There are many ways to define trauma. There are dictionary definitions, there are more subjective definitions, there are clinical definitions that don’t have a diagnostic criteria such as developmental trauma, and then there are formal diagnostic definitions with strict criteria that has to be met.
In this video lets have a discussion about the formal diagnostic criteria for post traumatic stress disorder.
Now we immediately run into a bit of an issue with this.
And that issue is that we actually have two sets of diagnostic criteria we can refer to.
One is the International Classification of Diseases - currently on its 11th revision and is produced by the World Health Organisation. This is often referred to as the ICD.
Secondly, there is the Diagnostic and Statistical Manual, currently on its 5th edition which is produced by the American Psychiatric Association, commonly referred to as the DSM.
Broadly speaking the DSM is used in the United States of America and the ICD is used elsewhere. Now I know that over 50% of viewers to this channel are from the US so they would use the DSM, and I live and work in the UK where we tend to use the ICD.
So I’m going to split this into video into two parts, one for the DSM criteria and one for the ICD criteria, because they are different.
DSMV
Lets start with the DSM and this applies to people over the age of 6, and it is split into 8 criteria which are denoted through letters A to H.
Lets start with criterion A
A. There must be exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways.
1 Directly experiencing the traumatic event. In other words it happened to you.
2 Witnessing, in person, the event as it occurred to others. So you saw it happen to someone else.
3 Learning that the traumatic event occurred to a close family member or close friend.
4 Experiencing repeated or extreme exposure to aversive details of the traumatic event.
So think here about professionals who might be exposed to details of abuse over and over again. And there is an additional note here for this part and that is that the exposure cannot be through electronic media, television, movies, or pictures unless this exposure is work related. So if you are watching horror movies for instance as entertainment then that would not count.
We then have criterion B, and this gets a little wordy so I will try my best to explain it in non clinical terms.
There must be present one or more of the following intrusion symptoms associated with the traumatic event, or events, beginning after the traumatic event occurred. So this is the part where we think about re-experiencing or reliving the event.
So the criteria are
1 Recurrent, involuntary, and intrusive distressing memories of the event or events. Recurrent meaning that it repeatedly happens, it is involuntary meaning that you don’t purposely bring it to mind, it just comes to you and when that happens it causes distress.
2 Recurrent distressing dreams in which the content are related to the event. Okay, so nightmares about what happened.
3 Dissociative reactions where it feels as if the event is recurring, we sometimes refer to this as flashbacks
4 Intense of prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the event. So, if something reminds you of the event, whether that reminder is something external to you (like a person or a place) or if that reminder is internal, so a thought for instance, and when you have that reminder you experience psychological distress then you would meet this criteria.
5 Marked physiological reactions to internal or external cues that symbolise or resemble an aspect of the traumatic events. This is similiar to the previous one but instead of being psychological distress, it causes distress within the body, so this could be activating a fight or flight response when something reminds you about what happened.
So that is criterion B.
Moving on to criteria C this is all about avoidance, and there are only two things to consider here.
1 That there is avoidance or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the event.
2 Avoidance or efforts to avoid external reminders such as people, places, conversations, activities, objects and situations) that arouse distressing memories, thoughts or feelings about or closely associated with the event.
Essentially you either avoid, or try to avoid anything that reminds you about what happened.
Criterion D.
This section is all about cognitions, so the way that you think and your mood.
There are 7 things and you have to have 2 that have started or got worse since the event.
And these 7 things are
Inability to remember an important aspect of the event. And this is due to the nature of the event itself not due to any alcohol, drugs or head injury.
Persistent and exaggerated negative beliefs or expectations about yourself, other people or the world.
Persistent, distorted cognitions about the cause of the consequences of the event that lead you to blame yourself or others.
Persistent negative emotional state, so you get stuck feeling fear, horror, anger, guilt or shame.
Markedly diminished interest or participation in significant activities. In other words there is a depressive element, you have lost interest in what you used to enjoy doing, or things that were important to you.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions such as inability to experience happiness, satisfaction, or loving feelings.
Criterion E looks at alterations in arousal or reactivity. Sometimes we describe this as hyperarousal. And again you need two of the following
Irritable behaviour and angry outbursts (with little or no provocation), and this is typically expressed as verbal or physical aggression toward people or objects.
