The Diagnostic Spectrum of Trauma-Related Disorders

DSM-5

ICD-11

A. Exposed to death/threatened death

A. Exposure to threat

Experienced/witnessed threat to life

B. Re-experiencing (at least 1 of):

Learning events occur to close other person

Intrusive memories

B. Re-experiencing (at least 1 of):

Flashbacks

Intrusive memories

Nightmares

C. Avoidance (at least 1 of):

Flashbacks

Thoughts

Distress to reminders

Situations

Physiological reactivity

D. Perceived threat (at least 1 of):

C. Avoidance (at least 1 of):

Hypervigilance

Avoid thoughts/feelings

Startle response

Avoid situations

E. Duration (at least several weeks)

D. Negative alterations in cognition/mood (at least 3 of):

F. Impairment

Dissociative amnesia

Negative expectations of self/world

Distorted blame

Negative emotional state

Diminished interest

Detachment

Emotional numbing

E. Hyperarousal (at least 2 of):

Reckless/self-destructive behaviour

Hypervigilance

Startle response

Concentration deficits

Sleep problems

F. Minimum 1 month after trauma

G. Impairment

Specifier: with dissociative symptoms

Specifier: with delayed expression

DSM-5 has few changes to the re-experiencing cluster. In contrast, the avoidance conceptualization has been markedly altered. Whereas DSM-IV presumed PTSD comprised three factors, multiple factor analytic studies have indicated that the construct is better explained by four factors: re-experiencing, active avoidance, passive avoidance (including numbing) and arousal (Asmundson et al. 2000; King et al. 1998; Marshall 2004). Accordingly, DSM-5 now has a separate cluster that requires the person to satisfy at least one of two active avoidance symptoms (of either internal or external reminders). The major change has been the addition of a new cluster, termed negative alterations in cognitions and mood. This cluster recognizes that numbing is distinct from active avoidance, but also notes the importance of exaggerated negative appraisals about the trauma and the range of emotional responses that can be experienced in PTSD. This has led to the addition of new symptoms. On the basis that many people with PTSD blame themselves and feel guilty (Feiring and Cleland 2007), self-blame has been added to this new cluster. Given the abundant evidence that people with PTSD have negative evaluations about themselves and the world (e.g. ‘I am a bad person’) and that they will not enjoy positive future experiences (‘Nothing will ever work for me’) (Ehring et al. 2008), the DSM-IV symptom of foreshortened future has been replaced by a symptom that involves exaggerated negative appraisals about oneself and the world. Evidence that PTSD can also exist in association with diverse negative mood states, including anger, shame and guilt (Leskela et al. 2002; Orth and Wieland 2006), led to the inclusion of a symptom of pervasive negative mood states. The arousal cluster has remained largely the same in DSM-5 as it was in DSM-IV, with a few exceptions. Based on evidence that reckless or self-destructive behaviour has been observed in a range of PTSD populations (Fear et al. 2008), this has been added as an additional symptom to the arousal cluster. The only further modification to this cluster was altering irritable mood to aggressive behaviour because this is seen as more indicative of PTSD (Jakupcak et al. 2007).

What is the impact of the altered PTSD definition in DSM-5? One study of traumatic injury survivors found comparable rates of PTSD across both DSM-5 (6.7 %) and DSM-IV (5.9 %) definitions (O’Donnell et al. 2014). Further, this study found that comorbidity with depression was comparable across both DSM-5 and DSM-IV definitions (67 % vs. 69 %). One interesting outcome of the DSM-5 modifications is that it has greatly expanded the possible number of permutations by which PTSD can now be diagnosed; whereas in DSM-IV there were 79,794 possible combinations, the added cluster and the new symptoms in DSM-5 have resulted in 636,120 possible clinical presentations of PTSD (Galatzer-Levy and Bryant 2013). It is premature to cast judgement on how the DSM-5 definition is faring relative to the DSM-IV iteration of the condition because it will require multiple studies conducted in different settings to answer this question.

