History of PTSD and Trauma Diagnoses

Early History of PTSD

• Ancient texts The Iliad of Homer and The Odyssey both describe soldiers traumatized by war.[8]:39-40
• In Shakespeare's King Henry IV, written in 1598, the character of Hotspur suffers from post-traumatic nightmares. [8]:39-40, [12]:5-7
• Post-Traumatic Neurosis was the term used in Britain for over two hundred years, and symptoms were described even earlier, e.g., in literature, and others form of art. [12]:5-7
• 1761: PTSD-like symptoms described among soldiers by Austrian physician Josef Leopold, who calls it nostalgia. Soldiers report missing home, feeling sad, sleep problems, and anxiety. This model of psychological injury persists into the U.S. Civil War.[9]
• 1813: a traumatized girl is described as suffering from what is known today as "repetitive dissociative attacks" including re-enacting behavior of invading French soldiers in Vilnuis, Lithuania. An early medical account of trauma.[8]:40

• Crimean War years: 1853-1856 (Britain, France, Russia, and others)

• Soldiers are frequently incapacitated with "irritable heart", but no physical heart problems are found. They are treated with rest and light duties. [16]:16
• Many years after the end of the Crimean War, traumatized veterans are recognized as suffering from Da Costa syndrome or Effort syndrome, although neither name is used until long after the war. [15]:455
• 1860: The first understanding that a traumatic event could cause psychological as well as physical injury. People traumatized by accidents on railways were referred to as having Railroad Spinal Syndrome by the English surgeon Frederick Erichsen. [14]:2, [15]:624 Erichsen believed concussion of the spine to be the cause of the accident survivors' "fear, fright and alarm".[15]:624 [12]:10
• 1863: Goya, a painter created Los Desastres de la Guerra [The Disasters of War] to illustrate atrocities (rather than heroic feats); many of which he saw during the French invasion of Spain in 1808. [8]:40

• U.S. Civil War years: 1861-1865

• Irritable heart is used to describe PTSD in civil war soldiers.[15]
• 1865: Unrelated to war, writer Charles Dickens wrote of experiencing "railway shaking" and a phobia of train travel after being traumatized in a railway accident, and witnessing people dying [12]:7
• 1870: Soldier's Heart is described by Charles Samuel Myers, a British military psychiatrist. [8]:20, [9]
• 1871: Da Costa, an army surgeon in the U.S. civil war, states that Soldier's Heart involves almost constant traumatic neurosis, with some experiencing sudden paralysis or loss of sensation (traumatic hysterical neurosis) - now known as Functional Neurological Symptom Disorder or Dissociative Conversion Disorder.[8]:20, [9], [15]
• 1878: Psychic trauma is a term proposed by Eulenberg for emotional shock leading to concussion of the brain.[8]:41
• 1879: Denial of PTSD: compensation neurosis is a term introduced by Rigler following an increase in disability after railway accidents that occurs with the introduction of compensation laws in Prussia (8 years beforehand).[8]:20

• 1882: In France, Jean-Martin Charcot uses the terms "Névrose Traumatique" and "Hystérie Traumatique" (Traumatic Neurosis and Traumatic Hysteria) to classify patients with post-traumatic symptoms, regarding them to have an "inherited predisposition". He claims that physical injury could produce psychological symptoms. Charcot later made significant contributions to the current understanding of Dissociation and Dissociative Identity Disorder (Multiple Personality Disorder). [2]:624
• 1882: a book about Concussion of the Spine is published by London surgeon John Eric Erichsen, which promotes recognition of PTSD, with the view that "Nervous shock" is caused by physical injuries resulting from railway accidents. [12]:8-9
• 1883: John Putnam claimed that many cases of "Railroad Spine Syndrome" were actually Hysterical Neuroses (hysteria).[2]:624, [12]:10
• 1885: Surgeon Henry Page discounts any spinal cause for PTSD symptoms, stating that nervous shock, which had previously been considered just a symptom, was psychological but caused the body's nervous system to malfunction. He introduces the terms Nervous shock and Functional Disorder.[15]
• 1885-1889: Traumatic Neurosis was used by Hermann Oppenheim, a German neurologist, to describe PTSD symptoms. Oppenheim claimed there was a physical "disturbance" in the cerebrum (within the brain). This began the use of word trauma in psychiatry, rather than solely in surgery.[2]:624, [8]:20
• 1889: George Miller Beard introduces the term "neurasthenia" (nervous exhaustion) which includes insomnia, fatigue, headaches and emotional problems including depression, neurasthenia becomes a recognized effect after trauma [15]:455
• 1896: The Aetiology of Hysteria and Studies on Hysteria what becomes known as the "seduction theory", an account of the damaging effects of child sexual abuse on females, which is based his patients. [21]:3-4

