Journal of Traumatic Stress

October 2013, 26, 563–566

COMMENTARY
The DSM-5 Got PTSD Right: Comment on Friedman (2013)
Dean G. Kilpatrick
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA

Friedman in his article in this issue describes the posttraumatic stress disorder (PTSD) diagnosis according to the Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5) and provides considerable information about the process that resulted in the revisions, as well
as how PTSD in the DSM-5 differs from proposals for PTSD in the International Classification of Mental Disorders and Related Health
Problems (ICD-11). In this commentary, I argue that (a) the placement of PTSD in the DSM-5 category of Trauma and Stressor-Related
Disorders is a major advance because it draws attention to the role of “nurture” when there is an overemphasis on “nature” by some; (b)
the broader construct of PTSD in DSM-5 is justified because it includes clinically important problems and can be reliably diagnosed; and
(c) the web surveys contributed substantially to the provision of data needed to support proposed changes. Concerns are raised about the
proposed ICD-11 approach, and the case is presented that substantial evidence should be required before these proposed changes are made
because they differ substantially from a DSM-5 PTSD diagnosis that has demonstrated reliability and validity.

Matthew Friedman in his article in this issue does a masterful
job in describing the objectives, process, and outcome of the
Sub-work group’s deliberations concerning revisions of post-
traumatic stress disorder (PTSD) and other trauma and stress-
related disorders for the fifth edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association
(DSM-5; American Psychiatric Association [APA], 2013). In
this commentary, I focus on three areas of Friedman’s article
with a primary emphasis on the DSM-5 PTSD diagnosis. Some
concerns and suggestions are raised about draft International
Classification of Mental Disorders and Related Health Prob-
lems (11th rev.; ICD-11) proposals (Maercker et al., 2013) for
revisions of the PTSD diagnosis and the fact that they differ
substantially from DSM-5.
As Friedman notes, the DSM-5 has a new section titled,
“Trauma and Stressor-Related Disorders” in which PTSD
is included. This change is extremely important. At a time
when there is considerable interest and a highly reductionistic
overemphasis on the nature, biological, and neuroscience part
of the nature–nurture model for understanding psychopathol-
ogy, the inclusion of this “Trauma and Stress-Related Dis-
Contents are solely the responsibility of the author and views expressed do not
necessarily represent those of the APA or other agencies.
Correspondence should be addressed to Dean G. Kilpatrick, 67 President Street,
South Building, Suite 200, Charleston, SC 29425. E-mail: kilpatdg@musc.edu
Copyright  C 2013 International Society for Traumatic Stress Studies. View
this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21844
orders” chapter provides a useful reminder that nurture also
plays a critical role. It reminds clinicians and researchers alike
that exposure to traumatic stressors and other stressful events
can interact with genetic, biological, and psychosocial risk and
protective factors to produce PTSD, acute stress disorder, and
adjustment disorders, as well as reactive attachment disorder
and disinhibited social engagement disorder. This placement
of PTSD in a new category of trauma and stressor-related dis-
orders should encourage clinicians and researchers to consider
the potential impact of exposure to traumatic and other stressors
on increasing risk for these and other mental disorders.
A broad PTSD construct approach was taken in DSM-5 that
attempted to include clinically important and relevant symp-
toms in the PTSD diagnosis. This contrasts with the more nar-
row approach focusing on core elements that is being proposed
by the ICD-11 (Maercker et al., 2013; World Health Organiza-
tion [WHO], 2012). There are several factors that support the
use of the less narrow criteria/symptom sets and the contention
that the DSM got it right. Researchers and clinicians use diag-
nostic criteria to identify key features and symptoms, and the
symptoms in the PTSD diagnosis guide us as to what to look
for in clinical or research assessment. The symptoms added to
the PTSD diagnosis are not newly discovered problems among
individuals with PTSD. They have always been an important
part of the clinical picture for many individuals with PTSD, and
they have often been the focus of PTSD treatment. However,
adding them to the diagnosis will encourage clinicians and re-
searchers to assess them, treat them, and include them in PTSD
research. As Friedman notes, the argument that the PTSD diag-
nosis in DSM-5 has too many symptoms and is too complicated

