Since its introduction into the diagnostic nomenclature, posttraumatic stress disorder (PTSD) Criterion A, known as the stressor criterion and referred to as simply ‘Criterion A,’ has been one of the most controversial aspects of the PTSD diagnosis. More specifically, since 1980, the PTSD field has debated where to draw the line between which experiences are considered ‘traumatic’ and which experiences are not. Even numerous attempts to revise the definition of PTSD Criterion A in subsequent editions of the Diagnostic and Statistical Manual for Mental Disorders (DSM) have not quelled the controversy. Opinions vary widely on how to best resolve the problem, especially in the wake of the recent events that have brought this debate to the forefront once again (e.g., the COVID-19 pandemic, the murder of George Floyd, and other racism-related stressors). Some scholars have suggested that Criterion A should be more inclusive, whereas others have suggested it should be narrower; still others have suggested that Criterion A should be eliminated altogether.
Proponents of expanding Criterion A point to the consistent finding that individuals can report PTSD-like symptoms in response to events that do not meet the current Criterion A definition. Proponents of narrowing Criterion A have argued that the current definition is overly inclusive, likely leading to the overdiagnosis of PTSD. This over inclusiveness, they say, prevents the field from identifying biomarkers of PTSD, shifts the focus from the stressor to intrapersonal vulnerabilities, undercuts the rationale for trauma-focused treatments for PTSD, and pathologizes normal emotional responses to stress and adversity. Those who have called for the elimination of Criterion A have done so on the grounds that it is challenging to offer a definition of Criterion A that disambiguates what events qualify as ‘traumatic’ stressors and that doing so is not sufficiently predictive of PTSD diagnostic status.
Another group of scholars have taken yet another position, namely that Criterion A should remain unchanged because there is no compelling evidence that the current definition is problematic, and that only when such evidence is uncovered should it be changed. Advocates of this position note that the previously mentioned positions suffer from several conceptual and methodological limitations. For example, nearly all studies used to support expanding, narrowing, or eliminating Criterion A altogether have relied upon responses to questionnaires or survey instruments to assess PTSD symptoms. Most of these studies have also used cross-sectional study designs that provide no information about the temporal association between stressor exposure and symptom onset. Further, most of these studies have not conducted a thorough assessment of participants’ trauma histories, properly determined which event or events should serve as the index event (i.e., most distressing traumatic event) for self-reported symptoms, or determined if the reported symptoms were trauma-related. Consequently, many participants’ responses in these studies likely reflect nonspecific and possibly nonclinical levels of distress. Further, none of the other approaches have explicated clear differences between ‘traumatic’ and nontraumatic stressors as well as differences in degree (i.e., magnitude or intensity) among stressors considered to be ‘traumatic’ based on the DSM.
In the service of making progress towards resolving the Criterion A debate once and for all, we recommend that the field address specific questions about Criterion A through research. Specific questions about Criterion A that have yet to be answered through research are: whether a revised Criterion A might improve understanding of the mechanisms involved in the development of PTSD; the ability to predict who develops, and recovers from, PTSD and the course of PTSD symptoms in the wake of exposure to traumatic events; and the ability to effectively treat individuals with PTSD. Related questions include: (a) What is the best way to characterize the range of significant distress reactions to stressors?; (b) What is the best way to characterize the range of stressful experiences that result in significant clinical distress?; (c) What are the genetic, epigenetic, molecular, neural circuitry, physiological, behavioral, and self-report correlates of the spectrum of adverse experiences, and are there intrinsic differences in these correlates among stressors that do and do not qualify for Criterion A status?; and (d) What is the best way to describe and quantify the differences in magnitude among stressors that do qualify for Criterion A? We also recommend the preservation of Criterion A in its current form until these and other questions are sufficiently answered. Finally, we recommend that researchers and clinicians use other diagnostic options for pathological responses to exposures that do not meet PTSD Criterion A. Such diagnostic options include (a) adjustment disorder and (b) other specified trauma- and stressor-related disorder. Unfortunately, there is very little research on effective treatments for either of these disorders, and these conditions thus include a wide variety of nonspecific symptoms that may or may not include symptoms of PTSD. More research on these other diagnostic options would be helpful to the field.
The published article is featured in the Journal of Traumatic Stress:
https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.23007
About the authors
Dr. Brian Marx has expertise in the assessment and treatment of veterans with PTSD as well as in the identification and treatment of Veterans and Active-Duty service members with suicidal thoughts and behaviors. He is the Deputy Director of and Senior Psychologist Clinician Investigator in the Behavioral Science Division of the National Center for PTSD and corresponding PI for the VA CSRD side of the Suicide Prevention Research Impact Network (SPRINT). He is also a Professor in the Department of Psychiatry at Boston University Chobanian and Avedisian School of Medicine. He is co-developer of Written Exposure Therapy for PTSD. He is the lead author on the Inventory of Psychosocial Functioning. Additionally, he is a co-author of all the most commonly used measures of PTSD diagnostic status and symptom severity and regularly conduct research on the best methods to assess PTSD and symptom change. His research program has translated NCPTSD and VA’s national research goals and priorities into specific scientific project activities of significant complexity and sufficient sustainability. Over his career, Dr. Marx has held funding simultaneously from VA, DoD, DARPA, NIH, CDC, and private industry. Dr. Marx was previously awarded the Robert S. Laufer, PhD Memorial Award for outstanding scientific achievement from ISTSS.
