. 2015 Nov 6;16(2):109–127. doi: 10.1016/j.ijchp.2015.09.002

Table 9.

Proposed ICD-11 diagnostic guidelines for Disorders Specifically Associated with Stress after revisions based on study results: Essential Features only.

PTSD Essential Features

• Exposure to an event or situation (either short- or long-lasting) of an extremely threatening or horrific nature. Such events include, but are not limited to, natural or human-made disasters; combat; serious accidents; torture; sexual violence; terrorism; assault; acute life-threatening illness (such as a heart attack); witnessing the threatened or actual injury or death of others in a sudden, unexpected, or violent manner; and experiencing the sudden, unexpected or violent death of a loved one.

• Following the traumatic event or situation (generally within 1 month but nearly always within several months), the development of a characteristic syndrome that lasts for at least several weeks, consisting of three core elements:

1. Re-experiencing the traumatic event in the present, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive images or memories; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings); or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations. Re-experiencing in the present can also involve being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event, which may occur in response to reminders of the event. Reflecting back or ruminating about the event(s) and remembering the feelings that one experienced at that time do not constitute re-experiencing.

2. Deliberate avoidance of reminders likely to produce re-experiencing of the traumatic event(s). This may take the form either of active internal avoidance of relevant thoughts and memories, or external avoidance of people, conversations, activities, or situations reminiscent of the event(s). In extreme cases the person may change his or her environment (e.g., move to a different city or change jobs) to avoid reminders.

3. Persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to events such as unexpected noises. Hypervigilant persons constantly guard themselves against danger and feel themselves or others close to them to be under immediate threat either in specific situations or more generally. They may adopt new behaviours designed to ensure safety (e.g., only sit in certain places on trains, repeatedly check in vehicles’ rear-view mirror).

• The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained only through significant additional effort, or is significantly impaired compared to the individual's prior functioning or what would be expected, then the individual would be considered impaired due to the disturbance.

Complex PTSD Essential Features

• History of exposure to a stressor of an extreme and prolonged or repetitive nature from which escape is difficult or impossible. Such events include, but are not limited to, torture, concentration camps, slavery, genocide campaigns and other forms of organized violence, prolonged domestic violence, and repeated childhood sexual or physical abuse.

• History of the following three core elements of PTSD that developed during or after the traumatic event (generally within one month but nearly always within several months) and lasting for at least several weeks:

1. Re-experiencing the traumatic event after the traumatic event has occurred, in which the event(s) is not just remembered but is experienced as occurring again in the here and now. This typically occurs in the form of vivid intrusive images or memories; flashbacks, which can vary from mild (there is a transient sense of the event occurring again in the present) to severe (there is a complete loss of awareness of present surroundings); or repetitive dreams or nightmares that are thematically related to the traumatic event(s). Re-experiencing is typically accompanied by strong or overwhelming emotions, such as fear or horror, and strong physical sensations.

• Severe and pervasive problems in affect regulation. Examples include heightened emotional reactivity to minor stressors, violent outbursts, reckless or self-destructive behavior, dissociative symptoms when under stress, and emotional numbing, particularly the inability to experience pleasure or positive emotions.

• Persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the stressor. For example, the individual may feel guilty about not having escaped from or succumbing to the adverse circumstance, or not having been able to prevent the suffering of others.

• Persistent difficulties in sustaining relationships and in feeling close to others. The person may consistently avoid, deride or have little interest in relationships and social engagement more generally. Alternatively, there may be occasional intense relationships, but the person has difficulty sustaining them.

Prolonged Grief Disorder Essential Features

• History of bereavement following the death of a partner, parent, child, or close other person.

• A persistent and pervasive grief response characterized by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain (e.g. sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one's self, an inability to experience positive mood, emotional numbness, difficulty in engaging with social or other activities).

• The grief response has persisted for an abnormally long period of time following the loss, clearly exceeding expected social, cultural or religious norms for the individual's culture and context. Grief responses within 6 months of the bereavement, and for longer periods in some cultural contexts, should not be considered to meet this requirement.

Adjustment Disorder Essential Features

• A maladaptive reaction to an identifiable psychosocial stressor or multiple stressors (e.g., single stressful event, ongoing psychosocial difficulty or a combination of stressful life situations) that usually emerges within a month of the stressor. Examples include divorce, illness or disability, socio-economic problems and conflicts at home or work.

• The reaction to the stressor is characterized by preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications.

• Failure to adapt to the stressor produces noticeable impairment in personal, social or occupational functioning, e.g., relationship conflict, performance problems at work or school, reduced ability to respond appropriately to normal stressors.

Acute Stress Reaction Essential Features (not considered a mental disorder but rather a normal reaction to severe stress that still may require treatment)

• The development of a response to the stressor that is considered to be normal given the severity of the stressor. The response to the stressor may include transient emotional, somatic, cognitive, or behavioural symptoms, such as being in a daze, confusion, sadness, anxiety, anger, despair, overactivity, inactivity, social withdrawal, or stupor. Autonomic signs of anxiety (e.g., tachycardia, sweating, flushing) are commonly present and may be the presenting feature.

• Symptoms typically appear within hours to days following the stressful event, and usually begin to subside within a few days after the event or following removal from the threatening situation, when this is possible. In cases where the stressor continues or removal is not possible, symptoms may persist but are usually greatly reduced within approximately 1 month as the person adapts to the changed situation.

Other Disorder Specifically Associated with Stress Essential Features

A diagnosis of Other Disorder Specifically Associated with Stress should be used only in cases in which:

• The clinical presentation does not satisfy the definitional requirements of any of the other disorders in this section or of Acute Stress Reaction;

• The symptoms are not better explained by another Mental or Behavioural Disorder specified elsewhere in ICD (e.g., a Depressive Disorder or an Anxiety Disorder);

• The clinical presentation is judged to be a Mental or Behavioural Disorder occurring in specific association with an identifiable stressor;

• The symptoms cause distress or functional impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained only through significant additional effort, or is significantly impaired compared to the individual's prior functioning or what would be expected, then the he or she would be considered impaired due to the disturbance.