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++PTSD in DSM5 Și ICD 11 PDF

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V O L U M E 2 5 / N O .

2 I S S N : 1 0 5 0 -1 8 3 5 2 0 1 4

Research Quarterly
advancing science and pr omoting unders tanding of traum atic stress

Published by:
National Center for PTSD Literature on Matthew J. Friedman MD, Ph.D.
VA Medical Center (116D)
215 North Main Street
White River Junction
DSM-5 and ICD-11 National Center for PTSD

Vermont 05009-0001 USA


(802) 296-5132
FAX (802) 296-5135 Although its been more than a year since the fifth anxiety disorder, 2) ICD-11 has taken a much less
Email: ncptsd@va.gov edition of the American Psychiatric Associations conservative approach so that DSM-5s requirement
All issues of the PTSD Research (APA) Diagnostic and Statistical Manual (DSM-5) for a large burden of scientific proof to change any
Quarterly are available online at: has been published, articles regarding the new DSM-IV criterion has not been a guiding principle.
www.ptsd.va.gov criteria have been appearing since 2011. This is As a result, the ICD-11 revision looks much more
because, any revisions of the DSM-IV criteria for drastic than DSM-5, and 3) ICD-11 will include
Editorial Members: PTSD (whether removal, addition or modification Complex PTSD as a separate diagnosis, whereas
Editorial Director
of specific symptoms) had to be supported by DSM-5 will not.
Paula P. Schnurr, PhD
strong empirical evidence. As a result, review
Scientific Editor With this as a background, I believe the best way
articles and position papers were undertaken to
Fran H. Norris, PhD
synthesize all relevant empirical findings in order to structure this guide to the literature is by
Managing Editor to guide final decisions regarding the diagnostic identifying four different types of articles: 1) literature
Heather Smith, BA Ed
criteria. This process was true for all DSM-5 reviews and position papers that provide the
diagnoses, not just for PTSD (Kupfer, Kuhl, & Regier, rationale and scientific basis for DSM-5 criteria,
National Center Divisions: 2) position papers and reviews supporting proposed
2013) Given the strong empirical approach and
Executive
the high burden of proof required for changing any ICD-11 revisions, 3) criticisms of DSM-5, and
White River Jct VT
diagnostic criterion, the DSM-5 process was 4) research on DSM-5 and/or ICD-11 criteria.
Behavioral Science
essentially conservative. Therefore, it should come
Boston MA
as no surprise, that except for Criterion A2 (which Literature Reviews and Position Papers
Dissemination and Training
was removed), all 17 DSM-IV PTSD criteria were Regarding DSM-5 Criteria
Menlo Park CA
retained although, in some cases, greatly modified.
Clinical Neurosciences The following literature reviews are really position
In addition three new symptoms were added.
West Haven CT papers that were written by members of the
Other major changes in DSM-5 were: 1) establishing
Evaluation DSM-5 work group as they developed the DSM-5
a new DSM-5 diagnostic category, Trauma and
West Haven CT criteria. Most were published before DSM-5 was
Stressor-Related Disorders for PTSD (and acute
Pacific Islands finalized in 2013, therefore some recommendations
stress disorder, adjustment disorders, and others)
Honolulu HI in the position papers were not accepted by
so that PTSD is no longer classified as an anxiety
Womens Health Sciences disorder, 2) reconceptualizing PTSD broadly to APA when the DSM-5 criteria were finalized. The
Boston MA include posttraumatic anhedonic/dysphoric, articles are particularly useful for providing the
externalizing and dissociative clinical presentations empirical evidence underlying the rationale for
along with the original fear-based anxiety proposed revisions to DSM-IV criteria. Friedman
disorder, and 3) establishment of preschool and et al. (2011a) provided the rationale for creating
dissociative subtypes. the new trauma and stressor-related disorders
category in DSM-5 (which will also be the case in
Temporally overlapping the DSM-5 process, the ICD-11). At the time the article was written, there
World Health Organization has been developing was serious consideration of expanding that
the eleventh edition of its International Classification category to include dissociative disorders.
of Diseases (ICD-11). Although publication of Because the research is mixed on whether all
ICD-11 wont occur until 2015, it looks like the dissociative disorders are preceded by exposure
PTSD criteria will be very different than in DSM-5. to an aversive/traumatic event and because there
There are a number of reasons for this: 1) ICD-11 was room within the DSM-5 metastructure for two
has endorsed a narrow approach that will focus separate diagnostic categories, dissociative
exclusively on PTSD as a stress-induced fear-based disorders were eventually classified separately.

Continued on page 2

Authors Address: Matthew J. Friedman, MD, Ph.D. is affiliated with the National Center for PTSD, Department of Veterans
Affairs, White River Junction, VT 05009 and the Geisel School of Medicine, Dartmouth College, Hanover, NH 03755. Email
Address: Matthew.J.Friedman@Dartmouth.edu.
Continued from cover

