GENERALIZED ANXIETY DISORDER INFORMATION PAGE and P.T.S.D. post traumatic stress disorder

Mayo Clinic information https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-causes/syc-20360803 AND https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

THE DESCRIPTIONS HERE ARE TAKEN FROM THE DSM-V STATISTICAL MANUEL OF MENTAL DISORDERS

Generalized Anxiety Disorder

Diagnostic Criteria 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than

not for at least 6 months, about a number of events or activities (such as work or school

performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms

(with at least some symptoms having been present for more days than not for the

past 6 months):

Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying

sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment

in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or

worry about having panic attacks in panic disorder, negative evaluation in social anxiety

disorder

[social phobia]

, contamination or other obsessions in obsessive-compulsive

disorder, separation from attachment figures in separation anxiety disorder,

reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia

nervosa, physical complaints in somatic symptom disorder, perceived appearance

flaws in body dysmorphic disorder, having a serious illness in illness anxiety

disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Features

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive

expectation) about a number of events or activities. The intensity, duration, or

frequency of the anxiety and worry is out of proportion to the actual likelihood or impact

of the anticipated event. The individual finds it difficult to control the worry and to keep

worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized

anxiety disorder often worry about everyday, routine life circumstances, such as

possible job responsibilities, health and finances, the health of family members, misfortune

to their children, or minor matters (e.g., doing household chores or being late for appointments).

Children with generalized anxiety disorder tend to worry excessively about

their competence or the quality of their performance. During the course of the disorder,

the focus of worry may shift from one concern to another.

Several features distinguish generalized anxiety disorder from nonpathological anxiety.

First, the worries associated with generalized anxiety disorder are excessive and typically interfere

significantly with psychosocial functioning, whereas the worries of everyday life

are not excessive and are perceived as more manageable and may be put off when more

pressing matters arise. Second, the worries associated with generalized anxiety disorder are

Generalized Anxiety Disorder 223

more pervasive, pronounced, and distressing; have longer duration; and frequently occur

without precipitants. The greater the range of life circumstances about which a person

worries (e.g., finances, children’s safety, job performance), the more likely his or her symptoms

are to meet criteria for generalized anxiety disorder. Third, everyday worries are much

less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up

or on edge). Individuals with generalized anxiety disorder report subjective distress due

to constant worry and related impairment in social, occupational, or other important areas

of functioning.

The anxiety and worry are accompanied by at least three of the following additional

symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty

concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although

only one additional symptom is required in children.

Associated Features Supporting Diagnosis

Associated with muscle tension, there may be trembling, twitching, feeling shaky, and

muscle aches or soreness. Many individuals with generalized anxiety disorder also experience

somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response.

Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of

breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety

disorders, such as panic disorder. Other conditions that may be associated with stress (e.g.,

irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.

Prevalence

The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and

2.9% among adults in the general community of the United States. The 12-month prevalence

for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk

is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The

prevalence of the diagnosis peaks in middle age and declines across the later years of life.

Individuals of European descent tend to experience generalized anxiety disorder more

frequently than do individuals of non-European descent (i.e., Asian, African, Native

American and Pacific Islander). Furthermore, individuals from developed countries are

more likely than individuals from nondeveloped countries to report that they have experienced

symptoms that meet criteria for generalized anxiety disorder in their lifetime.

Development and Course

Many individuals with generalized anxiety disorder report that they have felt anxious and

nervous all of their lives. The median age at onset for generalized anxiety disorder is 30

years; however, age at onset is spread over a very broad range. The median age at onset is

later than that for the other anxiety disorders. The symptoms of excessive worry and anxiety

may occur early in life but are then manifested as an anxious temperament. Onset of

the disorder rarely occurs prior to adolescence. The symptoms of generalized anxiety disorder

tend to be chronic and wax and wane across the lifespan, fluctuating between syndromal

and subsyndromal forms of the disorder. Rates of full remission are very low.