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to be used reliably by clinicians is refuted by the DSM-5 field
trial results, indicating that PTSD had one of the highest relia-
bilities of any DSM-5 diagnosis (Regier et al., 2013). Although
the PTSD diagnosis in the DSM-5 may be broad, it can be di-
agnosed reliably by clinicians and includes clinically relevant
symptoms and problematic behaviors. Therefore, the burden of
proof for supporters of a narrower PTSD construct is to provide
data documenting that a narrow approach has greater clinical
and research utility.
The definition of PTSD Criterion A will always be contro-
versial. Friedman provides an excellent overview of the justi-
fication for the DSM-5 changes in Criterion A in DSM-5, so
the focus here is on two changes that have clinical and research
relevance. First, as Friedman notes, learning about the nonac-
cidental, nonviolent deaths of family members or close friends
is no longer classified as a Criterion A event, and this was a
major reason for individuals meeting the DSM-IV (APA, 1994),
but not DSM-5 criteria for PTSD (Kilpatrick et al., 2013). This
will undoubtedly be a focus of controversy and is also likely
to generate research focusing on PTSD associated with differ-
ent types of death. Such research is needed to inform DSM-5.1
deliberations. Second, the DSM-5 PTSD criteria and text ac-
knowledge and place greater emphasis on the role of exposure
to multiple traumatic events in PTSD symptomatology. How to
incorporate exposure to multiple Criterion A events into assess-
ment of PTSD symptomatology will be a challenge (Kilpatrick,
Resnick, & Acierno, 2009; Kilpatrick et al., 2013), but it is a
challenge that must be addressed.
Changes in the PTSD diagnosis required substantial justifi-
cation. Based on the literature review conducted by Friedman,
Resick, Bryant, and Brewin (2011), many modifications in the
PTSD diagnosis were proposed. A major challenge for the sub-
work group was the need for data to justify proposed changes,
but extant studies were limited in their ability to provide data
about the impact of several of the proposed changes. For exam-
ple, the addition of new symptoms and modification of several
old symptoms required collection of new data to evaluate the
impact of changes in the proposed symptom clusters. Like-
wise, new data were needed to evaluate the impact of proposed
DSM-5 revision of Criterion A and symptom criteria on PTSD
prevalence and caseness. Finally, data were needed concerning
the operationalization of proposed new symptoms and the num-
ber of symptoms needed to meet the threshold for each of the
new criteria.
The Sub-work group had limited time and resources to de-
vote to data collection, but identified a viable strategy for col-
lecting the necessary information. Specifically, we designed
and implemented two large online surveys measuring exposure
to traumatic stressors, other stressful life events, and PTSD
symptoms among a national sample of U.S. adults (the Na-
tional Stressful Events Survey) and a sample of veterans (the
Veterans Web Survey). Both the National Stressful Events Sur-
vey and Veterans Web Survey were self-administered, but they
were constructed to mimic highly structured clinical interviews
as opposed to self-report questionnaires. More details about
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Kilpatrick
these surveys, their methodology, and key findings is provided
elsewhere (Kilpatrick et al., 2013; Miller et al., 2012).
Friedman (2013) describes how the findings from these two
surveys supported the new symptom structure and played a ma-
jor role in reducing the number of symptoms required to meet
Criterion D and Criterion E. However, these surveys also pro-
vided information about the impact of other proposed changes,
including the content and phrasing of symptoms and the types of
events included in Criterion A. Moreover, the National Stress-
ful Events Survey data confirmed that PTSD prevalence among
a national sample of U.S. adults using DSM-5 criteria was com-
parable to that obtained using DSM-IV criteria. Finally, findings
from the National Stressful Events Survey indicated that fail-
ure to have at least one active avoidance symptom was a major
reason adults met DSM-IV, but not DSM-5 criteria (Kilpatrick
et al., 2013). In summary, the online surveys provided key in-
formation to the Sub-work group and also were a cost-effective
way to assess exposure to traumatic events and PTSD symp-
tomatology.
As Friedman indicates, it appears that there will be substan-
tial differences between PTSD as defined in the DSM-5 and the
ICD-11 (Maercker et al., 2013; WHO, 2013). There are sev-
eral positive aspects of the ICD-11 proposal, but others that are
problematic. Like the DSM-5, the ICD-11 proposes to create a
category of disorders associated with stress, or more precisely
disorders that arise in specific association with the stressful
event or series of events. This is a good thing. Also like the
DSM-5 but unlike the ICD-10 (WHO, 1992), the ICD-11 pro-
poses to include functional impairment in its PTSD diagnoses.
This is a good addition because not including a functional im-
pairment requirement is a major reason that the prevalence
of PTSD is approximately twice as high using the ICD-10
as when using DSM-IV criteria (Peters, Slade, & Andrews,
1999).
However, there are several problems with the ICD-11 pro-
posal. First, it defines qualifying traumatic stressor events for
PTSD and complex PTSD only in very general terms, as de-
scribed by Maercker and colleagues (2013; i.e., exposure “to
an extremely threatening or horrific event or series of events,”
p. 1684). This is much less specific than the DSM-5 Criterion