Reckless or self destructive behaviour
Hypervigilance
Exaggerated startle response
problems with concentration
Sleep disturbance such as difficult falling asleep, staying asleep, or restless sleep.
So those are the main components of the diagnostic criteria, the next few parts are around how long this has been experienced for and the impact on functioning.
Criterion F says the duration of the disturbance must be more than 1 month.
Criterion G says the disturbance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.
And criterion H says the disturbance is not due to something else such as substance use (so drugs, prescribed medication or alcohol), or another medical condition.
And thats it for the DSM.
So to summarise
Theres been exposure to actual or threatened death, serious injury, or sexual violence.
There are intrusions such as memories or nightmares that cause physical or psychological distress.
There is avoidance or attempted avoidance of reminders of the event.
There are changes in mood and cognitions.
And there is an increase in arousal and reactivity.
This goes on for more than a month, causes significant distress or impairment of function, and cannot be explained by something else.
Lets now take a look at the ICD 11 diagnostic criteria.
ICD11
The ICD 11 diagnostic criteria is fairly similiar but there are some differences that are important, so here are the diagnostic requirements.
Firstly, there needs to be an exposure to an event or situation of an extremely threatening or horrific nature. The ICD gives some examples of what these events might be which are directly experiencing natural or human made disasters, combat, serious accidents, torture, sexual violence, terrorism, assault or acute life threatening illness (like a heart attack).
Or there needs to be witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner
or learning about the sudden, unexpected, or violent death of a loved one.
The ICD then says there needs to be the following core components that last for at least several weeks.
The core components are
Re-experiencing the traumatic event in the present. People generally refer to this as flashbacks. The event is not just remembered but is experienced as if it is occurring in the present. Usually this is in the form of vivid intrusive memories or images, which can vary from mild (this is more of an intrusive memory which you have an idea happened in the past) to severe (where complete loss of awareness of present surroundings takes place). This may also occur as repetitive dreams or nightmares that are related to the event.
Usually when this re-experiencing takes place it is accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations.
Re-experiencing can also involve feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, and may also occur when there are reminders of the event. And there is a note here in the criteria, it isnt enough to remember how you felt at the time, you have to actually be feeling that way in the present. So you cant say that made me feel fear at the time, you have to be feeling fear in the present when you think about the event.
So re-experiencing is one of the three core components.
The next core component that is addressed is avoidance. So deliberate avoidance of reminders likely to produce re-experiencing of the event. This might be active internal avoidance of thoughts and memories related to the event, or external avoidance of people, conversations, activities or situations that may remind you of the event.
And then the third core component is a perception of heightened current threat, for example hyper vigilance so always on edge, or an enhanced startle response to things like unexpected noises. If you are hypervigilant then you may constantly guard yourself against danger and feel that you are, or people close to you, are under immediate threat. This might be seen in behaviours like scanning a room when you first enter, not sitting with a back to a door, repeated checking if people are following you.
And those are the 3 core components, re experiencing, avoidance and hypervigilance.
And these have to persist for several weeks and result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
And that is the criteria to get a diagnosis of PTSD under ICD11.
Comparison
As you can both criteria has the core components of intrusions or re-experiencing, avoidance and hypervigilance. The largest difference between the two is probably that the DSM includes an additional set of symptoms related to changes in thoughts and feelings which are exaggerated negative beliefs about oneself, the world and other people. Distorted thoughts about what caused the event, persistent negative emotions, less interest in significant events and feeling detached or estranged from others and finding it impossible to experience positive emotions. The ICD criteria doesn’t do this as it has the separate diagnosis of Complex PTSD which introduces some of those elements, the DSM does not have the diagnosis of complex ptsd. We will cover complex ptsd in another video.
Conclusion
I understand that all of what I said is really clinical, and there are going to be a lot of people who just fall short of some of the criteria but are still really struggling. I appreciate there is also an entire debate around the use of a diagnostic model to begin with. I’m not going to get into a discussion in this video about how important a diagnosis is as it really is an individual perspective. For some people it helps them make sense, or offers an explanation, of the experiences they have had and the way it has impacted them. It can also open up formal pathways of treatment or intervention because quite often services us set up around diagnosis. For others a diagnostic label can feel stigmatising, or make someone feel as if they are seen as a set of symptoms instead of a person.
I hope this video was useful in understanding the diagnostic criteria for post traumatic stress disorder.
Next we will be looking at complex PTSD, and then taking a look at developmental trauma.
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