The clinical expression of generalized anxiety disorder is relatively consistent across

the lifespan. The primary difference across age groups is in the content of the individual’s

worry. Children and adolescents tend to worry more about school and sporting performance,

whereas older adults report greater concern about the well-being of family or their

own physical heath. Thus, the content of an individual’s worry tends to be age appropriate.

Younger adults experience greater severity of symptoms than do older adults.

The earlier in life individuals have symptoms that meet criteria for generalized anxiety

disorder, the more comorbidity they tend to have and the more impaired they are likely to

224 Anxiety Disorders

be. The advent of chronic physical disease can be a potent issue for excessive worry in the

elderly. In the frail elderly, worries about safety—and especially about falling—may limit

activities. In those with early cognitive impairment, what appears to be excessive worry

about, for example, the whereabouts of things is probably better regarded as realistic

given the cognitive impairment.

In children and adolescents with generalized anxiety disorder, the anxieties and worries

often concern the quality of their performance or competence at school or in sporting

events, even when their performance is not being evaluated by others. There may be excessive

concerns about punctuality. They may also worry about catastrophic events, such

as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist,

and unsure of themselves and tend to redo tasks because of excessive dissatisfaction

with less-than-perfect performance. They are typically overzealous in seeking

reassurance and approval and require excessive reassurance about their performance and

other things they are worried about.

Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis

is being considered in children, a thorough evaluation for the presence of other childhood

anxiety disorders and other mental disorders should be done to determine whether the

worries may be better explained by one of these disorders. Separation anxiety disorder, social

anxiety disorder (social phobia), and obsessive-compulsive disorder are often accompanied

by worries that may mimic those described in generalized anxiety disorder. For

example, a child with social anxiety disorder may be concerned about school performance

because of fear of humiliation. Worries about illness may also be better explained by separation

anxiety disorder or obsessive-compulsive disorder.

Risk and Prognostic Factors

Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm

avoidance have been associated with generalized anxiety disorder.

Environmental. Although childhood adversities and parental overprotection have been

associated with generalized anxiety disorder, no environmental factors have been identified

as specific to generalized anxiety disorder or necessary or sufficient for making the diagnosis.

Genetic and physiological. One-third of the risk of experiencing generalized anxiety

disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are

shared with other anxiety and mood disorders, particularly major depressive disorder.

Culture-Related Diagnostic Issues

There is considerable cultural variation in the expression of generalized anxiety disorder.

For example, in some cultures, somatic symptoms predominate in the expression of the

disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference

may be more evident on initial presentation than subsequently, as more symptoms

are reported over time. There is no information as to whether the propensity for excessive

worrying is related to culture, although the topic being worried about can be culture specific.

It is important to consider the social and cultural context when evaluating whether

worries about certain situations are excessive.

Gender-Related Diagnostic Issues

In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently

in females than in males (about 55%–60% of those presenting with the disorder are

female). In epidemiological studies, approximately two-thirds are female. Females and

males who experience generalized anxiety disorder appear to have similar symptoms but

Generalized Anxiety Disorder 225

demonstrate different patterns of comorbidity consistent with gender differences in the

prevalence of disorders. In females, comorbidity is largely confined to the anxiety disorders

and unipolar depression, whereas in males, comorbidity is more likely to extend to

the substance use disorders as well.

Functional Consequences of

Generalized Anxiety Disorder

Excessive worrying impairs the individual’s capacity to do things quickly and efficiently,

whether at home or at work. The worrying takes time and energy; the associated symptoms

of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating,

and disturbed sleep contribute to the impairment. Importantly the excessive worrying

may impair the ability of individuals with generalized anxiety disorder to encourage confidence

in their children.

Generalized anxiety disorder is associated with significant disability and distress that is

independent of comorbid disorders, and most non-institutionalized adults with the disorder

are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million

disability days per annum in the U.S. population.

Differential Diagnosis

Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder

associated with another medical condition should be assigned if the individual’s anxiety

and worry are judged, based on history, laboratory findings, or physical examination, to

be a physiological effect of another specific medical condition (e.g., pheochromocytoma,

hyperthyroidism).

