Week 9 _ assignment: posttraumatic stress disorder

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(F43.10)

Posttraumatic Stress Disorder

Diagnostic Criteria
Posttraumatic Stress Disorder in Individuals Older Than 6 Years

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6
years and younger, see corresponding criteria below.

A. 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(s).

2. Witnessing, in person, the event(s) as it occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of
actual or threatened death of a family member or friend, the event(s) must have been violent or
accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first
responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies,
or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects
of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic
event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic
event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).

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D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative
amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
(e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole
nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that
lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or
worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal
or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol)
or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress
disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent
symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one
were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a
dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world
around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or
another medical condition (e.g., complex partial seizures).

Specify if:

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With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the
event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder in Children 6 Years and Younger
A. In children 6 years and younger, 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(s).

2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.

3. Learning that the traumatic event(s) occurred to a parent or caregiving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s),
beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing and
may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the
traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to the
traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s)
were recurring. (Such reactions may occur on a continuum, with the most extreme expression
being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment
may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize
or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated
with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic
event(s), must be present, beginning after the event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of
the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse
recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame,
confusion).

4. Markedly diminished interest or participation in significant activities, including constriction of
play.

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

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D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after
the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal
or physical aggression toward people or objects (including extreme temper tantrums).

2. Hypervigilance.

3. Exaggerated startle response.

4. Problems with concentration.

5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in relationships with parents,
siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol)
or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress
disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

1.

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if
one were an outside observer of, one’s mental processes or body (e.g., feeling as though one
were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the
world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts) or another medical condition (e.g.,
complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the
event (although the onset and expression of some symptoms may be immediate).

Diagnostic Features
The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms
following exposure to one or more traumatic events. The clinical presentation of PTSD varies. In some individuals,
fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or
dysphoric mood states and negative cognitions may be most prominent. In some other individuals, arousal and
reactive-externalizing symptoms are prominent, while in yet others, dissociative symptoms predominate. Finally,
some individuals exhibit combinations of these symptom patterns.

The following discussion of specific criteria for PTSD refers to specific criteria for adults; criteria for children 6 years
or younger may differ in criterion numbering given differences in applicable criteria for this age group.

The traumatic events in Criterion A all involve actual or threatened death, serious injury, or sexual violence in some
way but differ in how the individual is exposed to them, which can be through directly experiencing the traumatic
event (Criterion A1), witnessing in person the event as it occurred to others (Criterion A2), learning that the event
occurred to a family member or a close friend (Criterion A3), or indirect exposure in the course of occupational

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duties, through being exposed to grotesque details of an event (Criterion A4). The disorder may be especially severe
or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence).

The directly experienced traumatic events in Criterion A include, but are not limited to, exposure to war as a
combatant or civilian, actual or threatened physical assault in which the threat is perceived as imminent and realistic
(e.g., physical attack, robbery, mugging, childhood physical abuse), being kidnapped, being taken hostage, terrorist
attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle
accidents.

Sexual trauma includes, but is not limited to, actual or threatened sexual violence or coercion (e.g., forced sexual
penetration; alcohol/drug-facilitated nonconsensual sexual penetration; other unwanted sexual contact; and other
unwanted sexual experiences not involving contact, such as being forced to watch pornography, exposure to the
display of genitals by an exhibitionist, or being the victim of unwanted photography or videotaping of a sexual nature
or the unwanted dissemination of these photographs or videos) (Basile et al. 2013).

Being bullied may qualify as a Criterion A1 experience when there is a credible threat of serious harm or sexual
violence. For children, sexually violent events may include developmentally inappropriate sexual experiences without
physical violence or injury.

A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Qualifying
events of this type include life-threatening medical emergencies (e.g., an acute myocardial infarction, anaphylactic
shock) or a particular event in treatment that evokes catastrophic feelings of terror, pain, helplessness, or imminent
death (e.g., waking during surgery, debridement of severe burn wounds, emergency cardioversion).

Witnessed events (Criterion A2) include, but are not limited to, observing threatened or serious injury, unnatural
death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war, or disaster.
For example, this would include parents witnessing their child in an acute life-endangering incident (e.g., a diving
accident) or a medical catastrophe during the course of their child’s illness or ongoing treatment (e.g., a life-
threatening hemorrhage).

Indirect exposure through learning about an event (Criterion A3) is limited to events affecting close relatives or
friends that were violent or accidental (i.e., death from natural causes does not qualify). Such events include murder,
violent personal assault, combat, terrorist attack, sexual violence, suicide, and serious accident or injury.

The indirect exposure of professionals to the grotesque effects of war, rape, genocide, or abusive violence inflicted on
others occurring in the context of their work duties can also result in PTSD and thus is considered to be a qualifying
trauma (Criterion A4). Examples include first responders exposed to serious injury or death and military personnel
collecting human remains. Indirect exposure can also occur through photos, videos, verbal accounts, or written
accounts (e.g., police officers reviewing crime reports or conducting interviews with crime victims, drone operators,
members of the news media covering traumatic events, and psychotherapists exposed to details of their patients’
traumatic experiences).

Exposure to multiple traumatic events is common and can take many forms. Some individuals experience different
types of traumatic events at different times (e.g., sexual violence during childhood and natural disaster as adults).
Others experience the same type of traumatic event at different times or in a series committed by the same
person/people over an extended period (e.g., child sexual or physical assault; physical or sexual assault by an
intimate partner). Others may experience numerous traumatic events that are the same or different during an
extended hazardous period such as deployment or living in a conflict zone. When one is assessing the PTSD criteria
in individuals who have experienced multiple traumatic events across their lives, it may be useful to determine if
there is a specific, discrete example that the individual considers to be the worst given that the symptomatic
expressions of PTSD Criterion B and Criterion C specifically refer to the traumatic event (e.g., recurrent, involuntary,
and intrusive distressing recollections of the traumatic event). However, if it is difficult for the individual to identify a
worst example, it is appropriate to consider the entire exposure as meeting Criterion A. In addition, some discrete
events may incorporate several traumatic event types (e.g., an individual involved in a mass casualty incident
sustains a major injury, witnesses someone else being injured, and then learns that a family member was killed in the
incident).

