Evidence-Based Reviews

PTSD: A systematic approach to diagnosis and treatment

Current Psychiatry. 2018 April;17(4):35-43

Carol S. North, MD, MPE

Barry A. Hong, PhD, ABPP

Dana L. Downs, MA, MSW

Accurate diagnosis and management depends on proper application of DSM-5 criteria.

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References

1. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association; 1980.
2. North CS, Surís AM, Smith RP, et al. The evolution of PTSD criteria across editions of the DSM. Ann Clin Psychiatry. 2016;28(3):197-208.
3. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013
4. Downs DL, North CS. Trauma-related disorders. Overview of posttraumatic stress disorder. https://www.deckerip.com/products/scientific-american-psychiatry/table-of-contents/. Published July 2017. Accessed February 27, 2018.
5. North CS. Disaster mental health epidemiology: methodological review and interpretation of research findings. Psychiatry. 2016; 79(2):130-146.
6. North CS, Yutzy SH. Goodwin and Guze’s Psychiatric Diagnosis, 6th ed. New York, NY: Oxford University Press; 2010.
7. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282(8):755-762.
8. North CS, Pfefferbaum B. Mental Health Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518.
9. North CS, Pollio DE, Smith, RP, et al. Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center. Disaster Med Public Health Prep. 2011;5(suppl 2):S205-S213.
10. North CS, Oliver J, Pandya A. Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters. Am J Public Health. 2012;102(10):e40-e48.
11. Whitman JB, North CS, Downs DL, et al. A prospective study of the onset of PTSD symptoms in the first month after trauma exposure. Ann Clin Psychiatry. 2013;25(3):163-172.
12. North CS, Oliver J. Analysis of the longitudinal course of PTSD in 716 survivors of 10 disasters. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1189-1197.
13. Jeffreys M, Capehart B, Friedman MJ. Pharmacotherapy for posttraumatic stress disorder: review with clinical applications. J Rehabil Res Dev. 2012;49(5):703-715.
14. Lee DJ, Schnitzlein CW, Wolf JP, et al. Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: systemic review and meta-analyses to determine first-line treatments. Depress Anxiety. 2016;33(9):792-806.
15. Foa EB, Keane T, Friedman MJ. Effective treatments for PTSD: practice guidelines from the International Society for traumatic stress studies. New York, NY: The Guilford Press; 2000.
16. Ursano RJ, Bell C, Eth S, et al; Work Group on ASD and PTSD. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association Publishing; 2004.
17. National Collaborating Centre for Mental Health. Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. London, UK: Gaskell and the British Psychological Society; 2005.
18. Foa EB, Keane TM, Friedman MJ, eds; The Board of Directors of the International Society for Traumatic Stress Studies. Effective treatments for PTSD. 2nd ed. Oakbrook Terrace, IL: The Guilford Press; 2005.
19. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guidelines. Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/. Published June 2017. Accessed February 26, 2018.
20. Phoenix Australia -Centre for Posttraumatic Mental Health. Australian guidelines for the treatment of acute stress disorder and posttraumatic stress disorder. Melbourne, Australia: Phoenix Australia Centre for Posttraumatic Mental Health; 2013.
21. World Health Organization. Guidelines for the management of conditions specifically related to stress. Geneva, Switzerland: World Health Organization Press; 2013.
22. Benedek DM, Friedman MJ, Zatzick D, et al. Guideline watch (March 2009): practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Focus. 2009;7(2):201-213.
23. Stein DJ, Ipser J, McAnda N. Pharmacotherapy of posttraumatic stress disorder: a review of meta-analyses and treatment guidelines. CNS Spectr. 2009;14(suppl 1):25-31.
24. Forbes D, Creamer M, Bisson JI, et al. A guide to guidelines for the treatment of PTSD and related conditions. J Trauma Stress. 2010;23(5):537-552.
25. Nash WP, Watson PJ. Review of VA/DOD clinical practice guideline on management of acute stress and interventions to prevent posttraumatic stress disorder. J Rehabil Res Dev. 2012;49(5):637-648.
26. Birur B, Moore NC, Davis LL. An evidence-based review of early intervention and prevention of posttraumatic stress disorder. Community Ment Health J. 2017;53(2):183-201.
27. Breslau N, Davis GC. Posttraumatic stress disorder in an urban population of young adults: Risk factors for chronicity. Am J Psychiatry. 1992;149(5):671-675.
28. North CS, Pfefferbaum B, Kawasaki A, et al. Psychosocial adjustment of directly exposed survivors seven years after the Oklahoma City bombing. Compr Psychiatry. 2011;52(1):1-8
29. Rasco SS, North CS. An empirical study of employment and disability over three years among survivors of major disasters. J Am Acad Psychiatry Law. 2010;38(1):80-86.

Posttraumatic stress disorder (PTSD) has increasingly become a part of American culture since its introduction in the American Psychiatric Association’s third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980.¹ Since then, a proliferation of material about this disorder—both academic and popular—has been generated, yet much confusion persists surrounding the definition of the disorder, its prevalence, and its management. This review addresses the essential elements for diagnosis and treatment of PTSD.

Diagnosis: A closer look at the criteria

Criteria for the diagnosis of PTSD have evolved since 1980, with changes in the definition of trauma and the addition of symptoms and symptom groups.² Table 1³ summarizes the current DSM-5 criteria for PTSD.

Trauma exposure. An essential first step in the diagnosis of PTSD is to determine whether the individual has experienced exposure to trauma. This concept is defined in Criterion A (trauma exposure).³ PTSD is nonconformist among the psychiatric diagnoses in that it requires a specific external event as part of its definition. Misapplication of the trauma exposure criterion by many clinicians and researchers has led to misdiagnosis and erroneously high prevalence estimates of PTSD.^4,5

A traumatic event is one that represents a threat to life or limb, specifically defined as “actual or threatened death, serious injury, or sexual violence.”³ DSM-5 does not allow for just any stressful event to be considered trauma. For example, no matter how distressing, failing an important test at school or being served with divorce proceedings do not represent a requisite trauma⁶ because these examples do not entail a threat to life or limb.

DSM-5 PTSD Criterion A also requires a qualifying exposure to the traumatic event. There are 4 types of qualifying exposures:

direct experience of immediate serious physical danger
eyewitness of trauma to others
indirect exposure via violent or accidental trauma experienced by a close family member or close friend
repeated or extreme exposure to aversive details of trauma, such as first responders collecting human remains or law enforcement officers being repeatedly exposed to horrific details of child abuse.³

Witnessed trauma must be in person; thus, viewing trauma in media reports would not constitute a qualifying exposure. Indirect trauma exposure can occur through learning of the experience of a qualifying trauma exposure by a close family member or personal friend.

It is critical to differentiate exposure to trauma (an objective construct) from the subjective distress that may be associated with it. If trauma has not occurred or a qualifying exposure is not established, no amount of distress associated with it can establish the experience as meeting Criterion A for PTSD. This does not mean that nonqualifying experiences of stressful events are not distressing; in fact, such experiences can result in substantial psychological angst. Conversely, exposure to trauma is not tantamount to a diagnosis of PTSD, as most trauma exposures do not result in PTSD.^7,8

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PTSD: A systematic approach to diagnosis and treatment

References

Diagnosis: A closer look at the criteria

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