The document discusses PTSD criteria according to DSM-IV and DSM-V, screening tools for PTSD, differentials, comorbidities, and management options. It compares the diagnostic criteria between DSM-IV and DSM-V, noting changes made in DSM-V. Screening tools mentioned include PCL-C, PCL-5, and SPAN. Differentials discussed are trauma-related disorders, anxiety disorders, depression, and adjustment disorder. Comorbidities mentioned include psychological, physical, and increased mortality. Management options discussed include pharmacotherapy with SSRIs and SNRIs as first-line treatment, and trauma-focused CBT and EMDR as best evidence psychotherapies.

1. PTSD: criteria, Diagnosis,
commorbidities, management
By Dr. Emmanuel MUSONI-RWILILIZA, PGY2- Psychiatry
Supervised by: Dr Nomi LEVY-CARRICK

2. Plan
• 1. Introduction
• 2. DSM IV vs DSM V
• 3. screening tools/Instruments
• 4. Differentials
• 5.comorbidities
• 6. management options
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3. Introduction: Definition
• “An abnormal reaction to an
abnormal situation is normal
behavior.”
Viktor E. Frankl, Man's Search for Meaning
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4. Introduction: Def..
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 ’’Normal reaction to an abnormal situation’’
 Response to an exceptionally threatening or catastrophic event ex.
 Natural or man-made disaster
 Combat
 Serious accident
 Witnessing the violent death of others
 Being victim of torture, terrorism, rape or other crimes.
 Etc.

5. Introduction: Def…
• Many people who go through traumatic events have difficulty adjusting and
coping for a while, but they don't have PTSD — with time and good self-
care, they usually get better. But if the symptoms get worse or last for
months or even years and interfere with your functioning, you may have
PTSD.
Mayo Clinic Staff
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6. 8/12/2022 6

7. DSM IV vs DSM V
Depress Anxiety. PMC 2014 October 28.
DSM-IV criteria
A1. Exposure to actual or threatened death, serious injury, a
threat physical integrity of oneself or others
A2. Response to the event involved fear, helplessness, or
horror
B. Persistent re-experiencing One of five
C. Persistent avoidance and numbing Three of seven
D. Persistent hyperarousal Two of five
E. Duration of at least 1 month
F. Clinically significant distress /impairment
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DSM-5 criteria
A. Exposure to actual or threatened death, serious injury,
sexual violence
B. Persistent re-experiencing (One of five)
C. Persistent avoidance (One of two)
D. Persistent numbing (Two of four)
E. Persistent hyperarousal (Two of five)
F. Duration of at least 1 month
G. Clinically significant distress /impairment