Several articles (Friedman, et al., 2011b; Kilpatrick, 2013) described Other critiques concerned the stressor criterion, Criterion A.
the empirical data and rationale for the current DSM-5 PTSD Roberts et al. (2012), using data from 3,013 women enrolled in
diagnostic criteria with a four factor model replacing DSM-IVs The Nurses Health Study, reprised the important question
three factor model. Scheeringa and colleagues (2012) provided (Brewin et al., 2009) about the utility of Criterion A. Although
the empirical data and rationale for the new PTSD preschool DSM-5 attempted to reduce ambiguity about the distinction
subtype for traumatized children six and younger; the diagnostic between traumatic and non-traumatic events, these articles
symptom thresholds have been lowered and subjective symptoms suggest that what really matters is whether individuals exhibit
eliminated. Lanius and colleagues (2012) shared the evidence and PTSD symptoms whether or not they were exposed to Criterion A
rationale for inclusion of the new PTSD dissociative subtype that events. Bensimon and colleagues (2013) argued that both DSM-5
is based on latent class analyses, brain imaging data and a and ICD-11 suffer from a Euro-American bias that makes Criterion
different pattern of treatment responses to current cognitive- A refer, mostly, to single traumatic incidents rather than to chronic
behavioral treatments. Initially, it did not appear likely that a national traumatic stress where exposure to terror is persistent,
dissociative subtype would be accepted for DSM-5 (See Friedman constant and of national proportions. Zoellner and colleagues
et al., 2011a). However, newer evidence changed that including (2011) criticized the removal of PTSD from the anxiety disorders
findings from 25,018 respondents from 16 countries enrolled in category arguing that there was insufficient evidence to do so and
the World Mental Health Survey showing that 14% of PTSD cases that there is a compelling evidence base arguing that PTSD is an
met criteria for the dissociative subtype throughout the world and anxiety disorder. Zoellner et al. (2013) reviewed the forensic
that dissociation was associated with greater symptom severity, implications of the DSM-5 revisions and argued that by increasing
role impairment and suicidality (Stein et al., 2013). Readers who the heterogeneity of individuals receiving the PTSD diagnosis,
are especially interested in the Dissociative Subtype should read there will be continued confusion about what constitutes a
the special issue of the PTSD Research Quarterly (Volume 24/No. 4) traumatic stressor, difficulties with differential diagnosis, increased
that is devoted entirely to this topic. Finally, Hinton and Lewis- ease in malingering, and improper linking of symptoms to causes
Fernandez (2011) reviewed the cross-cultural applicability and of behavior. Finally, Young (2014) reviewed the research domain
validity of PTSD. In this regard, there was a genuine effort to criteria (RDoC) as an alternative approach to diagnosis with a
incorporate cross-cultural symptom expression within all DSM-5 specific emphasis on genetic-linked neurobiological endophenotypes
diagnostic categories, rather than relegating such symptoms to underlying phenomenologically-based diagnostic classification
an appendix, as in DSM-IV. Friedman (2013) discussed how schemes such as DSM-5 and ICD-11. Perhaps there will be
and why decisions were made that resulted in the final DSM-5 sufficient evidence to incorporate the RDoC approach into DSM-6
PTSD criteria. or ICD-12, but we are not at that stage at present. There are other
articles criticizing the DSM-5 approach, in general that are
ICD-11 beyond the scope of this review. The Journal of Traumatic Stress
devoted a lively special section to the DSM-5 criteria with an
Because the ICD-11 process is at least two years behind DSM-5,
initial discussion (Friedman, 2013a) followed by three commentaries
with a projected publication date in 2015, there are only a few
(Brewin, 2013; Kilpatrick, 2013; Maerker & Perkonigg, 2013) and
available articles to give us a glimpse of what is to come. Three
a final rebuttal (Friedman, 2013b).
articles lay out the rationale for the narrow approach to PTSD and
restriction to six symptoms (Brewin, 2013; Maerker et al., 2013; Research on DSM-5 and/or ICD-11 Criteria
Maerker & Perkonigg, 2013). This approach can be traced back to
an important article by Brewin and colleagues (2009) that clearly A big question has been how changes in DSM-IV criteria would
influenced the ICD-11 work group. Another key position paper is affect prevalence estimates in DSM-5. Kilpatrick and colleagues
that providing the rationale and supporting data from latent profile (2013) reported results from a national sample of almost 3,000
analysis for inclusion of Complex PTSD in ICD-11 (Cloitre et al., 2013). adults recruited from an online panel. Comparing results for
different definitions of Criterion A, they found that prevalence
Critiques estimates for DSM-5 were slightly lower than DSM-IV. The major
reasons for differences were tightening of Criterion A for indirect
A number of critiques exist of DSM-5. Galatzer-Levy and Bryant
exposure in DSM-5; elimination of DSM-IVs A2 Criterion, and the
(2013) argued that one consequence of (the DSM-5 PTSD
requirement of one avoidance symptom for DSM-5. Miller et al.
symptom) expansion is that it increases the amorphous nature of
(2013) reporting on the same online civilian sample as well as a
the classification so that there are now 636,120 ways to have
convenience sample of U.S. military Veterans found the final
PTSD. Young and colleagues (2014) took this one step further
DSM-5 criteria and the DSM-IV criteria to yield similar estimates
and argued that when the most common conditions that are
of 16.6% and 16.4%, respectively, for lifetime PTSD. Utilizing
comorbid with PTSD are considered (e.g., major depressive
confirmatory factor analyses, these authors demonstrated the
disorder, chronic pain, neurocognitive disorder due to traumatic
goodness-of-fit of the four factor DSM-5 model of PTSD.
brain injury, alcohol use disorder, somatic symptom disorder and
Item-response theory analyses indicated that psychogenic
borderline personality disorder) there are one quintillion ways to
amnesia (D1) and reckless/self-destructive behavior deviated from
have PTSD comorbidity. The DSM-5 response to this is that
other symptoms in their respective symptom cluster. Elhai et al.
PTSD ranked among the three psychiatric disorders with the
(2012), reporting on data from college students, found small
highest inter-rater reliability in the DSM-5 field trials, with major
differences in prevalence estimates between DSM-IV and DSM-5.
depressive disorder showing very low inter-rater reliability
Their data also conformed well with the DSM-5 four factor model.
(Regier et al., 2013).

PAGE 2 P T S D R E S E A R C H Q U A R T E R LY
Finally, correlations with depression were not enhanced, as The controversy about whether complex PTSD is a unique,
expected, in DSM-5, despite addition of two symptoms in the empirically based diagnosis in its own right has raged for
Negative Mood and Cognitions category. Carmassi and colleagues decades. Resick and colleagues (2012) concluded that available
(2013) found 87% overlap in PTSD diagnosis between DSM-IV evidence does not support a new diagnostic category at this time.
and DSM-5 among Armenian high school earthquake survivors. (See also Friedman et al., 2011a; Friedman, 2013a). Based on
Major reasons for non-overlap were the requirement of at least such reviews of the literature, complex PTSD was not included in
one avoidance symptom. DSM-5 although Sar (2011) provided a thoughtful argument for its
adoption as a subtype of DSM-5 PTSD. On the other hand,
Another set of published works have addressed PTSD trajectories, ICD-11 came to a very different conclusion and decided to
assessment, and its relationship to depression. Santiago et al. include Complex PTSD as a unique diagnosis, with the condition
(2013) reviewed longitudinal studies published between 1988 and that such individuals must first meet PTSD diagnostic criteria
2010 and found that PTSD due to intentional causes increased (Maerker et al., 2013). Cloitre et al., (2013) utilizing latent profile
over time, whereas non-intentional trauma-related PTSD trajectories analysis on 302 treatment seeking individuals, concluded that
decreased over time. Koffel, Polusny, Arbisi & Erber (2012) utilizing there is a valid distinction between PTSD and complex PTSD.
pre/post- deployment data from National Guard servicemembers Wolf et al., (2014) disagreed on the basis of data collected from
deployed to Iraq, observed that increased anger was most closely 2,695 community participants and 323 Veterans. They not only
associated with PTSD whereas negative expectations and concluded that their results do not support a distinction between
aggressive behaviors were less specific, showing equivalent PTSD and complex PTSD but that Cloitre and associates would
correlations with depression and substance use. have come to the same conclusion had they utilized a factor
mixed model analysis. Finally, Knefel and Lueger-Schuster (2013)
Two articles have shown good correlations between PTSDs reported PTSD prevalence among 229 Austrian adult survivors of
negative mood and cognitions factor and depressive symptoms, childhood abuse with regard to ICD-10 (53%) and ICD-11 (17%).
especially the non-somatic depression factor (Biehn et al., 2013; When individuals with complex PTSD are included, ICD-11
Contractor et al., 2014). This is consistent with Koffel et al. (2012) prevalence is increased to 38%, indicating that it is highly
and the general concerns of the ICD-11 work group regarding relevant for individuals with a complex trauma history.
the nonspecificity of these symptoms. On the other hand, it is
inconsistent with Elhai et al. (2012) who found a negligible change Final Remarks
in depression co-morbidity in DSM-5.
It is apparent from this brief review of the new literature on DSM-5
With the change in diagnostic criteria, it is crucial that PTSD and ICD-11 that we have just begun to investigate the scientific
assessment instruments be revised accordingly. Weathers, Marx, and clinical implications of these very different sets of diagnostic
Friedman & Schnurr (2014) provide a thoughtful review of how criteria which are based on very different conceptualizations of
each DSM-5 PTSD symptom has been translated in the new PTSD. These controversies will definitely result in important new
revision of the Clinician Administered PTSD Scale for DSM-5 research that will advance our scientific understanding of PTSD
(CAPS-5). They conclude that published and future studies are in order to develop the best treatments for PTSD.
likely to show substantial diagnostic correspondence between
DSM-IV and DSM-5 with the latter being somewhat more
conservative and restrictive. FEATURED ARTICLES