The traumatic event can be reexperienced in various ways. Commonly, the individual has recurrent, involuntary, and
intrusive recollections of the event (Criterion B1). Intrusive recollections in PTSD are distinguished from depressive
rumination in that they apply only to involuntary and intrusive distressing memories. The emphasis is on recurrent
memories of the event that usually include intrusive, vivid, sensory, and emotional components that are distressing
and not merely ruminative. A common reexperiencing symptom is distressing dreams that replay the event itself or

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that are representative or thematically related to the major threats involved in the traumatic event (Criterion B2).
The individual may experience dissociative states that typically last a few seconds and rarely are of a longer duration,
during which components of the event are relived and the individual behaves as if the event were occurring at that
moment (Criterion B3). Such events occur on a continuum, ranging from brief visual or other sensory intrusions
about part of the traumatic event without loss of reality orientation to a partial loss of awareness of present
surroundings to a complete loss of awareness. These episodes, often referred to as “flashbacks,” are typically brief but
can be associated with prolonged distress and heightened arousal. For young children, reenactment of events related
to trauma may be expressed behaviorally in play or in dissociative states. Intense psychological distress (Criterion
B4) or physiological reactivity (Criterion B5) often occurs when the individual is exposed to triggering events or
somatic reactions that resemble or symbolize an aspect of the traumatic event (e.g., windy days after a hurricane,
seeing someone who resembles one’s perpetrator). The triggering cue could also be a physical sensation (e.g.,
dizziness for survivors of head trauma, rapid heartbeat for a previously traumatized child), particularly for
individuals with highly somatic presentations (Friedman et al. 2011).

Stimuli associated with the trauma are persistently avoided. The individual commonly makes deliberate efforts to
avoid thoughts, memories, or feelings (e.g., by utilizing distraction or suppression techniques, including substance
use, to avoid internal reminders) (Criterion C1), and to avoid activities, conversations, objects, situations, or people
who arouse recollections of it (Criterion C2).

Negative alterations in cognitions or mood associated with the traumatic event begin or worsen after exposure to the
event. These negative alterations can take various forms, including an inability to remember key and emotionally
painful aspects of the traumatic event. Such memory loss is typically attributable to dissociative amnesia and is not
attributable to head injury or impaired encoding of the memory due to drug or alcohol use (Criterion D1). Individuals
with PTSD often report that the traumatic event has irrevocably altered their lives and their view of the
world (Janoff-Bulman 1992; Lifton 1979). This is characterized by persistent and exaggerated negative beliefs and
expectations regarding important aspects of life applied to themselves, others, the world, or the future (Criterion D2)
(e.g., “Bad things will always happen to me”; “The world is dangerous, and I can never be adequately protected”; “I
can’t trust anyone ever again”; “My life is permanently ruined”; “I have lost any chance for future happiness”; “My
life will be cut short”). Individuals with PTSD may have persistent erroneous cognitions about the causes of the
traumatic event that lead them to blame themselves or others (e.g., “It’s all my fault that my uncle abused me”)
(Criterion D3). A persistent negative mood state (e.g., fear, dysphoria, horror, anger, guilt, shame) either began or
worsened after exposure to the event (Criterion D4). The individual may experience markedly diminished interest or
participation in previously enjoyed activities (Criterion D5), may feel detached or estranged from other people
(Criterion D6), or may experience a persistent inability to feel positive emotions (especially happiness, joy,
satisfaction, or emotions associated with intimacy, tenderness, and sexuality) (Criterion D7) (Friedman et al. 2011).

Negative alterations in arousal and reactivity also begin or get worse after exposure to the event. Individuals with
PTSD may exhibit irritable or angry behavior and may engage in aggressive verbal or physical behavior with little or
no provocation (e.g., yelling at people, getting into fights, destroying objects) (Criterion E1). They may also engage
voluntarily in reckless or self-destructive behavior that is dangerous, that shows a disregard for the physical safety of
themselves or others, and that could directly result in serious physical harm or death (Criterion E2). Examples
include, but are not limited to, dangerous driving (e.g., drunk driving, driving at dangerously high speeds), excessive
alcohol or drug use, having risky sex (e.g., unprotected sex with a partner whose HIV status is unknown, high
number of sexual partners), or self-directed violence including suicidal behaviors. Criterion E2 does not include
circumstances in which individuals must engage in dangerous situations as a part of their job (e.g., armed forces
members in combat situations or first responders in emergency situations) and take reasonable safety precautions to
reduce their risk or when individuals engage in behaviors that may be unwise, unhealthy, or financially harmful but
pose no direct risk of immediate serious physical harm or death (e.g., pathological gambling, poor financial decisions,
binge eating, unhealthy lifestyles). PTSD is often characterized by a heightened vigilance for potential threats,
including those that are related to the traumatic experience (e.g., following a motor vehicle accident, being especially
sensitive to the threat potentially caused by cars or trucks) and those not related to the traumatic event (e.g., being
fearful of suffering a heart attack) (Criterion E3) (Smith and Bryant 2000; Warda and Bryant 1998). Individuals
with PTSD may be very reactive to unexpected stimuli, displaying a heightened startle response, or jumpiness, to
loud noises or unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Criterion
E4). Startle responses are involuntary and reflexive (automatic, instantaneous), and stimuli that evoke exaggerated
startle responses (Criterion E4) need not be related at all to the traumatic event. Startle responses are distinguished
from the cued physiological arousal responses in Criterion B5, for which there needs to be at least some level of
conscious appraisal that the stimulus producing physiological responses is related to the trauma. Concentration
difficulties, including difficulty remembering daily events (e.g., forgetting one’s telephone number) or attending to
focused tasks (e.g., following a conversation for a sustained period of time), are commonly reported (Criterion E5).

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Problems with sleep onset and maintenance are common and may be associated with nightmares and safety concerns
or with generalized elevated arousal that interferes with adequate sleep (Criterion E6).

The diagnosis of PTSD requires that the duration of the symptoms in Criteria B, C, D, and E be more than 1 month
(Criterion F). For a current diagnosis of PTSD, Criteria B, C, D, and E must all be met for more than 1 month, for at
least the past month. For a lifetime diagnosis of PTSD, there must be a period of time lasting more than 1 month
during which Criteria B, C, D, and E have all been met for the same 1-month period of time.

A significant subgroup of individuals with PTSD experience persistent dissociative symptoms of either
depersonalization (detachment from their bodies) or derealization (detachment from the world around them). This
can be indicated by using the “with dissociative symptoms” specifier (Friedman et al. 2011; Hansen et al. 2017; van
Huijstee and Vermetten 2018).

Associated Features
Developmental regression, such as loss of language in young children, may occur. Auditory pseudo-hallucinations,
such as having the sensory experience of hearing one’s thoughts spoken in one or more different voices (Brewin and
Patel 2010), as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events
(e.g., childhood abuse, torture), the individual may additionally experience difficulties in regulating emotions or
maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event involves the
violent death of someone with whom the individual had a close relationship, symptoms of both prolonged grief
disorder and PTSD may be present.

