Reconceptualization of PTSD in DSM-5

Perhaps the most important decision regarding PTSD in the American Psychiatric Association’s (APA) fifth edition of its Diagnostics and Statistical Manual (DSM-5)1 was its removal from the anxiety disorders category. Originally conceptualized as a fear-based anxiety disorder in both DSM- III2 and DSM-IV,3 PTSD was reclassified as a trauma and stressor-related disorder in DSM-5. The major reason for this is that PTSD has a number of recognizable phenotypes: fear-based anxiety, anhedonia/dysphoria, externalizing features, and dissociative features. In practice, these different phenotypes are often seen in combination. Furthermore, it is possible that the predominance of a particular phenotype within the same individual may vary over time. Thus, this chapter reviews the rationale for placing PTSD in the trauma-and stressor-related disorders chapter of DSM-5 and then considers the implications of this reclassification for treatment and research.

We first consider three different sets of organizing principles that were considered by the authors of the DSM-5 with respect to the best chapter in which to classify PTSD in order to cluster it with other diagnoses with common properties. We will examine the arguments for placing PTSD within each specific category. First, we consider the rationale for designating PTSD as an “anxiety disorder,” as it has been since DSM-III. Second, we consider PTSD from the perspective of neurocircuitry with regard to excessive amygdala reactivity and prefrontal cortical hyporeactivity in response to stressful or fearful situations. Next, we consider PTSD with respect to internalizing and externalizing disorders. Finally, we discuss evidence for PTSD as a dissociative disorder. The major question we address is one of goodness-of-fit: namely, why PTSD should have been classified not as an anxiety, a stress-related fear circuitry, an internalizing disorder, or a dissociative disorder, but rather as one of the new trauma and stressor-related disorders.

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