Changing PTSD Criteria for the DSM-5
As a member of the Anxiety Disorders Association of America (ADAA), I receive their monthly journal Depression and Anxiety. The September issue—I know this post is a little late, it got caught up in editing—features an article on changes that are being considered for diagnosing PTSD in the upcoming DSM-5. It’s not certain that the proposed changes will make it in there, but they provide some interest food for thought.
What Causes PTSD?
PTSD is pretty unique among diagnoses in that the definition requires an external event (criterion A) that other diagnoses—such as depression and other forms of anxiety—do not. There is no posttraumatic stress disorder without a trauma. But what counts as a trauma?
People such as Harvard’s Richard McNally have criticized the current parameters of what can be considered a traumatic antecedent as being too broad. Some of this controversy came out of 9-11, where people were diagnosed with PTSD after seeing news footage of the collapse of World Trade Center, even though they didn’t know anyone who died or were endangered. Anthropologist Allan Young called this “PTSD of the virtual kind” (quoted in McNally, 2009). The point of this is not to diminish the impact of people’s subjective experiences; rather, that a definition that runs the spectrum from rape, torture, and combat violence all the way seeing something distressing on TV may not be clinically useful.
The authors of the proposed DSM-5 revision tighten up the definition and limit criterion A events to those involving threat of harm or death that are either witnessed by the individual or involve a close relative or friend. Additionally, they cut out entirely the second component—that the person experience “fear, helplessness, or horror.” The authors suggest that this second part is not clinically useful.
Expanding Symptom Clusters from Three to Four
Currently, the DSM clusters PTSD symptoms according to three categories: Re-experiencing (e.g., memories, nightmares, flashbacks); avoidant/numbing (e.g., avoiding internal/external reminders, psychic numbing); and hyperarousal (e.g., easily startled, hypervigilant). By contrast, the authors of this article expand the total number of symptoms from 17 to 2, and they categorize them according to four clusters.
The newly added symptoms are “erroneous self- or other-blame regarding the trauma,” “negative mood states,” and “reckless and maladaptive behavior.” I have no problem with the addition of negative mood states, and I think incorporating reckless and maladaptive behavior helps to capture aspects of PTSD that are often exhibited in military veterans.
I’m concerned, however, with the entire notion of “erroneous” beliefs. This is part of the new symptom category, “Alterations in Cognitions and Mood,” which puts more of a cognitive therapy spin on the diagnostic criteria. I find the word “erroneous” troubling, as it places the therapist in the role of deciding what’s realistic and what’s not. This is a problem I have with cognitive therapy, in general, so I’ll admit my bias here. And in fairness to the authors, they have obviously thought deeply about this change and cite their reasoning. Nonetheless, the label strikes me as less descriptive and more evaluative.
Additionally, the DSM in general tends to draw an imaginary and arbitrary line between thinking and feelings. For example, the new suggestions recast “detachment from others” as “Feeling [italics mine] of detachment or estrangement from others.” The use of the word “feeling” seems imprecise, as it’s impossible to imagine this experience except as filtered through thinking. For example, a dog may feel fear, but I doubt it ever feels estranged from others. This imprecision in the use of language is hardly unique to the PTSD, but pervades the DSM, unfortunately.
What About Complex PTSD?
Coined by psychiatrist Judith Herman, there’s a growing faction of people such as Bessel van der Kolk clamoring for the inclusion of Complex PTSD aka Disorders of Extreme Stress Not Otherwise Specified. They argue that the current definition of PTSD fails to describe victims of severe and prolonged abuse (e.g., some childhood sexual abuse survivors or tortured political refugees). These survivors demonstrate complex clinical pictures which may include features that overlap with borderline personality disorder and dissociative disorders. The authors examined the available research and concluded that there’s not enough evidence to include complex PTSD as a separate disorder. I think this is a reasonable position, and at the very least, provides motivation for advocates to refine their research, which is a little sparse to date.
It’s impossible to predict which of these suggestions will make it into the next edition of the DSM. The authors take pains to state that their suggestions remain speculative and should be subjected to further inquiry. At the very least, this article provides a wonderfully concise summary of current PTSD research, and I highly recommend anyone interested in trauma check it out.
Friedman, M.J., Resick, P.A., Bryant, R.A., & Brewin, C.R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769.