6.5.2 ICD-11

As noted above, ICD-11, which is expected to be published in 2017, proposes a considerably simpler definition than DSM-5 – and this is exemplified in the proposed definition of PTSD (see Table 6.1). It has been noted that PTSD was more readily diagnosed in ICD-10 than DSM-IV and that ICD-10 required an impairment requirement to raise the threshold for diagnostic criterion (Peters et al. 1999). ICD-11 is also introducing a formal stressor criterion to tighten the entry for the diagnosis (Maercker et al. 2013a). Arguably the biggest difference between DSM-5 and ICD-11 is the latter’s emphasis on re-experiencing symptoms. In an attempt to reduce comorbidity and focus PTSD on its core element (i.e. a memory-based disorder characterized by reliving of the traumatic experience), considerable weight was placed on the role of the distinctive types of memory for the trauma evident in PTSD (Maercker et al. 2013b). Specifically, whereas intrusive memories are evident across many disorders, the sense of reliving of a trauma is apparently distinctive to PTSD (Brewin et al. 2010; Bryant et al. 2011c). Accordingly, ICD-11 defines re-experiencing the traumatic event(s) in the present, reflected by either vivid intrusive memories, flashbacks or nightmares, accompanied by fear or horror; in this definition, flashbacks can range from transient experiences to a complete disconnection from one’s current state of awareness (Maercker et al. 2013b). ICD-11 also stresses avoidance of re-experiencing symptoms, which includes effortful avoiding of internal (e.g. thoughts, emotions) and external (e.g. situations) reminders. The third emphasis is an excessive sense of current threat, which can be reflected in hypervigilance or by exaggerated startle.

Overall, the ICD-11 definition is intended to simplify the diagnosis for clinicians and allow diagnosis to be made on the basis of satisfying two symptoms of each of the three central features of PTSD. This definition is clearly much simpler than the DSM-5 criteria and leads to much fewer potential permutations by which the diagnosis can be made. Some initial evidence has emerged about the relative performances of the DSM-5 and ICD-11 definitions of PTSD. In one study of 510 traumatically injured patients, PTSD current prevalence using DSM-5 criteria was markedly higher than the ICD-11 definition (6.7 % vs. 3.3 %), and ICD-11 tended to have lower comorbidity with depression (O’Donnell et al. 2014).

6.6 Acute Stress Disorder

DSM-5 and ICD-11 have two very different conceptualizations of acute stress responses, and they do not match onto each other. They are based on different premises, have very different timeframes and consequently are operationally defined in very distinct ways. In fact, ASD only exists in DSM and has never been a diagnosis in ICD, which instead has a construct termed acute stress reaction.

6.6.1 DSM-5

ASD was first introduced in DSM-IV for two stated reasons: (a) to describe severe acute stress reactions that predated the PTSD diagnosis (which can only be recognized 1 month after trauma exposure) and (b) as a means to identify people who are at high risk for developing subsequent PTSD (Spiegel et al. 1996). In DSM-IV, to meet criteria for ASD, one needed to experience a traumatic event and respond with fear, horror or helplessness (criterion A), and also dissociative (criterion B), re-experiencing (criterion C), avoidance (criterion D) and arousal (criterion E) symptom clusters. Whereas most clusters were similar to those in PTSD, although more loosely defined (Bryant and Harvey 1997), the exception was the dissociative cluster which required at least three of five possible symptoms (emotional numbing, derealization, depersonalization, reduced awareness of surroundings or dissociative amnesia). This emphasis resulted from arguments at the time that dissociative responses were central to posttraumatic response because they impeded emotional processing of the experience, and therefore were predictive of PTSD (Harvey and Bryant 2002).

In preparing the ASD diagnosis for DSM-5, a core question was: How well was ASD predicting PTSD? Longitudinal studies that indexed the relationship between ASD and later PTSD display a convergent pattern. Whereas the majority of individuals with a diagnosis of ASD do subsequently develop PTSD, most people who eventually experience PTSD do not initially display ASD (Bryant 2011). That is, although ASD is performing adequately in terms of most people who meet criteria are high risk for PTSD, it is performing poorly by not identifying most people who are high risk. For this reason, it was decided in DSM-5 that the ASD diagnosis should not be aiming to predict PTSD but rather simply describe severe stress reactions in the initial month (Bryant et al. 2011b). A driving reason for retaining the diagnosis was that a major utility of the ASD diagnosis is that within the US health-care system having a diagnosis can facilitate access to mental health services.

Recognizing that the requirement of dissociative symptoms was arguably too prescriptive in the DSM-IV definition and precluded many distressed people from being identified (Bryant et al. 2008; Dalgleish et al. 2008), the DSM-5 definition was modified such that to meet criteria one needs to satisfy at least 9 out of possible 14 symptoms without regard to any specific clusters (American Psychiatric Association 2013) (see Table 6.2). Although the diagnosis is structured in a way that does not require any specific symptoms or clusters, to meet criteria one nonetheless must display re-experiencing and/or avoidance symptoms. This retains the essential core of ASD as being comparable to PTSD. One study has reported that the DSM-5 (14 %) identifies more distressed people than the DSM-IV (8 %) definition (Bryant et al. in press). Interestingly, this study also reported that the DSM-5 definition also identified more participants who developed PTSD than DSM-IV criteria.