PTSD 1900-1939

• Boer War years: 1899-1902 (Britain, South Africa)

• Soldiers in the Boer War with PTSD symptoms are often diagnosed with disorderly action of the heart (DAH), the new name for "irritability of the heart" during the war. Anemia is believed to be a major contributor. [16]:10
• 1900: Surgeon Anthony Bowlby notes the high number of soldiers incapacitated with headaches and pains or muscle paralysis, often diagnosing rheumatism rather than recognizing these as post-traumatic responses. He remarks on the lack of mental disorders. [16]:10
• Dr Morgan Fincuane describes Boer War soldiers with healed gunshot wounds remaining debilitated due to nerve and muscle problems that are "associated with pyschical [mental/psychological] symptoms" similar to nervous shock after railway accidents. Soldiers are considered to have "railway spine". [16]:12
• 1904: An official report on the health of Boer War troops concludes that carrying heavy weights on large marches is responsible. "Excitement or nervousness of going under fire" is recognized as resulting in DAH returning to previous sufferers. [16]:10
• 1905: Denial of child sexual abuse: Freud publicly abandons his deeply unpopular "seduction theory" which linked child sexual abuse with mental illness, and presents an alternate theory, the Oedipus complex, which describes the reports of childhood sexual abuse as 'fantasy' caused by 'unconscious' childhood wishes for sex, and causing the resulting emotional conflicts. [21]:4, [8]:44 Freud still acknowledges that child sexual trauma is harmful, but few people research it until the 1970s. [8]:44 In modern times, the Oedipus complex, and many of Freud's views on women, have been challenged by new evidence, with new theories have been put forward; alternatively those loyal to Freud's writings have discarded parts, substituted them for Lacan's metaphorical reinterpretations, or reconceptualized his theory (e.g., Bion). [22], [23]
• 1911: Swiss psychiatrist Eduard Stierlin studies effects of natural disasters, a rail accident and a mining disaster, finding lasting PTSD symptoms, he states traumatic neurosis has no predisposition and the key causes are violent emotions and fright.
• 1914: The first description of PTSD syptoms in rescue personnel, based on the aftermath of explosions on French ships.[8]:45

• World War I years 1914-1918

• 1914-1918: Combat stress is studied during World War I. Disorderly action of the heart (DAH) and "neurasthenia" are among the terms used to describe PTSD symptoms.[8]:20, [8]:38, [15]
• 1915: Charles Myers uses the term "shell-shock" to describe PTSD in medical literature, later recognizing it in soldiers never directly in combat. The term was already in common use; high explosives used in this war were believed to cause brain damage, resulting in symptoms like panic and sleep problems. [8]:45, [9], [13]:76 Traumatic [physical] Brain Injury and PTSD remain a common combination in veterans today, with some overlapping symptoms. [5]:280
• 1916-1917: Moerchen suggests trauma or shock can cause abnormal biological responses in the central nervous system, which isn’t recognized in mainstream psychiatry under 80 years later. [8]:45
• Reactions are divided into shell shock, which had sudden onset, and combat exhaustion which had gradual onset, with a loss of energy. Some saw shell shock as a "disorder of will" to be dealt with by disciplinary action, and quick return to duty. [8]:46-47
• German psychiatrists in Berlin found many soldiers suffered from motor and sensory symptoms (which today would be Functional Neurological Symptom Disorder) but few had PTSD symptoms. Many are diagnosed with hysteria, viewed as caused by an individual's predisposition, not war trauma. Doctors note that such physical responses produce an "illness gain": protecting the soldier's life (by removal from combat) and self-esteem. [8]:46-47
• 1926: Denial of PTSD - German psychiatrist Bonhoeffer produces a study claiming almost all cases of "traumatic neurosis" occurring in the war are a "social illness" in patients with an inherent weakness who are motivated by compensation from health insurance. German veterans with "traumatic neurosis" are no longer given compensation. [8]:20
• Traumatized World War I veterans will later lead to American Abram Kardiner publishing The Traumatic Neuroses of War (in 1941), this work later influences the 1980 DSM-III PTSD criteria. Like Pierre Janet and Sigmund Freud, Kardiner suggests the traumatized veteran acts as if still in the traumatic situation. [8]:48
• In Russia, Pavlov notes the effects of inescapable shock in his dogs, who are traumatized when trapped in his flooded labatory, including the double approach-avoidance conflicts in trauma. [8]:48
• 1926: Sigmund Freud recognizes feelings like fright as a cause of traumatic neurosis, regarding helplessness and powerlessness as essential in trauma (but not present in other stressful events). [8]:49
• 1932: Sandor Ferenczi faces strong oppositon when presenting a paper on the dynamics of child sexual trauma, expanding on the seduction theory abandoned by Freud. The paper is only published years after his death. [8]:44

