Whether PTSD treatment is your niche or not, you have probably seen trauma survivors in your practice. Diagnosing PTSD is not always as straightforward as other disorders. One multinational survey of PTSD across 20 countries found that the majority of individuals with PTSD had experienced four or more traumas (Karam et al., 2014). Deciding what qualifies as a criterion A stressor for PTSD is one of the most overlooked challenges in diagnosing PTSD.
Diagnosing PTSD is Complicated
Diagnosing PTSD is more complicated than diagnosing depression or other disorders. When a person suffers from depression, the therapist only needs to assess symptoms. It doesn’t matter whether these symptoms were caused by a divorce, job loss, or an abusive childhood. As you probably realize, PTSD is a different animal. The DSM-5 specifies that no symptoms count toward a PTSD diagnosis unless they have been caused by a qualifying trauma, known as a criterion A stressor (because it is the first criterion listed in the DSM-5 for PTSD).
The DSM requires us to be part detective and part clinician when it comes to determining the causes of our patients’ symptoms. I’m sure you’re familiar with this idea but before you even start to say to your patient, “I think you could have PTSD,” you should stop yourself and think carefully about the reality of a criterion A trauma.
Most clinicians think it is more straightforward than its actuality. Why do I say this? As a psychologist who works with veterans and has seen many trauma survivors, I have seen the PTSD diagnosis misapplied, often because of a failure to carefully evaluate criterion A.
What Is Criterion A?
It is a traumatic event that involved the risk of death, serious injury, or sexual violence. It could also be seeing these events happen even though you were not the victim of them. An example would be coming across a car accident and seeing a dead body. It could be hearing about a close friend or loved one going through a trauma, for example, a mother hearing about the details of her son being killed in a roll-over car accident.
Or, it could be indirect exposure, as when healthcare workers or first responders hear about traumas from victims over and over.
Take Your Time in Evaluating Criterion A
To diagnose PTSD, you have to understand the traumatic event and make a judgment call about whether there was an actual threat or something disturbing enough to fit some form of criterion A. It sounds simple. Sometimes it is; other times it’s not.
Some events are clear criterion A no-brainers: a combat tour involving fire fights, a sexual assault, childhood sexual abuse, being mugged at knifepoint, a head-on car accident. Other traumatic events are clearly not criterion A: a bitter divorce, public humiliation, getting fired from your job, losing custody of your children.
At other times, it’s unclear whether an event meets criterion A. Suppose a police officer tells you that during a routine traffic stop he thought someone was going to pull out a weapon; however, the person only reached for an ID. This could meet criterion A, but then again, you could argue that there never was a threat and a PTSD diagnosis is out the window.
This is where you have to understand why the person thought the situation was life threatening. Was there any reason why the officer thought there could have been a weapon? Would other police officers have reacted similarly? Was the threat a gross misperception or distortion of reality? Does the officer perceive threats everywhere, which might indicate generalized anxiety? You have to understand the person to understand if it fits criterion A.
Get The Context When Assessing Criterion A
I once saw a client who was told by another clinician that his trauma didn’t meet criterion A because it wasn’t life threatening. My client, who was a soldier deployed oversees, was threatened by a local resident.
The possible criterion A event happened when the resident didn’t threaten to kill my client but grabbed his wrist and screamed in his native language. At first, I agreed that the latter event didn’t meet PTSD criteria. It was a bad event, but nowhere near as bad as what most service members describe about their deployments oversees.
But over time, I started to understand that the threat was more complicated and real to my patient than I initially realized. This individual harassed, threatened to stab, flashed weapons from afar, and menacingly stared down my patient. After understanding the context, I realized that the threat to my client was not just about a single event, but about a series of intimidations and threats.
My client really thought he was going to be shot, stabbed, or brutally beaten. He never was assaulted, but it shook him so badly that he could never excise the fear from his mind.
Cases like this one are the reason I take my time to explore criterion A and understand the context of the event. If you do a thorough job establishing criterion A, you’ll not only better diagnose PTSD, you’ll better understand your clients.
American Psychiatric Association, APA. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5: Washington, DC: American Psychiatric Pub.
Karam, E. G., Friedman, M. J., Hill, E. D., Kessler, R. C., McLaughlin, K. A., Petukhova, M., … & De Girolamo, G. (2014). Cumulative traumas and risk thresholds: 12‐month PTSD in the World Mental Health (WMH) surveys. Depression and anxiety, 31(2), 130-142. https://doi.org/10.1002/da.22169
Jason Drwal, Ph.D. is a licensed psychologist who specializes in the use of cognitive-behavioral and mindfulness interventions for the treatment of panic attacks, PTSD, and other conditions. In addition to his work as a therapist, he is the founder of Create Meaningful Change, an online CE provider that offers fun, engaging, and high quality webinars for mental health professionals. When he is not working, he is an avid (and incurable) reader of self-help books, proud parent of two beautiful children, self-described coffee addict (who refuses to get treatment), and amateur anthropologist.