Archives for : DSM-5

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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The Book of Woe, and why NIMH said goodbye to DSM-5

IMG_1078This book review and comment are a little off my beat, for they are about DSM-5 in general, not just its diagnosis of trauma, which I addressed in my post of January 20, 2015, http://www.traumatheory.com/?p=86.

The full title of Gary Greenberg’s book is The Book of Woe: The DSM and the Unmaking of Psychiatry. Greenberg is a psychologist and journalist. Some of the juiciest pieces of this book appeared in The New Yorker between 2010 and 2013 (Google Greenberg + DSM + New Yorker; they are all there).

The book begins with a story about Sandy, one of Greenberg’s patients. When Greenberg first saw him Sandy could barely go out of his house. By the end of therapy Sandy had a job, a girlfriend, and what most of us would call a life. Sandy and Greenberg exchanged emails after Sandy moved half way across the country from Connecticut. Eventually the emails stopped. A couple of years later Greenberg received a call from Sandy in the middle of the night. It ran something like this.

You’ve got to help me. They’ve sucked all the bones out of my body. I’m here in this hotel room and my bones are gone. My mother and my father and James. They’ve done this to me. And I don’t want to die. Please don’t let them kill me. You’re the only one who can help. Good-bye. Good-bye. (p. 9)

Greenberg tried to call Sandy back at the hotel he had called from, but there was no answer. He never heard from Sandy again.

The book turns on what to make of Sandy’s phone call.

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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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