PTSD may also present as somatic symptoms and frequent use of the medical system. The person may experience prominent feelings of guilt and shame, and a sense of “moral injury.” In military populations, guilt and shame are associated with later development of PTSD ( Nazarov et al., 2015). Other common presentations include low mood, anxiety and panic, specific phobias, anger problems, insomnia or nightmares, interpersonal difficulties, occupational dysfunction and emotional numbness. PTSD may also present as profound dysphoria and anhedonia, significant irritability and behavioural reactivity, or persistent dissociation and detachment. It has been moved into a new category called “trauma and stressor-related disorders.” This separate classification acknowledges that not all people with PTSD have a presenting complaint related to anxiety. In DSM-5, PTSD is no longer classified as an anxiety disorder. (See Diagnosis for full DSM-5 diagnostic criteria.) Symptoms must be present for more than one month and result in significant distress or impairment. The person must experience symptoms across four clusters: intrusions, avoidance, negative alterations in mood or cognition, and alterations in arousal. The first diagnostic criterion for PTSD is having experienced a traumatic event, which DSM-5 defines as “exposure to actual or threatened death, serious injury, or sexual violence” (APA, 2013). The DES cannot be used for diagnosis, but scoring over 20 per cent indicates the need to further explore dissociative symptoms ( Lanius et al., 2016). The general population average is 4 to 8 percent compared with 26 to 42 percent among people with PTSD ( Carlson & Putnam, 1993). The self-report Dissociative Experiences Scale (DES) asks respondents to rate what percentage of the time they experience a given dissociative symptom ( Bernstein & Putnam, 1986).
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