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.

A little history

In the United States, the diagnosis of PTSD was part of an attempt to make sense of, and ultimately politicize, the psychological damage done to veterans of the Vietnam War. “The task force that designed the new diagnostic category . . . was comprised of psychiatrists who were particularly sensitive to the problems afflicting Vietnam veterans.” (Fassin and Rechtman, 2009, p. 88) The task force included Robert Jay Lifton, who had written a book, Home from the War (1973), “recounting the psychopathological effects of serving in this ‘dreadful, filthy, unnecessary war.'” Another member was Jack Smith, who had been active in the Vietnam Veterans Against the War. Of the over 100 experts serving on various advisory committees to the DSM 3 task forces, Smith was the only one to lack a college degree. In 1978, the working group, consisting of Lifton, Chaim Shatan, and Smith, presented its final report to the Committee on Reactive Disorders. Shatan was the doctor who first proposed the diagnosis of post-Vietnam syndrome in the op-ed page of the New York Times on May 6, 1972. (Young, 1995, 109-110)

The symptoms of PTSD in DSM III were similar to what was called post-Vietnam war syndrome. However, veterans could neither be treated by the Veterans Administration nor compensated for unofficial diagnostic categories. Once PTSD was a recognized psychiatric category in DSM 3, they were eligible for both (Fassin and Rechtman, 2009, p. 88).

Key to the new definition was the idea that these symptoms were the result of placing normal people in an abnormal situation. The presence of the Vietnam War on the televisions in living rooms throughout the United States made this more plausible.

Rather than a sign of cowardice, or the consequence of prior mental illness, PTSD was the result of average men being thrown into a situation in which every rustle in the leaves could indicate the presence of death, where the encounter with mutilated bodies was an everyday occurrence, and where the feeling of being surrounded by invisible enemies was reality, not paranoia. It is no accident that the key definition of PTSD in DSM 3 (309.89) was that “The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone.” Rape, severe physical assault, military combat, and unusually serious automobile accidents were the leading examples.

As the definition of PTSD has changed over the years, it became more inclusive. DSM IV (1994) removed the stipulation that the traumatic event be “outside the range of usual human experience.” Sufficient was that it be the type of event that threatened death, serious injury, threat to physical integrity, fear, helplessness, or horror. Since the introduction of DSM IV, with its looser criteria, one study suggests as much as a 30 percent increase in diagnoses of PTSD.

In my opinion, DSM 5 has made more of a hash of the category, particularly if we recognize that it is the originating trauma that makes PTSD different from other diagnoses, many of which share the same symptoms. In DSM 5, the “fear, helplessness, or horror” criterion (A2) has been removed. Apparently many professionals dealing with death and dismemberment on a daily basis don’t experience “fear, helplessness, or horror,” yet go on to develop PTSD. However, the events that can cause trauma seem to include not just direct exposure as victim or witness, but learning that a close friend or relative has been involved in a traumatic experience.

As far as I can tell, this could include learning that a close friend was almost involved in a fatal automobile accident (but wasn’t), but would not include learning that a close relative died of a sudden heart attack at 40. Narrations about near death events to friends and relatives count only if they were the result of an accident.  Take a look at criterion A and decide for yourself. Finally, criterion A is specific that it is not enough to learn about terrible things happening to people on the television news. Good thing too, or we would all be traumatized.

It really doesn’t work, and the reason it doesn’t work is because defining trauma in terms of the traumatic event, unless one wants to make this event quite specific, such as actual physical trauma to oneself, really has no boundaries. In a sense, trauma is a misleading category to begin with, because it is drawn from medicine. “Blunt force trauma” in physical medicine refers to the causal agent. Psychic trauma, no matter how much we adjust the criteria, is really a subjective category: if I feel traumatized, and act traumatized by displaying the symptoms, then I am traumatized. Trouble is, this opens the door to all sorts of traumas, such as “unemployment trauma,” or “marriage on the rocks trauma.” I think that would be fine, but it’s not what the psychiatrists really want.

What is to be done?

It has been seriously suggested by the lead developer of DSM III, Gerald Rosen (2008), that PTSD no longer be defined by the initiating event. “Criterion creep” is one reason. The other is that different disorders, such as a combination of the symptoms of major depression and a specific phobia “fully constitutes the requisite criteria for diagnosing PTSD.”

So, how best to think about trauma? That trauma is a form of knowledge, “knowledge as disaster” as Michel Blanchot (1995, 11) puts it. Or as Julia S., a Holocaust survivor puts it, “You’re not supposed to see this; it doesn’t go with life.” Trauma is learning what a human being should never have to know: about vulnerability, about pain, about loss, and finally about the evil and vast carelessness of the world. The only way to come to terms with this knowledge is through grief. Mourning isn’t a cure for trauma. It is the way to live with trauma.

Symptoms need to be dealt with. Symptoms needs to be treated and cared for. But, they are not themselves trauma, and a diagnosis of trauma built on an ever more confusing definition of traumatic symptoms, and an ever more complicated checklist of symptoms that has taken on the quality of a Chinese menu (one from column A, one from column B) is not the best way to go.

To repeat myself: caring for people suffering from the symptoms of trauma comes first. This means treating symptoms. But symptoms are not a good way to define a disorder. Not in physical medicine, and not with PTSD. In physical medicine, one looks to the etiology, the cause. That hasn’t worked with PTSD, as the traumatic event is now beyond definition. Best to beginning thinking about the meaning of trauma, and to use the DSM 5 as a manual of billing codes, at least for PTSD.

References

Fassin, Didier and Rechtman, Richard (2009). The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton University Press.

Friedman, Matthew (2013). “Finalizing PTSD in DSM-5: Getting Here From There and Where to Go Next.” Journal of Traumatic Stress, 26, 548–556.

Rosen, Gerald (2008). The British Journal of Psychiatry, 192, 3-4.

Young, Allan (1995). The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton University Press.

 

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Comments (2)

  1. James Gachau

    Before I come across as an anti-psychiatrist, allow me to start by saying that I laud doctors who try to help people who suffer from psychic ailments; psychological suffering is real, no doubt!

    But psychiatry is ill-suited to deal with psychological pain. In fact, psychiatry should be abandoned and every problem it tries to deal with subsumed under either neurology or psychology. Neurology would handle Alzheimer’s, Parkinson’s, and other related diseases, while psychology would handle trauma. This would be the most rational arrangement, but we all know how mediocre men’s minds really are!

    • calford@umd.edu

      Dear James, first I think many psychologists are as committed to their particular approaches to trauma as psychiatrists are to their drugs. Even if the DSM 5 on trauma is deeply flawed, I don’t know how much better a group of psychologists would do. Probably somewhat better, but who knows?

      Second, psychoactive drugs have their place, and I think medical training is necessary here. Trouble is, drugs have so often replaced talk (they are cheaper, for one thing; require less compassion for another) that it is hard to know what the overall benefit is. In some cases, I think people’s lives have been saved by drugs.

      But already I think I’m generalizing too much. Fred

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