Prevalence
The national lifetime prevalence estimate for PTSD using DSM-IV criteria is 6.8% for U.S. adults (Kessler et al.
2005a). Lifetime prevalence for U.S. adolescents using DSM-IV criteria has ranged from 5.0% (Merikangas et al.
2010) to 8.1% (Kilpatrick et al. 2003b) and a past 6-month prevalence of 4.9% for adolescents (Kilpatrick et al.
2003a). While definitive, comprehensive population-based data using DSM-5 are not available, findings are
beginning to emerge. In two U.S. national epidemiological studies, lifetime DSM-5 PTSD prevalence estimates
ranged from 6.1% to 8.3%, and the national 12-month DSM-5 prevalence estimate was 4.7% in both
studies (Goldstein et al. 2016; Kilpatrick et al. 2013). National lifetime DSM-IV PTSD estimates from World Mental
Health Surveys in 24 countries varied substantially among countries, income country groups, and WHO regions but
was 3.9% overall (Koenen et al. 2017). In conflict-affected populations worldwide, the point prevalence of PTSD with
functional impairment is 11% after adjustment for age differences across studies (Charlson et al. 2019).

Rates of PTSD are higher among veterans and others whose vocation increases the risk of traumatic exposure (e.g.,
police, firefighters, emergency medical personnel). Highest rates (ranging from one-third to more than one-half of
those exposed) are found among survivors of rape, military combat and captivity, and ethnically or politically
motivated internment and genocide. The prevalence of PTSD may vary across development; children and
adolescents, including preschool children, generally have displayed lower prevalence following exposure to serious
traumatic events; however, this may be because previous criteria were insufficiently developmentally
informed (Scheeringa et al. 2011). Racial differences, based on DSM-IV data, show higher rates of PTSD among U.S.
Latinx, African Americans, and American Indians compared with Whites (Beals et al. 2002; Hinton and Lewis-
Fernández 2011; Perilla et al. 2002). Potential reasons for these prevalence variations include differences in
predisposing or enabling factors, such as exposure to past adversity and racism and discrimination, and in
availability or quality of treatment, social support, socioeconomic status, and other social resources that facilitate
recovery and are confounded with ethnic and racialized background (Chou et al. 2012; Hinton and Lewis-Fernández
2011; McClendon et al. 2019; Spoont et al. 2017).

Development and Course
PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin within the first 3 months
after the trauma, although there may be a delay of months, or even years, before full criteria for the diagnosis are
met. There is abundant evidence for what DSM-IV called “delayed onset” but is now called “delayed expression,” with
the recognition that some symptoms typically appear immediately and that the delay is in meeting full
criteria (Andrews et al. 2007).

Frequently, an individual’s reaction to a trauma initially meets criteria for acute stress disorder in the immediate
aftermath of the trauma. The symptoms of PTSD and the relative predominance of different symptoms may vary over
time. Duration of the symptoms also varies, with complete recovery within 3 months occurring in approximately one-

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half of adults, while some individuals remain symptomatic for longer than 12 months (Bryant et al. 2011) and
sometimes for more than 50 years. Symptom recurrence and intensification may occur in response to reminders of
the original trauma, ongoing life stressors, or newly experienced traumatic events.

The clinical expression of reexperiencing can vary across development. Developmental variations in clinical
expression inform the use of different criteria in children 6 years and younger and in individuals who are older.
Young children may report new onset of frightening dreams without content specific to the traumatic event. Children
age 6 and younger may develop PTSD as a result of severe emotional abuse (e.g., threat of abandonment), which can
be perceived as life-threatening. During treatment for life-threatening illness (e.g., cancer, solid organ
transplantation), the experience of young children of the severity and intensity of the treatment may contribute to
risk of developing posttraumatic stress symptoms (Stuber et al. 1997); the self-appraisal of threat may also
contribute to the risk of developing posttraumatic stress symptoms in adolescents (Mintzer et al. 2005). Before age 6
years, young children are more likely to express reexperiencing symptoms through play that refers directly or
symbolically to the trauma (see PTSD criteria for children 6 years and younger). They may not manifest fearful
reactions at the time of the exposure or during reexperiencing. Parents may report a wide range of emotional or
behavioral changes in young children. Children may focus on imagined interventions in their play or storytelling. In
addition to avoidance, children may become preoccupied with reminders. Because of young children’s limitations in
expressing thoughts or labeling emotions, negative alterations in mood or cognition tend to involve primarily mood
changes. Children may experience co-occurring traumas (e.g., physical abuse, witnessing domestic violence) and in
chronic circumstances may not be able to identify onset of symptomatology (Scheeringa et al. 2005; Scheeringa et al.
2006). Avoidant behavior may be associated with restricted play or exploratory behavior in young children; reduced
participation in new activities in school-age children; or reluctance to pursue developmental opportunities in
adolescents (e.g., dating, driving). Older children and adolescents may judge themselves as cowardly. Adolescents
may harbor beliefs of being changed in ways that make them socially undesirable and estrange them from peers and
lose aspirations for the future. Irritable or aggressive behavior in children and adolescents can interfere with peer
relationships and school behavior. Reckless behavior may lead to accidental injury to self or others, thrill-seeking, or
high-risk behaviors (Pynoos et al. 2009). In older individuals, the disorder is associated with negative health
perceptions, primary care utilization, and suicidal thoughts (Rauch et al. 2006). In addition, declining health,
worsening cognitive functioning, and social isolation may exacerbate PTSD symptoms (Thorp et al. 2011).

Risk and Prognostic Factors
Risk factors for PTSD can operate in many ways, including predisposing individuals to trauma or to extreme
emotional responses when exposed to traumatic events. Risk (and protective) factors are generally divided into
pretraumatic, peritraumatic, and posttraumatic factors.

Pretraumatic Factors

Temperamental

High-risk factors include childhood emotional problems by age 6 years (e.g., externalizing or anxiety problems) and
prior mental disorders (e.g., panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]).
Individual differences in premorbid personality may influence the trajectory of response to trauma and treatment
outcomes. Personality traits associated with negative emotional responses such as depressed mood and anxiousness
represent risk factors for the development of PTSD (Jakšic et al. 2012). Such traits might be captured in measures of
negative affectivity (neuroticism) on standardized personality scales. Premorbid trait impulsivity tends to be
associated with externalizing manifestations of PTSD and comorbidities of the externalizing spectrum, including
substance use disorder or aggressive behavior.

Environmental

As documented among U.S. civilians and veterans, these risk factors include lower socioeconomic status; lower
education; exposure to prior trauma (especially during childhood) (Binder et al. 2008; Cougle et al. 2009; Smith et
al. 2008); childhood adversity (e.g., economic deprivation, family dysfunction, parental separation or death); lower
intelligence; ethnic discrimination and racism (Chou et al. 2012); and a family psychiatric history. Social support
prior to event exposure is protective.