Table 6.2

DSM-5 criteria for acute stress disorder and proposed ICD-11 criteria for acute stress reaction

DSM-5	ICD-11
A. Exposed to death/threatened death	A. Exposure to threat
Witnessed death/threat	B. Transient emotional, somatic cognitive or behavioural symptoms
Learning events occur to close other person	C. Normal response to severe stressor
B. Presence of at least 9 of:	D. Symptoms appear within days
Intrusive memories	E. Symptoms subside within 1 week or removal of stressor
Nightmares	F. Symptoms do not meet criteria for mental disorder
Flashbacks
Psychological/ physiological reactivity
Numbing/detachment
Derealization/depersonalization
Dissociative amnesia
Avoidance of thoughts/feelings
Avoidance of situations
Hypervigilance
Irritable/aggressive behaviour
Startle response
Sleep problems
Concentration deficits
C. Symptoms lasts at least 3 days to 1 month after trauma
D. Impairment
E. Not due to substance or medical causes

6.6.2 ICD-11

Acute stress reactions (ASR) have always been conceptualized in ICD as transient responses that are not necessarily psychopathological (Table 6.2). It is a category that is meant to capture the initial distress that is commonly experienced after traumatic exposure, and it was expected that these reactions would subside within a week or soon after the threat has eased (Isserlin et al. 2008). In this way, ASR is qualitatively different from DSM-5’s ASD because it is neither a mental disorder in its own right nor a predictor of subsequent disorder. It is also worth noting that in ICD-11 there is no minimal time in which PTSD can be diagnosed, and so the issue of having a diagnostic ‘gap’ to describe posttraumatic stress responses (which existed in DSM prior to DSM-IV) does not apply to ICD.

In terms of its definition, ASR has never been limited to strict PTSD definitions because it is intended to encompass the broader array of reactions that can occur in the initial aftermath of trauma. Motivated by the need to be applicable to emergency workers, military personnel and disaster agencies who respond initially to trauma, especially large-scale events, the described symptoms are intentionally very broad and non-prescriptive. The symptoms may include shock, sense of confusion, sadness, anxiety, anger, despair, overactivity, stupor and social withdrawal. Underscoring the intent that ASR is not a mental disorder, it is coded as a ‘Z’ code, distinguishing it from mental disorders. ICD-11 proposes that if the symptoms of ASR persist beyond a week, one should consider a diagnosis of adjustment disorder or PTSD.

6.7 Complex PTSD

Perhaps the most difficult traumatic stress condition to categorize over the past 20 years has been the notion of complex PTSD. Dating back to the early 1990s, the notion of more complicated PTSD responses has been discussed at length, typically in the context of describing the more complex reactions suffered by survivors of prolonged, and often childhood, trauma. It was argued that those who had suffered sustained and severe trauma, such as childhood abuse, torture or domestic violence, can experience marked problems with their sense of identity and organization of emotions (Herman 1992). Termed disorders of extreme distress not otherwise specified (DESNOS), it was never well defined and accordingly not systematically studied.

In more recent years, the field has moved towards the construct of complex PTSD, which has enjoyed a tighter definition. This is a proposed condition that requires the PTSD symptoms noted above but also reflects the impact that trauma can have on systems of self-organization, specifically in affective, self-concept and relational domains. Unlike the PTSD symptoms in which reactions of fear or horror are tied to trauma-related stimuli, these three latter types of disturbances are pervasive and persistent and occur across various contexts and relationships regardless of proximity to traumatic reminders. Specifically, the construct has evolved to comprise three major sets of disturbances in addition to the core PTSD responses: affective regulation, self-construct and interpersonal. These have been identified both from studies of patients (Roth et al. 1997) and expert clinicians (Cloitre et al. 2011). Though not defined by exposure to prolonged trauma, this constellation of reactions is typically associated with very prolonged and severe traumatic experiences (van der Kolk et al. 2005).