PTSD 1940-1980

• World War II years 1939-1945

• 1940: Charles Myers (a British army psychiatrist) recognizes that "shell shock" is a poorly chosen term, which should be divided into shell concussion (now known as Traumatic Brain Injury) and shell shock itself. Myers recognizes that fright and horror often occur before shell shock, that can result from emotional stress rather than only exploding missiles, and that it can cause hysteria, neurasthenia and psychiatric illnesses.[12]:8
• 1941: Kardiner states that battle neurosis, battle fatigue, combat exhaustion and shell shock are the same: "the common acquired disorder consequent on war stress", and suggests that traumatic neuroses in peacetime is the same condition.[12]:8
• Combat exhaustion is used to describe the gradual onset of PTSD symptoms, anxiety and physical responses to trauma. Fear and anxiety are higher than in World War I due to factors like "mechanized terror", unpredictability, and more deadly weaponry. "Psychiatric caualties" make up 20-50% of discharges. [8]:49
• Forward psychiatry, a mix of "preventative and therapeutic interventions" developed during World War I, is rediscovered as psychiatric casuality escalate. [8]:47, [8]:49-50
• The support of colleagues, comrades and neighbors is found to be both preventative and curative for traumatized troops, leading to group psychotherapy approaches for civilians in post-war years. [8]:50
• 1948: A health diagnostic manual, the International Classification of Diseases (ICD) produced by the World Health Organization, includes a section of mental disorders for the first time in it's ICD-6 version. The mental health section is based on diagnostic manuals developed by the American Armed Forces and Veterans Association, [13]:118-120, [17]:40, [18] The first PTSD-like diagnosis is called Acute situational maladjustment, code 326.3. Three kinds are listed: Abnormal excitability under minor stress; Combat fatigue; and Operational fatigue [17]:40, [18].

• Korean War years: 1950-1953

• Forward psychiatry is relearned again. [8]:49-50
• World War II and its aftermath results in descriptions of war-traumatized civilians and war trauma responses which are not the result of combat or Prisoner of War (POW) experiences, e.g., civilian responses to bombings, concentration camp effects, politican oppression, torture, death camps, and effects of living under hostile, military occupation e.g., German occupation of other countries. These post-traumatic responses are often ignored in America psychiatry; American war traumas had been primarily overseas. The impact of mass trauma in civilians appears transient: during post-war years: they were able to return to work and establish families. [8]:50
• Some war-traumatized civilians experience gradual deterioration; work published by researchers - some of whom are survivors of the concentration camps - is largely ignored in psychiatry and viewed as of "historical" interest. [8]:50
• 1952: Gross Stress Reaction is included in the first edition of the Diagnostic and Statistic Manual of Mental Disorders, now known as DSM-I, the U.S.A.'s new psychiatric manual. Gross Stress Reaction is within the "Transient Situational Personality Disorders" and describes a PTSD-like "reservible reaction" that occurs in someone with no existing personality disorder. Causes can be either severe physical demands or extreme emotional stress resulting from either (1) combat, or (2) civilian catastrophe. [1]:53
• 1953: The Kinsey Institute releases a study that reports child sexual abuse occurs in 25% of females, but claims it is "not likely to do the child any appreciable harm". [21]:5
• 1954: Hermann and Thygesen describe concentration camp syndrome, which they believe to be physical rather than psychological - and regard as an accelerated aging process. Signs include emotional disturbances, vegetative symptoms, intellectual deterioration and visible physical decline. [8]:50
• 1955: Weinberg's child sexual abuse research claims the prevelance is 9 cases per million in the U.S., and the incest rate is 1 case per million - figures that are based on court cases only, and conflict with the Kinsey Institute's finding. The link to PTSD and other mental disorders is not recognized. [21]:5-6

