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DSM Criteria A, B, C, and D PTSD Symptoms: Combat Physiology
In the last section we will give a review of EMDR as a means of beginning the conversation about EMDR therapy with your PTSD client.
In this section we will discuss the four types of DSM criteria which categorize PTSD reactions. While this is probably a review for you as a mental health professional, by helping your client understand these different categories, you and client can get a better handle of how they can cope with their PTSD.
Along with the definition of what constitutes a traumatic event (Criteria A), there are specific reactions, or symptoms, that define PTSD. Symptoms must be found in all three categories (Criteria B, C, and D).
This criteria concerns the definition of a traumatic event. A traumatic event can include any event that is perceived to be life-threatening. Secondly, the definition includes an abnormal response to trauma which involves "fear, helplessness, or horror."
To give you a sense of each criteria category, I will give you an example from a client of mine, Greg, age 30, who finished three tours of duty with the army. He shared with me, "All we do is roll on missions and hope we don’t get blown up, and then when we get hit there is nothing we can do but watch my dead friends get pulled out in pieces." By his quote it is clear to see that Greg felt that his life was threatened.
Under this category are all symptoms surrounding the re-experiencing of the trauma. This can be through flashbacks, nightmares, intrusive thoughts, memories, etc. Memories of traumatic and life threatening events are stored differently and are processed differently than everyday memories. They are stored deeper in your limbic system, which is connected with basic functioning to survive, and are not a part of our conscious control. These memories are more emotionally charged and have a deeper, more vivid connection to our senses. These memories are often highly detailed because in times of danger and threat, the limbic system compresses more information at one time than the brain would normally process.
These criteria B re-experiences can be triggered by anything that reminds the client of the war zone or other site of the trauma. For some it is the smell of diesel fuel and for others it is an offhanded comment someone makes.
When Greg came to my office, he shared with me that memories of his time in the army would come back at any moment. He shared with me "whenever I am in a crowd, I begin to feel like I am back on tour. I just need to get out of their fast." Another example that he shared with me is "I have this recurring nightmare where I am sleeping in the kerosene soaked tents again. In the nightmare I am the only one on the top of the bunk bed while rounds are coming in."
For your client, understanding how the limbic system helps you survive is a way to prevent these memories from disrupting his or her life. I explained to Greg, "it is impossible to erase these memories but you can reach a point where they are not as intense or frequent and don’t cause as intense of reactions."
This next criteria has to do with the symptoms connected with withdrawal, avoidance, and emotional detachment. In many cases, these symptoms are a way for clients to cope with Criteria B symptoms. They may try to avoid situations out of a desire to avoid triggering strong reactions.
In combat, shutting down emotions is a necessary skill and it can be difficult to return to expressing emotions once the soldier returns. For some, when they do "turn on" their emotions it often comes out like a floodgate. I explained to Greg, "It takes adjustment to begin the process of connecting with your emotions."
In working with Greg, I saw examples of Criteria C symptoms when he shared with me, "I don’t talk much about my stress or personal matters. I don’t like to discuss them." On another occasion he mentioned to me, "I used to love the beach, but ever since my tours, I can’t stand the sand and avoid going anymore." Even more exemplary of this Criteria C was when Greg explained that he no longer care about anything including his wife’s tears. When I talked to Greg’s wife, she also noted, "he was very distant after coming home- it seemed he didn’t care."
This criteria focuses on the physiological responses a person has in response to a traumatic event. For many soldiers, their physiological responses can include: feeling revved up, being easily startled, becoming angry easily, difficulties with sleeping, and difficulties with concentrating. These responses are created because the body continues to be on high alert and is triggered very easily to react with a "flight-or-fight" response. These little triggers can create big physical reactions such as increased heart rate, rapid breathing, muscle tension, increased sense of fear or anxiety, jumpiness, and irritability. These responses are labeled as hypervigilance.
Greg shared with me, "I’m jumpy when I hear thunder, door slams, fireworks. I also do not get enough sleep. Yesterday I went to bed at 10:00 pm and I woke up at 1:00 am this morning and I just could not get back to sleep."
By sharing these criteria with your client and having a conversation about how your client sees these in themselves, they can begin to understand how to help themselves overcome their PTSD. Since everyone has varying levels of severity for each criteria, it is important that you explore this topic with your client.
In this section we discussed the four types of DSM criteria which categorize PTSD reactions. Criteria A concerns the definition of a traumatic event. A traumatic event can include any event that is perceived to be life-threatening. In Criteria B are all symptoms surrounding the re-experiencing of the trauma. This can be through flashbacks, nightmares, intrusive thoughts, memories, etc.
Criteria C has to do with the symptoms connected with withdrawal, avoidance, and emotional detachment. In many cases, these symptoms are a way for clients to cope with Criteria B symptoms. Criteria D focuses on the physiological responses a person has in response to a traumatic event. For many soldiers, their physiological responses can include: feeling revved up, being easily startled, becoming angry easily, difficulties with sleeping, and difficulties with concentrating.
What are the four types of DSM criteria which categorize PTSD reactions? To select and enter your answer go to .