PTSD symptoms and the DSM-5 criteria, in plain language.

Criterion A: the traumatic event

PTSD begins with a defined exposure. The DSM-5 requires exposure to actual or threatened death, serious injury, or sexual violence, in at least one of four ways: directly experiencing it, witnessing it in person, learning that it happened violently or accidentally to a close family member or friend, or repeated or extreme exposure to aversive details in the course of work — first responders, police, medical examiners, child-protection investigators.

Watching it on television or reading about it does not meet the criterion unless the exposure is work-related. This is a genuine boundary in the diagnosis, and it excludes many deeply distressing life experiences — divorce, job loss, non-violent bereavement — that can still cause serious psychiatric illness under a different name.

The four symptom clusters

1. Intrusion (at least one)

• Recurrent, involuntary, intrusive memories of the event
• Recurrent distressing dreams related to it
• Dissociative reactions — flashbacks, in which some part of you experiences the event as happening now
• Intense psychological distress at reminders
• Marked physical reactions to reminders — racing heart, sweating, nausea

2. Avoidance (at least one)

• Avoiding internal reminders: memories, thoughts, feelings connected to the event
• Avoiding external reminders: people, places, conversations, activities, objects, situations

3. Negative changes in thoughts and mood (at least two)

• Inability to remember an important part of the event
• Persistent exaggerated negative beliefs — "I am permanently damaged," "no one can be trusted"
• Distorted blame of self or others for the event or its consequences
• Persistent negative emotional state: fear, horror, anger, guilt, shame
• Markedly reduced interest in significant activities
• Feeling detached or estranged from other people
• Persistent inability to feel positive emotions

4. Changes in arousal and reactivity (at least two)

• Irritability or angry outbursts with little provocation
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Concentration problems
• Sleep disturbance

That last cluster is why PTSD is so frequently mistaken for ADHD, and why the concentration and sleep complaints often bring people in before the trauma is ever mentioned.

Duration, distress, and exclusions

Symptoms must persist for more than one month, cause clinically significant distress or impairment in social, occupational, or other functioning, and not be attributable to a substance or another medical condition.

Onset does not have to be immediate. Delayed expression — full criteria not met until six months or more after the event — is formally recognized and not unusual.

The DSM-5 also specifies a dissociative subtype, where depersonalization or derealization are prominent, which has treatment implications.

PTSD versus acute stress disorder

The symptom picture in the first month after a trauma is called acute stress disorder when it lasts three days to one month. If symptoms persist past the one-month mark, the diagnosis becomes PTSD. Most people who develop acute stress symptoms after a trauma do not go on to develop PTSD — recovery is the more common outcome.

A note on complex PTSD

Complex PTSD (C-PTSD) is recognized in the ICD-11 but is not a separate DSM-5 diagnosis. It describes the presentation that follows prolonged, repeated trauma — childhood abuse, captivity, long-term domestic violence — and adds persistent problems with emotional regulation, self-concept, and relationships to the core PTSD picture. In the United States it is usually documented as PTSD with the relevant additional diagnoses. Clinically, it matters: the treatment sequence typically emphasizes stabilization and skills before trauma processing.

How PTSD is actually diagnosed

By clinical interview. A screening measure like the PCL-5 is a legitimate, validated instrument — 20 items mapped directly to the DSM-5 criteria, with a provisional cutoff around 31–33 — but a score is a starting point, not a diagnosis. A clinician still has to establish Criterion A, confirm the symptom counts in each cluster, verify duration and impairment, and consider what else could account for the picture, including depression, panic disorder, traumatic brain injury, and substance withdrawal.

What treatment looks like

First-line treatment for PTSD is trauma-focused psychotherapy: prolonged exposure, cognitive processing therapy, or EMDR. The evidence for these is stronger than for any medication.

Medication has a real supporting role. SSRIs — sertraline and paroxetine both carry FDA approval for PTSD — and the SNRI venlafaxine have the best evidence. Prazosin is used for trauma nightmares. Benzodiazepines are specifically not recommended; they do not treat PTSD and may interfere with the extinction learning that therapy depends on.

Our role at MindHealth is the psychiatric side: diagnosis, medication management, stabilization, and coordination with a trauma-focused therapist. If you are in crisis, call or text 988 at any time.

Frequently asked questions