Differential diagnoses are summarized in Table 1. Distinguishing features include the following:
• the type of stressor (adjustment disorders, enduring personality change)
• the symptom pattern (adjustment disorders, enduring personality change)
• the duration of the symptoms (acute stress disorder, acute stress reaction)
• the question of whether the avoidance, numbing, and hyperarousal symptoms were present before the traumatic event occurred (other anxiety or depressive disorders)
• the nature of the intrusive cognitions and perceptual disturbances (obsessive-compulsive disorder, psychotic symptoms, substance-induced symptoms).
Prolonged repeated trauma, such as captivity or repeated childhood sexual abuse, may lead to a more complex pattern of symptoms, 'complex PTSD', that is characterized by somatization, dissociation, affect dysregulation, poor impulse control, self-destructive behaviour, and pathological patterns of relationships. (20) It was debated whether to include a category 'disorders of extreme stress not otherwise specified' ( DESNOS) into DSM-IV to accommodate these cases, but the decision was not to include it.(16) In ICD-10, the diagnosis 'Enduring personality changes after catastrophic experience' covers such long-standing consequences of enduring trauma.
Furthermore, it is currently being debated whether an additional diagnostic category 'traumatic grief' should be included into the psychiatric classification system. (21,22) Ongoing research on symptom criteria
Recent research has questioned the symptom clusters of DSM-IV. In particular, it emerges that it may be preferable to assess the emotional numbing symptoms separately from the avoidance symptoms, because these symptoms do not load on the same factor in factor analyses and may have different underlying mechanisms. Furthermore, it may be preferable to include severity criteria for the symptoms rather than relying on counting the presence of symptoms. (23>
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