Substance/medication-induced anxiety disorder. A substance/medication-induced

anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance

or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically

related to the anxiety. For example, severe anxiety that occurs only in the context of heavy

coffee consumption would be diagnosed as caffeine-induced anxiety disorder.

Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory

anxiety that is focused on upcoming social situations in which they must perform or

be evaluated by others, whereas individuals with generalized anxiety disorder worry,

whether or not they are being evaluated.

Obsessive-compulsive disorder. Several features distinguish the excessive worry of

generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder.

In generalized anxiety disorder the focus of the worry is about forthcoming problems,

and it is the excessiveness of the worry about future events that is abnormal. In

obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of

intrusive and unwanted thoughts, urges, or images.

Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present

in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the

anxiety and worry are better explained by symptoms of posttraumatic stress disorder.

Anxiety may also be present in adjustment disorder, but this residual category should be

used only when the criteria are not met for any other disorder (including generalized anxiety

disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an

identifiable stressor within 3 months of the onset of the stressor and does not persist for

more than 6 months after the termination of the stressor or its consequences.

Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common

associated feature of depressive, bipolar, and psychotic disorders and should not be di226

Anxiety Disorders

agnosed separately if the excessive worry has occurred only during the course of these

conditions.

Comorbidity

Individuals whose presentation meets criteria for generalized anxiety disorder are likely

to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders.

The neuroticism or emotional liability that underpins this pattern of comorbidity is

associated with temperamental antecedents and genetic and environmental risk factors

shared between these disorders, although independent pathways are also possible. Comorbidity

with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive

disorders is less common.


Mayo Clinic information https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

THE DESCRIPTIONS HERE ARE TAKEN FROM THE DSM-V STATISTICAL MANUEL OF MENTAL DISORDERS

Posttraumatic Stress Disorder

Diagnostic Criteria 309.81 (F43.10)

Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

For children 6 years and younger, see corresponding criteria below.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or

more) of the following ways:

1. Directly experiencing the traumatic event(s).

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

3. Learning that the traumatic event(s) occurred to a close family member or close

friend. In cases of actual or threatened death of a family member or friend, the

event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic

event(s) (e.g., first responders collecting human remains; police officers repeatedly

exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television,

movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic event(s) occurred:

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

Note: In children older than 6 years, repetitive play may occur in which themes or

aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are

related to the traumatic event(s).

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

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if

the traumatic event(s) were recurring. (Such reactions may occur on a continuum,

with the most extreme expression being a complete loss of awareness of present

surroundings.)

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

4. Intense or prolonged psychological distress at exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble

an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after

the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about

or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations,

activities, objects, situations) that arouse distressing memories, thoughts, or feelings

about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s),

beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or

more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative

amnesia and not to other factors such as head injury, alcohol, or drugs).

272 Trauma- and Stressor-Related Disorders

2. Persistent and exaggerated negative beliefs or expectations about oneself, others,

or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely

dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic

event(s) that lead the individual to blame himself/herself or others.

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

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience

happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning

or worsening after the traumatic event(s) occurred, as evidenced by two (or

more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed

as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

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

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

G. The disturbance causes clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic

stress disorder, and in addition, in response to the stressor, the individual experiences

persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from,

and as if one were an outside observer of, one’s mental processes or body (e.g.,

feeling as though one were in a dream; feeling a sense of unreality of self or body

or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings

(e.g., the world around the individual is experienced as unreal, dreamlike, distant,

or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the

physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication)

or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months

after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury,

or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

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

Posttraumatic Stress Disorder 273

Note: Witnessing does not include events that are witnessed only in electronic media,

television, movies, or pictures.

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

B. Presence of one (or more) of the following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic

event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing

and may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are

related to the traumatic event(s).

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

the traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the

traumatic event(s) were recurring. (Such reactions may occur on a continuum, with

the most extreme expression being a complete loss of awareness of present surroundings.)

Such trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event(s).