Genetic and physiological

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The risk of developing PTSD following traumatic exposure has been demonstrated to be modestly heritable in twin
studies (Stein et al. 2002) and molecular studies (Duncan et al. 2018). Genome-wide association data from a large
multiethnic cohort support the heritability of PTSD and demonstrate three robust genome-wide significant loci that
vary by geographic ancestry (Nievergelt et al. 2018). Susceptibility to PTSD may also be influenced by epigenetic
factors (Smith et al. 2019). Genome-wide association data from U.S. veterans identify eight significant regions in
Americans of European descent associated with intrusive reexperiencing symptoms of PTSD; data from the United
Kingdom also support these associations (Gelernter et al. 2019).

Peritraumatic Factors

Environmental

These include severity (dose) of the trauma, perceived life threat, personal injury, interpersonal violence (particularly
trauma perpetrated by a caregiver or involving a witnessed threat to a caregiver in children) (Scheeringa et al. 2006),
and, for military personnel, being a perpetrator, witnessing atrocities, or killing the enemy. Finally, dissociation, fear,
panic, and other peritraumatic responses that occur during the trauma and persist afterward are risk factors.

Posttraumatic Factors

Temperamental

These include negative appraisals, inappropriate coping strategies, and development of acute stress disorder.

Environmental

These include subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or
other trauma-related losses. Posttraumatic experiences such as forced migration and high levels of daily stressors
may contribute to different conditional risks of PTSD across cultural contexts (Bustamante et al. 2017; Miller and
Rasmussen 2010; Rasmussen et al. 2010). Exposure to racial and ethnic discrimination has been associated with a
more chronic course among African American and Latinx adults (Sibrava et al. 2019). Social support (including
family stability, for children) is a protective factor that moderates outcome after trauma (Breslau 2009; Vogt et al.
2007).

Culture-Related Diagnostic Issues
Different demographic, cultural, and occupational groups have different levels of exposure to traumatic
events (Blanco 2011), and the relative risk of developing PTSD following a similar level of exposure (e.g., religious
persecution) may also vary across cultural, ethnic, and racialized groups (Alcántara et al. 2013; Hinton and Lewis-
Fernández 2011). Variation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of the
meaning attributed to the traumatic event (e.g., inability to perform funerary rites after a mass killing), the ongoing
sociocultural context (e.g., residing among unpunished perpetrators in postconflict settings), exposure to racial and
ethnic discrimination (Chou et al. 2012; Sibrava et al. 2019), and other cultural factors (e.g., acculturative stress in
migrants) may influence the risk of onset and severity of PTSD across cultural groups (Hinton and Lewis-Fernández
2011; Kohrt and Hruschka 2010; Shala et al. 2020). Some communities are exposed to pervasive and ongoing
traumatic environments, rather than isolated Criterion A events (Bensimon et al. 2013; Rasmussen et al. 2014); in
these communities, the predictive power of individual traumatic events for the development of PTSD may
diminish (Bensimon et al. 2013). In cultures where social image (e.g., maintaining a family’s “face”) is emphasized,
public defamation or shaming may magnify the impact of Criterion A events (Bockers et al. 2016; Budden
2009; Hinton and Lewis-Fernández 2011). Some cultures may attribute PTSD syndromes to negative supernatural
experiences (Rasmussen et al. 2014).

The clinical expression of the symptoms or symptom clusters of PTSD can vary culturally in both adults and children.
In many non-Western groups, avoidance is less commonly observed, whereas somatic symptoms (e.g., dizziness,
shortness of breath, heat sensations) are more common; other symptoms that vary cross-culturally are distressing
dreams, amnesia not related to head injury, and reckless but nonsuicidal behavior (Doric et al. 2019; Hinton and
Lewis-Fernández 2011; Rasmussen et al. 2014). Negative moods, especially anger, are common cross-culturally in
individuals with PTSD (Caspi et al. 2015; Rasmussen et al. 2014), as are distressing dreams and sleep
paralysis (Hinton and Good 2016). Across cultures, somatic symptoms are frequent, occurring in both children and
adults (Gupta 2013; Rasmussen et al. 2014), especially after sexual trauma (Kugler et al. 2012). Symptoms that vary
cross-culturally in relation to PTSD among children include intrusive thoughts, diminished participation in activities,

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inability to experience positive emotions, irritability, aggression, and hypervigilance. Distressing dreams, flashbacks,
psychological distress upon exposure to trauma cues, and efforts to avoid memories and thoughts are common in
children with PTSD across cultures (Doric et al. 2019).

In certain cultural contexts, it may be normative to respond to traumatic events with negative beliefs about oneself or
with spiritual attributions that may appear exaggerated to others. For example, blaming oneself may be consistent
with ideas of karma in South and East Asia, destiny or “spoiled medicine law” in West Africa, and cultural differences
in locus of control and conceptions of self (Adams 1998; Chung et al. 2006; Davidson et al. 2005; Jobson
2009, Kenny 1996; Kohrt and Hruschka 2010).

In many populations around the world, there are cultural concepts of distress that resemble PTSD and are
characterized by diverse manifestations of psychological distress attributed to frightening or traumatic
experiences (Hinton and Lewis-Fernández 2011; Kohrt et al. 2014; Lewis-Fernández and Kirmayer 2019; Rasmussen
et al. 2014). Thus, cultural concepts of distress influence the expression of PTSD and the range of its comorbid
disorders (see “Culture and Psychiatric Diagnosis” in Section III).

Sex- and Gender-Related Diagnostic Issues
PTSD is more prevalent among women than among men across the life span. Lifetime prevalence of PTSD ranges
from 8.0% to 11.0% for women and 4.1% to 5.4% for men based on two large U.S. population-based studies using
DSM-5 criteria (Goldstein et al. 2016; Kilpatrick et al. 2013). Some of the increased risk for PTSD in women appears
to be attributable to a greater likelihood of exposure to childhood sexual abuse, sexual assault, and other forms of
interpersonal violence, which carry the highest risk for development of PTSD (Kessler et al. 1995). Women in the
general population also experience PTSD for a longer duration than do men (Kessler et al. 2005b). However, other
factors likely contributing to the higher prevalence in women include gender differences in the emotional and
cognitive processing of trauma (Street and Dardis 2018), as well as effects of reproductive hormones (Ramikie and
Ressler 2018). When responses of men and women to specific stressors are compared, gender differences in risk for
PTSD persist (Blanco et al. 2018). On the other hand, PTSD symptom profiles and factor structures are similar
between men and women (Rivollier et al. 2015).