Two important papers comparing DSM-5 with ICD-11 have


Biehn, T.L., Elhai, J.D., Seligman, L.D., Tamburrino, M., Armour,
appeared although others are in various stages of preparation.
C., and Forbes, D. (2013). Underlying dimensions of DSM-5
ODonnell et al. (2014) compared PTSD prevalence according to
posttraumatic stress disorder and major depressive disorder
DSM-IV, DSM-5, ICD-10 and ICD-11 criteria respectively among
symptoms. Psychological Injury and Law, 6, 290-298. doi:10.1007/
510 randomly selected injury patients assessed 72 months s12207-013-9177-4 This study examined the relationship
post-trauma. ICD-11 prevalence, co-morbidity with depression between the underlying latent factors of major depression
and disability rates were lower than with the other three systems. symptoms and DSM-5 PTSD symptoms (American Psychiatric
Although there was great overlap between individuals who met Association, 2013). A nonclinical sample of 266 participants with
both DSM-5 and ICD-11 criteria, a substantial number met criteria a trauma history participated in the study. Confirmatory factor
for one but not for the other. Similar findings were reported by analyses were conducted to evaluate the fit
Stein et al. (2014) from 23,936 respondents from 13 countries of the DSM-5 PTSD model and dysphoria model, as well as a
included in the World Mental Health Survey. Only one-third of depression model comprised of somatic and nonsomatic factors.
broadly defined cases met criteria in all four classification The DSM-5 PTSD model demonstrated somewhat better fit over
schemes (e.g., DSM-IV/5 and ICD-10/11) and another third met the dysphoria model. Wald tests indicated that PTSDs negative
PTSD criteria in only one of the four systems. The authors alterations in cognitions and mood factor was more strongly
concluded that all four definitions (of PTSD) are providing related to depressions nonsomatic factor than its somatic factor.
information on unique clinically significant cases that are omitted This study furthers a nascent line of research examining the
from the other systems so that any one diagnostic system will relationship between PTSD and depression factors in order to
overlook many individuals who suffer from clinically significant better understand the nature of the high comorbidity rates
symptoms including distress and impairment (page 502). between the two disorders. Moreover, this study provides an
initial analysis of the new DSM-5 diagnostic criteria for PTSD.

VOLUME 25/NO. 2 2014 PAGE 3


FEATURED ARTICLES continued

Brewin, C.R., Lanius, R.A., Novac, A., Schnyder, U., and Galea, S. potential differences in the type of stressor and severity of impairment
(2009). Reformulating PTSD for DSM-V: Life after Criterion A. associated with each profile. Method: An LPA and related analyses
Journal of Traumatic Stress, 22, 366-373. doi:10.1002/jts.20443 were conducted on 302 individuals who had sought treatment for
The diagnosis of PTSD has been criticized on numerous grounds, interpersonal traumas ranging from chronic trauma (e.g., childhood
but principally for three reasons (a) the alleged pathologizing of abuse) to single-incident events (e.g., exposure to 9/11 attacks).
normal events, (b) the inadequacy of Criterion A, and (c) symptom Results: The LPA revealed three classes of individuals: (1) a complex
overlap with other disorders. The authors review these problems PTSD class defined by elevated PTSD symptoms as well as
along with arguments why the diagnosis is nevertheless worth disturbances in three domains of self-organization: affective
retaining in an amended form. A proposal for DSM-V is put forward dysregulation, negative self-concept, and interpersonal problems;
that involves abolishing Criterion A, narrowing the B criteria to (2) a PTSD class defined by elevated PTSD symptoms but low
focus on the core phenomena of flashbacks and nightmares, scores on the three self-organization symptom domains, and
and narrowing the C and D criteria to reduce overlap with other (3) a low symptom class defined by low scores on all symptoms
disorders. The potential advantages and disadvantages of this and problems. Chronic trauma was more strongly predictive of
formulation are discussed. complex PTSD than PTSD and, conversely, single-event trauma
was more strongly predictive of PTSD. In addition, complex PTSD
Carmassi, C., Akiskal, H.S., Yong, S.S., Stratta, P., Calderani, E. was associated with greater impairment than PTSD. The LPA
Massimetti, E., et al. (2013). Post-traumatic stress disorder in analysis was completed both with and without individuals with
DSM-5: Estimates of prevalence and criteria comparison versus borderline personality disorder (BPD) yielding identical results,
DSM-IV-TR in a non-clinical sample of earthquake survivors. suggesting the stability of these classes regardless of BPD
Journal of Affective Disorders, 151, 843-848. doi:10.1016/j.jad.2013. comorbidity. Conclusion: Preliminary data support the proposed
07.020 Background: The latest edition of DSM (DSM-5) introduced ICD-11 distinction between PTSD and complex PTSD and support
important revisions to PTSD symptomatological criteria, such as a the value of testing the clinical utility of this distinction in field
four-factor model and the inclusion of new symptoms. To date, trials. Replication of results is necessary.
only a few studies have investigated the impact that the proposed
DSM-5 criteria will have on prevalence rates of PTSD. Methods: An Contractor, A.A., Durham, T.A., Brennan, J.A., Armour, C., Wutrick, H.R.,
overall sample of 512 adolescents who survived the LAquila 2009 Frueh, B.C., et al. (2014). DSM-5 PTSDs symptom dimensions
earthquake and were previously investigated for the presence of and relations with major depressions symptom dimensions in
full and partial PTSD, using DSM-IV-TR criteria, were reassessed a primary care sample. Psychiatry Research, 215, 146-153.
according to DSM-5 criteria. All subjects completed the Trauma doi:10.1016/j.psychres.2013.10.015 Existing literature indicates
and Loss Spectrum-Self Report (TALS-SR). Results: A DSM-5 significant comorbidity between PTSD and major depression. We
PTSD diagnosis emerged in 39.8% of subjects, with a significant examined whether PTSDs dysphoria and mood/cognitions factors,
difference between the two sexes (p<0.001), and an overall 87.1% conceptualized by the empirically supported four-factor DSM-5
consistency with DSM-IV-TR. Most of the inconsistent diagnoses PTSD models, account for PTSDs inherent relationship with
that fulfilled DSM-IV-TR criteria but not DSM-5 criteria can be depression. We hypothesized that depressions somatic and
attributed to the subjects not fulfilling the new criterion C (active non-somatic factors would be more related to PTSDs dysphoria
avoidance). Each DSM-5 symptom was more highly correlated and mood/cognitions factors than other PTSD model factors.
with its corresponding symptom cluster than with other symptom Further, we hypothesized that PTSDs arousal would significantly
clusters, but two of the new symptoms showed moderate to weak mediate relations between PTSDs dysphoria and somatic/
item-cluster correlations. Among DSM-5 PTSD cases: 7 (3.4%) non-somatic depression. Using 181 trauma-exposed primary care
endorsed symptom D3; 151 (74%) D4; 28 (13.7%) both D3 and D4; patients, confirmatory factor analyses (CFA) indicated a well-fitting
75 (36.8%) E2. Limitations: The use of a self-report instrument; DSM-5 PTSD dysphoria model, DSM-5 numbing model and
no information on comorbidity; homogeneity of study sample; two-factor depression model. Both somatic and non-somatic
lack of assessment on functional impairment; the rates of depression factors were more related to PTSDs dysphoria and
DSM-IV-TR qualified PTSD in the sample was only 37.5%. mood/cognitions factors than to re-experiencing and avoidance
Conclusions: This study provides an inside look at the empirical factors; non-somatic depression was more related to PTSDs
performance of the DSM-5 PTSD criteria in a population exposed dysphoria than PTSDs arousal factor. PTSDs arousal did not
to a natural disaster, which suggests the need for replication in mediate the relationship between PTSDs dysphoria and somatic/
larger epidemiological samples. non-somatic depression. Implications are discussed.

