PTSD: Diagnostic Criteria, Assessment, and Treatment for Counseling Exams

Understanding Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) develops in some individuals following exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. The DSM-5-TR moved PTSD from the anxiety disorders chapter to a new category called Trauma- and Stressor-Related Disorders, reflecting the understanding that PTSD involves more than anxiety alone. Approximately 6.8% of Americans will experience PTSD at some point in their lives.

DSM-5-TR Diagnostic Criteria

PTSD diagnosis requires meeting criteria across four symptom clusters, with symptoms lasting more than one month.

Criterion A: Exposure to Trauma

The individual must have been exposed to actual or threatened death, serious injury, or sexual violence through one or more of the following: direct experience, witnessing in person, learning that a close family member or friend experienced the event, or repeated or extreme exposure to aversive details of the event (first responders, for example). Importantly, exposure through electronic media, television, movies, or pictures does not qualify unless it is work-related.

Criterion B: Intrusion Symptoms (at least 1)

Recurrent, involuntary, and intrusive distressing memories
Recurrent distressing dreams related to the trauma
Dissociative reactions (flashbacks) in which the individual feels or acts as if the event is recurring
Intense or prolonged psychological distress at exposure to cues resembling the trauma
Marked physiological reactions to reminders of the trauma

Criterion C: Avoidance (at least 1)

Avoidance of distressing memories, thoughts, or feelings associated with the trauma
Avoidance of external reminders (people, places, conversations, activities, objects, situations)

Criterion D: Negative Alterations in Cognitions and Mood (at least 2)

Inability to remember an important aspect of the trauma
Persistent and exaggerated negative beliefs about oneself, others, or the world
Persistent distorted cognitions about the cause or consequences of the trauma leading to self-blame
Persistent negative emotional state (fear, horror, anger, guilt, shame)
Markedly diminished interest or participation in significant activities
Feelings of detachment or estrangement from others
Persistent inability to experience positive emotions

Criterion E: Arousal and Reactivity (at least 2)

Irritable behavior and angry outbursts
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance

Specifiers

The DSM-5-TR includes two important specifiers. The dissociative subtype applies when the individual experiences persistent depersonalization (feeling detached from one's own mind or body) or derealization (experiencing surroundings as unreal or dreamlike). The delayed expression specifier applies when full diagnostic criteria are not met until at least six months after the event, though some symptoms typically appear sooner.

Differential Diagnosis

Acute Stress Disorder: Similar symptom profile but lasts only 3 days to 1 month after trauma exposure
Adjustment Disorder: Response to a stressor that does not meet Criterion A for trauma
Traumatic Brain Injury: Cognitive and emotional symptoms may overlap; neurological evaluation may be needed
Dissociative Disorders: May co-occur with PTSD but can also present independently

Evidence-Based Treatments

Trauma-Focused Therapies

Prolonged Exposure (PE) therapy, developed by Edna Foa, involves systematic confrontation with trauma-related memories and situations through imaginal and in vivo exposure. Cognitive Processing Therapy (CPT), developed by Patricia Resick, helps clients identify and challenge unhelpful beliefs (stuck points) related to the trauma. EMDR (Eye Movement Desensitization and Reprocessing), developed by Francine Shapiro, uses bilateral stimulation during trauma memory processing. All three are strongly recommended by treatment guidelines.

Other Approaches

Trauma-Focused CBT (TF-CBT) is the leading evidence-based treatment for children and adolescents with PTSD. Narrative Exposure Therapy (NET) is effective for individuals with multiple traumatic experiences, such as refugees. Seeking Safety is an evidence-based approach for individuals with co-occurring PTSD and substance use disorders.

Exam Tips

PTSD is now classified under Trauma- and Stressor-Related Disorders, not Anxiety Disorders
Symptoms must last more than one month; under one month consider Acute Stress Disorder
Know the four symptom clusters and minimum symptoms required for each: B(1), C(1), D(2), E(2)
PE, CPT, and EMDR are the three most commonly cited evidence-based PTSD treatments
The dissociative subtype is a frequently tested specifier
Criterion A trauma is specific; not all distressing events qualify