Archives for : DESNOS

It’s time to stop letting the stressor define PTSD

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It’s time to stop letting the stressor define PTSD.  Not doing so makes the new categories of C-PTSD and DESNOS largely irrelevant.

I’ve been posting on this blog for about eighteen months now, a total of fifty-two posts.  Though I’ve written a couple of books on trauma (my latest is Trauma, Culture, and PTSD),  I still feel like a newcomer to the field.  In this post I want to talk about what still puzzles me about trauma theory.  The experience of writing this blog has led to more questions than answers.

I’ve been able to reconstruct to my own satisfaction the origins of PTSD in the Vietnam War  The new diagnostic category served political ends, pointing out what war does to the people who fight it.  The introduction of the disorder called PTSD was progressive politics.  It was also a humane diagnosis, helping to explain to those who suffered from it what was happening to them, giving both soldiers and their families a vocabulary for their pain. 

PTSD in DSM-5

At almost the same time as DSM-5 was being released, the National Institutes of Mental Health was refusing to fund any more research based on the DSM.

National Institute of Mental Health (NIMH) announcement
By Thomas Insel on April 29, 2013

Patients with mental disorders deserve better. . . . That is why NIMH will be re-orienting its research away from DSM categories . . . . The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

If the DSM were the model for physical medicine, then a heart attack would be defined as “chest pain disorder,” a symptom without a cause.

Henceforth, the NIMH research goal is to fill in the “Draft Research Domain Criteria Matrix,” which links 5 basic natural formations, such as “systems for social processes,” including attachment and fear, with eight columns of units of analysis, such as genes, molecules, and cells.

The goal is to move from mind to brain, so that there will no longer be any need to talk about mind at all. It’s all about electricity and meat, as Gary Greenberg puts it.  And electricity and meat can be measured.  Not, however, in the language of human suffering. 

American psychiatry and psychology have been cut off from the official world of science, but not from VA funding (over 100 million dollars since 2012 for PTSD).   This has consequences.  One, I believe, is the failure of more trauma specialists to object to the VA’s endorsement of cognitive behavioral therapy (CBT), including exposure therapy, as the treatment of choice, the only “evidence based treatments.”

These treatments are short-term, can be learned from a manual, and administered by lesser trained persons.  CBT is quick and cheap compared to long term therapy by well trained persons.  But consider CBT’s difference not only from traditional talk therapy, but also from the rap groups that sprang up in the Vietnam War era, in which veterans could exchange experiences.  CBT discourages “cross talk,” as people talking with each other is called (Tasman et al., p. 1928).  The potential of PTSD to help sufferers explain to each other the varieties of torment and relief has been lost. 

This does not mean we should abandon the diagnosis of PTSD.  Indeed, when this is proposed it is often sufferers who object most strenuously, for the diagnosis has helped many people make sense of their disrupted lives.  It does mean that we should rethink the category. 

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Whatever happened to DESNOS?

IMG_0319_edited-2DESNOS stands for Disorders of Extreme Stress Not Otherwise Specified, about as clumsy a diagnosis as one could imagine, and an only slightly better acronym. It owes its existence to the persistence of Judith Herman, who in her classic Trauma and Recovery, argued for a special category of trauma she called complex PTSD (C-PTSD). C-PTSD = DESNOS for all practical purposes.

It has long been recognized that there are different types of trauma, but no one has figured out what to do about it as far as PTSD is concerned. Rape, a serious car accident, most wartime trauma takes place during a specified period of time, and often results in the familiar symptoms of PTSD, such as flashbacks, nightmares, sleeplessness, hypervigilance, and a gradual retreat into a smaller world in which the victim is less likely to encounter situations reminding him or her of the original trauma.

But, some trauma doesn’t fit this pattern, generally because it is prolonged, frequently happens at an early age, and often involves people with whom the victim has an intimate relationship. Child abuse is exemplary, but prolonged captivity and confinement of any type also fits the pattern. This includes emotional and physical abuse in marriage or other relationships.

The about to be released International Classification of Diseases, ICD-11, which serves as the DSM for the rest of the world, includes C-PTSD, but only if the victim first fulfills all the requirements of a diagnosis for PTSD. DSM-5 includes most of the symptoms of C-PTSD, achieved in part by enlarging the number of symptoms to twenty. In addition, it includes a dissociative subtype and a pre-school subtype. As with the ICD-11, the basic requirements of PTSD must first be met. DSM-5 does not officially recognize C-PTSD, but one professional’s comment on PTSD in DSM-5 gets it right, remarking that it has become more “DESNOS-ish.”

Here’s the problem

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What’s going on with the new PTSD diagnosis in DSM 5?

There seems to be movement, but not much change, in the diagnosis of PTSD in DSM 5. PTSD is no longer a fear or anxiety disorder, but has its own category. In part, this seems to be the result of the popularity of PTSD. The APA justifies this stand-alone category partly in terms of the presence of PTSD “at the center of public as well as professional discussion.” (www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf)

In reality, PTSD was created as a result of popular pressure, and it was expanded for the same reason. That is not necessarily a bad thing.
Intriguing is the movement of PTSD toward the category of a dissociative disorder.

The move has not yet been completed, but as Matthew Friedman points out, locating trauma and stress related disorders next to dissociative disorders in the “DSM metastructure” is no accident. The thinking of many seems to be that in the future they will be more closely related. This may be an attempt to come to terms with Chronic-PTSD, or DESNOS (disorders of extreme stress not otherwise specified), championed by Judith Herman, Bessel van Kolk, and others. As Friedman (2013, p. 524) puts it, “I recall overhearing a comment after my . . . presentation in 2011 on DSM-5, that the PTSD criteria were becoming more “DESNOS-ish.”

I’m going to assume that readers are familiar with the major changes in the diagnostic criteria for PTSD in DSM 5, and write more generally about the problem of thinking about trauma in terms of diagnostic criteria. Many diseases have similar symptoms, such as fever, swollen lymph nodes, low blood count, etc., but very different causes. It would be far better, and not just for PTSD, for the DSM to devote less time and attention to parsing symptoms, and instead looking for causes. But apparently the science is not up to the task. In effect, ever since the introduction of PTSD in DSM III in 1980, PTSD has been defined by the traumatic event that precedes it.

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