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Can I use trauma-focused treatment if a trauma doesn’t meet criterion A of the PTSD diagnosis?

In DSM-5, criterion A of the PTSD diagnostic criteria specifies what kinds of events constitute a traumatic stressor. This is because PTSD has historically been conceived of as a condition that only arises from exceptionally threatening experiences, rather than from any stressful life event.


DSM-5 defines a criterion A trauma as one involving experiencing or witnessing actual or threatened death, serious injury or sexual violence. In contrast, ICD-11 uses more general and potentially inclusive wording, defining trauma as “an extremely threatening or horrific event”.


What constitutes a trauma diagnostically has always been controversial and has also changed with each iteration of the DSM manual. Indeed some researchers have advocated getting rid of criterion A completely, arguing that it is the distinct clinical picture of symptoms, rather than the event itself which is key to making the diagnosis (Brewin et al., 2009).


So, if the criterion is so controversial, does the nature of the trauma really matter when we decide what treatment to offer? After all, we wouldn't want people to miss out on effective treatment because of a technicality. On the other hand, isn’t all of our research on treatment for PTSD based on defining it a particular way? So, we don't really know if our trauma focused treatments work if someone’s symptoms don’t meet those criteria.


Treatment decision-making may vary between settings. A client whose trauma and/or symptoms don’t meet full criteria for PTSD wouldn’t usually be included in a research trial. However, if someone presents in a routine clinical setting in distress, with traumatic stress symptoms after an event that doesn’t technically meet criterion A, the pragmatic and emphatic approach most therapists would take would be to offer treatment, albeit mindful they are working on the edge of the evidence base.


In this situation, it is important to carry out a detailed assessment of all the PTSD symptom criteria and especially the re-experiencing cluster, before deciding to use trauma-focused therapy. Because traumatic events can be triggers for many different psychological problems, exposure to a trauma does not necessarily mean symptoms are best understood as PTSD. And our formulations and treatments would differ markedly if a diagnosis like depression or adjustment disorder is a better fit to the symptoms and patient’s goals.


In these situations, even if there are clear links with a traumatic or stressful event, we should offer the best evidence-based treatment for what we consider to be the primary diagnosis. This might still mean developing a formulation where the role of trauma is central, but with potentially less focus on processing memories if they aren’t re-experienced as flashbacks and nightmares. Instead, the focus may be more on the threatening or maladaptive meanings of the trauma, alongside whatever unhelpful cognitive and behavioural coping strategies are maintaining the emotional problems (e.g. rumination and self-attack, behavioural avoidance, emotional suppression, vigilance etc).


In fact, many treatments for other disorders now incorporate elements derived from trauma-focused treatments, where a traumatic or stressful event (or series of events) is an important aspect of the formulation. For example, imagery rescripting is commonly integrated into cognitive therapy interventions for depression (e.g. Wheatley et al., 2011) and social anxiety disorder (e.g. Wild & Clark, 2011), as earlier traumatic memories so often play an important role in the formation of relevant negative core beliefs.


But, again, here the emphasis is more on addressing the meaning of the events rather than changing the nature of the trauma memory i.e. contextualising it and making it less fragmented, key process typically driving re-experiencing symptoms in PTSD.


For example, if a client has social anxiety disorder and has a history of being bullied as a child, but isn’t re-experiencing particular memories, we wouldn’t use imaginal reliving but might still use imagery rescripting to address the beliefs and emotions linked to those experiences e.g. “I’m unlikeable, defective, pathetic, weak”. Here, we may seek to change the meanings experientially by activating the memory briefly in imagination, then asking the client to enter the scene in their mind’s eye as their adult self, stand up to the bullies and comfort their child self.


In our experience, where our clients report PTSD symptoms without a strict criterion A trauma, there is often something else in the formulation which explains why the event was experienced as particularly threatening, when it perhaps wasn’t objectively as dangerous. For example, the event might have reminded them of earlier experiences or activated a set of negative core beliefs which need more investigation.


One client we worked with who was briefly trapped in a lift (not a criterion A trauma), had a history of panic disorder, and believed in those few minutes that she would run out of air and die. Another client who felt very frightened during a meeting at work (but was not objectively in danger), had a history of domestic abuse and felt as if her manager might attack her when he seemed angry. In both cases, the clients were re-experiencing these events in flashbacks, nightmares and intrusive memories despite them not meeting strict criterion A, and benefited from a trauma-focused treatment approach.




Practice points

· The criterion A diagnosis has long been controversial and has changed over time

· However, research into PTSD is based on these diagnostic criteria so we do know if treatment is effective if clients do not meet the criteria

· Deciding whether to offer treatment may vary in different settings

· A full assessment, particularly of re-experiencing symptoms, is especially important if the trauma does not meet criterion A

· Traumatic experiences are an important part of many disorders as well as PTSD so differential diagnoses should be considered and relevant treatment offered

· Treatments for other disorders may still incorporate elements of trauma-focused treatments, such as imagery rescripting

· Often, if an experience does not meet criterion A but the client has PTSD symptoms, there are additional factors that explain why the event was experienced as highly threatening.


References

Brewin, C. R., Lanius, R. A., Novac, A., Schnyder, U., & Galea, S. (2009). Reformulating PTSD for DSM‐V: life after criterion A. Journal of Traumatic Stress, 22(5), 366-373.

Wheatley, J., & Hackmann, A. (2011). Using imagery rescripting to treat major depression: Theory and practice. Cognitive and Behavioral Practice, 18(4), 444-453.

Wild, J., & Clark, D. M. (2011). Imagery rescripting of early traumatic memories in social phobia. Cognitive and Behavioral Practice, 18(4), 433-443.


Further reading

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