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Just imagine you acquired Post-Traumatic Stress Disorder (PTSD) symptoms after experiencing major trauma but that you could not get the PTSD diagnosis because you did not experience a certain type of trauma. This situation happens with some frequency for autistic people because a diagnosis of PTSD requires meeting all criteria, including at least one of a narrow list of traumas. Without a PTSD diagnosis, it would be difficult (if not impossible) to get the necessary treatment.
PTSD Basics
PTSD is a major mental health condition that results from experiencing or witnessing certain types of traumas. PTSD symptoms can include, but are not limited to, having intrusive thoughts, flashbacks, nightmares, emotional suffering when reminded of the trauma, insomnia, anger, guilt, anxiety, negative thoughts, and hopelessness. Other symptoms include reliving experiences, avoiding situations that remind person of trauma, being easily scared, and acting in self-destructive ways. Symptoms can vary in intensity. They can last for years, but some people can have PTSD indefinitely.
PTSD is not that uncommon. Around one in 11 people will get a PTSD diagnosis in his/her life. Every year, approximately five of 100 adults will experience PTSD. Military veterans have a greater chance than civilians of getting PTSD. Race is not a risk factor, but race-related trauma that involves Criterion A (which is described later in this piece) trauma types can cause PTSD. Race-related trauma can exacerbate PTSD. Native Americans, Hispanics, and African-Americans experience trauma that is more likely to cause PTSD.
PTSD is different in men and women. While men are more likely to have trauma “from physical violence, combat, accidents, or disaster,” women are more likely to have trauma “from rape, sexual assault or childhood sexual abuse.” Women are two to three times more at risk than men to get PTSD.
PTSD and Autism
Although just one in three people who endure major trauma gets PTSD, some people, especially autistic individuals, are more likely to get at least PTSD symptoms. Over sixty percent of autistic adults have probable PTSD during their life, and autistic people get PTSD symptoms at higher rates even when they do not meet Criterion A. While around four percent of the general population most likely have PTSD, an estimated 32 percent to 45 percent of autistic people have probable PTSD. Autistic women, LGBTQ+ people, and BIPOC individuals are more likely to have PTSD after a traumatic incident.
Autistic people are more likely to have PTSD symptoms for a variety of reasons. Due to their communication and behavior issues, they could be more likely to be victims of bullying, abuse, and other trauma that place them at higher risk of getting PTSD symptoms. In addition, a larger variety of events is traumatic to autistic people. The design of the autistic brain could also predispose this population to PTSD. Some autistic people experience perseveration, which involves repeated thoughts and rumination. Perseveration signs include the same thoughts about previous conversations, constantly talking about the past, and continued anger. After autistic individuals experience trauma, they could frequently think about what happened, predicting future PTSD symptoms.
History of PTSD in the DSM
PTSD first appeared in the third edition of the Diagnostic and Statistical Manual (DSM-III) in 1980. This addition was controversial. The diagnostic criteria were noteworthy because of the requirement that the cause was an external factor (such as a traumatic event), not an internal vulnerability (such as a traumatic condition). According to the DSM-III, the trauma needed for a PTSD diagnosis was a disaster that many people do not experience. Examples of such trauma that could qualify for that diagnosis include “war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions), and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents).” If people were negatively affected by ordinary events, then the DSM would classify their problems as Adjustment Disorders, not PTSD. The authors of the initial PTSD diagnosis divided effects by type of trauma because they assumed that many people could handle results of ordinary occurrences, but not trauma.
Later versions of the DSM [DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000), and DSM-V (2013) changed elements of PTSD as they did for other conditions. Although the criteria changed in other ways, this paragraph solely covers the type of trauma that is needed for a PTSD diagnosis. The PTSD diagnostic criteria (Criterion A) in the DSM-IV merely said “The person has been exposed to a traumatic event.” Since it did not specify the types of traumas that had to be experienced to qualify for a PTSD diagnosis, people with just PTSD symptoms from any trauma could be viewed as having PTSD and could get treatment.
