Understanding DSM-5 Criteria for PTSD: A Disorder of Extinction

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course "Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians".

Highlights

  • The DSM-5 diagnostic criteria for PTSD includes an outside event: the trauma.
  • The subcategories include symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity.
  • The DSM symptoms of PTSD are part of the normal response to trauma.

 

Transcript

Welcome to video 2, PTSD: A Disorder of Extinction.
First, let's talk briefly about the DSM-5 PTSD diagnostic criteria. PTSD is the only anxiety disorder—and yes, I still consider PTSD an anxiety disorder—in which an external event is part of the diagnostic criteria. And that's exposure to actual or threatened death, serious injury, sexual violation, or in one of the following ways which includes: directly experiencing the traumatic event, witnessing the traumatic event, learning that it happened to someone that you love, or repeated or extreme exposure to very aversive details.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

There are five subcategories of symptoms for PTSD. The trauma. Criterion B is intrusion. Criterion C is avoidance. Criterion D, negative alterations in cognitions and mood. And criterion E, marked alterations in arousal and reactivity.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

The specific symptoms, we start with the re-experiencing. And the way I see PTSD is that someone is haunted by what happened to them in their past. And the haunting nature comes out in distressing memories, distressing dreams or nightmares. I had one young woman who hated her nightmares so much that she would try to stay awake all night long, would finally fall asleep exhausted about 6 a.m. Obviously not a good way to be very functional the rest of her life.
Flashbacks are another symptom. I had one veteran who reported getting triggered while he was driving on the highway and he said that the entire trauma played out before his eyes as if the windshield was a movie screen and that he felt it was happening again. Intense psychological distress and physiological reactions.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

In general, people with PTSD are very avoidant. They don't want to think about it. They don't want to talk about it. They don't want anything to remind them of it. Sometimes we see what used to be called psychogenic amnesia, an inability to remember important parts of the trauma. So very often, people can't remember minor details and that's okay. That doesn't meet the criteria for a symptom. But for example, I remember treating a woman who remembered encountering the assailant on a stairwell and the next thing she knew it was about 45 minutes later and she was back in her apartment. She had no memory for anything that occurred. Her first clue that anything bad had happened was when she went to the bathroom and she had cuts on her thighs. As an aside, it turns out she was also the victim of childhood sexual abuse, and I think more prone to dissociate at the time of the traumatic event.
There's also the inability to experience positive emotions. People will tell us they know that they love their family, they know they love their kids, but they just can't feel it.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

There is often persistent and distorted blame of self or others. For example, not an uncommon story from Iraq or Afghanistan veterans: say someone was driving back to base, they hit an IED—an improvised explosive device. Their Humvee blew up. Their friend next to them died. And they feel like it was their fault since they were driving. And so that blame has been persistent. Another persistent symptom is negative emotional state. So very often, we see people with PTSD who are stuck in anger or stuck in guilt or stuck in fear. I always like to remember that we're animals and that in the animal world, predators have their eyes in the front of their head like we do, like humans do. And prey have their eyes in the sides of their heads. And it's almost like I can see people with PTSD or as they're developing PTSD—their eyes move to the side of the head, that they're living in fear.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Another symptom is diminished interest or participation in significant activities that they used to enjoy. Detachment or estrangement from others and negative beliefs or expectations about the world, themselves, or others. For example, the world is dangerous. I'm bad. No one can be trusted.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Other symptoms include anger, angry outbursts, and irritable behavior. I never excuse anger or aggression and use the excuse of PTSD. But I do want to educate people that as hard as it is to live with PTSD, it can also be hard to live with someone with PTSD.
We sometimes see reckless or self-destructive behavior. It's not uncommon, for example, in our veteran population, to hear about them driving their motorcycles over 100 miles an hour down the driveway. Sometimes, after sexual assault, especially when it happens to very young children, we will see reckless sexual behavior. Other symptoms are hypervigilance and exaggerated startle response. Part of how I see this is I think people don't walk through life as calmly as they did before after experiencing something that triggers PTSD.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

We see problems with concentration. After the bonfire collapse at Texas A&M University, one young kid who was an emergency technician responder said he was a college student; before the bonfire collapse, he had a 3.0 GPA. And after the bonfire collapse, he had a 0.6 GPA. He described his problems concentrating. He said he would try to do his assignments and they were just words on a page. He couldn't make any sense of them.
We see a lot of sleep disturbance with PTSD, and there are a lot of reasons for sleep disturbances with PTSD. We talked about the nightmares. We talked about the fear. If you're scared, nighttime is a really scary time. The house is quiet. Everyone's asleep. It's very easy to misinterpret the house noises or weather outside and think, “Oh my gosh, is someone trying to break in?” And then they go into these defensive maneuvers in their head. Also, about half of people with PTSD have comorbid major depression. And we know that there are a lot of sleep problems in major depression. And lastly, I think a lot of people that I've seen who seem to be coping pretty well with the PTSD, one way that they cope is by keeping themselves very busy and very distracted all day long. So at nighttime when they lie down and these distractions are cleared away, often these thoughts that they have been holding at bay about the traumatic event come flooding back.

References

DSM 5:American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

So we did a study trying to prospectively plot the course of PTSD in female rape survivors starting immediately after the assault. So we met with rape survivors right after the assault and every week for 12 weeks, or 3 months.

References

Rothbaum, B., Foa, E., Riggs, D., Murdock, T. and Walsh, W., 1992. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5(3), pp.455-475.

We were surprised to find that in that first week after the assault 94% of the rape survivors met symptomatic criteria for PTSD. They didn't meet the duration criteria. So what that says to me are all those PTSD symptoms that we just talked about, that's the normal response to trauma. Again, someone holds a knife to your throat, says, “Don't scream or I'll cut you,” you're going to have a fear response. You're going to be scared to go outside by yourself. You're going to have problems concentrating. That's normal. We wanted to figure out when a normal response to trauma ends and a psychopathological response that requires a diagnosis and treatment begins.
So we followed people weekly for 3 months, 12 weeks. And we were surprised to see 12 weeks later almost half had met full criteria for PTSD.

References

Rothbaum, B., Foa, E., Riggs, D., Murdock, T. and Walsh, W., 1992. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5(3), pp.455-475.

So what we did is divide people up according to their PTSD status at week 12. And then it tells a little different story. Everyone starts off high with PTSD symptoms. Everyone comes down a lot in that first 4 weeks, in that first month. After week 4, the people who recovered—we can use that term loosely, who don't end up with PTSD—they continued to improve steadily across time. But for the people who end up with chronic PTSD, after week 4 they don't change. They don’t get worse, but they don't get better.

References

Rothbaum, B., Foa, E., Riggs, D., Murdock, T. and Walsh, W., 1992. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5(3), pp.455-475.

And this has led some of us to think of PTSD as a disorder of extinction. Fear and anxiety are a normal response to trauma. For the majority of people, that fear will extinguish over time. For a minority of people, it won’t.

References

McSweeney, F. and Swindell, S., 2002. Common Processes May Contribute to Extinction and Habituation. The Journal of General Psychology, 129(4), pp.364-400.

So the key points from video 2 are that the DSM-5 diagnostic criteria for PTSD includes an outside event, the trauma. The subcategories of DSM-5 diagnostic criteria for PTSD include symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity. The DSM symptoms of PTSD are part of the normal response to trauma.

More PE presentations