Cloitre, M., Garvert, D.W., Brewin, C.R., Bryant, R.A., and Maercker, A. Elhai, J.D., Miller, M.E., Ford, J.D., Biehn, T.L., Palmieri, P.A., and
(2013). Evidence for proposed ICD-11 PTSD and complex PTSD: Frueh, B.C. (2012). Posttraumatic stress disorder in DSM-5:
A latent profile analysis. European Journal of Psychotraumatology, 4, Estimates of prevalence and symptom structure in a nonclinical
1-12. doi:10.3402/ejpt.v4i0.20706 Background: The WHO International sample of college students. Journal of Anxiety Disorder, 26, 58-64.
Classification of Diseases, 11th version (ICD-11), has proposed doi:10.1016/j.janxdis.2011.08.013 We empirically investigated
two related diagnoses, PTSD and complex PTSD within the recent proposed changes to the PTSD diagnosis for DSM-5 using
spectrum of trauma and stress-related disorders. Objective: To a non-clinical sample. A web survey was administered to 585
use latent profile analysis (LPA) to determine whether there are college students using the Stressful Life Events Screening
classes of individuals that are distinguishable according to the Questionnaire to assess for trauma exposure but with additions
PTSD and complex PTSD symptom profiles and to identify for the proposed traumatic stressor changes in DSM-5 PTSD.

PAGE 4 P T S D R E S E A R C H Q U A R T E R LY
FEATURED ARTICLES continued

For the 216 subjects endorsing previous trauma exposure and The major focus is on PTSD because it has received the most
nominating a worst traumatic event, we administered the original attention, regarding its proper placement among the psychiatric
PTSD Symptom Scale based on DSM-IV PTSD symptom criteria diagnoses. It is discussed whether PTSD should be considered
and an adapted version for DSM-5 symptoms, and the Center an anxiety disorder, a stress-induced fear circuitry disorder, an
for Epidemiological Studies-Depression Scale. While 67% of internalizing disorder, or a trauma and stressor-related disorder.
participants endorsed at least one traumatic event based on Then, ASD, AD, and DD are considered from a similar perspective.
DSM-IV PTSDs trauma classification, 59% of participants would Evidence is examined pro and con, and a conclusion is offered
meet DSM-5 PTSDs proposed trauma classification. Estimates recommending inclusion of this cluster of disorders in a section
of current PTSD prevalence were .4-1.8% points higher for the entitled Trauma and Stressor-Related Disorders. The
DSM-5 (vs. the DSM-IV) diagnostic algorithm. The DSM-5 recommendation to shift ASD and PTSD out of the anxiety
symptom set fit the data very well based on confirmatory factor disorders section reflects increased recognition of trauma as
analysis, and neither symptom sets factors were more correlated a precipitant, emphasizing common etiology over common
with depression. phenomenology. Similar considerations are addressed with
regard to AD and DD.
Friedman, M.J. (2013a). Finalizing PTSD in DSM-5: Getting here
from there and where to go next. Journal of Traumatic Stress, 26, Friedman, M.J., Resick, P.A., Bryant, R.A., and Brewin, C.R. (2011b).
548-556. doi:10.1002/jts.21840 The process that resulted in the Considering PTSD for DSM-5. Depression and Anxiety, 28,
diagnostic criteria for PTSD in the Diagnostic and Statistical 750-769. doi:10.1002/da.20767 This is a review of the relevant
Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric empirical literature concerning the DSM-IV-TR diagnostic criteria
Association) was empirically based and rigorous. There was a for PTSD. Most of this work has focused on Criteria A1 and A2,
high threshold for any changes in any DSM-IV diagnostic criterion. the two components of the A (Stressor) Criterion. With regard to A1,
The process is described in this article. The rationale is presented the review considers: (a) whether A1 is etiologically or temporally
that led to the creation of the new chapter, Trauma- and related to the PTSD symptoms; (b) whether it is possible to distinguish
Stressor-Related Disorders, within the DSM-5 metastructure. traumatic from non-traumatic stressors, and (c) whether A1
Specific issues discussed about the DSM-5 PTSD criteria should be eliminated from DSM-5. Empirical literature regarding
themselves include a broad versus narrow PTSD construct, the the utility of the A2 criterion indicates that there is little support
decisions regarding Criterion A, the evidence supporting other for keeping the A2 criterion in DSM-5. The B (reexperiencing),
PTSD symptom clusters and specifiers, the addition of the C (avoidance/numbing) and D (hyperarousal) criteria are also
dissociative and preschool subtypes, research on the new criteria reviewed. Confirmatory factor analyses suggest that the latent
from both Internet surveys and the DSM-5 field trials, the addition structure of PTSD appears to consist of four distinct symptom
of PTSD subtypes, the non-inclusion of complex PTSD, and clusters rather than the three-cluster structure found in DSM-IV.
comparisons between DSM-5 versus the World Health Associations It has also been shown that in addition to the fear-based symptoms
forthcoming International Classification of Diseases (ICD-11) emphasized in DSM-IV, traumatic exposure is also followed by
criteria for PTSD. The PTSD construct continues to evolve. dysphoric, anhedonic symptoms, aggressive/externalizing
In DSM-5, it has moved beyond a narrow fear-based anxiety symptoms, guilt/shame symptoms, dissociative symptoms,
disorder to include dysphoric/anhedonic and externalizing PTSD and negative appraisals about oneself and the world. A new set
phenotypes. The dissociative subtype may open the way to a of diagnostic criteria is proposed for DSM-5 that: (a) attempts to
fresh approach to complex PTSD. The preschool subtype sharpen the A1 criterion, (b) eliminates the A2 criterion, (c) proposes
incorporates important developmental factors affecting the four rather than three symptom clusters, and (d) expands the
expression of PTSD in young children. Finally, the very different scope of the B-E criteria beyond a fear-based context. The final
approaches taken by DSM-5 and ICD-11 should have a profound sections of this review consider: (a) partial/subsyndromal PTSD,
effect on future research and practice. (b) disorders of extreme stress not otherwise specified (DESNOS)/
complex PTSD, (c) cross- cultural factors, (d) developmental
Friedman, M.J., Resick, P.A., Bryant, R.A., Strain, J., Horowitz, M., factors, and (e) subtypes of PTSD.
and Spiegel, D. (2011a). Classification of trauma and stressor-
related disorders in DSM-5. Depression and Anxiety, 28, 737-749. Hinton, D.E., and Lewis-Fernndez, R. (2011). The cross-cultural
doi:10.1002/da.20845 This review examines the question of whether validity of posttraumatic stress disorder: Implications for DSM-5.
there should be a cluster of disorders, including the adjustment Depression and Anxiety, 28, 783-801. doi:10.1002/da.20753
disorders (ADs), acute stress disorder (ASD), PTSD, and the Background: There is considerable debate about the cross-cultural
dissociative disorders (DDs), in a section devoted to abnormal applicability of the PTSD category as currently specified. Concerns
responses to stress and trauma in the DSM-5. Environmental risk include the possible status of PTSD as a Western culture-bound
factors, including the individuals developmental experience, would disorder and the validity of individual items and criteria thresholds.
thus become a major diagnostic consideration. The relationship This review examines various types of cross-cultural validity of
of these disorders to one another is examined and also their the PTSD criteria as defined in DSM-IV-TR, and presents options
relationship to other anxiety disorders to determine whether they and preliminary recommendations to be considered for DSM-5.
are better grouped with anxiety disorders or a new specific Methods: Searches were conducted of the mental health literature,
grouping of trauma and stressor-related disorders. First how particularly since 1994, regarding cultural-, race-, or ethnicity-
stress responses have been classified since DSM-III is reviewed. related factors that might limit the universal applicability of the
diagnostic criteria of PTSD in DSM-IV-TR and the possible criteria

