avoidance or a strong effort to avoid either memories, places, objects, or situations. The changes that are made in criteria C, roll over into D, and therefore the number of criteria categories in the DSM-V are two longer.
Criteria D is markedly different between the two editions. In the DSM-IV-TR, the symptoms that are listed include those that are related to increased arousal. There are then five symptoms listed in which a person must meet two or more. In the DSM-V, criteria D is described as “negative alterations in cognitions and mood associated with the traumatic event.” There are then seven different symptoms listed in which a person must experience at least two of. Criteria D in the DSM-V is a new category that is not present in the previous edition. Therefore, criteria E in the DSM-V is more similar to criteria D from DSM-IV-TR. While the symptoms listed are the same, the DSM-V added one more: “reckless or self-destructive behavior.” Criteria E and F from the DSM-IV-TR, correspond with criteria F and G in the DSM-V. The DSM-V added criteria H which reiterates the fact that these symptoms must not be attributed to any other explanation.
Following the diagnostic criteria, there is a section that is used to specify the disorder to a further degree. In the DSM-IV-TR, there is acute and severe, as well as, another specifier if there is delayed onset, meaning if the symptoms begin 6 months after the stressor or trauma. The DSM-V begins with specifying whether there are symptoms of either depersonalization or de-realization. Following that specifier, is a note that states that the dissociative symptoms must not be attributed to any other cause such as drugs, another mental illness, or medical condition. While the second specifier listed in the DSM-V is very similar in its description to the delayed onset listed in the DSM-IV-TR, it is instead titled, delayed expression (American Psychiatric Association, 2013). The DSM-V seems to break down the diagnostic criteria a bit further than the DSM-IV-TR, which aids in a proper and more accurate diagnosis.
There are some cultural considerations to consider with the PTSD diagnosis. The DSM-V has a section following the diagnostic criteria labeled, culture-related diagnostic issues. It discusses the potential risk, onset, and severity of PTSD that differs across groups due to different forms of traumatic experiences. The differences across cultures may also be attributed to, “the impact on disorder severity of the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing sociocultural context, and other cultural factors (e.g., acculturative stress in immigrants)” (American Psychiatric Association, 2013). A review of the DSM-IV-TR’s cultural considerations found that the DS-IV-TR was valid cross-culturally. It did go on to suggest that, “…cultural syndromes may shape symptom comorbidities and symptom profiles in important ways that should be assessed and document to increase content validity in the assessment of trauma-related disorder (Hinton & Lewis-Fernández, 2011). This review suggested that the DSM-V should either add a chapter on the cultural aspects of psychiatric diagnosis, or expand the glossary of cultural syndromes.