Reformulating PTSD for DSM-V: Life after Criterion
Brewin, C.R., Lanius, R.A., Novac, A., Schnyder, U., & Galea, S. (2009)
A. Journal of Traumatic Stress, 22, 366-373.

Abstract

The diagnosis of posttraumatic stress disorder has been criticised on three main reasons, namely: 1) the alleged pathologizing of normal events 2) the inadequacy of criterion A 3) symptom overlap with other disorders.

PTSD has a multifactorial etiology.

Evaluation of three criticisms of PTSD

Criticism 1: PTSD pathologizes normal distress

One criticism of PTSD is that it creates a medical condition out of normal distress.

Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology, as well as to a variety of serious medical conditions.

A popular view currently is that PTSD reflects a failure of adaptation, whereby normal reactions to extreme stress do not correct themselves. What is pathological about PTSD is defined by the persistence of its symptoms.

Evidence supports a distinctive biological profile associated with PTSD.

Criticism 2: inadequacy of criterion A

Three fundamental issues with the A criterion are: 1) how broadly or narrowly should trauma be defined? 2) can trauma be measured reliably and validly? 3) what is the relationship between trauma and PTSD?

Trauma is not exclusively associated with PTSD.

Other disorders are linked to traumatic (criterion A) events

Trauma is associated with an increased prevalence of other disorders. If these can be diagnosed after a traumatic event, the question arises why the same could not be true of PTSD.

Trauma’s do not increase the risk for other disorders independently of the increased risk for PTSD. PTSD plays a central role in the psychological response to trauma.

Insufficient specificity of criterion A

The original conceptualization of PTSD was a response to an event ‘generally outside the range of usual human experience’. This was broadened, due to which there is a conceptual creep that is causing PTSD to be diagnosed in response to situations that are far removed from the original concept of trauma (according to critics).

There are few cases with PTSD after circumstances like divorce or money problems.

Trauma of lower intensity would be expected to provoke PTSD in vulnerable individuals with a limited capacity do dampen ther physiological response to stress. Such vulnerability may be genetic, interacting with lifetime exposure to trauma or epigenetic. It can also be related to greater levels of

Comparison of DSM-IV and proposed ICD-11 formulations of PTSD among civilian survivors of war and war veterans
Morina, N., Van Emmerik, A.A.P., Andrews, B., & Brewin, C.R. (2014).
Journal of Traumatic Stress, 27, 647-654

Introduction

Proposals for the ICD-11 have included a reduction and simplification in the symptoms required for a PTSD diagnosis. An proposed innovation involves specifying core elements rather than typical features of PTSD. Core elements are those that on empirical or theoretical grounds most clearly distinguish PTSD from other disorders.

Core elements consist of: 1) re-experiencing the traumatic event(s) in the present, a evidenced by either flashbacks or nightmares, accompanied by fear or horror. Flashbacks are intrusive waking memories in which re-experiencing in the present can vary from a transient sensation to a complete disconnection from the current environment. 2) Avoidance of intrusions, evidenced by marked internal avoidance of thoughts and memories, or external avoidance of activities or situations 3) Excessive sense of current threat, evidenced by hypervigilane or exaggerated startle.

PTSD is defined in terms of the presence of at least one of the two symptoms of each of these core elements. In addition there must be impairment in functioning.

Findings

The new approach proposed for ICD-11 need not make a substantial difference to PTSD prevalence.

The 17 symptoms described in the DSM-IV are not all required to access PTSD.

More individuals meet the avoidance criterion in the ICD-11 system.

The reduced set of symptoms led to less comorbidity.

Psychological theories of posttraumatic stress disorder.
Brewin, C.R., & Holmes, E.A. (2003)
Clinical Psychology Review, 23, 339-376

Psychological processes and PTSD

Memory and PTSD

In PTSD, there are a number of changes in memory functioning that are comparable with depressed patients: 1) a bias toward enhanced recall of trauma-related material 2) difficulties in retrieving autobiographical memories of specific incidents.

Specific changes in memory of PTSD are: 1) a contradictory patterns of recall related to the traumatic material itself. High levels of emotions are in some studies associated with more vivid and long-lasting memories, but in others with vague memories, lacking in detail and error prone. PTSD is described as characterized by both high-frequency, distressing, intrusive memories and by amnesia for the details of the event. 2) the reliving of memories, or flashbacks to the trauma. Flashbacks are dominated by sensory detail. These images and sensations are typically disjointed and fragmentary. Reliving is reflected in a distortion in the sense of time, such that the traumatic event seems to be happening in the present rather than belonging in the past. Reliving episodes are triggered involuntarily by specific reminders that relate in some way to the circumstances of the trauma.

Flashbacks are a distinctive feature of PTSD.

Individual differences in working memory capacity appear to be related to the ability to prevent unwanted material from intruding and negatively affecting task performance.

Attention and PTSD

Research does not provide evidence that the effects of an attentional bias are unique to PTSD.

Dissociation and PTSD

Dissociation are any kind of temporary breakdown in what we think of as the relatively continuous, interrelated processes of perceiving the world around us, remembering the past, or having a single identify that links our past with our future.

Mild dissociative reactions are common under stress.

Dissociative symptoms most commonly encountered in trauma include: emotional numbing, derealisation, depersonalisation, out-of-body experiences. They are related to the severity of the trauma, fear of death, and feeling helpless.

It has been suggested that such reactions reflect a defensive response related to freezing in animals.

When these symptoms occur in the course of a traumatic experience, they are referred to as ‘peri-traumatic dissociation’.

The presence of dissociative symptoms occurring after rather than during trauma is not consistently associated with risk for later PTSD.

Cognitive-affective reactions and PTSD

A requirement of the PTSD diagnosis according to the DSM-IV, is to experience intense fear, helplessness, or horror at the time of the trauma.

There is a strong relationship between each of the