Association With Suicidal Thoughts or Behavior
Traumatic events such as childhood abuse or sexual trauma increase an individual’s suicide risk in both
civilians (Affi et al. 2008; Dworkin et al., 2017; Gradus et al. 2012; Klomek et al. 2015; Ranney et al. 2016) and
veterans (Kimerling et al. 2016). PTSD is associated with suicidal thoughts, suicide attempts, and death from
suicide (Gradus et al. 2015; Sareen et al. 2005; Sareen et al. 2007). The presence of PTSD has been associated with
an increased likelihood of transitioning from suicidal thoughts to a suicide plan or attempt (Nock et al. 2010), and
this effect of PTSD occurs independently of the increased risk of mood disorders on the likelihood of suicidal
behaviors (Bentley et al. 2016; Naifeh et al. 2019). Among adolescents there is also a significant relationship between
PTSD and suicidal thoughts or behavior even after adjustment for the effects of comorbidity (Panagioti et al. 2015).

Functional Consequences of Posttraumatic Stress Disorder
PTSD is associated with high impairment in social, occupational, and physical functioning; reduced quality of life;
and physical health problems (Goldstein et al. 2016; Kessler et al. 2005a; Olatunji et al. 2007; Ryder et al.
2018; Sayer et al. 2011; Schnurr et al. 2009). Impaired functioning is exhibited across social, interpersonal,
developmental, educational, physical health, and occupational domains. In community and veteran samples, PTSD is
associated with poor social and family relationships, absenteeism from work, lower income, and lower educational
and occupational success (Olatunji et al. 2007; Sayer et al. 2011; Schnurr et al. 2009).

Differential Diagnosis

Adjustment disorders

In adjustment disorders, the stressor can be of any severity or type rather than a stressor involving exposure to actual
or threatened death, serious injury, or sexual violence as required by PTSD Criterion A. The diagnosis of an
adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet all other
PTSD criteria (or criteria for another mental disorder). An adjustment disorder is also diagnosed when the symptom
pattern of PTSD occurs in response to a stressor that does not meet PTSD Criterion A (e.g., spouse leaving, being
fired) (Strain and Friedman 2011).

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Other posttraumatic disorders and conditions

Not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed
to PTSD. The PTSD diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent
symptoms. If the symptom response pattern to the extreme stressor meets criteria for another mental disorder, these
diagnoses should be given instead of, or in addition to, PTSD. Other diagnoses and conditions are excluded if they are
better explained by PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic reminders). If
severe, symptom response patterns to the extreme stressor that meet criteria for another mental disorder may
warrant a separate diagnosis (e.g., dissociative amnesia) in addition to PTSD.

Acute stress disorder

Acute stress disorder is distinguished from PTSD because the symptom pattern in acute stress disorder is restricted
to a duration of 3 days to 1 month following exposure to the traumatic event.

Anxiety disorders and obsessive-compulsive disorder

In OCD, there are recurrent intrusive thoughts, but these meet the definition of an obsession. In addition, the
intrusive thoughts are not related to an experienced traumatic event, compulsions are usually present, and other
symptoms of PTSD or acute stress disorder are typically absent. Neither the arousal and dissociative symptoms of
panic disorder nor the avoidance, irritability, and anxiety of generalized anxiety disorder are associated with a
specific traumatic event. The symptoms of separation anxiety disorder are clearly related to separation from home or
family, rather than to a traumatic event.

Major depressive disorder

Major depression may or may not be preceded by a traumatic event and should be diagnosed if full criteria have been
met. Specifically, major depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it
include a number of symptoms from PTSD Criterion D or E. However, if full criteria for PTSD are also met, both
diagnoses may be given.

Attention-deficit/hyperactivity disorder

Both ADHD and PTSD may include problems in attention, concentration, and learning. In contrast to ADHD, where
the problems in attention, concentration, and learning must have their onset prior to age 12, in PTSD the symptoms
have their onset following exposure to a Criterion A traumatic event. In PTSD, disruptions in the individual’s
attention and concentration can be attributable to alertness to danger and exaggerated startle responses to reminders
of the trauma.

Personality disorders

Interpersonal difficulties that had their onset, or were greatly exacerbated, after exposure to a traumatic event may
be an indication of PTSD, rather than a personality disorder, in which such difficulties would be expected
independently of any traumatic exposure.

Dissociative disorders

Dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder may or may not be
preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms. When full PTSD
criteria are also met, however, the PTSD “with dissociative symptoms” subtype should be considered.

Functional neurological symptom disorder (conversion disorder)

New onset of somatic symptoms within the context of posttraumatic distress might be an indication of PTSD rather
than functional neurological symptom disorder.

Psychotic disorders

Flashbacks in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may
occur in schizophrenia, brief psychotic disorder, and other psychotic disorders; depressive and bipolar disorders with

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psychotic features; delirium; substance/medication-induced disorders; and psychotic disorders due to another
medical condition. PTSD flashbacks are distinguished from these other perceptual disturbances by being directly
related to the traumatic experience and by occurring in the absence of other psychotic or substance-induced features.

Traumatic brain injury

Some types of traumatic events increase risk of both PTSD and traumatic brain injury (TBI) because they can
produce head injuries (e.g., military combat, bomb blasts, child physical abuse, intimate partner violence, violent
crime, motor vehicle or other accidents). In such cases, individuals presenting with PTSD may also have TBI, and
those presenting with TBI may also have PTSD. Individuals with PTSD who also have TBI may have persistent
postconcussive symptoms (e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits)
(Ackland et al. 2019; Bryant 2011; Iverson et al. 2017). However, such symptoms may also occur in non-brain-

injured populations, including individuals with PTSD (Meares et al. 2008). Because symptoms of PTSD and TBI-
related neurocognitive symptoms can overlap, a differential diagnosis between PTSD and neurocognitive disorder
symptoms attributable to TBI may be possible based on the presence of symptoms that are distinctive to each
presentation. Whereas reexperiencing and avoidance are characteristic of PTSD and not the effects of TBI, persistent
disorientation and confusion are more specific to TBI (neurocognitive effects) than to PTSD. TBI-related memory
problems concerning the traumatic event are typically attributable to injury-related inability to encode the
information, whereas PTSD-related memory problems typically reflect dissociative amnesia. Sleep difficulties are
common to both disorders.

Comorbidity
Individuals with PTSD are more likely than those without PTSD to have symptoms that meet diagnostic criteria for at
least one other mental disorder, such as depressive, bipolar, anxiety, or substance use disorders (Bryant et al.
2011; Goldstein et al. 2016; Greer et al. 2020; Smith et al. 2016). PTSD is also associated with increased risk of major
neurocognitive disorder (Yaffe et al. 2010). In a U.S.-based study, women were more likely to develop PTSD
following a mild TBI (Yue et al. 2019). Although most young children with PTSD also have at least one other
diagnosis, the patterns of comorbidity are different than in adults, with oppositional defiant disorder and separation
anxiety disorder predominating (Scheeringa et al. 2005; Scheeringa et al. 2006).

