Table 1 Criteria for post-traumatic stress disorder in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

Directly experiencing the traumatic event(s)

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

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.

Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (for example, first responders collecting human remains)

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

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

Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s)

Dissociative reactions (for example, 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.)

Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

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:

Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

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:

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)

Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (for example, ‘I am bad’, ‘No one can be trusted’, ‘The world is completely dangerous’, ‘My whole nervous system is permanently ruined’)

Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others

Persistent negative emotional state (for example, fear, anger, guilt, or shame)

Markedly diminished interest or participation in significant activities

Feelings of detachment or estrangement from others

Persistent inability to experience positive emotions (for example, 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:

Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects

Reckless or self-destructive behavior

Hyper-vigilance

Exaggerated startle response

Problems with concentration

Sleep disturbance (for example, difficulty falling or staying asleep or restless sleep)