8. ICD 10 vs ICD 11
Depress Anxiety. PMC 2014 October 28.
ICD-10 criteria
A. Exposure to a stressful event or situation of
exceptionally threatening catastrophic nature likely to
cause pervasive distress in almost anyone
B. Persistent re-experiencing
C. Avoidance
D. Either (1) or 2) below:
1. Inability to recall important aspects of the stressor
2. Persistent hyperarousal (Two of five)
E. Criteria B, C, and D must all be met within 6
months of the stressful event.
ICD-11 criteria
A. Exposure to a stressful event or situation of
exceptionally threatening horrific nature likely to
cause pervasive distress in almost anyone
B. Persistent re-experiencing that involves not only
remembering the TE, but also experiencing it as
occurring again
C. Avoidance
D. Persistent hyperarousal (i.e., heightened perception
of current threat)
E. Clinically significant functional impairment.
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9. DSM IV vs DSM V
DSM IV: A
• Traumatic event exposure with the presence
of:
• 1-person experienced, witnessed or was
confronted with an event or events that
involved actual or threatened death or
serious injury, or a threat to the physical
integrity of self or others
• 2-person’s response involved intense fear,
helplessness, or horror
DSM V: 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
• 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) (eg first responders
collecting human remains; police officers repeatedly
exposed to details of child abuse)
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10. DSM IV vs DSM V
DSM IV
B. The traumatic event is persistently re-experienced in one (or
more) of the following ways:
• 1-recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions
• 2-recurrent distressing dreams of the event
• 3-acting or feeling as if the traumatic event were recurring
• 4-Intense psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event
• 5-Physiological reactivity on exposure to internal or
external cues that symbolize or resemble an aspect of the
traumatic event.
DSM V
B. Presence of one (or more) of the following intrusion
symptoms associated with traumatic event(s), beginning after
the traumatic event(s) occurred:
• 1-recurrent, involuntary, and intrusive distressing memories
of the traumatic event(s)
• 2-recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic event(s)
• 3-Dissociative reactions (e.g. flashbacks) in which the
individual feels or acts as if the traumatic event(s) were
recurring.
• 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 traumatic event(s)
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11. DSM IV vs DSM V
DSM IV
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma), as
indicated by three (or more) of the following:
• 1-efforts to avoid thoughts, feelings, or conversations associated
with the trauma
• 2-efforts to avoid activities, places or people that arouse
recollections of the trauma
• 3-inability to recall an important aspect of the trauma
• 4-markedly diminished interest or participation in significant
activities
• 5-feeling of detachment or estrangement from others
• 6-restricted range of affect (e.g. unable to have loving feelings)
• 7-sense of a foreshortened future.
DSM V
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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12. DSM IV vs DSM V
DSM IV
• D. Persistent symptoms of increased arousal (not present before
the trauma), as indicated by two (or more) of the following:
• 1-difficulty falling or staying asleep
• 2-irritability or outbursts of anger
• 3-difficulty concentrating
• 4-hypervigilance
• 5-exaggerated startle response
DSM V
• D. Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidence by two (or more) of the following:
• 1-inability to remember an important aspect of the traumatic event(s)
• 2-persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world.
• 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.
• 5-Markedly diminished interest or participation in 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).
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13. DSM IV vs DSM V
DSM IV
E. Duration of the disturbance
(symptoms in B, C, and D) >1 month
F. The disturbance causes clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning.
DSM V
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
• 2-Reckless or self-destructive behavior
• 3-Hypervigilance
• 4-exaggerated startle response
• 5-problems with concentration
• 6-sleep disturbance
F. Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
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14. DSM IV vs DSM V
DSM IV
• G. none
• H none
• Specify if: Acute: if duration of symptoms is
less than 3 months
• Chronic: if duration of symptoms is 3
months or more
• Specify if:
• With delayed onset: if onset of symptoms
is at least 6 months after the stressor
DSM V
G. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
or 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
• 1-depersonalization
• 2-derealization
Specify if:
• With delayed expression: if the full diagnostic criteria
are not met until at least 6 months after the event.
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15. http://www.ptsd.va.gov/professional/assessment/screens/screens-for-ptsd.asp
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16. Screening Tools
http://www.ptsd.va.gov/professional/assessment/all_measures.asp
• PCL-C (DSM IV) and PCL-5 (DSM V)
• SPAN: 4 items: startle, physically upset,
anger and numbness).
• SPRINT: Short PTSD Rating Interview
• TSQ: trauma screening questionnaire
• SSS for PTSD: short screening scale
• PC-PTSD: Primary care
• BAI-PC: Beck Anxiety Inventory.
CAPS-CA-5: clinical administrated PTSD
scale.
M-PTSD: Mississippi
Childreen’s PTSD Inventory
CITES-2: children’s impact of TE scale.
DTS: Davidson trauma scale
CPTS-RI
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17. Differentials
• Trauma-related disorders : PTSD, complex PTSD, lasting personality change
following extreme stress, dissociative identity disorder, Ajustement disorder.
• Anxiety disorders, depression, addiction.
(Post-Traumatic Stress Disorder-a Diagnostic and Therapeutic Challenge,Ulrich Frommberger et al, Dtsch Arztebl Int 2014; 111(5): 59−65)
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18. Differentials
• – PTSD symptoms are associated with
the traumatic event and can be
triggered by recollections/reminders
• – Acute stress reaction: symptoms last
less than 1month (DSM criterion)
• – Adjustment disorders: less severe
trauma/stress; symptoms usually less
severe, or not all symptoms present.
• – Complex PTSD : more
wideranging, far-reaching
symptoms such as lasting mistrust;
affective dysregulation; disorders
affecting relationships, intimacy and
sexuality, identity, and self-
perception; chronic suicidal
thoughts; self-harm
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19. Comorbidities
• a) Psychological disorders:
• Affective disorder, anxiety disorder, somatization disorder, borderline personality
disorder, dependency, psychosis, dissociative identity disorder
• – b) Physical disorders:
• Following accidents; pain syndromes, cardiovascular, pulmonary, and
rheumatic diseases
• – c) Increased mortality.
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20. Management: Psychiatric pharmacotherapy for
PTSD
• Early intervention:
• – Effectiveness not guaranteed;
• to be avoided: benzodiazepines
• ● Complete clinical picture of PTSD:
• – Tricyclic antidepressants (TCAs):
• amitriptyline, imipramine
• – Monoaminoxydase (MAO) inhibitors:
• phenelzine, moclobemide
• – Selective serotonin reuptake inhibitors (SSRIs):
• paroxetine, sertraline, fluoxetine
– Selective serotonin and noradrenalin reuptake
inhibitors (SNRIs): venlafaxine
– Noradrenergic and specific serotonergic
antidepressants (NASSAs): mirtazapine
– Mood stabilizers: carbamazepine, lamotrigine
→ Authorized for the indication PTSD in Germany:
paroxetine (paroxetine and sertraline in the USA)
→ Cochrane Review: SSRIs are first-line drugs
→ Review of meta-analyses and guidelines:
SSRIs and SNRIs (venlafaxine) are first-line drugs
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21. Management: psychotherapy for PTSD
● Early intervention:
• Conflicting results, probably trauma-focused
cognitive behavioral therapy lasting several hours
● Best evidence psychotherapeutic approaches
(evaluated in randomized controlled trials [RCTs]):
• – Trauma-focused cognitive behavioral therapy (CBT)
• – Eye movement desensitization and reprocessing
(EMDR)
● Other promising treatments (evaluated in
RCTs):
– Imagery rescripting and reprocessing therapy
(IRRT), in combination with other methods only:
high effect sizes
– Narrative exposure therapy (NET)
– Brief eclectic psychotherapy (BEP)
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22. THANK YOU
Questions are welcome.
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