When a client presents with intrusions, avoidance, negative mood and cognition and hyperarousal after prolonged exposure to other people’s trauma (for example, a teacher who has repeatedly become aware of students being sexually abused, going hungry, or being unsafe at home), the symptom picture often looks exactly like PTSD, but the exposure may not satisfy DSM-5-TR Criterion A.
This is not a gap in your assessment; it is a recognised and long-running issue in the trauma literature known as the “Criterion A problem”.
Three things from the research are worth holding in mind.
First, the symptom profile does not reliably tell you whether Criterion A was met:
Several studies (Gold et al., 2005; Franklin et al., 2019; Howard et al., 2024) found that people exposed to non-qualifying stressors reported PTSD symptom severity and cluster patterns comparable to people with qualifying traumas.
Where a difference appears, it is usually in the hyperarousal cluster, which tends to be more strongly tied to direct threat. The most recent authoritative review (Marx et al., 2024) accepts that this happens but concludes the evidence for changing Criterion A is still too weak, and recommends Adjustment Disorder or Other Specified Trauma- and Stressor-Related Disorder when Criterion A is not met.
Second, secondary traumatic stress is a well-described construct in helping professions as well as in teachers:
Figley defined it as the natural stress response to knowing about a traumatising event experienced by a significant other, and the main measure (Bride’s Secondary Traumatic Stress Scale) was deliberately built to mirror the PTSD symptom clusters, so a high scorer will look like PTSD by design.
Let's take school teachers as an example.
Australian work on teachers (Crivari et al., 2025; Oberg et al., 2023) documents exactly the exposures and symptoms described above and notes that this is under-recognised as an occupational injury.
Moral injury (the distress of knowing children are at risk and being unable to make the system act) is a useful additional lens and helps explain presentations that are heavy on guilt, anger and betrayal but lighter on fear.
Third, the diagnostic work is in the exposure history, not the symptom checklist:
Before concluding Criterion A fails, ask specifically about direct events that are common in schools and easy to miss (witnessing or restraining a violent student, being assaulted or threatened, seeing injuries from abuse, a student’s serious self-harm or death, a critical incident).
Consider whether A4 applies: the DSM-5-TR example is police officers repeatedly exposed to details of child abuse, and repeated detailed disclosures may sit close to that, although this remains contested. Consider ICD-11 PTSD, whose stressor definition (“an extremely threatening or horrific event or series of events”) is less route-specific than DSM-5-TR and places more weight on the symptom pattern than on the type of exposure.
If none of these is met, Other Specified Trauma- and Stressor-Related Disorder is the literature’s preferred diagnosis and is a legitimate, codable one.
Adjustment Disorder is appropriate only if it fits; in compensation settings it is often read as milder, so do not default to it. Independent Medical Examiners seem to often default to this, and do not explain the "trauma like" presentation.
In the report, separate the exposure history from the symptom assessment, state which Criterion A part/s (A1 to A4) you considered and why, use a structured instrument anchored to the exposure (CAPS-5 or PCL-5; ITQ for ICD-11), and cite the equivalence literature so that a non-PTSD label is not misread as a lesser injury.
Treatment recommendations can be trauma-focused regardless of the label.
I have had more than one client where the insurer has perceived the adjustment disorder as something that simply requires some counselling, and then they should have recovered. Whereas when the client is presenting with trauma-like symptoms, they will still likely require EMDR treatments to reprocess specific memories, and this can be longer term. It's important to make these distinctions in your reports each time.
Reading list:
Start with Marx et al. (2024) for the current state of the debate, then Franklin et al. (2019) and Howard et al. (2024) for the evidence, then Crivari et al. (2025) and Klemme et al. (2025) for the teacher and school context.
Allwood, M. A., et al. (2024). Moving forward with a culturally inclusive PTSD Criterion A: Commentary on Marx et al. (2023). Journal of Traumatic Stress, 37(1). https://doi.org/10.1002/jts.23016
Brewin, C. R., Lanius, R. A., Novac, A., Schnyder, U., & Galea, S. (2009). Reformulating PTSD for DSM-V: Life after Criterion A. Journal of Traumatic Stress, 22(5), 366–373. https://doi.org/10.1002/jts.20443
Brewin, C. R., Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., et al. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1–15. https://doi.org/10.1016/j.cpr.2017.09.001
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2004). Development and validation of the Secondary Traumatic Stress Scale. Research on Social Work Practice, 14(1), 27–35. https://doi.org/10.1177/1049731503254106
Crivari, C., Oxford, R., Schroder, K., Anderson, R., & McMillan, J. (2025). “It’s something you can’t wash off; you carry it with you”: A qualitative study into teachers’ experiences of vicarious trauma symptoms during the COVID-19 pandemic in Victoria, Australia. Frontiers in Education, 10, 1659431. https://doi.org/10.3389/feduc.2025.1659431
Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.
