The Debate Over Trauma in the New DSM Revision

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When I use the word "trauma," something different may come to mind for each of you, highlighting its subjective nature and how a traumatic event may impact each of us differently. However, in the world of traumatic stress research and clinical practice, defining trauma and finding the line of what counts (or doesn’t count) as a traumatic event becomes critical to correct diagnosis and resulting treatment.

Post-traumatic stress disorder (PTSD) is a unique mental health condition in that it requires the existence of an event to precipitate the onset of PTSD symptoms. Specifically, as outlined in the Diagnostic and Statistical Manual, 5th edition text revision (DSM-5-TR¹), in order to be diagnosed with PTSD, an individual first has to be exposed to a traumatic event (i.e., Criterion A). That event must fall outside the realm of normal human experience and include things like exposure to actual or threatened death, serious injury, or sexual violence through the direct experience or witnessing of the event, learning about it happening to a loved one, or through repeated exposure as part of one’s job. The DSM-5 made efforts to restrict the definition of trauma to ensure the definition distinguished the extreme nature of Criterion A events from lower magnitude stressors.

Importantly, the rules and stipulations of what counts as a trauma based on the DSM-5-TR can mean that very difficult life experiences that may lead to trauma responses are left out, such as being confronted with the death of a loved one to cancer or being witness to a debilitating chronic illness of one’s child. The current definition of Criterion A trauma also does not account for experiences of racial discrimination, leaving out highly impactful and distressing life events that have been shown to lead to the same symptom profile as PTSD.

The debate on Criterion A within the trauma field is well laid-out in a recent review article by Marx and colleagues² in which they describe four potential paths that the PTSD trauma definition could take moving forward:

1. Expanding Criterion A
2. Narrowing Criterion A
3. Eliminating Criterion A
4. Keeping Criterion A unchanged

A recent meta-analysis by Georgescu et al.³ highlights a main argument behind the expansion of Criterion A by finding that across 124 studies, the pooled average of potential PTSD symptoms following non-Criterion A events (such as racial discrimination or cancer) was comparable to those observed in studies of PTSD from Criterion A events. These results suggest that by maintaining a narrow definition of trauma, we may be missing people with PTSD symptom profiles that are clinically significant. Is defining trauma actually necessary or can the focus be on who displays PTSD symptoms? This is a primary question raised among those who also consider the full elimination of Criterion A from the PTSD diagnosis. Alternatively, experts advocating for narrowing Criterion A suggest that the exclusion of any indirect exposures from qualifying for Criterion A can clarify the difference between traumatic and nontraumatic stressors and limit misclassification of PTSD or diagnosis drift. However, as Marx et al.² point out, there is still a great deal we need to discover about how changes to the DSM-5 definition of trauma may affect our understanding of PTSD as a disease, its underlying mechanisms, and who is most likely to develop or recover from PTSD.

As a trauma researcher, it is easy for me to get in the weeds about these paths and their implications because while strict adherence to diagnostic criteria ensures rigor and reproducibility across studies, narrow definitions can result in missed opportunities to capture clinically relevant symptom presentations. Each option has its drawbacks.

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This debate necessarily translates to the clinical space as well. The diagnosis we determine for a client should lead to an evidence-based treatment that aligns with that condition. If PTSD is present, but missed, the focus of the treatment may be misaligned with the primary symptoms and could lead to delayed recovery for the client. In the current diagnostic landscape, adjustment disorder and other trauma and stressor-related disorders are viable options for diagnosis when Criterion A is not present. Ultimately, as a clinician, the key should be thorough assessment of both traumatic experiences and difficult life events not captured in trauma inventories, like racial discrimination, childbirth, or non-traumatic loss, and how those may influence psychological symptom presentation. Understanding common experiences of the population you serve is key. If you do not ask, you will not know. Instead of getting caught in the debate, we can learn from it, and still make choices about how we conceptualize and treat clients based on their symptoms while keeping the whole person – and all the experiences that have come with them – in mind.