Posttraumatic Stress Disorder 497
Clinician Guideline 12.2
Acute stress disorder (ASD) is an immediate anxiety state in response to a traumatic event
in which acute dissociative symptoms predominate along with some trauma- related reexpe-
riencing, avoidance, and heightened arousal symptoms that together cause significant dis-
tress or functional impairment. The majority of individuals with ASD will eventually meet
criteria for PTSD.Diagnostic Controversy
There has been much debate on the conceptual and practical problems associated with
the diagnosis of PTSD (Rosen, Spitzer, & McHugh, 2008; Spitzer, First, & Wakefield,
2007). First, it is apparent that occurrence of a traumatic stressor (i.e., Criterion A) is
neither necessary nor sufficient for PTSD (Rosen et al., 2008). Individuals can meet
PTSD symptom criteria following non- Criterion A events such as marital disruption,
divorce, bereavement, breaking up with a best friend, and the like (Rosen & Lilienfeld,
2008) and support for a dose– response assumption (i.e., the most severe PTSD is not
necessarily associated with the most severe trauma) has been inconsistent (McNally,
2003a; Rosen & Lilienfeld, 2008). McNally (2003a) has been critical of the expanded
number of events that qualify as Criterion A stressors under DSM-IV, noting that this
“bracket creep” may be medicalizing expected human reactions to trauma.
Second, there is weak and inconsistent support from factor- analytic studies for the
three core DSM-IV symptom clusters (reexperiencing, avoidance/numbing, and physi-
ological arousal) (e.g., Palmieri, Weathers, Difede, & King, 2007; Simms, Watson, &
Doebbeling, 2002; see also Resick et al., 2008, for review). Moreover, taxometric analy-
sis suggests that PTSD is not a discrete syndrome but rather a dimensional condition
that represents the more severe end of a continuum with milder reactions to traumatic
experiences (Ruscio et al., 2002).
Third, there are other negative emotional responses to trauma such as guilt and
shame that are evident in PTSD but not included in DSM-IV (see Resick et al., 2008).
Other diagnostic problems include (1) the presence of PTSD symptoms in other disor-
ders like major depression (Bodkin, Pope, Detke, & Hudson, 2007), (2) a marked vari-
ability in symptom presentation across PTSD cases, (3) a high rate of comorbidity, and
(4) failed attempts to find a distinct biological or psychological marker for the disorder
(Rosen & Lilienfeld, 2008). These diagnostic issues may have important implications
in terms of making it difficult for clinicians to reliably diagnosis PTSD without the use
of structured diagnostic interviews (Nielssen & Large, 2008). Furthermore, concerns
about diagnostic validity could lead to a high false positive rate (McNally, 2007b). In
light of these diagnostic problems, many researchers are again calling for a reconsidera-
tion of the nosology of PTSD with major revisions suggested for DSM-V (Rosen et al.,
2008; Spitzer et al., 2007).
Clinician Guideline 12.3
The defining diagnostic features of PTSD continue to be debated, including the nature and
severity of the traumatic experience required for the diagnosis.