PTSD Diagnostic Criteria: A Psychiatrist’s Perspective

Understanding the Clinical Reality Behind the Diagnosis

When you tell someone you have PTSD, they might picture a veteran startled by fireworks or unable to watch war movies. But Post-Traumatic Stress Disorder is far more complex than popular culture suggests. It’s a neurobiological condition with specific diagnostic criteria, and understanding these criteria matters—both for treatment and for VA disability claims. Many veterans struggle to get their PTSD properly diagnosed or service-connected because clinicians or VA examiners don’t fully appreciate the nuances of trauma-related symptoms in military populations.

Related: Learn more about MST-related PTSD claims.

This article explains PTSD from a psychiatrist’s perspective: the DSM-5 diagnostic criteria, how PTSD manifests uniquely in combat veterans, and what makes a strong medical opinion for VA claims purposes.

DSM-5 Diagnostic Criteria for PTSD

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is the standard used by psychiatrists and psychologists to diagnose PTSD. Understanding these criteria helps you recognize whether your symptoms meet the clinical threshold for diagnosis.

Criterion A: Exposure to Trauma

The diagnosis begins with trauma exposure. The person must have experienced or witnessed:

• Actual or threatened death
• Serious injury
• Sexual violence

This exposure can occur through:

• Direct experience
• Witnessing the event happen to others
• Learning that a traumatic event happened to a close family member or friend
• Repeated or extreme exposure to aversive details of traumatic events (common in military roles like EOD, medics, or investigators)

For veterans, combat exposure, military sexual trauma, accidents, or witnessing death and injury clearly meet Criterion A.

Criterion B: Intrusion Symptoms (at least 1 required)

These are unwanted memories or re-experiencing symptoms:

1. Intrusive memories: Recurrent, involuntary distressing memories of the trauma
2. Nightmares: Distressing dreams related to the traumatic event
3. Flashbacks: Feeling or acting as if the trauma is happening again
4. Psychological distress: Intense distress when exposed to reminders of the trauma
5. Physiological reactions: Physical reactions (rapid heartbeat, sweating) to trauma reminders

Veterans often describe intrusive memories of firefights, IED explosions, or traumatic losses. These aren’t voluntary reminiscences—they’re involuntary, distressing intrusions that disrupt daily life.

Criterion C: Avoidance (at least 1 required)

Persistent avoidance of trauma-related stimuli:

1. Avoiding internal reminders: Avoiding thoughts, feelings, or memories related to the trauma
2. Avoiding external reminders: Avoiding people, places, conversations, activities, objects, or situations that trigger memories

Veterans may avoid crowded places, refuse to watch war movies, stay away from VA hospitals that remind them of injuries, or avoid talking about their service experiences.

Criterion D: Negative Alterations in Cognitions and Mood (at least 2 required)

These symptoms often go unrecognized but are critical to PTSD diagnosis:

1. Inability to remember important aspects of the trauma (dissociative amnesia)
2. Persistent negative beliefs about oneself, others, or the world (“I’m damaged,” “No one can be trusted”)
3. Distorted blame of self or others for the trauma
4. Persistent negative emotional state (fear, horror, anger, guilt, shame)
5. Diminished interest in activities once enjoyed
6. Feeling detached or estranged from others
7. Inability to experience positive emotions (emotional numbing)

This criterion reflects the profound psychological impact of trauma beyond just fear and memories. Veterans with PTSD often describe feeling emotionally “flat,” disconnected from family, or unable to enjoy life.

Criterion E: Alterations in Arousal and Reactivity (at least 2 required)

These are hyperarousal symptoms:

1. Irritability or aggressive behavior
2. Reckless or self-destructive behavior
3. Hypervigilance (constantly scanning for threats)
4. Exaggerated startle response
5. Difficulty concentrating
6. Sleep disturbance

Veterans with PTSD often describe needing to sit with their back to the wall in restaurants, difficulty sleeping, or being “always on alert.” Family members notice irritability or angry outbursts.

Criterion F: Duration

Symptoms must persist for more than 1 month. (If symptoms last less than a month, the diagnosis may be Acute Stress Disorder instead.)

Criterion G: Functional Impairment

The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning. PTSD isn’t just having bad memories—it interferes with your ability to work, maintain relationships, or function in daily life.

Criterion H: Not Due to Substance Use or Medical Condition

The symptoms can’t be better explained by substance use, medication, or another medical condition.

PTSD in Combat Veterans: Unique Presentations

While the DSM-5 criteria apply universally, PTSD in combat veterans presents unique clinical features that VA examiners and clinicians must understand.

1. Complex Trauma Exposure

Unlike single-event traumas (car accidents, natural disasters), military combat often involves repeated, prolonged trauma exposure. Veterans may have experienced multiple firefights, IED attacks, mortar rounds, or witnessed numerous casualties over months or years of deployment.

This cumulative trauma can result in more severe, treatment-resistant PTSD.

2. Moral Injury

Many veterans experience “moral injury”—psychological distress resulting from actions that violate one’s moral or ethical code. This might include:

• Killing in combat, even if justified
• Witnessing atrocities
• Being unable to prevent a comrade’s death
• Following orders that resulted in civilian casualties

Moral injury often manifests as intense guilt, shame, and difficulty forgiving oneself. While not a separate DSM diagnosis, it’s a critical component of combat PTSD.

3. Delayed Onset

Some veterans don’t develop full PTSD symptoms until months or even years after leaving service. During active duty, military structure and mission focus may suppress symptoms. After discharge, when structure disappears, PTSD symptoms emerge.

Delayed-onset PTSD can make VA claims more difficult because service medical records may not document psychiatric symptoms. This is where a thorough psychiatric evaluation and Independent Medical Opinion become essential.