Criterion A was viewed as PTSD’s “most controversial” section” in the DSM-IV. Some critics thought the trauma element in the DSM-IV was too broad. In 2009, one of them wrote about his fear that due to the new definition of trauma, almost everyone in the U.S. survived trauma.
Others felt that Criterion A should be eliminated. According to a study, the DSM not requiring a specific type of trauma for a diagnosis of PTSD would be beneficial. PTSD would become more comparable with anxiety conditions and depression. The problem of whether a trauma meets Criterion A no longer would happen. Doctors would be able to focus on symptoms and treatment.
The DSM-V, which changed the classification of PTSD from “Anxiety Disorder” to “Trauma- and Stressor-Related Disorders,” seemingly eliminated the subjective definition of trauma by defining the types of trauma that a person must have been exposed to for a PTSD diagnosis. Now, to qualify for a PTSD diagnosis, an individual must have been exposed to at least one the following: “actual or threatened death, serious injury, or sexual violence.” According to a study, certain illnesses (i.e. – terminal cancer) and medical and medical events with natural causes (i.e. – heart attack) currently do not meet Criterion A.
Current Concerns about Criterion A
Criterion A continues to be problematic in large part because individuals need to meet this criterion to get a PTSD diagnosis. Unlike most other DSM conditions, PTSD is not defined solely on symptoms. Concerns about the 2013 definitions arose quickly. In 2016, professors wrote that the way Criterion A is written excludes oppression-related trauma.
Although PTSD is frequently associated with war and other major traumatic events, in reality, people can get PTSD symptoms despite not being exposed to Criterion A-specified trauma. According to a journal article, Criterion A should include instances as oppression as non-Criterion A traumas are similar to Criterion A traumas and also cause PTSD symptoms.
Experts wrote that the limited number of traumas of Criterion A potentially results in missing out on PTSD symptoms that are traumatic to the individual but that do not meet Criterion A. For example, individuals could be traumatized from emotional abuse but could not get a PTSD diagnosis because they did not experience Criterion A trauma.
PTSD Symptoms from Non-Criterion A Traumas
Concerns about the 2013 definitions came about quickly because PTSD symptoms come from a wider variety of causes. Some experts believe that a toxic workplace can create PTSD symptoms. Workplace PTSD has been defined as “different emotional, cognitive, and physical challenges people experience when they have difficulty coping with negative, abusive, or traumatic aspects of their jobs.” Workplace PTSD’s symptoms look and feel like PTSD symptoms resulting from other circumstances. Workplace PTSD needs to be taken seriously and treated as it can have many negative repercussions, including detachment from others, difficulties concentration, “apathy, anxiety, depression, hopelessness, despair, and even suicidal ideation.” People of marginalized groups, including autistic individuals, have a greater chance of getting workplace PTSD because they often are the subject of discrimination.
PTSD symptoms can also be acquired from relationships, typically “repeated abuse trauma.” That abuse can be physical (including sexual) and emotional. Abusive relationships, which include violence and threatened violence, can cause PTSD. Experts coined PTSD symptoms from relationships – post-traumatic relationship syndrome (PTRS). After relationships end, some repeatedly think about their trauma and might place blame on themselves for their abuse. Relationship-created PTSD symptoms include nightmares, flashbacks or reliving one’s trauma, extreme reactions to some stressors, continued thoughts about one’s trauma, angst when reminded of one’s trauma, anxiety symptoms when thinking about one’s trauma, feeling of irritations, concentration problems, and sleep issues. Relationship-related symptoms include, “An attraction to unhealthy relationship dynamics, Jumping into a relationship when you’re not emotionally ready, Feeling like you don’t deserve a healthy relationship, Struggling to trust others, Blaming yourself for the abuse, Self-isolation, and Losing interest in sex.”
