Arieh Y. Shalev

Unraveling Trauma


The Changing Faces of Trauma

Trauma definitions in DSM-III, IV, IV-TR and 5

Posted Apr 21, 2016


Photo by Flicker User Anders Eriksson
When he who walks in the dark whistles, he/she may feel better but does not see better
Source: Photo by Flicker User Anders Eriksson

Confused by roman numerals? Wait till you delve into content. Trauma is not what it used to be, at least per successive editions of the American Psychiatric Association Diagnostic and Statistical Manual’s definition of trauma leading to post-traumatic stress disorder (PTSD). Trauma used to be an overwhelming event "outside the range of normal human experience" that "would produce significant symptoms in almost anyone" (DSM-III), it then was allowed to be somewhat less outstanding and only optionally associated with symptoms (DSM-IIIR), then a floodgate opened and virtually any stressful experience qualified, whether occurring to oneself or others, provided that it provoked an initial reaction of fear, helplessness or horror (DSM-IV). The recent DSM 5 scrapped the initial reaction and awkwardly reduced the range of indirect exposures by specifying that those should concern “a close family member or close friend.” and “In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.” Very specific indeed.    

DSM 5 definition also extended the number of disorder-defining symptoms from 17 to 20, and that of diagnostic criteria from 3 to 4, splitting the previous “Avoidance and Numbing” criterion into “Avoidance of Trauma Related Stimuli” and “Negative Alterations in Cognition and Mood.” It also significantly modified eight symptom criteria borrowed from DSM IV. With such precision and affluence, there are currently 636,120 different ways in which a person can meet DSM 5 diagnosis of PTSD (1).

Aren’t we blessed by having so much flexibility? Perhaps. Our patients, however, are not. Field studies, following DSM-5 publication have shown that only 55% of those with DSM-IV PTSD ‘have’ DSM-5 PTSD. Interestingly, those picked by DSM-IV or DSM-5 criteria reported similar degree of distress and impairment. Paradoxically, the recently revised International Classification of Diseases (ICD-11) reduced the number of PTSD symptom criteria to six (!) creating another brand of the disorder. You might have guessed: only 30% of afflicted trauma survivors will 'have' PTSD by all three diagnostic definitions.

It actually matters a lot: if you used to think that PTSD is more frequent in women – this is not the case any more for ICD-11 PTSD (2). Also, had you relied on 20 years of research on PTSD epidemiology, neurobiology, treatment and what not, there is no guarantee that the results will hold for DSM-5 or IDC-11 defined populations. Researchers must either go back and reproduce the entire body of research or be left ‘assuming’ that it’s OK to ‘believe’ that, for example, exposure based cognitive behavioral therapy is the still a first line treatment for patients whose PTSD is more heavily weighted by ‘alterations in cognition and mood’ and who had lost a “sense of foreshortened future’ criterion in the DSM-IV-to-5 transition.

Perhaps the only good reason not to moan about DSM-5 is that this might accelerate a DSM-6 (or VI) with even newer tunes to march by. One is reminded of Sigmund Freud's adage 'when he who walks in the dark whistles, he/she may feel better, but does not see better.' Another version of that poetry, whether in three or four stanzas (“criteria”), 17 or 20 verses (“symptoms”), would be another exercise in self soothing. It would not alleviate the darkness.   

NYC Subway Map by MTA
Source: NYC Subway Map by MTA

Fortunately our patients do not know about the obsessive madness of ‘classifiers.’  They may soon learn, however, e.g., if they are denied coverage for their all too real post-traumatic disorder because they no longer meet criterion B or C or half of D or one required E symptom. And no, it does not take a New York Subway map to understand that these B, C, or D spaghetti nominations are, perhaps, representative of the system, particularly at rush hours, but do not define it.

This definition blunder may have one beneficial effect. It can help us, providers and consumers, understand that the disabling effects of trauma are not reliably subsumed by DSM criteria, that both current or previous DSM versions were rough approximations, and that moving from one approximation to another does not increase accuracy: it adds confusion. Most important, we must agree that patients should not be denied care if they do not strictly meet numbers IV, 5 or 11 decision rules.

Seriously? What the WHO and APA ‘Diagnostic and Statistical’ templates were originally meant to provide were criteria for reliable reporting of diseases prevalence in countries, and worldwide. This is what the “statistical” in DSM means. In a twist, they became a tool for sanctioning clinical practice: prescriptive, top-down, one size fits all. Coming from a High Place, and meeting our own need for structured realities, they were promptly reified and now everyone believes that PTSD, as per DSM or another sanctified scripture, is a real, ‘natural object.’ Except that we now have three PTSDs! I believe that it is about time to place diagnostic and statistical manuals back in their natural habitat: tools for reliable reporting, poorly suited as guides for clinical work and biological research.            

Criteria change, time passes, but afflicted trauma survivors remain the same. As professionals and educated consumers, we should not confound the cookbook with the meal else we will be eating paper (or tablets, as technology wants it) instead of food. To develop a serious discussion about trauma and post-traumatic psychopathology we need to, first, overcome classifications’ fascination and our own addiction to their pseudo objects. More on that in subsequent blogs.

1. Galatzer-Levy IR, Bryant RA (2013): 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science. 8:651-662.

2. Knefel M, Lueger-Schuster B: An evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood institutional abuse. European Journal of Psychotraumatology, 2013,  doi: