Chapter 20. Posttraumatic Stress Disorder and Acute Stress Disorder

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. The person has been 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.

2. The traumatic event is persistently re-experienced in one (or more) of the following ways:

   1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions

      Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

      2. Recurrent distressing dreams of the event

         Note: In children, there may be frightening dreams without recognizable content.

      3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)

         Note: In young children, trauma-specific reenactment may occur.

      4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

      5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) 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 have loving feelings)

   7. Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (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

5. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

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

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Washington DC: American Psychiatric Association, 2000.)

General Considerations

Despite abundant evidence for persisting and sometimes disabling psychological sequelae of exposure to extreme stressors, the evolution of posttraumatic stress disorder (PTSD) as a modern diagnosis was relatively recent. PTSD-like disorders were described in the U.S. Civil War (DaCosta's Syndrome, Irritable Heart of Soldiers), associated with railroad accidents in the late nineteenth century (Railway Spine), following World Wars I and II (Shell Shock, Traumatic Neurosis, Neurasthenia, ...