6.7.1 DSM-5

The possibility of introducing complex PTSD in DSM-5 was debated; however, it was rejected. It was decided to not consider complex PTSD as a separate entity because in the DSM-IV field trials, only 8 % of those who displayed DESNOS did not also have PTSD; thus, it was suggested that it could only be considered as a subtype (Friedman et al. 2011). It was argued that it was premature to introduce this subtype because it had not been adequately defined, insufficient data existed to warrant its distinction from other disorders (including Borderline Personality Disorder), and there was no evidence that people with this presentation respond differentially to treatments that work effectively with PTSD (Resick et al. 2012). In contrast, DSM-5 did introduce a dissociative subtype of PTSD which was regarded as a viable alternative to complex PTSD. This subtype builds on evidence of two types of presentation of PTSD: one characterized by elevated arousal and one by blunting/dissociative responses. This division is largely based on some evidence that people who present with dissociative symptoms show less reactivity at both peripheral (Griffin et al. 1997) and neural (Felmingham et al. 2008; Lanius et al. 2012) levels relative to those with non-dissociative symptoms. Although other studies have reported that there is no difference in reactivity in dissociative and non-dissociative presentations of PTSD (Kaufman et al. 2002; Nixon et al. 2005), this subtype was nonetheless introduced into DSM-5 in recognition that it was a valid sub-entity.

6.7.2 ICD-11

It appears that a different approach is being taken in ICD-11. ICD has a different organizational structure than DSM, and so if accepted, complex PTSD may be a ‘sibling’ disorder to PTSD rather than a subtype. The proposal being put forward for ICD-11 is based on the core PTSD symptoms with the addition of affective, self and relational disturbance (see Table 6.3). Affective disturbances include emotional reactivity, extreme outbursts, self-destructive behaviour and potentially dissociative states. Disturbances in self may include the sense of worthlessness, or of being defeated or diminished. Difficulties in relations often involve deficits in maintaining a sense of intimacy with others, disinterest in social relations or oscillating between intimate relations and estrangement. Initial evidence supporting this proposal comes from a latent profile analysis that showed patients with affective, self and relational disturbances comprised a distinct class from PTSD patients who were low on these symptoms; further, the former class were more likely to have suffered chronic rather than discrete traumas (Cloitre et al. 2013). Further evidence for the complex PTSD construct has come from other studies that have found supporting confirmatory factor analyses of the proposed structure, and higher rates of the proposed symptoms in survivors of childhood abuse (Knefel and Lueger-Schuster 2013), as well as from other studies using latent class analysis indicating a distinct class of complex PTSD (Elkit et al. 2014). Whether complex PTSD is introduced into ICD-11 is yet to be determined, and if it is, what form it will ultimately take remains to be seen. At this stage, it is gathering more support than it received in DSM-5, arguably because the several years delay in production of DSM-5 and ICD-11 means the latter can benefit from targeted research that is developing a broader evidence base to influence the final decision.

Table 6.3

Proposed ICD-11 criteria for complex PTSD

1. Exposure to extreme/prolonged trauma

2. Core symptoms of PTSD (re-experiencing, avoidance, perceptions of threat)

3. Pervasive problems with:

(a) Affect regulation

(b) Sense of self as diminished, defeated or worthless

6.8 Prolonged Grief Disorder

6.8.1 DSM-5

One of the vehemently debated diagnoses in DSM-5 was the issue of introducing a diagnosis describing complicated grief reactions. DSM has traditionally not recognized grief as a mental disorder because it is concerned about pathologizing a normal response to bereavement. Much work has focused on the condition over the past decade, resulting in a much greater body of evidence than previously existed. Although most normative grief reactions subside after the initial period of mourning, this condition refers to the proportion of grief reactions that persist. There are mixed opinions about the optimal term for the condition. Whereas some prefer the term ‘complicated grief’ to reflect the fact that the symptoms are qualitatively different from normal grief reactions (Shear et al. 2011), others support the term ‘prolonged grief’ in recognition of the condition being a persistence of the same symptoms observed in the acute bereavement phase (Prigerson et al. 2009). Although there is disagreement about the finer details, the generally accepted definition involves intense yearning or emotional pain that persists beyond 6 months after the death and potentially having difficulty accepting the death, anger over the loss, a diminished sense of one’s identity, feeling that life is empty and problems in engaging in new relationships or activities (Bryant 2012). Studies estimate that 10–15 % of bereaved people may suffer this condition, depending on the nature of the death and the relationship to the person (Shear et al. 2011). It was finally decided to not introduce the diagnosis on the basis that insufficient evidence exists to warrant its introduction as a separate diagnosis, instead relegating it to the Appendix as an area for future study.

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