However, these types of traumas do not meet Criterion A. According to a study, stressful events that do not entail a threat to life or physical harm do not count for a PTSD diagnosis. Divorce or job loss are examples of such instances.
Since people can develop PTSD symptoms from non-Criterion A traumas, Criterion A is a barrier to diagnosis and treatment. This barrier is especially detrimental for autistic individuals, who are more likely to encounter bullying and traumas.
PTSD in the International Classification of Diseases
The International Classification of Diseases is used outside the United States to diagnose conditions and inside the U.S. for billing purposes. The current ICD-11 has a more expansive view of what types of events or situations are required for a PTSD diagnosis:
Exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Such events include, but are not limited to, directly experiencing natural or human-made disasters, combat, serious accidents, torture, sexual violence, terrorism, assault or acute life-threatening illness (e.g., a heart attack); witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and learning about the sudden, unexpected or violent death of a loved one.
Recommendations
The best solution is to expand Criterion A. Criterion A is necessary because without it, people could say their relatively minor incident (i.e. – a zit that ruined their appearance for an interview) is trauma. However, as people acquire PTSD symptoms from trauma that does not qualify for a PTSD diagnosis, Criterion A must be expanded, as the currently-narrowly defined Criterion A can cause obstacles to care. A broader definition of trauma in Criterion A would ensure that people with PTSD symptoms receive the proper treatment.
An expansion of Criterion A could benefit autistic people. According to a 2020 study, 22 of 35 autistic adults had PTSD symptoms although they did not experience DSM traumas. This finding is not surprising since autistic people can have strong reactions to less serious occurrences. Thus, less extreme events than Criterion A traumas could cause PTSD symptoms in autistic individuals. Patients who do not meet Criteria A do not receive a PTSD diagnosis and often do not receive treatment for trauma. If Criterion A included a greater number and types of traumas, then autistic people could be diagnosed with PTSD. This diagnosis could lead to necessary treatment.
The DSM sometimes extends a definition to create a more tailored diagnosis that would help with treatment. These extensions, called specifiers, are already used for PTSD. The next edition of the DSM should add new specifiers relating to Criterion A (i.e. – rape, war, workplace, bullying, blatant discrimination). Criterion A-related PTSD specifiers could affect treatment.
References
6B40 Post traumatic stress disorder
The Advantages and Limitations of International Classification of Diseases, Injuries and Causes of Death from Aspect of Existing Health Care System of Bosnia and Herzegovina, 2008
Anger Rumination and Autism: 7 Strategies to Help with Mental Regulation, 2024
CAN WE FIX PTSD IN DSM-V?, 2009
Defining Relationship PTSD, 2023
Expanding Criterion A for Posttraumatic Stress Disorder: Considering the Deleterious Impact of Oppression, 2016
Experience of Trauma and PTSD Symptoms in Autistic Adults: Risk of PTSD Development Following DSM-5 and Non-DSM-5 Traumatic Life Events, 2020
How to Recognize and Heal from Relationship PTSD, 2021
Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health
International Classification of Diseases, (ICD-10-CM/PCS) Transition – Background
Is a Criterion A trauma necessary to elicit posttraumatic stress symptoms?, 2024
Literature on DSM-5 and ICD-11: An Update, 2021
Post-traumatic stress disorder (PTSD), 2024
Post-traumatic stress disorder in autistic people, 2022
Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations, 2017
PTSD and Autism, 2024
PTSD History and Overview, 2022
PTSD Statistics And Facts: How Common Is It?, 2023
Racial and Ethnic Disparities in PTSD, 2020
Racial Trauma, 2024
Reformulating PTSD for DSM-V: Life After Criterion A, 2009
Rumination
Specifiers for Mood Disorders, 2022
Understanding The Connection Between Autism and PTSD, 2024
What Is Workplace PTSD — and How Can You Support Your Employees Who Suffer From It?, 2021
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