Dr. Brittany Hall-Clark is a Texas-licensed clinical psychologist in private practice, and an Assistant Professor within the Division of Behavioral Medicine and the Department of Psychiatry at the University of Texas Health Science Center at San Antonio, and a consultant in the PTSD Consultation Program at VA's National Center for PTSD. Her clinical specialties include trauma, nightmares, insomnia, sleep and anxiety. She has been certified as a Master Prolonged Exposure clinician and has extensive experience in working with active-duty Service members and Veterans. She has also been trained in Cognitive Behavioral Therapy (CBT) for Insomnia and Nightmares as well as Cognitive Behavioral Conjoint Therapy (CBCT) for PTSD. Dr. Hall-Clark's research interests include acculturative stress, cultural identity, and delivery of culturally sensitive treatment. For 8 years, she worked at the Ft. Hood site of STRONG STAR--a multidisciplinary PTSD research consortium--as a cognitive-behavioral research therapist for several randomized clinical trials focused on PTSD and related conditions in active-duty military personnel and Veterans. She obtained her PhD in clinical psychology at the University of Texas at Austin.
Paul Holtzheimer, MD, is the Deputy Director for Research at the National Center for Posttraumatic Stress Disorder and the Director of the National PTSD Brain Bank. He is Professor of Psychiatry and Surgery at the Geisel School of Medicine at Dartmouth, and a staff psychiatrist at Dartmouth-Hitchcock Medical Center and the White River Junction VA Medical Center. His clinical and research interests include developing better interventions for PTSD, depression and related disorders, especially for patients with treatment-resistant and comorbid illness. Dr. Holtzheimer has expertise in brain imaging and brain stimulation therapies (including transcranial magnetic stimulation, electroconvulsive therapy, vagus nerve stimulation, and deep brain stimulation). He also oversees a preclinical lab focused on assessing and developing interventions for the neuropsychiatric-like consequences of traumatic blast injury in rodent models. Dr. Holtzheimer is an author on over 100 publications in psychiatry, neurology, neurosurgery and neuroimaging. He has received research funding from the National Institutes of Health, the Department of Veterans Affairs and multiple non-profit foundations. He has served on the Council of the Society of Biological Psychiatry and on the Board of Directors for the Anxiety and Depression Association of America. He is a Fellow of the American College of Neuropsychopharmacology.
Dr. Matthew Friedman is founder and former Executive Director of the National Center for Posttraumatic Stress Disorder, US Department of Veterans Affairs, and Professor of Psychiatry and of Pharmacology and Toxicology at the Geisel School of Medicine at Dartmouth. He has worked with PTSD patients as a clinician and researcher for thirty-five years and has published extensively on stress and PTSD, biological psychiatry, psychopharmacology, and clinical outcome studies on depression, anxiety, schizophrenia, and chemical dependency. He has over 200 publications, including 23 books and monographs. Listed in The Best Doctors in America, he is a Distinguished Lifetime Fellow of the American Psychiatric Association, past-president of the International Society for Traumatic Stress Studies (ISTSS), past chair of the scientific advisory board of the Anxiety and Depression Association of America (ADAA), member of APA's DSM-5 Anxiety Disorders Work Group, (and chair of the Trauma and Dissociative Disorders SubWork Group). He has served on many VA, DoD and NIMH research, education and policy committees. He has received many honors including the ISTSS Lifetime Achievement Award in 1999 and the ISTSS Public Advocacy Award in 2009. He was a finalist for the 2011 Samuel J. Heyman Service to America Medal in the Career Achievement Division.
Dr. Paula Schnurr is the Executive Director of the National Center for Posttraumatic Stress Disorder and had previously served as Deputy Executive Director of the Center since 1989. She is a Professor of Psychiatry at the Geisel School of Medicine at Dartmouth and Editor of the Clinician's Trauma Update-Online. She received her PhD in Experimental Psychology at Dartmouth College in 1984 and then completed a post-doctoral fellowship in the Department of Psychiatry at the Geisel School of Medicine at Dartmouth. Dr. Schnurr is Past-President of the International Society for Traumatic Stress Studies and is a fellow of the American Psychological Association and of the Association for Psychological Science. She previously served as Editor of the Journal of Traumatic Stress. She has investigated risk and resilience factors associated with the long-term physical and mental health outcomes of exposure to traumatic events. She is an expert on psychotherapy research and has conducted a number of clinical trials of PTSD treatment, including multi-site trials of Prolonged Exposure for female veterans and active duty personnel with PTSD and of group psychotherapy for PTSD in Vietnam veterans.