References: Posttraumatic Stress Disorder

Ackland PE, Greer N, Sayer NA, et al: Effectiveness and harms of mental health treatments in service members and
veterans with deployment-related mild traumatic brain injury. J Affect Disord 252:493–501, 2019

Adams V: Suffering the winds of Lhasa: politicized bodies, human rights, cultural difference, and humanism in
Tibet. Med Anthropol Q 12(1):74–102, 1998

Affi TO, Enns MW, Cox BJ, et al: Population attributable fractions of psychiatric disorders and suicide ideation and
attempts associated with adverse childhood experiences. Am J Public Health 98(5):946–952, 2008

Alcántara C, Casement MD, Lewis-Fernández R: Conditional risk for PTSD among Latinos: a systematic review of
racial/ethnic differences and sociocultural explanations. Clin Psychol Rev 33(1):107–119, 2013

Andrews B, Brewin CR, Philpott R, Stewart L: Delayed-onset posttraumatic stress disorder: a systematic review of
the evidence. Am J Psychiatry 164(9):1319–1326, 2007

Basile KC, Smith SG, Breiding M, et al: Sexual Violence Surveillance: Uniform Definitions and Recommended Data
Elements, Version 2.0. Atlanta, GA, National Center for Injury Prevention and Control, Centers for Disease Control
and Prevention, 2013

Beals J, Manson SM, Shore JH, et al: The prevalence of posttraumatic stress disorder among American Indian
Vietnam veterans: disparities and context. J Trauma Stress 15(2):89–97, 2002

Bensimon M, Solomon Z, Horesh D: The utility of Criterion A under chronic national terror. Isr J Psychiatry Relat
Sci 50(2):81–83, 2013

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 13/18

Bentley KH, Franklin JC, Ribeiro JD, et al: Anxiety and its disorders as risk factors for suicidal thoughts and
behaviors: a meta-analytic review. Clin Psychol Rev 43:30–46, 2016

Binder EB, Bradley RG, Liu W, et al: Association of FKBP5 polymorphisms and childhood abuse with risk of
posttraumatic stress disorder symptoms in adults. JAMA 299(11):1291–1305, 2008

Blanco C: Epidemiology of PTSD, in Post-Traumatic Stress Disorder. Edited
by Stein DJ, Friedman MJ, Blanco C. Oxford, England, Wiley-Blackwell, 2011, pp 49–74

Blanco C, Hoertel N, Wall MM, et al: Toward understanding sex differences in the prevalence of posttraumatic
stress disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin
Psychiatry 79(2):16m11364, 2018

Bockers E, Roepke S, Michael L, et al: The role of generalized explicit and implicit guilt and shame in interpersonal
traumatization and posttraumatic stress disorder. J Nerv Ment Dis 204(2):95–99, 2016

Breslau N: The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma Violence
Abuse 10(3):198–210, 2009

Brewin CR, Patel T: Auditory pseudohallucinations in United Kingdom war veterans and civilians with
posttraumatic stress disorder. J Clin Psychiatry 71(4):419–425, 2010

Bryant RA: Mental disorders and traumatic injury. Depress Anxiety 28(2):99–102, 2011 21284062

Bryant RA, Friedman MJ, Spiegel D, et al: A review of acute stress disorder in DSM-5. Depress Anxiety 28(9):802–
817, 2011

Budden A: The role of shame in posttraumatic stress disorder: a proposal for a socio-emotional model for DSM-
V. Soc Sci Med 69(7):1032–1039, 2009

Bustamante LHU, Cerqueira RO, Leclerc E, Brietzke E: Stress, trauma, and posttraumatic stress disorder in
migrants: a comprehensive review. Braz J Psychiatry 40(2):220–225, 2017

Caspi Y, Slobodin O, Klein E: Cultural perspectives on the aftereffects of combat trauma: review of a community
study of Bedouin IDF servicemen and their families. Rambam Maimonides Med J 6(2):e0021, 2015

Charlson F, van Ommeren M, Flaxman A, et al: New WHO prevalence estimates of mental disorders in conflict
settings: a systematic review and meta-analysis. Lancet 394(10194):240–248, 2019

Chou T, Asnaani A, Hofmann SG: Perception of racial discrimination and psychopathology across three U.S. ethnic
minority groups. Cultur Divers Ethnic Minor Psychol 18(1):74–81, 2012

Chung MC, Preveza E, Papandreou K, Prevezas N: Spinal cord injury, posttraumatic stress, and locus of control
among the elderly: a comparison with young and middle-aged patients. Psychiatry 69(1):69–80, 2006

Cougle JR, Resnick H, Kilpatrick DG: Does exposure to interpersonal violence increase risk of PTSD following
subsequent exposure? Behav Res Ther 47(12):1012–1017, 2009

Davidson JRT, Connor KM, Lee L-C: Beliefs in karma and reincarnation among survivors of violent trauma—a
community survey. Soc Psychiatry Psychiatr Epidemiol 40(2):120–125, 2005

Doric A, Stevanovic D, Stupar D, et al: UCLA PTSD Reaction Index for DSM-5 (PTSD-RI-5): a psychometric study
of adolescents sampled from communities in eleven countries. Eur J Psychotraumatol 10(1):1605282, 2019

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 14/18

Duncan LE, Ratanatharathorn A, Aiello AE, et al: Largest GWAS of PTSD (N=20 070) yields genetic overlap with
schizophrenia and sex differences in heritability. Mol Psychiatry 23(3):666–673, 2018

Dworkin ER, Menon SV, Bystrynski J, Allen NE: Sexual assault victimization and psychopathology: a review and
meta-analysis. Clin Psychol Rev 56:65–81, 2017

Friedman MJ, Resick PA, Bryant RA, Brewin CR: Considering PTSD for DSM-5. Depress Anxiety 28(9):750–
769, 2011

Gelernter J, Sun N, Polimanti R, et al: Genome-wide association study of post-traumatic stress disorder
reexperiencing symptoms in >165,000 US veterans. Nat Neurosci 22(9):1394–1401, 2019

Goldstein RB, Smith SM; Chou SP, et al: The epidemiology of DSM-5 posttraumatic stress disorder in the United
States: results from the National Epidemiologic Survey on Alcohol and Related Conditions–III. Soc Psychiatry
Psychiatr Epidemiol 51(8):1137–1148, 2016

Gradus JL, Qin P, Lincoln AK, et al: Sexual victimization and completed suicide among Danish female
adults. Violence Against Women 18(5):552–561, 2012 22790557