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

C. One (or more) of the following symptoms, representing either persistent avoidance of

stimuli associated with the traumatic event(s) or negative alterations in cognitions and

mood associated with the traumatic event(s), must be present, beginning after the

event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse

recollections of the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations

that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt,

sadness, shame, confusion).

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

of play.

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning

or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of

the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed

as verbal or physical aggression toward people or objects (including extreme

temper tantrums).

2. Hypervigilance.

3. Exaggerated startle response.

4. Problems with concentration.

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

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

274 Trauma- and Stressor-Related Disorders

F. The disturbance causes clinically significant distress or impairment in relationships

with parents, siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication or alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic

stress disorder, and the individual experiences persistent or recurrent symptoms

of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from,

and as if one were an outside observer of, one’s mental processes or body (e.g.,

feeling as though one were in a dream; feeling a sense of unreality of self or body

or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings

(e.g., the world around the individual is experienced as unreal, dreamlike, distant,

or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the

physiological effects of a substance (e.g., blackouts) or another medical condition

(e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least

6 months after the event (although the onset and expression of some symptoms may

be immediate).

Diagnostic Features

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic

symptoms following exposure to one or more traumatic events. Emotional reactions

to the traumatic event (e.g., fear, helplessness, horror) are no longer a part of

Criterion A. The clinical presentation of PTSD varies. In some individuals, fear-based reexperiencing,

emotional, and behavioral symptoms may predominate. In others, anhedonic

or dysphoric mood states and negative cognitions may be most distressing. In some

other individuals, arousal and reactive-externalizing symptoms are prominent, while in

others, dissociative symptoms predominate. Finally, some individuals exhibit combinations

of these symptom patterns.

The directly experienced traumatic events in Criterion A include, but are not limited

to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g.,

physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual

violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive

sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being

taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-

made disasters, and severe motor vehicle accidents. For children, sexually violent

events may include developmentally inappropriate sexual experiences without physical

violence or injury. A life-threatening illness or debilitating medical condition is not necessarily

considered a traumatic event. Medical incidents that qualify as traumatic events involve

sudden, catastrophic events (e.g., waking during surgery, anaphylactic shock).

Witnessed events include, but are not limited to, observing threatened or serious injury,

unnatural death, physical or sexual abuse of another person due to violent assault, domestic

violence, accident, war or disaster, or a medical catastrophe in one’s child (e.g., a lifethreatening

hemorrhage). Indirect exposure through learning about an event is limited to

experiences affecting close relatives or friends and experiences that are violent or accidental

(e.g., death due to natural causes does not qualify). Such events include violent perPosttraumatic

Stress Disorder 275

sonal assault, suicide, serious accident, and serious injury. The disorder may be especially

severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual

violence).

The traumatic event can be reexperienced in various ways. Commonly, the individual

has recurrent, involuntary, and intrusive recollections of the event (Criterion B1). Intrusive

recollections in PTSD are distinguished from depressive rumination in that they apply

only to involuntary and intrusive distressing memories. The emphasis is on recurrent

memories of the event that usually include sensory, emotional, or physiological behavioral

components. A common reexperiencing symptom is distressing dreams that replay the

event itself or that are representative or thematically related to the major threats involved

in the traumatic event (Criterion B2). The individual may experience dissociative states

that last from a few seconds to several hours or even days, during which components of

the event are relived and the individual behaves as if the event were occurring at that moment

(Criterion B3). Such events occur on a continuum from brief visual or other sensory

intrusions about part of the traumatic event without loss of reality orientation, to complete

loss of awareness of present surroundings. These episodes, often referred to as “flashbacks,”

are typically brief but can be associated with prolonged distress and heightened

arousal. For young children, reenactment of events related to trauma may appear in play

or in dissociative states. Intense psychological distress (Criterion B4) or physiological reactivity

(Criterion B5) often occurs when the individual is exposed to triggering events that

resemble or symbolize an aspect of the traumatic event (e.g., windy days after a hurricane;

seeing someone who resembles one’s perpetrator). The triggering cue could be a physical

sensation (e.g., dizziness for survivors of head trauma; rapid heartbeat for a previously

traumatized child), particularly for individuals with highly somatic presentations.