VOLUME 25/NO. 2 2014 PAGE 5


FEATURED ARTICLES continued

for DSM-5. Results: Substantial evidence of the cross-cultural Questionnaire data were collected pre- and postdeployment and
validity of PTSD was found. However, evidence of cross-cultural interview data were collected postdeployment. Scales to measure
variability in certain areas suggests the need for further research: the DSM-5 symptoms were created using structural analyses and
the relative salience of avoidance/numbing symptoms, the role were correlated with interview and self-report measures of PTSD,
of the interpretation of trauma-caused symptoms in shaping depression, and substance use. Results: The DSM-5 symptom of
symptomatology, and the prevalence of somatic symptoms. anger shows the most increase from pre- to postdeployment in
This review also indicates the need to modify certain criteria, participants diagnosed with PTSD. In addition, this scale showed
such as the items on distressing dreams and on foreshortened the strongest relation to PTSD and showed some evidence of
future, to increase their cross-cultural applicability. Text additions specificity. Other symptom scales, including those measuring
are suggested to increase the applicability of the manual across negative expectations and aggressive behaviors, showed
cultural contexts: specifying that cultural syndromes-such as equivalent correlations with PTSD, depression, and substance
those indicated in the DSM-IV-TR Glossary-may be a prominent use. Conclusions: It will be important to continue studying the
part of the trauma response in certain cultures, and that those specificity of anger with PTSD. Several of the other new and
syndromes may influence PTSD symptom salience and comorbidity. revised DSM-5 symptoms appear to be nonspecific, and it is
Conclusions: The DSM-IV-TR PTSD category demonstrates various unlikely that their inclusion in the diagnostic criteria for PTSD
types of validity. Criteria modification and textual clarifications are will improve differential diagnosis.
suggested to further improve its cross-cultural applicability.
Lanius, R.A., Brand, B., Vermetten, E., Frewen, P.A., and Spiegel, D.
Kilpatrick, D.G., Resnick, H.S., Milanak, M.E., Miller, M.W., (2012). The dissociative subtype of posttraumatic stress disorder:
Keyes, K.M., and Friedman, M.J. (2013). National estimates of Rationale, clinical and neurobiological evidence, and implications.
exposure to traumatic events and PTSD prevalence using Depression and Anxiety, 29, 701-708. doi:10.1002/da.21889
DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26, Background: Clinical and neurobiological evidence for a dissociative
537-547. doi:10.1002/jts.21848 Prevalence of PTSD defined subtype of PTSD has recently been documented. A dissociative
according to DSM-5 (2013) and DSM-IV (1994) was compared in subtype of PTSD is being considered for inclusion in the
a national sample of U.S. adults (N = 2,953) recruited from an forthcoming DSM-5 to address the symptoms of depersonalization
online panel. Exposure to traumatic events, PTSD symptoms, and derealization found among a subset of patients with PTSD.
and functional impairment were assessed online using a highly This article reviews research related to the dissociative subtype
structured, self-administered survey. Traumatic event exposure including antecedent, concurrent, and predictive validators as
using DSM-5 criteria was high (89.7%), and exposure to multiple well as the rationale for recommending the dissociative subtype.
traumatic event types was the norm. PTSD caseness was determined Methods: The relevant literature pertaining to the dissociative
using Same Event (i.e., all symptom criteria met to the same event subtype of PTSD was reviewed. Results: Latent class analyses
type) and Composite Event (i.e., symptom criteria met to a point toward a specific subtype of PTSD consisting of symptoms
combination of event types) definitions. Lifetime, past-12-month, of depersonalization and derealization in both Veteran and civilian
and past 6-month PTSD prevalence using the Same Event samples of PTSD. Compared to individuals with PTSD, those with
definition for DSM-5 was 8.3%, 4.7%, and 3.8% respectively. the dissociative subtype of PTSD also exhibit a different pattern
All 6 DSM-5 prevalence estimates were slightly lower than their of neurobiological response to symptom provocation as well as a
DSM-IV counterparts, although only 2 of these differences were differential response to current cognitive behavioral treatment
statistically significant. DSM-5 PTSD prevalence was higher designed for PTSD. Conclusions: We recommend that consideration
among women than among men, and prevalence increased with be given to adding a dissociative subtype of PTSD in the revision
greater traumatic event exposure. Major reasons individuals met of the DSM. This facilitates more accurate analysis of different
DSM-IV criteria, but not DSM-5 criteria were the exclusion of phenotypes of PTSD, assist in treatment planning that is informed
nonaccidental, nonviolent deaths from Criterion A, and the new by considering the degree of patients dissociativity, will improve
requirement of at least 1 active avoidance symptom. treatment outcome, and will lead to much-needed research about
the prevalence, symptomatology, neurobiology, and treatment of
Koffel, E., Polusny, M.A., Arbisi, P.A., and Erbes, C.R. (2012). individuals with the dissociative subtype of PTSD.
A preliminary investigation of the new and revised symptoms of
posttraumatic stress disorder in DSM-5. Depression and Anxiety, 29, Miller, M.W., Wolf, E.J., Kilpatrick, D., Resnick, H., Marx, B.P.,
731-738. doi:10.1002/da.21965 Background: Research has shown Holowka, D.W., et al. (2013). The prevalence and latent structure
that PTSD is highly comorbid with other mental disorders. The of proposed DSM-5 posttraumatic stress disorder symptoms in
DSM-5 marks an opportunity to increase the differential diagnosis U.S. national and Veteran samples. Psychological Trauma: Theory,
of PTSD by emphasizing symptoms that are specific to PTSD Research, Practice, and Policy, 5, 501-512. doi:10.1037/a0029730
and deemphasizing symptoms that are common to many mental The Diagnostic and Statistical Manual, Fourth Edition (DSMIV)
disorders. This study analyzes the new and revised PTSD symptom is currently undergoing revisions in advance of the next edition,
criteria proposed for DSM-5 by examining their relations with DSM-5. The DSM-5 posttraumatic stress disorder workgroup
diagnoses and measures of PTSD. In addition, we report the has proposed numerous changes to the PTSD diagnosis. These
specificity of DSM-5 symptoms with PTSD compared to depressive include the addition of new symptoms, revision of existing ones,
disorders and substance use. Methods: This study utilized pre- and and a new four-cluster organization (Friedman, Resick, Bryant,
postdeployment data collected from a sample of 213 National & Brewin, 2011). We conducted two Internet-based surveys to
Guard Brigade Combat Team soldiers who were deployed to Iraq. provide preliminary information about how proposed changes