• Vietnam War years: 1955-1975

• 1958: Venzlaff publishes a study of victims of Nazi persecution in Germany, suggesting that the extreme stress (traumatic stress) causes a "life event-based personality change". Over 30 years later, in 1992, the World Health Organization adds Enduring Personality Change After Catastrophic Experiences to its ICD-10 diagnostic manual - this disorder is now known as Complex PTSD. [8]:51
• 1960: Harald Wolff questions the effect of catastrophic stress on lifespans, pointing out that uninjured U.S. veterans imprisoned by the Japanese had triple the rate of accidental death, and those who experienced the most severe stress had 7 times as many admissions to veterans’ hospitals. [8]:50
• 1961: Survivor syndrome is a term coined by Niederland, who emphasizes survivor guilt and the inability to grieve for those killed while in concentration camps. Eitinger notes the lowered capacity to tolerate stress in later life, and the additional Complex PTSD-like symptoms of survivors, including chronic anxiety, inability to experience pleasure or establish new interpersonal relationships, and reduced ability to work. [8]:51
• 1961: Denial of PTSD. Unrelated to war, Miller introduces the term Accident Neurosis which refers to PTSD symptoms as exaggerated or faked (malingered) in order to gain compensation. Miller claims symptoms disappear once compensation is gained. [12]:10-11
• 1962: Dr Henry Kempe et al. publish The Battered Child Syndrome, describing post-traumatic symptoms in children. [21]:5
• 1968: The World Health Organization includes the Transient situational disturbance category in its the ICD-8 diagnostic manual, replacing the term Acute situational maladjustment. This includes the PTSD-like diagnoses of Combat fatigue and Gross Stress Reaction, and the non-trauma related Adjustment reaction; the earlier ICD-7 version made no changes relevant to PTSD. [19], [13]
• 1968: DSM-II diagnostic manual is published in America, with PTSD symptoms also recognized as a Transient Situational Disturbance called Adjustment reaction of adult life. This covers the impact of both traumatic and non-traumatic events (which will later keep the name Adjustment Reaction). Importantly, the effects of trauma are no longer considered a "personality-related" disorder. The condition is described as expecting to improve "as the stress is reduced," with another, unnamed disorder suggested for those with longer term symptoms, making this closer to Acute Stress Disorder than PTSD. [2]:48-49

• Rape Trauma Syndrome: 1974

• The Vietnam war and the women's movement lead to greater public interest and more research. Variants of PTSD described include Post-Vietnam syndrome, Abused Child Syndrome and Battered Women Syndrome. [13]:61, [12]:12
• 1974: Ann Burgess and Lynda Lytle Holstrom describe Rape Trauma Syndrome, commenting that the flashbacks and nightmares resembled "traumatic neuroses" from war. [15]:457
• 1974: U.S. passes the Child Abuse Prevention and Treatment Act, requiring mandatory reporting for cases of child abuse. [21]:6
• 1975: The key American psychiatric textbook, The Comprehensive Textbook of Psychiatry by Kaplan, Freedman and Sadock, is updated and repeats Weinberg's estimate of incest occurring in only 1 in a million children, ignoring the far higher rates found in other research. [21]:6
• 1977: Acute reaction to stress with predominant disturbance of emotions, consciousness, or psychomotor disturbance or mixed included in the ICD-9 diagnostic manual.
• 1978: Charles Figley, himself a Vietnam veteran, publishes Stress disorders among Vietnam veterans, the first edited book about PTSD in Vietnam veterans. [13]:61