Stimuli associated with the trauma are persistently (e.g., always or almost always)

avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories,

feelings, or talking about the traumatic event (e.g., utilizing distraction techniques to avoid

internal reminders) (Criterion C1) and to avoid activities, objects, situations, or people

who arouse recollections of it (Criterion C2).

Negative alterations in cognitions or mood associated with the event begin or worsen

after exposure to the event. These negative alterations can take various forms, including an

inability to remember an important aspect of the traumatic event; such amnesia is typically

due to dissociative amnesia and is not due to head injury, alcohol, or drugs (Criterion D1).

Another form is persistent (i.e., always or almost always) and exaggerated negative expectations

regarding important aspects of life applied to oneself, others, or the future (e.g.,

“I have always had bad judgment”; “People in authority can’t be trusted”) that may manifest

as a negative change in perceived identity since the trauma (e.g., “I can’t trust anyone

ever again”; Criterion D2). Individuals with PTSD may have persistent erroneous cognitions

about the causes of the traumatic event that lead them to blame themselves or others

(e.g., “It’s all my fault that my uncle abused me”) (Criterion D3). A persistent negative

mood state (e.g., fear, horror, anger, guilt, shame) either began or worsened after exposure

to the event (Criterion D4). The individual may experience markedly diminished interest

or participation in previously enjoyed activities (Criterion D5), feeling detached or estranged

from other people (Criterion D6), or a persistent inability to feel positive emotions

(especially happiness, joy, satisfaction, or emotions associated with intimacy, tenderness,

and sexuality) (Criterion D7).

Individuals with PTSD may be quick tempered and may even engage in aggressive

verbal and/or physical behavior with little or no provocation (e.g., yelling at people, getting

into fights, destroying objects) (Criterion E1). They may also engage in reckless or selfdestructive

behavior such as dangerous driving, excessive alcohol or drug use, or selfinjurious

or suicidal behavior (Criterion E2). PTSD is often characterized by a heightened

sensitivity to potential threats, including those that are related to the traumatic experience

(e.g., following a motor vehicle accident, being especially sensitive to the threat potentially

276 Trauma- and Stressor-Related Disorders

caused by cars or trucks) and those not related to the traumatic event (e.g., being fearful of

suffering a heart attack) (Criterion E3). Individuals with PTSD may be very reactive to unexpected

stimuli, displaying a heightened startle response, or jumpiness, to loud noises or

unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Criterion

E4). Concentration difficulties, including difficulty remembering daily events (e.g.,

forgetting one’s telephone number) or attending to focused tasks (e.g., following a conversation

for a sustained period of time), are commonly reported (Criterion E5). Problems

with sleep onset and maintenance are common and may be associated with nightmares

and safety concerns or with generalized elevated arousal that interferes with adequate sleep

(Criterion E6). Some individuals also experience persistent dissociative symptoms of detachment

from their bodies (depersonalization) or the world around them (derealization);

this is reflected in the “with dissociative symptoms” specifier.

Associated Features Supporting Diagnosis

Developmental regression, such as loss of language in young children, may occur. Auditory

pseudo-hallucinations, such as having the sensory experience of hearing one’s

thoughts spoken in one or more different voices, as well as paranoid ideation, can be present.

Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse,

torture), the individual may additionally experience difficulties in regulating emotions or

maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic

event produces violent death, symptoms of both problematic bereavement and PTSD

may be present.

