Beyond PTSD: Limitations of Current Trauma-Related Diagnoses
By Dr. Julianne Ludlam
This is the first article in a series of three.
For most people, traumatic reactions are associated with the diagnosis of Posttraumatic Stress Disorder, or PTSD. This is understandable, given that it is the primary trauma-related diagnosis in the Diagnostic and Statistical Manual for Mental Disorders, currently in its fifth edition (DSM-5). However, it may be useful for attorneys and legal professionals to understand the limitations of the current diagnostic system as it relates to trauma, and to be aware of various ways that reactions to trauma can manifest.
The PTSD Diagnosis
We sometimes use the word, “trauma,” to refer to negative experiences (i.e., “That halftime show really traumatized me,” or “Traffic today was so traumatic!”). Importantly, the actual definition of trauma in the DSM-5 was carefully constructed to ensure that not every bad experience would be classified as a traumatic one. The DSM-5 (American Psychiatric Association, 2013) lists specific requirements that define a trauma in order to avoid subjective assessments; it must involve exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Thus, the DSM-5 describes, in detail, the context of the exposure to a trauma; it must involve having one’s life threatened or having direct, personal experience of seeing someone else being threatened, killed, or hurt. We may casually use the term to describe any stressful or upsetting event, but diagnostically, trauma has a specific definition. The requirements above are collectively referred to as the “stressor criterion” and are considered a form of gatekeeper. The stressor criterion was intended to restrict the diagnosis of PTSD to individuals experiencing serious and horrible events, not merely unpleasant ones. The diagnosis of PTSD was not meant to include indirect or impersonal experiences of trauma, such as watching, from the safety of one’s living room, a news report of a catastrophe occurring to strangers.
Other Trauma-Related and Stressor-Related Disorders
Aside from PTSD, there are other specific trauma- and stressor-related disorders in the DSM-5. Acute Stress Disorder is most closely related to PTSD and differs primarily in timeframe. Acute Stress Disorder is diagnosed when an individual experiences symptoms between three days to one month after the event; PTSD is diagnosed when symptoms last longer than one month. Because many individuals may have symptoms in the immediate aftermath of a trauma, the minimum number of days of symptoms was set at three; it is the persistence of problems after that timeframe that define diagnosable traumatic reaction. Approximately 80% of cases of Acute Stress Disorder appear to develop into PTSD, but many cases are not identified and diagnosed, despite the possibility of ongoing functional impairment.
Other disorders in the DSM-5’s “trauma- and stressor-related” category include Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. These disorders are diagnosed in children and adolescents and are considered reactions to neglect and deprivation experienced in childhood; they generally involve disturbed attachment behaviors. The prevalence of these disorders is unknown, and both are diagnosed relatively rarely. Both emphasize social neglect by caregivers rather than any other form of traumatic experience.
Other diagnoses in the category include Adjustment Disorder, which is considered a mild, temporary condition resulting from an external stressor, and “Other Trauma- and Stressor-Related Disorders.” The latter diagnosis is used when individuals do not meet full criteria for a disorder in the category but exhibit enough symptoms to merit clinical attention. Unfortunately, disorders that fall into this “other” diagnostic grouping are typically stereotyped as minor or less pathological, despite the fact that they can still be quite problematic for individuals; this issue will be discussed in more detail in the third article.
While diagnostic clarity at this level is not always be necessary for treatment purposes, it is important in forensic and psychological evaluations. Individuals can engage in therapy without a formal diagnosis, and in some cases, an over-emphasis on diagnosis can distract clients and therapists from focusing on emotions and behaviors, processing grief, or developing coping skills. In forensic or psychological evaluations, however, diagnostic specificity is key, given the necessity of clear recommendations and conclusions to guide decision-making in legal settings.
Overall, the diagnosis of PTSD requires that several specific criteria be met, including a detailed and rather restrictive criterion that defines a “trauma.” Although there are other diagnoses in the DSM-5’s “trauma- and stressor-related” category, these are limited by their timeframe, emphasis, or severity. When individuals have symptoms that do not meet criteria for any of these diagnoses, there is an “other” category that can be used. Problems falling into this “other” category may tend to be ignored or discounted, and this important issue will be addressed in the third article in the series. The second article in this series will explore severe forms of trauma that many researchers feel are not adequately captured by our diagnostic system.