PTSD Diagnosis: 1980 onwards

• 1980: DSM-III psychiatric manual published, including Post-traumatic Stress Disorder as a separate diagnosis for the first time. PTSD is in the Anxiety Disorders section. The DSM-III contains diagnostic criteria for the first time. The traumatic event that caused PTSD is expected to be "outside the range of usual human experience", and examples of trauma list both civilian and military combat trauma. PTSD is described as more likely to be severe and last longer if the trauma is of "human design", rather than an accident. No direct mention is made of domestic violence or child abuse. "Dissociative-like states" are referred to as a rare consequence of PTSD, a separate Dissociative Disorders section is also created. [3]:236-238, [6]
• 1987: The DSM-III-R is published, revising the PTSD diagnostic criteria. Avoidance symptoms are now required for diagnsosis, and symptoms must last a least one month. It also states that "intense fear, terror or helplessness" is typically experienced during the trauma. [3]:247-251
• 1992: Complex PTSD is proposed by Judith Herman to cover those with the most debilitating symptoms after protracted traumas. It is defined to "encompass 3 non-PTSD post-traumatic disorders: Dissociative Identity Disorder, Borderline Personality Disorder and Somatization Disorder". Symptoms include behavioral difficulties like self-destructiveness and impulsivity, emotional difficulties like rage and panic, dissociation and identity changes, interpersonal difficulties and somatization (physical symptoms without a known physical cause). This is renamed to Disorders of Extreme Stress Not Otherwise Specified (DESNOS) by the DSM-IV workgroup, who ultimately reject it, viewing it as a more severe form of PTSD.[20]:32
• 1992: The ICD-10 manual is published, including three post-traumatic conditions: Acute stress reaction (lasting under a month after the trauma), Post-traumatic stress disorder (occurring for at least a month after the trauma), both considered Anxiety Disorders, and EPCACE (Enduring Personality Change After Catastrophic Experiences: a more complex, long-lasting disorder now known as Complex PTSD, classed as an adult Personality Disorder). EPCACE lasts at least two years and is characterized by "a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement". [11]
• 1994: DSM-IV psychiatric manual published, adding Acute Stress Disorder, a post-traumatic disorder that is similar to PTSD but begins very soon after trauma and is often short term. [4] Complex PTSD is left out, but it's symptoms are briefly mentioned in the description of PTSD. [11]
• 1995: Compassion fatigue, also known as Secondary Traumatic Stress Disorder is named by Charles Figley, which involves PTSD-like symptoms in professionals helping those with PTSD. This was first recognized in the 1970s and referred to as "burnout". It is not considered a diagnosis. [15]
• 2013: DSM-5 published. Changes include moving Posttraumatic Stress Disorder and Acute Stress Disorder from the Anxiety Disorders section to a newly-created Trauma and Stressor-related Disorders section. A dissociative subtype of PTSD is introduced. Complex PTSD is left out (again). [5],[10]

Historical names for PTSD

• Post-Traumatic Neurosis was the term used in Britain for over 200 years. [12]:5
• 1761: "nostalgia" is used to describe PTSD-like symptoms among soldiers by Austrian physician Josef Leopold.[9]
• 1860: Railroad Spinal Syndrome by the English surgeon Frederick Erichsen for people traumatized by railway accidents. [14]:2, [15]:624 Clevenger later proposes the name Erichsen's Disease in 1889.[12]:10

• 1865: Writer Charles Dickens wrote of experiencing "railway shaking" and a phobia of train travel after being traumatized by a railway accident. [12]:7
• 1870: Soldier's Heart is a term introduced by Dr Arthur Myers. "Irritable heart"is also used for PTSD in soldiers during the U.S. Civil War. [15]
• 1871: Da Costa Syndrome, named after Jacob Mendes Da Costa, an army surgeon in the U.S. Civil War. "Effort syndrome" also becomes a popular diagnosis in soldiers. [8]:20, [9], [15]:455
• 1878: Psychic trauma is a term proposed by Eulenberg for emotional shock leading to concussion of the brain.[8]:41
• 1882: a book about Concussion of the Spine is published by London surgeon John Eric Erichsen, with the subtitle "Nervous shock". [12]:8-9
• 1882: "Névrose Traumatique" and "Hystérie Traumatique" (Traumatic Neurosis and Traumatic Hysteria) are used in France by Jean-Martin Charcot to refer to post-traumatic symptoms. [2]:624
• 1883: John Putnam claims many cases of "Railroad Spine Syndrome" are actually Hysterical Neuroses (hysteria).[2]:624, [12]:10
• 1885: Nervous shock and Functional Disorder were terms introduced by surgeon Henry Page. [15]
• 1885-1889: Traumatic Neurosis was used by Hermann Oppenheim, a German neurologist, to describe PTSD symptoms. This began the use of word trauma in psychiatry, rather than solely in surgery.[2]:624, [8]:20
• 1899-1902: Boer War. Irritable heart is renamed disordered action of the heart (DAH) and is frequently diagnosed. [16]:10
• 1914-1918: Combat stress is studied during World War I (the Great War).[8]:38
• 1915: Charles Myers uses the term "shell-shock" in medical literature [13]:76
• World War I: "disorderly action of the heart", "neurocirculatory asthenia", and "neurasthenia" are used. [8]:20, [15]
• World War II: 1941: Kardiner state that that battle neurosis, battle fatigue, combat exhaustion and shell shock are the same as each other, and the same condition as traumatic neuroses in peacetime.[12]:8
• 1948: Acute situational maladjustment is the PTSD-like diagnosis introduced in the World Health Organization's ICD-6 diagnostic manual, more specific names listed are Abnormal excitability under minor stress, Combat fatigue and Operational fatigue [17]:40, [18]
• 1952: Gross Response Syndrome is a PTSD-like diagnosis included in the American DSM-I psychiatric manual. [1]:53
• 1954: Concentration camp syndrome is described, involving a mix of PTSD symptoms with physical and intellectual decline. [8]:50
• 1961: Survivor syndrome is a term coined by Niederland, based on symptoms of concentration camp survivors. [8]:51
• 1962: Battered Child Syndrome is used to describe post-traumatic symptoms in children. [21]:5
• 1968: Adjustment reaction of adult life is included in the DSM-II psychiatric manual, a disorder that covers both PTSD and Adjustment Disorders. [2]:48-49
• Early 1970s: Post-Vietnam syndrome, Rape Trauma Syndrome, Abused Child Syndrome, Battered Women Syndrome (BWS) are among the variants of PTSD described. [12]:12, [13]:6
• 1977: Trauma-based disorders are called Acute reaction to stress in the ICD-9 manual, which also includes Dissociative [conversion] disorders. Catastrophic stress, Exhaustion delirium and Combat fatigue are listed are alternative terms. The PTSD-like diagnoses are predominant disturbance of emotions, predominant disturbance of consciousness, fugues fulfilling the above criteria, predominant psychomotor disturbance and agitation states, stupor fulfilling the above criteria. [20]
• 1980: Post-traumatic Stress Disorder becomes a separate diagnosis with the publication of the American Psychiatric Association's DSM-III psychiatric manual. [3]:236
• 1992: Complex PTSD is proposed by Judith Herman and renamed to Disorders of Extreme Stress Not Otherwise Specified (DESNOS) by the DSM-IV workgroup, who ultimately reject it as a diagnosis. [20]:32
• 1992: The ICD-10 manual is published, introducing two new post-traumatic disorders besides PTSD; Enduring Personality Change After Catastrophic Experiences (EPCACE), which is another name for Complex PTSD, and Acute stress reaction (which lasts only a few days after the trauma). [11]
• 1994: Acute Stress Disorder is introduced with the DSM-IV's publication, a reaction to trauma that is similar to PTSD but short term. [4]
• 1995: Compassion fatigue, also known as Secondary Traumatic Stress Disorder is named by Charles Figley, which involves PTSD-like symptoms in professionals helping those with PTSD. [15]
• 2013: DSM-5 published, A dissociative subtype of PTSD is introduced. [5]