Franklin, C. L., Raines, A. M., & Hurlocker, M. C. (2019). No trauma, no problem: Symptoms of posttraumatic stress in the absence of a Criterion A stressor. Journal of Psychopathology and Behavioral Assessment, 41, 107–111. https://doi.org/10.1007/s10862-018-9692-4
Gold, S. D., Marx, B. P., Soler-Baillo, J. M., & Sloan, D. M. (2005). Is life stress more traumatic than traumatic stress? Journal of Anxiety Disorders, 19(6), 687–698. https://doi.org/10.1016/j.janxdis.2004.06.002 Howard, J., Lorenzo-Luaces, L., Lind, C., Lakhan, P., & Rutter, L. A. (2024). Is a Criterion A trauma necessary to elicit posttraumatic stress symptoms? Journal of Psychiatric Research, 170, 58–64. https://doi.org/10.1016/j.jpsychires.2023.12.008
Hydon, S., Wong, M., Langley, A. K., Stein, B. D., & Kataoka, S. H. (2015). Preventing secondary traumatic stress in educators. Child and Adolescent Psychiatric Clinics of North America, 24(2), 319–333. https://doi.org/10.1016/j.chc.2014.11.003
Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. https://doi.org/10.1002/jts.21848
Klemme, P. M., Pierce, B., Turman, J. E., Brown, J. R., & Fukui, S. (2025). A systematic review of secondary traumatic stress in school personnel: A synthesis of quantitative findings. Journal of School Health, 96(1), e70087. https://doi.org/10.1111/josh.70087
Levin, A. P., Kleinman, S. B., & Adler, J. S. (2014). DSM-5 and posttraumatic stress disorder. Journal of the American Academy of Psychiatry and the Law, 42(2), 146–158. https://jaapl.org/content/42/2/146 Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706.
Marx, B. P., Hall-Clark, B., Friedman, M. J., Holtzheimer, P., & Schnurr, P. P. (2024). The PTSD Criterion A debate: A brief history, current status, and recommendations for moving forward. Journal of Traumatic Stress, 37(1), 5–15. https://doi.org/10.1002/jts.23007
McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149. Oberg, G., Carroll, A., & Macmahon, S. (2023). Compassion fatigue and secondary traumatic stress in teachers: How they contribute to burnout and how they are related to trauma-awareness. Frontiers in Education, 8, 1128618. https://doi.org/10.3389/feduc.2023.1128618
Ormiston, H. E., Nygaard, M. A., & Apgar, S. (2022). A systematic review of secondary traumatic stress and compassion fatigue in teachers. School Mental Health, 14, 802–817. https://doi.org/10.1007/s12310-022-09525-2
Pai, A., Suris, A. M., & North, C. S. (2017). Posttraumatic stress disorder in the DSM-5: Controversy, change, and conceptual considerations. Behavioral Sciences, 7(1), 7. https://doi.org/10.3390/bs7010007
Weathers, F. W., & Keane, T. M. (2007). The Criterion A problem revisited: Controversies and challenges in defining and measuring psychological trauma. Journal of Traumatic Stress, 20(2), 107–121. https://doi.org/10.1002/jts.20210
Horesh, D. (2016). The reconstruction of Criterion A in DSM-5: Is it a true incorporation of secondary traumatization into the PTSD diagnosis? Journal of Loss and Trauma, 21(5). https://doi.org/10.1080/15325024.2015.1072016
Oberg, G. (2025). Moral injury in teaching: The systemic roots of ethical conflict and emotional burnout in education. Educational Review. https://doi.org/10.1080/00131911.2025.2504523
Note: all DOIs and links were checked on 5 September 2026. Page numbers for Horesh (2016) were not available at the time of checking.