Prevalence

In the United States, projected lifetime risk for PTSD using DSM-IV criteria at age 75 years

is 8.7%. Twelve-month prevalence among U.S. adults is about 3.5%. Lower estimates are

seen in Europe and most Asian, African, and Latin American countries, clustering around

0.5%–1.0%. Although different groups have different levels of exposure to traumatic

events, the conditional probability of developing PTSD following a similar level of exposure

may also vary across cultural groups. Rates of PTSD are higher among veterans and

others whose vocation increases the risk of traumatic exposure (e.g., police, firefighters,

emergency medical personnel). Highest rates (ranging from one-third to more than onehalf

of those exposed) are found among survivors of rape, military combat and captivity,

and ethnically or politically motivated internment and genocide. The prevalence of PTSD

may vary across development; children and adolescents, including preschool children,

generally have displayed lower prevalence following exposure to serious traumatic

events; however, this may be because previous criteria were insufficiently developmentally

informed. The prevalence of full-threshold PTSD also appears to be lower among

older adults compared with the general population; there is evidence that subthreshold

presentations are more common than full PTSD in later life and that these symptoms are

associated with substantial clinical impairment. Compared with U.S. non-Latino whites,

higher rates of PTSD have been reported among U.S. Latinos, African Americans, and

American Indians, and lower rates have been reported among Asian Americans, after adjustment

for traumatic exposure and demographic variables.

Development and Course

PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin

within the first 3 months after the trauma, although there may be a delay of months, or

even years, before criteria for the diagnosis are met. There is abundant evidence for what

DSM-IV called “delayed onset” but is now called “delayed expression,” with the recognition

that some symptoms typically appear immediately and that the delay is in meeting

full criteria.

Posttraumatic Stress Disorder 277

Frequently, an individual’s reaction to a trauma initially meets criteria for acute stress

disorder in the immediate aftermath of the trauma. The symptoms of PTSD and the relative

predominance of different symptoms may vary over time. Duration of the symptoms

also varies, with complete recovery within 3 months occurring in approximately one-half

of adults, while some individuals remain symptomatic for longer than 12 months and

sometimes for more than 50 years. Symptom recurrence and intensification may occur in

response to reminders of the original trauma, ongoing life stressors, or newly experienced

traumatic events. For older individuals, declining health, worsening cognitive functioning,

and social isolation may exacerbate PTSD symptoms.

The clinical expression of reexperiencing can vary across development. Young children

may report new onset of frightening dreams without content specific to the traumatic event.

Before age 6 years (see criteria for preschool subtype), young children are more likely to express

reexperiencing symptoms through play that refers directly or symbolically to the

trauma. They may not manifest fearful reactions at the time of the exposure or during reexperiencing.

Parents may report a wide range of emotional or behavioral changes in young

children. Children may focus on imagined interventions in their play or storytelling. In addition

to avoidance, children may become preoccupied with reminders. Because of young

children’s limitations in expressing thoughts or labeling emotions, negative alterations in

mood or cognition tend to involve primarily mood changes. Children may experience cooccurring

traumas (e.g., physical abuse, witnessing domestic violence) and in chronic circumstances

may not be able to identify onset of symptomatology. Avoidant behavior may

be associated with restricted play or exploratory behavior in young children; reduced participation

in new activities in school-age children; or reluctance to pursue developmental opportunities

in adolescents (e.g., dating, driving). Older children and adolescents may judge

themselves as cowardly. Adolescents may harbor beliefs of being changed in ways that

make them socially undesirable and estrange them from peers (e.g., “Now I’ll never fit in”)

and lose aspirations for the future. Irritable or aggressive behavior in children and adolescents

can interfere with peer relationships and school behavior. Reckless behavior may lead

to accidental injury to self or others, thrill-seeking, or high-risk behaviors. Individuals who

continue to experience PTSD into older adulthood may express fewer symptoms of hyperarousal,

avoidance, and negative cognitions and mood compared with younger adults

with PTSD, although adults exposed to traumatic events during later life may display more

avoidance, hyperarousal, sleep problems, and crying spells than do younger adults exposed

to the same traumatic events. In older individuals, the disorder is associated with negative

health perceptions, primary care utilization, and suicidal ideation.

Risk and Prognostic Factors

Risk (and protective) factors are generally divided into pretraumatic, peritraumatic, and

posttraumatic factors.

Pretraumatic factors

Temperamental. These include childhood emotional problems by age 6 years (e.g., prior

traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g.,

panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]).