PAGE 6 P T S D R E S E A R C H Q U A R T E R LY
FEATURED ARTICLES continued

might impact PTSD prevalence and clarify the latent structure of separate occasions, in clinical settings, and evaluated with usual
the new symptom set. We used a newly developed instrument to clinical interview methods. Method: Eleven academic centers in the
assess event exposure and lifetime and current DSM-5 PTSD United States and Canada were selected, and each was assigned
symptoms among a nationally representative sample of American several target diagnoses frequently treated in that setting.
adults (N = 2,953) and a clinical convenience sample of U.S. Consecutive patients visiting a site during the study were screened
military Veterans (N = 345). Results from both samples indicated and stratified on the basis of DSM-IV diagnoses or symptomatic
that the originally proposed DSM-5 symptom criteria (i.e., requiring presentations. Patients were randomly assigned to two clinicians
1 B, 1 C, 3 D, and 3 E symptoms) yielded considerably lower for a diagnostic interview; clinicians were blind to any previous
PTSD prevalence estimates compared with DSMIV estimates. diagnosis. All data were entered directly via an Internet-based
These estimates were more comparable when the DSM-5 D and software system to a secure central server. Detailed research
E criteria were relaxed to 2 symptoms each (i.e., the revised design and statistical methods are presented in an accompanying
proposal). Confirmatory factor analyses (CFA) indicated that the article. Results: There were a total of 15 adult and eight child/
factor structure implied by the four-symptom criteria provided adolescent diagnoses for which adequate sample sizes were
adequate fit to the data in both samples, and a DSM-5 version obtained to report adequately precise estimates of the intraclass
of a dysphoria model (Simms, Watson, & Doebbeling, 2002) kappa. Overall, five diagnoses were in the very good range
yielded modest improvement in fit. Item-response theory and (kappa=0.600.79), nine in the good range (kappa=0.400.59),
CFA analyses indicated that the psychogenic amnesia and new six in the questionable range (kappa=0.200.39), and three in the
reckless/self-destructive behavior symptom deviated from the unacceptable range (kappa values <0.20). Eight diagnoses had
others in their respective symptom clusters. Implications for final insufficient sample sizes to generate precise kappa estimates at
formulations of DSM-5 PTSD criteria are discussed. any site. Conclusions: Most diagnoses adequately tested had good
to very good reliability with these representative clinical populations
ODonnell, M.L., Alkemade, N., Nickerson, A., Creamer, M., assessed with usual clinical interview methods. Some diagnoses
McFarlane, A.C., Silove, D., et al. [in press] Impact of the diagnostic that were revised to encompass a broader spectrum of symptom
changes to post-traumatic stress disorder for DSM-5 and expression or had a more dimensional approach tested in the good
the proposed changes to ICD-11. British Journal of Psychiatry. to very good range.
Background: There have been changes to the criteria for diagnosing
PTSD in DSM-5 and changes are proposed for ICD-11. Aims: To Resick, P.A., Bovin, M.J., Calloway, A.L., Dick, A.M., King, M.W.,
investigate the impact of the changes to diagnostic criteria for Mitchell, K.S., et al. (2012). A critical evaluation of the complex
PTSD in DSM-5 and the proposed changes in ICD-11 using a large PTSD literature: Implications for DSM-5. Journal of Traumatic
multisite trauma-exposed sample and structured clinical interviews. Stress, 25, 241-251. doi:10.1002/jts.21699 Complex PTSD has
Method: Randomly selected injury patients admitted to four hospitals been proposed as a diagnosis for capturing the diverse clusters
were assessed 72 months post trauma (n = 510). Structured clinical of symptoms observed in survivors of prolonged trauma that are
interviews for PTSD and major depressive episode, as well as outside the current definition of PTSD. Introducing a new diagnosis
self-report measures of disability and quality of life were administered. requires a high standard of evidence, including a clear definition
Results: Current prevalence of PTSD under DSM-5 scoring was not of the disorder, reliable and valid assessment measures, support
significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, p = 0.59). for convergent and discriminant validity, and incremental validity
However, the ICD-11 prevalence was significantly lower than ICD-10 with respect to implications for treatment planning and outcome.
(3.3% v. 9.0%, z = -3.8, p<0.001). The PTSD current prevalence In this article, the extant literature on complex PTSD is reviewed
was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, within the framework of construct validity to evaluate the proposed
z = 2.5, p = 0.01). Using ICD-11 tended to show lower rates of diagnosis on these criteria. Although the efforts in support of
comorbidity with depression and a slightly lower association with complex PTSD have brought much needed attention to limitations
disability. Conclusions: The diagnostic systems performed in different in the trauma literature, we conclude that available evidence does
ways in terms of current prevalence rates and levels of comorbidity not support a new diagnostic category at this time. Some directions
with depression, but on other broad key indicators they were for future research are suggested.
relatively similar. There was overlap between those with PTSD
diagnosed by ICD-11 and DSM-5 but a substantial portion met one Scheeringa, M.S., Myers, L., Putnam, F.W., and Zeanah, C.H. (2012).
but not the other set of criteria. This represents a challenge for Diagnosing PTSD in early childhood: An empirical assessment
research because the phenotype that is studied may be markedly of four approaches. Journal of Traumatic Stress, 25, 359-367.
different according to the diagnostic system used. doi:10.1002/jts.21723 Prior studies have argued that DSM-IV
criteria were insensitive for diagnosing PTSD in young children.
Regier, D.A., Narrow, W.E., Clarke, D.E., Kraemer, H.C., Kuramoto, S.J., Four diagnostic criteria sets were examined in 284 3- to 6-year-old
Kuhl, E.A., et al. (2013). DSM-5 field trials in the United States and trauma-exposed children. The DSM-IV criteria resulted in significantly
Canada, Part II: Test-retest reliability of selected categorical fewer cases (13%) compared to an alternative algorithm for young
diagnoses. American Journal of Psychiatry, 170, 59-70. doi:10.1176/ children (PTSD-AA, 45%), the proposed DSM-5 posttraumatic stress
appi.ajp.2012.12070999 Objective: The DSM-5 Field Trials were in preschool children (44%), and the DSM-5 criteria with 2 symptoms
designed to obtain precise (standard error <0.1) estimates of the that are under consideration by the committee (DSM-5-UC, 49%).
intraclass kappa as a measure of the degree to which two clinicians Using DSM-IV as the standard, the misclassification rate was
could independently agree on the presence or absence of selected 32% for PTSD-AA, 32% for DSM-5, and 37% for DSM-5-UC. The
DSM-5 diagnoses when the same patient was interviewed on proposed criteria sets showed high agreement on the presence

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FEATURED ARTICLES continued

(100%), but low agreement on the absence (58-64%) of diagnoses. assessment. DSM-IV and ICD-10 PTSD were assessed for the
The misclassified cases were highly symptomatic, M = 7 or more 23,936 respondents who reported lifetime TEs in these surveys
symptoms, and functionally impaired, median = 2 domains impaired. with the fully structured Composite International Diagnostic Interview
The additional symptoms had little impact. Evidence for convergent (CIDI). DSM-5 and proposed ICD-11 criteria were approximated.
validation for the proposed diagnoses was shown with elevations Associations of the different criteria sets with indicators of clinical
on comorbid disorders and Child Behavior Checklist Total scores severity (distress-impairment, suicidality, comorbid fear-distress
compared to a control group (n = 46). When stratified by age disorders, PTSD symptom duration) were examined to investigate
(3-4 years and 5-6 years), diagnoses were still significantly elevated the implications of using the different systems. Results: A total of
compared to controls. These findings lend support to a developmental 5.6% of respondents met criteria for broadly defined PTSD
subtype for PTSD. (i.e., full criteria in at least one diagnostic system), with prevalence
ranging from 3.0% with DSM-5 to 4.4% with ICD-10. Only one-third
Stein, D.J., Koenen, K.C., Friedman, M.J., Hill, E., McLaughlin, K.A., of broadly defined cases met criteria in all four systems and
Petukhova, M., et al. (2012). Dissociation in posttraumatic stress another one-third in only one system (narrowly defined cases).
disorder: Evidence from the world mental health surveys. Biological Between-system differences in indicators of clinical severity
Psychiatry, 73, 302312. doi:10.1016/j.biopsych.2012.08.022 suggest that ICD-10 criteria are least strict and DSM-IV criteria
Background: Although the proposal for a dissociative subtype most strict. The more striking result, though, is that significantly
of PTSD in DSM-5 is supported by considerable clinical and elevated indicators of clinical significance were found even for
neurobiological evidence, this evidence comes mostly from narrowly defined cases for each of the four diagnostic systems.
referred samples in Western countries. Cross-national population Conclusions: These results argue for a broad definition of PTSD
epidemiologic surveys were analyzed to evaluate generalizability defined by any one of the different systems to capture all clinically
of the subtype in more diverse samples. Methods: Interviews significant cases of PTSD in future studies.
were administered to 25,018 respondents in 16 countries in the
World Health Organization World Mental Health Surveys. The Weathers, F.W. Marx, B.P., Friedman, M.J., and Schnurr, P.P. (2014).
Composite International Diagnostic Interview was used to assess Posttraumatic stress disorder in DSM-5: New criteria, new
12-month DSM-IV PTSD and other common DSM-IV disorders. measures, and implications for assessment. Psychological Injury
Items from a checklist of past-month nonspecific psychological and Law, 7, 93-107. doi:10.1007/s12207-014-9191-1 The diagnostic
distress were used to assess dissociative symptoms of criteria for PTSD were substantially revised for DSM-5. This in
depersonalization and derealization. Differences between PTSD turn necessitated revision of DSM-correspondent assessment
with and without these dissociative symptoms were examined measures of PTSD. We describe the various changes to the PTSD
across a variety of domains, including index trauma characteristics, diagnostic criteria and the corresponding changes to National
prior trauma history, childhood adversity, sociodemographic Center for PTSD measures. We also discuss the implications of
characteristics, psychiatric comorbidity, functional impairment, the new criteria for assessment of trauma exposure and PTSD.
and treatment seeking. Results: Dissociative symptoms were Although the DSM-5 version of PTSD departs significantly in
present in 14.4% of respondents with 12-month DSM-IV/Composite some respects from previous versions, we conclude that there is
International Diagnostic Interview PTSD and did not differ between fundamental continuity with the original DSM-III conceptualization
high and low/middle income countries. Symptoms of dissociation of PTSD as a chronic, debilitating mental disorder that develops
in PTSD were associated with high counts of re-experiencing in response to catastrophic life events.
symptoms and net of these symptom counts with male sex,
childhood onset of PTSD, high exposure to prior (to the onset of Wolf. E.J., Miller, M.W., Kilpatrick, D., Resnick, H.S., Badour, C.L.,
PTSD) traumatic events and childhood adversities, prior histories Marx, B.P., et al. [in press]. ICD-11 complex PTSD in US national
of separation anxiety disorder and specific phobia, severe role and Veteran samples: Prevalence and structural associations
impairment, and suicidality. Conclusion: These results provide with PTSD. Clinical Psychological Science. The ICD-11 is under
community epidemiologic data documenting the value of the development and current proposals include major changes to
dissociative subtype in distinguishing a meaningful proportion of trauma-related psychiatric diagnoses, including a heavily restricted
severe and impairing cases of PTSD that have distinct correlates definition of PTSD and the addition of complex PTSD. We aimed
across a diverse set of countries. to test the postulates of complex PTSD in samples of 2,695
community participants and 323 trauma-exposed military Veterans.
Stein, D.J., McLaughlin, K.A., Koenen, K.C., Atwoli, L., Friedman, M.J., Complex PTSD prevalence estimates were 0.6% and 13% in the
Hill, E.D., et al. (2014). DSM-5 and ICD-11 definitions of community and Veteran samples, respectively; one-quarter to
posttraumatic stress disorder: Investigating narrow and one-half of those with PTSD met criteria for complex PTSD.
broad approaches. Depression and Anxiety, 31, 494-505. There were no differences in trauma exposure across diagnoses.
doi:10.1002/da.22279 Background: The development of the DSM-5 A factor mixture model with two latent dimensional variables and
and ICD-11 has led to reconsideration of diagnostic criteria for four latent classes provided the best fit in both samples: classes
PTSD. The World Mental Health (WMH) surveys allow investigation differed by their level of symptom severity but did not differ as a
of the implications of the changing criteria compared to DSM-IV function of the proposed PTSD vs. complex PTSD diagnoses.
and ICD-10. Methods: WMH surveys in 13 countries asked These findings should raise concerns about the distinctions
respondents to enumerate all their lifetime traumatic events (TEs) between complex PTSD and PTSD proposed for ICD-11.
and randomly selected one TE per respondent for PTSD

PAGE 8 P T S D R E S E A R C H Q U A R T E R LY
ADDITIONAL CITATIONS

Bensimon, M., Solomon, Z., and Horesh, D. (2013). The utility alone, was 21.4% with 40.4% women and 15.8% men meeting
of Criterion A under chronic national terror. Israeli Journal of criteria for complex PTSD. The authors argue that (complex)
Psychiatry and Related Sciences, 50, 81-83. This is an editorial PSTD is a highly relevant classification for individuals with complex
arguing that both DSM and ICD appear to be larger products of trauma history.
the North American and European societies and therefore, may be
culturally-biased. The authors argue that both diagnostic systems Kupfer, D.J., Kuhl, E.A., and Regier, D.A. (2013). DSM-5The future
focus too much on events and fail to incorporate the everyday arrived. JAMA, 309, 1691-1692. doi:10.1001/jama.2013.2298
realities of individuals in nations such as Israel, Afghanistan, and This brief editorial by the leaders of the DSM-5 process outlines
Iraq who are chronically exposed to terrorist attacks and other how it differs from the DSM-IV. Among these, the focus on
traumatic events. diagnosis and clinical care is emphasized along with special
attention to the influence of development, gender and culture on
Brewin, C.R. (2013). I Wouldnt Start From HereAn alternative the presentation of disorders.
perspective on PTSD from the ICD-11: Comment on Friedman.
Journal of Traumatic Stress, 26, 557-559. doi:10.1002/jts.21843 Maercker, A., Brewin, C.R., Bryant, R.A., Cloitre, M., Reed, G.M.,
This is a commentary in response to Friedman (2013a) that van Ommeren, M., et al. (2013). Proposals for mental disorders
eloquently criticizes the DSM-5 approach while arguing forcefully specifically associated with stress in the International
for the ICD-11s simple approach to diagnosis that can be used Classification of Diseases-11. Lancet, 381, 1683-1685.
in minimally resourced, non-English-speaking-countries. doi:10.1016/S0140-6736 This brief editorial is written by ICD-11s
working group that addresses mental disorder specifically associated
Friedman, M.J. (2013b). PTSD in the DSM-5: Reply to Brewin with stress. The article outlines major decisions regarding diagnoses
(2013), Kilpatrick (2013), and Maercker and Perkonigg (2013). included in this category, such as: 1) a separate diagnostic category
Journal of Traumatic Stress, 26, 567569. doi:10.1002/jts.21847 This for stress-related disorders, 2) attention to the distinction between
is the final article in a special section of the Journal of Traumatic PTSD and normal adaptive fear reactions to ongoing trauma
Stress (2013), 548-569. It begins with Friedman (2013a) and is (e.g., continuing conflict, forced migration, and natural disasters),
followed by three commentaries, Brewin, 2013; Kilpatrick, 2013; 3) the narrow PTSD diagnostic criteria, restricted to two symptoms
and Maercker and Perkonigg, 2013 (all cited here). This is a reply from each of three core elements (e.g., re-experiencing, avoidance,
to these commentaries. and arousal), 4) inclusion of complex PTSD, 5) inclusion of
Prolonged Grief Disorder, 6) inclusion of Adjustment Disorder,
Galatzer-Levy, I.R., and Bryant, R.A. (2013). 636,120 ways to have
7) identifying Acute Stress Reaction as a normal reaction to an
posttraumatic stress disorder. Perspectives on Psychological
abnormal event, and 8) emphasizing the advantage of ICD-11
Science, 8, 651-662. doi:10.1177/1745691613504115 Using a
binomial equation to elucidate possible symptom combinations, over DSM-5 because of greater simplicity, greater clinical utility
the authors demonstrate DSM-5s high level of symptom profile and greater feasibility in low resource and humanitarian settings.
heterogeneity. Whereas there were 79,794 ways to meet PTSD
Maercker, A., and Perkonigg, A. (2013). Applying an international
diagnostic criteria in DSM-IV, there are now 636,120 combinations
perspective in defining PTSD and related disorders: Comment
in DSM-5. They further argue that this heterogeneity indicates
on Friedman (2013). Journal of Traumatic Stress, 26, 560-562.
the limitations of DSM-based diagnostic entities for classification
doi:10.1002/jts.21852 This is another commentary to Friedman
in research and elucidates inherent flaws that are either specific
(2013a) that appeared in the special section of the Journal of
artifacts from the history of the DSM or intrinsic to the underlying
Traumatic Stress. It essentially reiterates the points make by
logic of the DSMs method of classification.
Maecker, et al. (2013) mentioned previously.
Kilpatrick, D.G. (2013). The DSM-5 got PTSD right: Comment
Roberts, A.L., Dohrenwend, B.P., Aiello, A.E., Wright, R.J., Maercker, A.,
on Friedman (2013). Journal of Traumatic Stress, 26, 563566.
Galea, S., et al. (2012). The stressor criterion for posttraumatic
doi:10.1002/jts.21844 This is another commentary in response
stress disorder does it matter? Journal of Clinical Psychiatry, 73,
to Friedman (2013a) that strongly argues in favor of the DSM-5
e264-e270. doi:10.4088/JCP.11m07054 Used data from the 2009
revisions. Specifically, it states that: 1) placement of PTSD in the
PTSD diagnostic subsample (n=3013) of women from the Nurses
new Trauma and Stress-related Disorders category, 2) broadening
the PTSD construct, and 3) utilizing the best empirical data, including Health Study II to investigate the relative importance of traumatic
recent surveys, are all major advances. The author raises concerns events (as defined both in DSM-III and DSM-IV) as compared to
about the ICD-11 approach and suggest that substantial evidence non-traumatic events (e.g., miscarriage, financial problems, legal
be required before (its) proposed changes are made. difficulties, etc.). The major comparison was between women who
met all other PTSD diagnostic criteria whether or not they met
Knefel, M., and Lueger-Schuster, B. (2013). An evaluation of Criterion A in either DSM-III or DSM-IV. The authors found that
ICD-11 PTSD and complex PTSD criteria in a sample of adult sequelae of PTSD did not vary systematically with the type of
survivors of childhood institutional abuse. European Journal stressful event that initiated PTSD symptoms (whether it was
of Psychotraumatology, 4, 22608. doi.10.3402/ejpt.v4i0.22608 traumatic or non-traumatic). The authors conclude, given their
This article compared the appropriateness of ICD-10 and ICD-11 finding that events not considered traumatic produced PTSD
with respect to 229 adult survivors of childhood institutional abuse. as consequential as PTSD precipitated by a Criterion A event
Prevalence was 52.8% for ICD-10; 17% for ICD-11; and 38.4% in either DSM-III or DSM-IV, that PTSD may be an aberrantly
for ICD-11 + complex PTSD. The prevalence of complex PTSD, severe but nonspecific stress response syndrome.