A History of PTSD in the DSM

• DSM-I (1952)
  The first edition of the DSM psychiatric manual recognized both civilian and military experiences could cause Posttraumatic Stress Disorder, although it was described as a brief reaction rather than a potentially long-term disorder.
  
  DSM-I PTSD: Gross stress reaction - Code 000-x81
  Under conditions of great or unusual stress, a normal personality may utilize established patterns of reaction to deal with overwhelming fear. The patterns of such reactions differ from those of neurosis or psychosis chiefly with respect to clinical history, reversibility of reaction, and its transient character. When promptly and adequately treated, the condition may clear rapidly. It is also possible that the condition may progress to one of the neurotic reactions. If the reaction persists, this term is to be regarded as a temporary diagnosis to be used only until a more definitive diagnosis is established. This diagnosis is justified only in situations in which the individual has been exposed to severe physical demands or extreme emotional stress, such as in combat or in civilian catastrophe (fire, earthquake, explosion, etc.). In many instances this diagnosis applies to previously more or less "normal" persons who have experienced intolerable stress. The particular stress involved will be specified as (1) combat or (2) civilian catastrophe.
• DSM-II (1968)
  PTSD was combined with adjustment disorders in the second edition of the DSM, and placed in the Transient Situational Disturbances category.
  
  Transient Situational Disturbances
  "This major category is reserved for more or less transient disorders of any severity (including those of psychotic proportions) that occur in individuals without any apparent underlying mental disorders and that represent an acute reaction to overwhelming environmental stress. A diagnosis in this category should specify the cause and manifestations of the disturbance so far as possible. If the patient has good adaptive capacity his symptoms usually recede as the stress diminishes. If, however, the symptoms persist after the stress is removed, the diagnosis of another mental disorder is indicated."
  Disorders in this category were classified by age, the only example relevant to PTSD is:
  
  DSM-II PTSD (1968): Adjustment reaction of adult life - Code 307.3

  • "Example: Resentment with depressive tone associated with an un-wanted pregnancy and manifested by hostile complaints and suicidal gestures."
  • "Example: Fear associated with military combat and manifested by trembling, running and hiding."
  • "Example: A Ganser syndrome associated with death sentence and manifested by incorrect but approximate answers to questions."
  Importantly, the DSM-II no longer categorizes the effects of trauma as a personality-related disorder. The condition is described as expecting to improve "as the stress is reduced," with another, unnamed disorder suggested for those with longer term symptoms, making this closer to Acute Stress Disorder than PTSD. [2]:14-49
• DSM-III (1980)
  Post-traumatic Stress Disorder becames a separate diagnosis in the year 1980, with two pages of description included, plus a page stating the diagnostic criteria and subtypes. PTSD could be diagnosed in both children and adults and was classed as an Anxiety Disorder.
  