Environmental. These include lower socioeconomic status; lower education; exposure to

prior trauma (especially during childhood); childhood adversity (e.g., economic deprivation,

family dysfunction, parental separation or death); cultural characteristics (e.g., fatalistic

or self-blaming coping strategies); lower intelligence; minority racial/ethnic status;

and a family psychiatric history. Social support prior to event exposure is protective.

Genetic and physiological. These include female gender and younger age at the time of

trauma exposure (for adults). Certain genotypes may either be protective or increase risk

of PTSD after exposure to traumatic events.

278 Trauma- and Stressor-Related Disorders

Peritraumatic factors

Environmental. These include severity (dose) of the trauma (the greater the magnitude

of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, interpersonal

violence (particularly trauma perpetrated by a caregiver or involving a witnessed

threat to a caregiver in children), and, for military personnel, being a perpetrator,

witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma

and persists afterward is a risk factor.

Posttraumatic factors

Temperamental. These include negative appraisals, inappropriate coping strategies,

and development of acute stress disorder.

Environmental. These include subsequent exposure to repeated upsetting reminders, subsequent

adverse life events, and financial or other trauma-related losses. Social support (including

family stability, for children) is a protective factor that moderates outcome after trauma.

Culture-Related Diagnostic Issues

The risk of onset and severity of PTSD may differ across cultural groups as a result of variation

in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of

the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after

a mass killing), the ongoing sociocultural context (e.g., residing among unpunished perpetrators

in postconflict settings), and other cultural factors (e.g., acculturative stress in

immigrants). The relative risk for PTSD of particular exposures (e.g., religious persecution)

may vary across cultural groups. The clinical expression of the symptoms or symptom

clusters of PTSD may vary culturally, particularly with respect to avoidance and

numbing symptoms, distressing dreams, and somatic symptoms (e.g., dizziness, shortness

of breath, heat sensations).

Cultural syndromes and idioms of distress influence the expression of PTSD and the

range of comorbid disorders in different cultures by providing behavioral and cognitive

templates that link traumatic exposures to specific symptoms. For example, panic attack

symptoms may be salient in PTSD among Cambodians and Latin Americans because of

the association of traumatic exposure with panic-like khyâl attacks and ataque de nervios.

Comprehensive evaluation of local expressions of PTSD should include assessment of cultural

concepts of distress (see the chapter “Cultural Formulation” in Section III).

Gender-Related Diagnostic Issues

PTSD is more prevalent among females than among males across the lifespan. Females in

the general population experience PTSD for a longer duration than do males. At least some

of the increased risk for PTSD in females appears to be attributable to a greater likelihood

of exposure to traumatic events, such as rape, and other forms of interpersonal violence.

Within populations exposed specifically to such stressors, gender differences in risk for

PTSD are attenuated or nonsignificant.

Suicide Risk

Traumatic events such as childhood abuse increase a person’s suicide risk. PTSD is associated

with suicidal ideation and suicide attempts, and presence of the disorder may indicate which

individuals with ideation eventually make a suicide plan or actually attempt suicide.

Functional Consequences of

Posttraumatic Stress Disorder

PTSD is associated with high levels of social, occupational, and physical disability, as well

as considerable economic costs and high levels of medical utilization. Impaired functionPosttraumatic

Stress Disorder 279

ing is exhibited across social, interpersonal, developmental, educational, physical health,

and occupational domains. In community and veteran samples, PTSD is associated with

poor social and family relationships, absenteeism from work, lower income, and lower educational

and occupational success.

Differential Diagnosis

Adjustment disorders. In adjustment disorders, the stressor can be of any severity or

type rather than that required by PTSD Criterion A. The diagnosis of an adjustment disorder

is used when the response to a stressor that meets PTSD Criterion A does not meet

all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is

also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that

does not meet PTSD Criterion A (e.g., spouse leaving, being fired).