Gradus JL, Antonsen S, Svensson E, et al: Trauma, comorbidity, and mortality following diagnoses of severe stress
and adjustment disorders: a nationwide cohort study. Am J Epidemiology 182:451–458, 2015

Greer N, Sayer NA, Spoont M, et al: Prevalence and severity of psychiatric disorders and suicidal behavior in service
members and veterans with and without traumatic brain injury: systematic review. J Head Trauma
Rehabil 35(1):1–13, 2020

Gupta MA: Review of somatic symptoms in post-traumatic stress disorder. Int Rev Psychiatry 25(1):86–99, 2013

Hansen M, Ross J, Armour C: Evidence of the dissociative PTSD subtype: a systematic literature review of latent
class and profile analytic studies of PTSD. J Affect Disord 213:59–69, 2017

Hinton DE, Good B: The culturally sensitive assessment of trauma: eleven analytic perspectives, a typology of
errors, and the multiplex models of distress generation, in Culture and PTSD: Trauma in Global and Historical
Perspective. Edited by Hinton D, Good B. Philadelphia, University of Pennsylvania Press, 2016, pp 50–114

Hinton D, Lewis-Fernández R: The cross-cultural validity of posttraumatic stress disorder: implications for DSM-
5. Depress Anxiety 28(9):783–801, 2011

Iverson KM, Dardis CM, Pogoda TK: Traumatic brain injury and PTSD symptoms as a consequence of intimate
partner violence. Compr Psychiatry 74:80–87, 2017

Jakšic N, Brajkovic L, Ivezic E, et al: The role of personality traits in posttraumatic stress disorder
(PTSD). Psychiatr Danub 24(3):256–266, 2012

Janoff-Bulman R: Shattered Assumptions: Towards a New Psychology of Trauma. New York, Free Press, 1992

Jobson L: Drawing current posttraumatic stress disorder models into the cultural sphere: the development of the
“threat to the conceptual self” model. Clin Psychol Rev 29(4):368–381, 2009

Kenny MG: Trauma, time, illness, and culture: an anthropology approach to traumatic memory, in Tense Past :
Cultural Essays in Trauma and Memory. Edited by Antze P, Lambek M. New York, Routledge, 1996, pp 151–171

Kessler RC, Sonnega A, Bromet E, et al: PTSD in the National Comorbidity Survey. Arch Gen
Psychiatry 52(12):1048–1060, 1995

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 15/18

Kessler RC, Berglund P, Demler O, et al: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in
the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593–602, 2005a

Kessler RC, Chui WT, Demler O, et al: Prevalence, severity, and comorbdity of 12-months DSM-IV disorders in the
National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627, 2005b

Kilpatrick DG, Ruggiero KJ, Acierno RE, et al: Violence and risk of PTSD, major depression, substance
abuse/dependence, and comorbidity: results from the National Survey of Adolescents. J Consult Clin
Psychol 71(4):692–700, 2003a

Kilpatrick DG, Saunders BE, Smith DW: Youth Victimization: Prevalence and Implications. Washington, DC, U.S.
Department of Justice, National Institute of Justice, 2003b, pp 1–19

Kilpatrick DG, Resnick HS, Milanak ME, et al: National estimates of exposure to traumatic events and PTSD
prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress 26(5):537–547, 2013

Kimerling R, Makin-Byrd K, Louzon S, et al: Military sexual trauma and suicide mortality. Am J Prev
Med 50(6):684–691, 2016

Klomek AB, Sourander A, Elonheimo H: Bullying by peers in childhood and effects on psychopathology, suicidality,
and criminality in adulthood. Lancet Psychiatry 2(10):930–941, 2015

Koenen KC, Ratanatharathorn A, Ng L, et al: Posttraumatic stress disorder in the World Mental Health
Surveys. Psychol Med 47(13):2260–2274, 2017

Kohrt BA, Hruschka DJ: Nepali concepts of psychological trauma: the role of idioms of distress, ethnopsychology
and ethnophysiology in alleviating suffering and preventing stigma. Cult Med Psychiatry 34(2):322–352, 2010

Kohrt BA, Rasmussen A, Kaiser BN, et al: Cultural concepts of distress and psychiatric disorders: literature review
and research recommendations for global mental health epidemiology. Int J Epidemiol 43(2):365–406, 2014

Kugler BB, Bloom M, Kaercher LB, et al: Somatic symptoms in traumatized children and adolescents. Child
Psychiatry Hum Dev 43(5):661–673, 2012

Lewis-Fernández R, Kirmayer LJ: Cultural concepts of distress and psychiatric disorders: understanding symptom
experience and expression in context. Transcult Psychiatry 56(4):786–803, 2019

Lifton RJ: The Broken Connection: On Death and the Continuity of Life. New York, Simon & Schuster, 1979

McClendon J, Perkins D, Copeland LA, et al: Patterns and correlates of racial/ethnic disparities in posttraumatic
stress disorder screening among recently separated veterans. J Anxiety Disord 68:102145, 2019

Meares S, Shores EA, Taylor AJ, et al: Mild traumatic brain injury does not predict acute postconcussion
syndrome. J Neurol Neurosurg Psychiatry 79(3):300–306, 2008

Merikangas KR, He J-P, Burstein M, et al: Lifetime prevalence of mental disorders in U.S. adolescents: results from
the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc
Psychiatry 49(10):980–989, 2010

Miller KE, Rasmussen A: War exposure, daily stressors, and mental health in conflict and post-conflict settings:
bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med 70(1):7–16, 2010

Mintzer L, Stuber M, Seacord D, et al: Traumatic stress symptoms in adolescent organ transplant
recipients. Pediatrics 115(6):1640–1644, 2005

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 16/18

Naifeh JA, Ursano RJ, Kessler RC, et al: Transition to suicide attempt from recent suicide ideation in U.S. Army
soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Depress
Anxiety 36(5):412–422, 2019 30549394

Nievergelt CM, Maihofer AX, Klengel T, et al: Largest genome-wide association study for PTSD identifies genetic
risk loci in European and African ancestries and implicates novel biological pathways. bioRxiv 458562; posted
November 1, 2018

Nock MK, Hwang I, Sampson NA, Kessler RC: Mental disorders, comorbidity and suicidal behavior: results from
the National Comorbidity Survey Replication. Mol Psychiatry 15(8):868–876, 2010

Olatunji BO, Cisler JM, Tolin DF: Quality of life in the anxiety disorders: a meta-analytic review. Clin Psychol
Rev 27(5):572–581, 2007

Panagioti M, Gooding PA, Triantafyllou K, Tarrier N: Suicidality and posttraumatic stress disorder (PTSD) in
adolescents: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 50(4):525–537, 2015

Perilla JL, Norris FH, Lavizzo EA: Ethnicity, culture, and disaster response: identifying and explaining ethnic
differences in PTSD six months after Hurricane Andrew. J Soc Clin Psychol 21:20–45, 2002