4. Comorbid Conditions

PTSD rarely occurs in isolation. Common comorbidities include:

• Major Depressive Disorder (up to 50% of PTSD cases)
• Substance Use Disorders (often self-medication for PTSD symptoms)
• Anxiety Disorders
• Sleep Disorders
• Chronic Pain (bidirectional relationship—pain worsens PTSD, PTSD worsens pain perception)

VA claims often involve both primary PTSD and secondary conditions like depression or sleep disorders.

The Difference Between Clinical PTSD and VA Rating

It’s critical to understand that diagnosis and rating are separate processes.

Clinical Diagnosis: Meets DSM-5 criteria
VA Rating: Measures the severity of functional impairment (0%, 10%, 30%, 50%, 70%, 100%)

You can meet the diagnostic criteria for PTSD but receive different ratings based on how severely your symptoms impair your occupational and social functioning.

VA Rating Criteria (38 CFR § 4.130):

• 0%: Diagnosis present but symptoms not severe enough to interfere with work or relationships
• 10%: Mild symptoms, occasional decrease in work efficiency during periods of stress
• 30%: Occasional decrease in work efficiency, intermittent inability to perform occupational tasks
• 50%: Considerable impairment in most areas, difficulty maintaining effective relationships
• 70%: Severe impairment in most areas, inability to establish and maintain effective relationships
• 100%: Total occupational and social impairment

A strong Independent Medical Opinion addresses both diagnosis (DSM-5 criteria) and functional impairment (VA rating criteria).

How IMOs Address PTSD for VA Claims

VA compensation and pension (C&P) examinations for PTSD are often brief and may not capture the full complexity of a veteran’s symptoms. An Independent Medical Opinion from a board-certified psychiatrist provides comprehensive evaluation that addresses VA requirements.

Components of a Strong PTSD IMO:

1. Criterion A Documentation
The IMO reviews service records, personnel files, and the veteran’s account to document trauma exposure. For combat PTSD, this includes deployment records, combat action reports, and unit histories.

2. Complete Symptom Assessment
The psychiatrist systematically evaluates all DSM-5 criteria (Criteria B through H), documenting specific symptoms and their severity.

3. Nexus Statement
The IMO provides a clear opinion: “It is at least as likely as not that the veteran’s PTSD is related to his combat service in Iraq.” The opinion includes medical rationale explaining how the documented trauma exposure led to the current PTSD symptoms.

4. Functional Impairment Analysis
The IMO addresses VA rating criteria, explaining how the veteran’s symptoms impair occupational and social functioning.

5. Differential Diagnosis
The psychiatrist rules out other conditions that could explain symptoms (e.g., traumatic brain injury, depression without PTSD, personality disorders).

Learn about secondary conditions related to PTSD

Key Takeaways

• PTSD has specific DSM-5 criteria involving trauma exposure, intrusion symptoms, avoidance, negative cognitions/mood, and hyperarousal.
• Combat PTSD often involves complex, repeated trauma and may include moral injury components.
• Delayed-onset PTSD is common in veterans, making service connection more difficult without expert medical opinions.
• Clinical diagnosis and VA rating are separate. Diagnosis establishes the condition; rating measures functional impairment.
• Independent Medical Opinions from psychiatrists provide the detailed diagnostic and functional assessment VA claims require.

How VetNexusMD Can Help

Dr. Ronald Lee is a board-certified psychiatrist with extensive experience evaluating PTSD in veterans. Dr. Lee’s Independent Medical Opinions provide comprehensive DSM-5 diagnostic assessments, nexus opinions for service connection, and functional impairment analysis for VA rating purposes.

Whether you’re filing an initial PTSD claim, appealing a denial, or seeking an increased rating, Dr. Lee’s psychiatric expertise ensures your evaluation meets the highest clinical and legal standards.

Learn more about psychiatric Independent Medical Opinions or request a consultation today.

Frequently Asked Questions

Can I have PTSD if I wasn’t in direct combat?
Yes. PTSD can result from any trauma meeting Criterion A: actual or threatened death, serious injury, or sexual violence. Veterans who experienced military sexual trauma, accidents, witnessing casualties, or handling remains can develop PTSD even without direct combat exposure.

What if I don’t remember parts of my trauma?
Dissociative amnesia (inability to remember important aspects of the trauma) is actually one of the DSM-5 criteria for PTSD (Criterion D). This is a recognized symptom, not evidence that trauma didn’t occur.

How is PTSD different from depression or anxiety?
While PTSD often co-occurs with depression and anxiety, PTSD specifically involves trauma exposure, intrusive re-experiencing symptoms (flashbacks, nightmares), and trauma-related avoidance. Depression focuses on persistent sadness and loss of interest, while anxiety involves excessive worry. A skilled psychiatrist can differentiate these conditions and diagnose comorbidities when present.

Can PTSD symptoms get worse over time?
Yes. Untreated PTSD often worsens, especially when compounded by life stressors, additional traumas, or lack of social support. Veterans may file for increased ratings when symptoms become more severe and disabling.

Do I need to be in treatment to file a PTSD claim?
No. You don’t need to be in active treatment, but treatment records documenting your symptoms strengthen your claim. If you’re not in treatment, a comprehensive Independent Medical Opinion becomes even more important to document your current symptoms and their severity.

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VetNexusMD provides Independent Medical Opinions for VA disability claims. We do not provide psychiatric treatment or establish doctor-patient treatment relationships. For mental health treatment, please contact the VA or a licensed mental health provider.

Next Steps

Understanding diagnostic criteria is essential, but getting the right nexus letter is equally important. See: PTSD Nexus Letters: The Complete Guide to Strengthening Your VA Disability Claim.