  DSM-III Diagnostic criteria for Post-traumatic Stress Disorder (1980)
  

  • A. Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone.
  • B. Reexperiencing of the trauma as evidenced by at least one of the following:
    • (1) recurrent and intrusive recollections of the event
    • (2) recurrent dreams of the event
    • (3) sudden acting or feeling as if the traumatic event were reoccurring, because of an association with an environmental or ideational stimulus
  • C. Numbing of responsiveness to or reduced involvement with the external world, beginning some time after the trauma, as shown by at least one of the following:
    • (1) markedly diminished interest in one or more significant activities
    • (2) feeling of detachment or estrangement from others
    • (3) constricted affect
  • D. At least two of the following symptoms that were not present before the trauma:
    • (1) hyperalertness or exaggerated startle response
    • (2) sleep disturbance
    • (3) guilt about surviving when others have not, or about behavior required for survival
    • (4) memory impairment or trouble concentrating
    • (5) avoidance of activities that arouse recollection of the traumatic event
    • (6) intensification of symptoms by exposure to events that symbolize or resemble the traumatic event
  Two PTSD subtypes were listed:
  • Post-traumatic Stress Disorder, Acute (code 309.80)
    • A. Onset of symptoms within six months of the trauma.
    • B. Duration of symptoms less than six months.
  • Post-traumatic Stress Disorder, Chronic or Delayed (code 309.81) - Either of the following, or both:
    • (1) duration of symptoms six months or more (chronic)
    • (2) onset of symptoms at least six months after the trauma (delayed) [3]:235-237
  A significant change from the DSM-II PTSD criteria was that PTSD could now be diagnosed in someone with an existing personality disorder, and was recognized as more likely to occur in someone with a pre-existing mental disorder. The traumatic events recognized as causes for PTSD is described as outside the range of usual human experience, the examples listed were rape, assault, military combat, terrorism,bombing, torture, death camps, natural disasters (floods, earthquakes), and accidental man-made disasters (car accidents involving death or serious physical injury, airplane crashes, large fires). It was recognized that the risk of PTSD varied with the type of trauma: "Some [traumatic] stressors frequently produce the disorder (e.g., torture) and others produce it only occasionally (e.g., car accidents)." [3]:236
  Types of trauma now known to cause PTSD which are were not listed in the original PTSD critieria include life-threatening illness, and witnessing trauma. [5]:272-274 Trauma triggers leading to worsening symptoms were recognized as situations or activities that resemble or symbolize the original trauma (e.g., cold snowy weather or uniformed guards for death-camp survivors, hot, humid weather for veterans of the South Pacific). [3]:236-237
  The DSM-III recognized PTSD as having many possible complications, such as interpersonal relationship problems (described as caused by emotional numbing), "self-defeating behavior or suicidal actions" can resulting from the depression, emotional instability, or guilt caused by PTSD. Other disorders that could develop after PTSD were listed as Anxiety, Depressive, or Substance Use Disorders (e.g., alcoholism), and Organic Mental Disorder (e.g., resulting from a trauma involving a physical head injury).
• DSM-III-R (1987)
  This revision to the DSM occurred only 7 years after PTSD became a separate diagnosis. Significant changes include increased emphasis on avoidance symptoms, with the previous numbing criterion now included in the avoidance criterion, symptoms must last at least a month, and a recognition of differences in PTSD symptoms in children.
  