Pynoos RS, Steinberg AM, Layne CM, et al: DSM-5 PTSD diagnostic criteria for children and adolescents: a
developmental perspective and recommendations. J Trauma Stress 22(5):391–398, 2009

Ramikie TS, Ressler KJ: Mechanisms of sex differences in fear and posttraumatic stress disorder. Biol
Psychiatry 83(10):876–885, 2018

Ranney ML, Patena JV, Nugent N, et al: PTSD, cyberbullying and peer violence: prevalence and correlates among
adolescent emergency department patients. Gen Hosp Psychiatry 39:32–38, 2016

Rasmussen A, Nguyen L, Wilkinson J, et al: Rates and impact of trauma and current stressors among Darfuri
refugees in Eastern Chad. Am J Orthopsychiatry 80(2):227–236, 2010

Rasmussen A, Keatley E, Joscelyne A: Posttraumatic stress in emergency settings outside North America and
Europe: a review of the emic literature. Soc Sci Med 109:44–54, 2014

Rauch S, Morales KH. Zubritsky C, et al: Posttraumatic stress, depression and health among older adults in primary
care. Am J Geriatr Psychiatry 14(4):316–324, 2006

Rivollier F, Peyre H, Hoertel N, et al: Sex differences in DSM-IV posttraumatic stress disorder symptoms
expression using item response theory: a population-based study. J Affect Disord 187:211–217, 2015

Ryder AL, Azcarate PM, Cohen BE: PTSD and physical health. Curr Psychiatry Rep 20(12):116, 2018 30367276

Sareen J, Houlahan T, Cox B, Asmundson GJ: Anxiety disorders associated with suicidal ideation and suicide
attempts in the National Comorbidity Survey. J Nerv Ment Dis 193(7):450–454, 2005

Sareen J, Cox BJ, Stein MB, et al: Physical and mental comorbidity, disability, and suicidal behavior associated with
posttraumatic stress disorder in a large community sample. Psychosom Med 69(3):242–248, 2007

Sayer NA, Carlson K, Schnurr P: Assessment of functioning and disability in individuals with PTSD, in Clinical
Manual for the Management of Posttraumatic Stress Disorder. Edited by Benedek D, Wynn GH. Washington,
DC, American Psychiatric Publishing, 2011, pp 255–287

Scheeringa MS, Zeanah CH, Myers L, Putnam FW: Predictive validity in a prospective follow-up of PTSD in
preschool children. J Am Acad Child Adolesc Psychiatry 44(9):899–906, 2005

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 17/18

Scheeringa MS, Wright MJ, Hunt JP, Zeanah CH: Factors affecting the diagnosis and prediction of PTSD
symptomatology in children and adolescents. Am J Psychiatry 163(4):644–651, 2006

Scheeringa MS, Zeanah CH, Cohen JA: PTSD in children and adolescents: toward an empirically based
algorithm. Depress Anxiety 28(9):770–782, 2011

Schnurr PP, Lunney CA, Bovin MJ, Marx BP: Posttraumatic stress disorder and quality of life: extension of findings
to veterans of the wars in Iraq and Afghanistan. Clin Psychol Rev 29(8):727–735, 2009

Shala M, Morina N, Gross CS, et al: A point in the heart: concepts of emotional distress among Albanian-speaking
immigrants in Switzerland. Cult Med Psychiatry 44(1):1–34, 2020

Sibrava NJ, Bjornsson AS, Pérez Benítez ACI, et al: Posttraumatic stress disorder in African American and Latinx
adults: clinical course and the role of racial and ethnic discrimination. Am Psychol 74(1):101–116, 2019

Smith K, Bryant RA: The generality of cognitive bias in acute stress disorder. Behav Res Ther 38(7):709–715, 2000

Smith AK, Ratanatharathorn A, Maihofer AX, et al: Epigenome-wide meta-analysis of PTSD across 10 military and
civilian cohorts identifies novel methylation loci. bioRxiv 585109; posted March 21, 2019

Smith SM, Goldstein RB, Grant BF: The association between post-traumatic stress disorder and lifetime DSM-5
psychiatric disorders among veterans: data from the National Epidemiologic Survey on Alcohol and Related
Conditions–III (NESARC-III). J Psychiatr Res 82(20):16–22, 2016

Smith TC, Wingard DL, Ryan MA, et al: Prior assault and posttraumatic stress disorder after combat
deployment. Epidemiology 19(3):505–512, 2008

Spoont MR, Sayer NA, Kehle-Forbes SM, et al: A prospective study of racial and ethnic variation in VA
psychotherapy services for PTSD. Psychiatr Serv 68(3):231–237, 2017

Stein MB, Jang KL, Taylor S, et al: Genetic and environmental influences on trauma exposure and posttraumatic
stress disorder symptoms: a twin study. Am J Psychiatry 159(10):1675–1681, 2002

Strain JJ, Friedman MJ: Considering adjustment disorders as stress response syndromes for DSM-5. Depress
Anxiety 28(9):818–823, 2011

Street AE, Dardis CM: Using a social construction of gender lens to understand gender differences in posttraumatic
stress disorder. Clin Psychol Rev 66:97–105, 2018

Stuber ML, Kazak AE, Meeske K, et al: Predictors of posttraumatic stress symptoms in childhood cancer
survivors. Pediatrics 100(6):958–964, 1997

Thorp SR, Sones HM, Cook JM: Posttraumatic stress disorder among older adults, in Cognitive Behavior Therapy
With Older Adults: Innovations Across Care Settings. Edited by Sorocco KH, Lauderdale S. New
York, Springer, 2011, pp 189–217

van Huijstee J, Vermetten E: The dissociative subtype of post-traumatic stress disorder: research update on clinical
and neurobiological features. Curr Top Behav Neurosci 38:229–248, 2018

Vogt DS, King DW, King LA: Risk pathways for PTSD: making sense of the literature, in Handbook of PTSD:
Science and Practice. Edited by Friedman MJ, Keane TM, Resick PA. New York, Guilford, 2007, pp 99–115

Warda G, Bryant RA: Cognitive bias in acute stress disorder. Behav Res Ther 36(12):1177–1183, 1998

7/25/22, 9:25 PM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders 18/18

Yaffe K, Vittinghoff E, Lindquist K, et al: Posttraumatic stress disorder and risk of dementia among US
veterans. Arch Gen Psychiatry 67(6):608–613, 2010

Yue JK, Levin HS, Suen CG, et al; TRACK-TBI Investigators: Age- and sex-mediated differences in six-month
outcomes after mild traumatic brain injury in young adults: a TRACK-TBI study. Neurol Res 41(7):609–623, 2019