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Consider PTSD subtypes in patient workup

Categorizing PTSD into subtypes might help better define the diagnosis and benefit patients by improving evidence-based medicine

Vol. 8, No. 9 / September 2009

Posttraumatic stress disorder (PTSD) is a confusing diagnostic category because it includes victims of trauma as well as individuals exposed to trauma. Also, PTSD encompasses exposure to different types of trauma, which can have significant implications for symptom development and treatment.

Consider the treatment history of a male combat veteran who exhibits multiple PTSD symptoms, including nightmares, flashbacks, social isolation, anger, and guilt related to his war experiences. Several psychiatrists saw the patient, which resulted in multiple medication changes but little benefit. On further assessment, the practitioners noted that the veteran’s war experiences were minimally problematic; the prominent nightmares, ruminations, flashbacks, and guilt were related to his witnessing a civilian female being sexually assaulted. The veteran’s guilt about not intervening was the basis of his PTSD. This led to a change in treatment from pharmacotherapy to a focus on supportive therapy.

Conceptualizing subtypes of PTSD—similar to many DSM-IV-TR diagnoses such as phobias or delusional disorders—might help better define the diagnosis. Each sub-type, as conceptualized below, might have its own prognosis and treatment. Our hope is that this strategy will benefit the patient by improving research and evidence-based practice.

PTSD subtypes

Victim-related trauma. Related to witnessing a criminal act or being a victim of a criminal act such as rape or assault. The patient is in a passive role.

Natural disasters, such as a tornado, earthquake, or hurricane.

Survivor guilt. The patient is not a perpetrator and might have been exposed to trauma, but symptoms are related to surviving while others close to the patient did not.

Perpetrator guilt. It is debatable whether this should be a PTSD subtype but our experience suggests that this pattern severely complicates PTSD diagnosis and treatment. It often is not initially disclosed by patients but surfaces when treatment is not working despite a strong therapeutic alliance.

PTSD not otherwise specified. This subtype is typical in patients who were not directly involved in a traumatic event but experienced symptoms related to it. Examples include picking up dead bodies, cleaning up a tornado site, or observing siblings being beaten. This category also may reflect an unclear picture if no primary subtype accounts for the majority of symptoms.


Individuals who previously have been exposed to trauma are more vulnerable to subsequent trauma. Experiencing ongoing multiple traumatic events—such as in military combat—can have a cumulative effect. Thus, identifying episodes of trauma also should be part of the PTSD assessment.

Single event. The patient is exposed to a single traumatic episode, such as being the victim of a crime.

Multiple events/single episode. The patient is exposed to repeated, related traumatic events. Examples include ongoing military combat or child abuse.

Multiple events. The patient is exposed to ≥2 separate traumatic events. A combination such as this might include a serious motor vehicle accident followed by a natural disaster.

As the diagnosis of PTSD evolves, utilizing subtypes and qualifiers might clarify treatment strategies because some subtypes might be more amenable to certain psychopharmacologic or psychotherapeutic treatment regimens.

Diagnostic confusion

Some researchers question whether traumatic stress causes PTSD syndrome,1 whereas others recommend “tightening” the diagnostic criteria.2 Concerns regarding PTSD diagnosis are multiple and include:

  • the importance of ruling out malingering3
  • the effects of different diagnostic criteria resulting in disparate prevalence rates
  • emphasizing the importance of dysfunction as a criterion for PTSD.4

Conceptual inconsistencies in DSM-IV-TR diagnostic criteria also can lead to confusion. Although there is a category of arousal symptoms, Criterion B4 (intense psychological distress) and Criterion B5 (physiological reactivity) are listed as re-experiencing symptoms rather than arousal symptoms. Finally, the criteria presented do not follow a logical progression. Research suggests that re-experiencing symptoms do not lead to avoidance but result in arousal symptoms, which in turn trigger avoidance.5


1. Bodkin JA, Pope HG, Detke MJ, et al. Is PTSD caused by traumatic stress? J Anxiety Disord. 2007;21:176-182.

2. Spitzer RL, First MB, Wakefield JC. Saving PTSD from itself in DSM-V. J Anxiety Disord. 2007;21:233-241.

3. Rosen GM, Taylor S. Pseudo-PTSD. J Anxiety Disord 2007;21:201-210.

4. Zahava S, Horesh D. Changes in diagnostic criteria for PTSD: implications from two prospective longitudinal studies. Am J Orthopsychiatry. 2007;77:182-188.

5. Resick PA, Monson CM, Chard KM. Cognitive processing therapy: veteran/military version. Washington, DC: Department of Veterans Affairs; 2007.

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