Changing PTSD Criteria for the DSM-5

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.

Final Thoughts

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.

Reference:

 

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.

Do Antipsychotics Help With PTSD? A New VA Study Says, “No”

Do Antipsychotics Help With PTSD? A New VA Study Says, “No”

This may be just my limited, subjective impression, but I’ve noticed lately more and more clients who’ve been prescribed antipsychotic medications for reasons other than psychosis—sleep   problems, rumination, or suicidal ideation, for example. I’m not anti-med, but given the documented side effects of antipsychotics—weight gain, diabetes, and motor control problems—I think we should be cautious in how these meds are used.

When a recent New York Times article came across my desk that suggested a commonly prescribed antipsychotic, risperidone, may not be very useful in the treatment of PTSD, I was intrigued. Being a dutiful scientist, I tracked down the original article in the Journal of the American Medical Association.

What Did the Study Look At?

In this study, patients were recruited from multiple Veterans Affairs Hospitals across the country. Veterans with PTSD who had not responded to at least two trials of antidepressants were recruited. The 296 participants were randomly assigned to receive either risperidone or a placebo for 6 months. The vast majority of the veterans were Vietnam era and male (96.6%). Nearly three-fourths had also received outpatient mental health services in the preceding month.

The results: There were no difference between antipsychotic medication and placebo

At the end of 6 months, there was no difference between veterans who received risperidone and those who received placebo on PTSD symptoms or anything else that was measured, including depression, anxiety, and quality of life. I will note that contrary to my concern about the potential dangers of antipsychotics, the researchers didn’t find any notable adverse effects of risperidone—at least within the 6-month trial. Given that most of these veterans are Vietnam era and older, it’s very sad that no treatment has been very successful in addressing their PTSD.

Antipsychotics May Not Be an Effective Treatment for PTSD

According to this study, antipsychotics don’t appear to contribute to improvements in PTSD—at least for veterans with whom antidepressants didn’t work. Knowing what doesn’t work can be as important as knowing what does work. It was also heartening to see that, despite listing multiple ties to various pharmaceutical companies, the two main authors of this study let the data speak for itself. Too often, I read about researchers receiving pharmaceutical money massaging data to look more favorably for the meds they’re studying. The authors here seemed very conscientious in how they interpreted the data.

In the same issue of JAMA, Dr. Charles Hoge offers a commentary on treating veterans with PTSD. He supports the use of psychotherapy, antidepressants, and the hypertensive medication prazosin, and warns against the use of antipsychotics and benzodiazepines.

Off label use of antipsychotics seems to be a growing trend. A study that came out last month found that antipsychotic prescriptions for anxiety disorders more than doubled in 10 years—even though there’s no published data suggesting antipsychotics are an effective treatment for anxiety! This trend is worth keeping an eye on.

UPCOMING TRAINING EVENTS


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 11, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.