Using DSM-5 Criteria to Evaluate PTSD Claims in Litigation

There seems to be a growing trend of plaintiffs attempting to recover damages for emotional distress and specifically claims related to post-traumatic stress disorder (PTSD). The diagnosis of PTSD is strictly interpreted by the medical profession, or should be. There have been multiple changes contained in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In the most recent DSM, there are additional criteria that must be met in order for a person to qualify for the diagnosis of PTSD. All five of the criteria must be met as set forth in the DSM-5. These changes also removed PTSD from the anxiety-based disorders to its own separate category of illnesses.

• The first criteria: The claimant has faced exposure to death, threatened death, serious injury, or sexual violence, either through direct experience, witnessing firsthand trauma, learning a relative or a close friend was exposed to trauma, and repeated or extreme exposure to aversive details of trauma (typically experienced by first responders).
• The second criteria: There has to be a presence of one or more intrusive symptoms associated with the traumatic event or events after the event occurs. These symptoms include recurrent distressing memories, recurring nightmares, flashbacks in which the person feels the trauma repeatedly, intense or prolonged psychological distress in the face of these reminders, or physical reactions in the face of the reminder.
• The third criteria: The claimant avoids stimuli associated with the trauma, such as avoiding distressing memories and thoughts about the trauma, or avoiding distressing external reminders of the trauma, like people, places, conversations, and activities.
• The fourth criteria: There is a negative alteration to mood and cognition as evidenced by two or more of the following:
  • inability to remember important aspects of the trauma
  • exaggerated negative thoughts about oneself, others, or the world
  • blaming oneself or others for the trauma
  • persistent negative emotional state, like fear, harm, anger, guilt, or shame
  • diminished interest in activities
  • feelings of detachment or estrangement from others
  • inability to experience positive emotions
• The fifth criteria: There are alterations in arousal and reactivity as evidenced by two or more of the following:
  • irritability and angry outbursts with little or no provocation
  • reckless and self-destructive behavior
  • hypervigilance
  • exaggerated startled response
  • problems with concentration
  • difficulty sleeping

The duration of the disturbance must last for more than one month, the disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning, and the symptoms must not be due to medication, substance abuse, or another medical condition.

In the DSM-4, a patient only needed to meet 4 criteria — which included reliving the event, avoiding anything that reminded them of the event, having more negative thoughts and feelings than before the event, and finally, feeling on edge or keyed up (hyper arousal).

The changes made from the DSM-4 to the DSM-5 now classify PTSD as part of the newly created category of trauma- and stressor-related disorders.^[i]  Clinicians have noted that “[w]ith this new classification, a clinician may be more inclined to consider a PTSD diagnosis for a trauma-exposed patient rather than other disorders commonly associated with reactions to trauma and other stressors, such as depression, borderline personality disorder, and generalized anxiety disorder.”^[ii] Given the high degree of the co-occurrence between PTSD and Major Depressive Disorder (MDD), there is a danger that the diagnosis of these disorders may skew to PTSD over MDD, especially if financial gain is in play.

The bottom line is that, for trauma survivors, as with previous DSM editions, clinical diagnosis must carefully assess pre-trauma functioning. Consideration should also be given to the possibility that another diagnosis besides PTSD may be equally, if not more, appropriate, even if trauma has occurred. Within the context of litigation, a qualified medical expert must consider all the criteria necessary for a diagnosis of PTSD, and not misidentify one diagnosis with another.

[i] Lori A. Zoellner, Michele A. Bedard-Gilligan, Janie J. Jun, Libby H. Marks, Natalia M. Garcia, “The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications,” Psychological Injury and Law 2013 Nov 30.

[ii] Bryant RA, O’Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. “The psychiatric sequelae of traumatic injury,” The American Journal of Psychiatry. 2010;167:312–320.