Other posttraumatic disorders and conditions. Not all psychopathology that occurs in

individuals exposed to an extreme stressor should necessarily be attributed to PTSD. The

diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent

symptoms. Moreover, if the symptom response pattern to the extreme stressor meets criteria

for another mental disorder, these diagnoses should be given instead of, or in addition

to, PTSD. Other diagnoses and conditions are excluded if they are better explained by

PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic reminders).

If severe, symptom response patterns to the extreme stressor may warrant a separate

diagnosis (e.g., dissociative amnesia).

Acute stress disorder. Acute stress disorder is distinguished from PTSD because the

symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month

following exposure to the traumatic event.

Anxiety disorders and obsessive-compulsive disorder. In OCD, there are recurrent

intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive

thoughts are not related to an experienced traumatic event, compulsions are usually present,

and other symptoms of PTSD or acute stress disorder are typically absent. Neither the

arousal and dissociative symptoms of panic disorder nor the avoidance, irritability, and

anxiety of generalized anxiety disorder are associated with a specific traumatic event. The

symptoms of separation anxiety disorder are clearly related to separation from home or

family, rather than to a traumatic event.

Major depressive disorder. Major depression may or may not be preceded by a traumatic

event and should be diagnosed if other PTSD symptoms are absent. Specifically, major

depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it

include a number of symptoms from PTSD Criterion D or E.

Personality disorders. Interpersonal difficulties that had their onset, or were greatly exacerbated,

after exposure to a traumatic event may be an indication of PTSD, rather than a

personality disorder, in which such difficulties would be expected independently of any

traumatic exposure.

Dissociative disorders. Dissociative amnesia, dissociative identity disorder, and depersonalization-

derealization disorder may or may not be preceded by exposure to a traumatic

event or may or may not have co-occurring PTSD symptoms. When full PTSD criteria

are also met, however, the PTSD “with dissociative symptoms” subtype should be considered.

Conversion disorder (functional neurological symptom disorder). New onset of somatic

symptoms within the context of posttraumatic distress might be an indication of PTSD

rather than conversion disorder (functional neurological symptom disorder).

Psychotic disorders. Flashbacks in PTSD must be distinguished from illusions, hallucinations,

and other perceptual disturbances that may occur in schizophrenia, brief psychotic

disorder, and other psychotic disorders; depressive and bipolar disorders with

280 Trauma- and Stressor-Related Disorders

psychotic features; delirium; substance/medication-induced disorders; and psychotic disorders

due to another medical condition.

Traumatic brain injury. When a brain injury occurs in the context of a traumatic event (e.g.,

traumatic accident, bomb blast, acceleration/deceleration trauma), symptoms of PTSD may

appear. An event causing head trauma may also constitute a psychological traumatic event,

and tramautic brain injury (TBI)–related neurocognitive symptoms are not mutually exclusive

and may occur concurrently. Symptoms previously termed postconcussive (e.g., headaches,

dizziness, sensitivity to light or sound, irritability, concentration deficits) can occur in braininjured

and non-brain-injured populations, including individuals with PTSD. Because symptoms

of PTSD and TBI-related neurocognitive symptoms can overlap, a differential diagnosis

between PTSD and neurocognitive disorder symptoms attributable to TBI may be possible

based on the presence of symptoms that are distinctive to each presentation. Whereas reexperiencing

and avoidance are characteristic of PTSD and not the effects of TBI, persistent disorientation

and confusion are more specific to TBI (neurocognitive effects) than to PTSD.

Comorbidity

Individuals with PTSD are 80% more likely than those without PTSD to have symptoms

that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipolar,

anxiety, or substance use disorders). Comorbid substance use disorder and conduct

disorder are more common among males than among females. Among U.S. military personnel

and combat veterans who have been deployed to recent wars in Afghanistan and

Iraq, co-occurrence of PTSD and mild TBI is 48%. Although most young children with

PTSD also have at least one other diagnosis, the patterns of comorbidity are different than

in adults, with oppositional defiant disorder and separation anxiety disorder predominating.

Finally, there is considerable comorbidity between PTSD and major neurocognitive

disorder and some overlapping symptoms between these disorders.