A definition; its vagueness suggests that it will be interpreted
very differently by various clinicians and researchers. How-
ever, Maercker and colleagues (2013) state that, “the diagnosis
is mainly based on symptom presentation rather than on de-
termination of whether or not the event constitutes an eligible
traumatic stressor” (p. 1684). This approach is based on a pro-
posal by Brewin, Lanius, Novac, Schnyder, and Galea (2009) to
eliminate Criterion A per se, but identify stressors as traumatic
based on the content of intrusion and avoidance responses. Pre-
sumably, this approach would still require some determination
of whether events referenced in intrusion and avoidance symp-
toms are traumatic stressors or other stressors, so clinicians and
researchers will still have to make this determination using the
vague and nonspecific definition described above. An alterna-
tive approach would be to simply state that if a stressor produces
 The DSM-5 Got PTSD Right
sufficient PTSD symptoms to meet diagnostic criteria, it is, by
definition, a traumatic stressor. However, the proposed ICD-11
definition fudges these two approaches by neither providing
a clear definition of the boundaries of traumatic stressors nor
by clearly stating that any event can be a traumatic stressor
event if it produces PTSD symptoms and functional impair-
ment. In any case, this approach has not solved the Criterion
A problem.
Second, the ICD-11 proposal to split PTSD into two sepa-
rate disorders, PTSD and complex PTSD, is likely to be highly
controversial given that major questions have been raised about
the conceptual coherence and empirical support for the com-
plex PTSD construct (e.g., Resick et al., 2012). Moreover, the
ICD-11 version of PTSD has been pared down to the core ele-
ments of reexperiencing, avoidance of reminders, and percep-
tions of heightened current threat indicated by various forms of
arousal. Although much will depend on how these core elements
are operationalized into symptoms, it is unclear how PTSD
using this definition will differ from a severe phobia. Com-
plex PTSD includes the PTSD core elements, but is also “ac-
companied by enduring disturbances in the domains of affect,
self, and interpersonal relationships” (Maercker et al., 2013,
p. 1684).
Clearly, how these general features are operationalized
by symptoms will be important. It is worthy of note that
the PTSD diagnosis in DSM-5 includes symptoms tapping
some of these domains, so it remains unclear the extent to
which the proposed complex PTSD diagnosis adds much of
value.
Third, difficulty sustaining relationships is identified as one
of the persistent and pervasive features of complex PTSD, but
relationship difficulties are generally included as a major com-
ponent of PTSD-related functional impairment. Unless diffi-
culty sustaining relationships as a complex PTSD symptom is
clearly differentiated from problems with relationships as an
indicator of functional impairment, there is potential for dou-
ble counting relationship difficulties; once as a complex PTSD
symptom and once as an indicator of functional impairment.
Moreover, because relationship problems are already captured
in the functional impairment criterion of PTSD in the DSM-5,
the value of including these problems as a symptom of complex
PTSD is unclear.
Finally, in many ways, the ICD-11 proposals for PTSD and
complex PTSD are radically different from the approach taken
in DSM-5. As noted by Friedman (2013), the changes in PTSD
for DSM-5 required substantial empirical justification, and there
is substantial evidence supporting the reliability and validity of
the revised diagnosis. Given the aspirational goal to harmonize
the ICD and DSM diagnostic systems, it is reasonable to sug-
gest that these ICD-11 PTSD proposals should be subjected to
rigorous scrutiny and should require substantial empirical jus-
tification prior to their approval. Furthermore, a strong case can
be made that the DSM-5 PTSD is now the standard and that the
burden for making ICD-11 changes must be to demonstrate in-
creases in reliability, validity, and utility in clinical or research
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
565
situations over what has already been achieved by PTSD in the
DSM-5.
Providing the type of empirical data needed to meet this chal-
lenge is not impossible and might be facilitated by the types of
web surveys used by the DSM-5 Sub-work group. In my view,
it is important to address these issues in generally representa-
tive population samples as well as clinical samples because the
former permit estimation of prevalence of traumatic event expo-
sure and PTSD prevalence at a population level. Internet access
is not prevalent in all nations, but it is in many. The existence
of online panels in many nations makes conducting such stud-
ies feasible. Our experience with the National Stressful Events
Survey and Veterans Web Survey suggests that online, self-
administered assessment measures can be developed that are
applicable to the general population as well as trauma-exposed
groups. Development and implementation of such surveys has
the added benefit of forcing those who are attempting to mea-
sure new symptoms or constructs to define more clearly what
they are attempting to measure and then to develop questions
that measure these symptoms and constructs. Engaging in this
exercise improved the deliberations of the Sub-work group for
the DSM-5 and also likely contributed to the fact that PTSD was
one of the most reliable diagnoses. I respectfully submit that
our colleagues deliberating about PTSD in the ICD-11 might
benefit from a similar approach.
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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.