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ADDITIONAL CITATIONS continued

Santiago, P.N., Ursano, R.J., Gray, C.L., Pynoos, R.S., Spiegel, D., combinations are possible. They recommend prioritizing PTSD
Lewis-Fernandez, R. et al. (2013). A systematic review of PTSD and comorbidities as primary (e.g., unique marker), secondary
prevalence and trajectories in DSM-5 defined trauma exposed (e.g., core essential) and tertiary (e.g., common cross-diagnostic).
populations: Intentional and non-intentional traumatic events. They assert that such prioritization might help make the next
PLOS One, 8, e59236. doi:10.1371/journal.pone.0059236 The authors version of the DSM more clinically useful both to clinicians and
reviewed all longitudinal studies on PTSD published between to court.
1998-2010 with regard to clinical trajectories. In general mean
prevalence decreased across all studies from 28.8% (at 1 month) Zoellner, L.A., Bedard-Gilligan, M.A., Jun, J.J., Marks, L.H., and
to 17.0% (at 12 months). When traumatic events were categorized Garcia, N.M. (2013). The evolving construct of posttraumatic
as intentional (e.g., assault, war) or non-intentional (e.g., distress, stress disorder (PTSD): DMS-5 criteria changes and legal
accidents) the PTSD trajectories diverged with a 12 month increase implications. Psychology Injury and the Law, 6, 277-289.
in PTSD prevalence (11.8% to 23.3%) for intentional trauma as doi:10.1007/s12207-013-9175-6 This editorial considers the
compared with a decrease for non-intentional trauma (30.1% to forensic implications of the DSM-5criteria. The changes ... have
14.0%). Among those with PTSD 34.8% remit after 3 months, the potential to increase the heterogeneity of individuals receiving
39.1% have a chronic course and a small fraction (3.5%) of new a PTSD diagnosis by altering what qualifies as a traumatic event
PTSD cases appear after three months. and by adding symptoms commonly occurring in other disorders
... Legal implications of these changes include continued confusion
Sar, V. (2011). Developmental trauma, complex PTSD, and regarding what constitutes a traumatic stressor, difficulties with
the current proposal of DSM-5. European Journal of different diagnosis, increased ease in malingering, and improper
Psychotraumatology, 2, 5622. doi:10.3402/ejpt.v2i0.5622 linking of symptoms to causes of behavior.
This is a very thoughtful review by and international expert on
Dissociative Disorders who participated in the DSM-5 process. Zoellner, L.A., Rothbaum, B.O., and Feeny, N.C. (2011). PTSD not
He commends DSM-5 for setting aside a new category for an anxiety disorder? DSM committee proposal turns back the
trauma/stress disorders and argues for inclusion of Dissociative hands of time. Depression and Anxiety, 28, 853-856. doi:10.1002/da.
Disorders in that category. He recommends inclusion of a complex 20899 This editorial is strongly critical of the DSM-5s removal of
PTSD subtype of PTSD in DSM-5 and expresses concerns that PTSD from the Anxiety Disorder category. Arguments are: 1) fear
the new Dissociative Subtype may be too narrow because it is a critical construct for the development of PTSD, 2) treating
excludes some of the mood and interpersonal symptoms of trauma-related fear and avoidance is central to PTSD, 3) a lack of
complex PTSD. In fact a broader understanding of dissociation evidence exists for a stressor meta-construct separate from the
would not only support new empirical research and novel Anxiety Disorders, and 4) this shift ignores cumulative evidence
treatment modalities on trauma-related disorders, but it would and moves the field backward.
also facilitate formulation of new theoretical paradigms necessary
to provide integrated solutions for conceptual dilemmas of the
field. Other topics considered are Borderline Personality Disorder
and the clinical expression of developmental trauma.

Young, G. (2014). PTSD, endophenotypes, the RDoC, and the


DSM-5. Psychological Injury and Law, 7, 75-91. doi:10.1007/s12207-
014-9187-x This paper examines endophenotypes (e.g., measurable
aspects in the pathway between genotype and disease) in relation
to the NIMH RDoC and the DSM-5. The author proposes a model
for the study of endophenotypes that respects multiple influences
on the etiology of psychiatric disorder, including psychosocial,
without sacrificing the goal of finding causal links from genes to
behavior. He concludes that it is currently premature to seek
individual biomarkers for PTSD given the current state of the field,
but that we should all keep up to date on the future breakthroughs
since research is burgeoning.

Young, G., Lareau, C., and Pierre, B. (2014). One quintillion ways to
have PTSD comorbidity: Recommendations for the disordered
DSM-5. Psychological Injury and Law, 7, 61-74. doi:10.1007/s12207-
014-9186-y This is an elaboration on Galatzer-Levy and Bryant
(2013-see above) which considers the number of the ways to
have PTSD and its most common comorbid conditions (e.g., major
depressive disorder, chronic pain, neurocognitive disorder due to
traumatic brain injury, alcohol use disorder and trauma-related/
exacerbated premorbid personality disorder such as borderline
personality disorder). They calculate that over one quintillion

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