  DSM-III-R Diagnostic Criteria for Post-Traumatic Stress Disorder (1987) - code 309.89
  

  • A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one’s home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence.
  • B. The traumatic event is persistently reexperienced in at least one of the following ways:
    • (1) recurrent and intrusive distressing recollections of the event (in young children, repetitive play in which themes or aspects of the trauma are expressed)
    • (2) recurrent distressing dreams of the event
    • (3) sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon awakening or when intoxicated)
    • (4) intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma
  • C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
    • (1) efforts to avoid thoughts or feelings associated with the trauma
    • (2) efforts to avoid activities or situations that arouse recollections of the trauma
    • (3) inability to recall an important aspect of the trauma (psychogenic amnesia)
    • (4) markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills)
    • (5) feeling of detachment or estrangement from others
    • (6) restricted range of affect, e.g., unable to have loving feelings
    • (7) sense of a foreshortened future, e.g., does not expect to have a career, marriage, or children, or a long life.
  • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
    • (1) difficulty falling or staying asleep
    • (2) irritability or outbursts of anger
    • (3) difficulty concentrating
    • (4) hypervigilance
    • (5) exaggerated startle response
    • (6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator)
  • E. Duration of the disturbance (symptoms in B, C, and D) of at least one month. [6]:250-251

  
  Specify delayed onset if the onset of symptoms was at least six months after the trauma.
  Several new types of trauma were recognized in the DSM-III-R description of PTSD including witnessing another person's trauma, and in some cases "learning about a serious threat or harm to a close friend or relative, e.g., that one’s child has been kidnapped, tortured, or killed" but this does not include "simple bereavement". Also recognized was the effect of a trauma anniversary. Additional symptoms recognized as a potential consequence of PTSD include forgetting an important part of the trauma (psychogenic amnesia, now called Dissociative Amnesia), trauma-related hallucinations, and a sense of a foreshortened future. The mind-body link involving physical reactions to trauma triggers/reminders is now recognized and included as a symptom. Survivor guilt is described in the text, but no longer considered a symptom of PTSD. [6]:247-251
• DSM-IV (1994) and DSM-IV-TR (text revision, 2000)
  Significant changes from the DSM-III include the introduction of Acute Stress Disorder, a post-traumatic disorder which can only be diagnosed for symptoms lasting less between up to 4 weeks. Symptoms of Acute Stress Disorder are slightly different to those of PTSD and begin within a month of trauma. [4] There were no differences in the PTSD Diagnostic criteria between the DSM-IV and its DSM-IV-TR revision, which was published in 2000, although the description text was updated. [4]:467-468
  
  DSM-IV Criteria for Posttraumatic Stress Disorder (1994) - code 309.81

  • A. The person has been exposed to a traumatic event in which both of the following have been present:
    • (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    • (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
  • B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
    • (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
    • (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
    • (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
    • (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
    • (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  • C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
    • (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
    • (2) efforts to avoid activities, places, or people that arouse recollections of the trauma
    • (3) inability to recall an important aspect of the trauma
    • (4) markedly diminished interest or participation in significant activities
    • (5) feeling of detachment or estrangement from others
    • (6) restricted range of affect (e.g., unable to have loving feelings)
    • (7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
  • D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
    • (1) difficulty falling or staying asleep
    • (2) irritability or outbursts of anger
    • (3) difficulty concentrating
    • (4) hypervigilance
    • (5) exaggerated startle response
  • E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
  • F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.[4]:467-468
  • Specify if:
    • Acute: if duration of symptoms is less than 3 months
    • Chronic: if duration of symptoms is 3 months or more
  • Specify if:
    • With Delayed Onset: if onset of symptoms is at least 6 months after the stressor [4]:427-429
  The main change to the PTSD diagnosis since the DSM-III-R was adding the A2 criterion, which required the person to report feeling intense fear, helplessness, or horror during rather than after the trauma(s), although this criterion was removed with the publication of the DSM-5 in 2013. An additional change in the DSM-IV was adding criterion F - which requires either significant distress or impairment resulting from the PTSD symptoms. The DSM-IV's PTSD section included information of prevalance for the first time, which was listed as affecting around 8% of the U.S. population in the 2000 version. [4]:463-468
  Complex PTSD was not included in the DSM-IV-TR as a diagnosis, but PTSD's Associated Features and Disorders section of the DSM-IV-TR included a description of it, along with the types of trauma known to cause Complex PTSD:
  "The following associated constellation of symptoms may occur and are more commonly seen in association with an interpersonal stressor (eg, childhood sexual or physical abuse, domestic battering): impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual's previous personality characteristics." [4]:465
• DSM-5 (2013)
  Several significant changes were made, including introducing a Dissociative Subtype for PTSD. Children under 6 years old have separate diagnosis criteria. [5]:270-281 See DSM-5 Diagnostic criteria and PTSD changes between the DSM-IV & DSM-5.

• See also: Posttraumatic Stress Disorder current information
• See also: Complex PTSD
• See also: Self-help Books
• See also: Treatment for PTSD, which includes a medication overview
• See also: PCL-5 PTSD checklist test to help assess PTSD
• See also: Trauma and abuse