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PTSD and DSM-5: unintended consequences of change
Comment
NARONG SANGNAK/epa/Corbis
PTSD and DSM-5: unintended consequences of change
Published Online August 14, 2014 http://dx.doi.org/10.1016/ S2215-0366(14)70321-9 See Articles page 269
246
The choice of diagnostic criteria for post-traumatic stress disorder (PTSD) is especially important because these criteria are used in legal jurisdictions and for the determination of pensions.1 Charles Hoge and colleagues’ Article2 in The Lancet Psychiatry draws attention to the worrying discordance between DSM-IV and DSM-5 criteria3 for the diagnosis of PTSD in veterans, substantiating similar findings from previous studies.4 Specifically, Hoge and colleagues’ findings showed that, of soldiers who met DSM-IV-TR symptom criteria, 30% did not meet DSM-5 criteria and that 45% of those meeting either criteria had a discordant classification when the two sets of criteria were compared.2 The fact that this observation is mostly accounted for by the redefinition of the criterion C in DSM-5 is a matter of concern. A question that needs to be answered is whether the DSM-5 criteria have been excessively influenced by theoretical cognitive behavioural constructs due to the dominance of this treatment in field, despite the specific effectiveness being questioned,5 at the expense of other domains of evidence. Paradoxically, one of the major advances of DSM-III was to adopt an atheoretical position, renounce the psychoanalytic theory of neurosis and move to a scientific approach to phenomenology.6 Has this issue been forgotten? The dominance of the cognitive behavioural model has led to the separation of avoidance symptoms from numbing, with both persistent effortful avoidance and negative alterations in cognition and mood now being required for the diagnosis.3 There is a confused logic in requiring avoidance symptoms to be present to reach the diagnostic threshold because their manifestation can be substantially affected by an individual’s professional training. Military and emergency services personnel learn to override their avoidance and fear reactivity to do their duties. Military training makes people suppress their emotional reactivity during exposure to traumatic events7 yet they still develop PTSD. Hoge and colleagues’ finding of diagnostic discordance between DSM-IV and DSM-5 due the reformulation of the C criterion draws attention to the importance of the issue. Veterans’ training means they use techniques to ignore their desire for avoidance or alternatively use dissociative strategies to minimise awareness of traumatic triggers, which leads to numbing. These
strategies do not mean the psychophysiological abnormalities of PTSD are not present and therefore do not need treatment. Furthermore, people with PTSD are at times not aware of the traumatic origins of their physiological arousal,8 and are hence unable to mount an avoidant response or report the disorder. For example, the inability of individuals to recognise the traumatic origins of their avoidance behaviour led to the under-diagnosis of PTSD in children exposed to a bushfire disaster when reassessed in adulthood.9 Rather they were diagnosed with weather phobia in a structured interview. The participants did not understand how the extreme wind that occurred before and during the fire led to their fear of storms. In military populations a further issue is that avoidance strategies can drive alcohol and substance abuse, both of which are not reflected in the criteria. Also, DSM-5 specifies PTSD with dissociative symptoms and this pattern of reactivity might lead to a predominant pattern of numbing that overrides avoidance behaviours,3 and is also disruptive to interpersonal relationships. The reformulation of emotional numbing in DSM-5 is also problematic and can lead to further diagnostic discordance, particularly because this is a fundamental emotional state in veterans’ adaptation to the extended exposure to the threat of combat and reinforced in the training environment. While DSM-IV characterised numbing as a restricted range of affect indicative of a substantially reduced ability to feel emotions, in DSM-5 it has been changed to the persistent inability to experience positive emotions. 2,3 The DSM-5 construct is at variance with the neurobiological research into this phenomenon, despite DSM-5 supposedly being an update to incorporate the use of such evidence.3 Findings from neuroimaging studies have defined two distinct patterns of reactivity in PTSD, namely where there is emotional undermodulation and overmodulation.10 Overmodulation is associated with excessive corticolimbic inhibition mediated by structures including the dorsal anterior cingulate and the medial prefrontal cortex. This pattern of activation underpins a sense of emotional disengagement that is marked by numbing and the constriction of ideation, a general occurence10 that is not restricted to positive emotion as would be suggested by the new criteria of DSM-5. Furthermore, findings from electrophysiological studies www.thelancet.com/psychiatry Vol 1 September 2014
Comment
in PTSD have shown abnormalites in processing of angry, fearful, and happy faces, indicative of disrupted affect registration that is not limited to positive emotion.11 This disruption of affect registration is a major source of social impairment that needs to be addressed in treatment. Therefore, the new definition of numbing is at variance with a body of neurobiological data contrary to the broader aims of DSM-5. From a statistical standpoint, the decision to separate the C criterion of DSM-IV into separate avoidance and dysphoria components was based on the published confirmatory factor analyses. 8 However the methodological approach used in these analyses has been critiqued and it has been suggested that the acceptance of the four-factor solution that DSM-5 has adopted is based on a methodological artefact arising from the order in which the symptoms of PTSD are typically assessed.12 This modification has also been criticised from a conceptual standpoint with the suggestion that the differentiation of numbing and the dysphoria constructs has been exaggerated despite empirical evidence to the contrary.12 These substantial points further strip away one of the primary foundations of the case for the revision of PTSD in DSM-5 that separated avoidance and numbing. Clinicians’ inter-rater reliability when interpreting the reworded symptoms is a further concern that needs urgent investigation. The D criteria involving negative alterations in mood require subtle interpretation of the meaning and content of an individual’s thoughts and beliefs, and these are liable to substantial differences in interpretation because they depend on the appraisal of the risk of further trauma exposure and the cultural context. Another reason for the diagnostic discordance reported by Hoge and colleagues might arise from the participants’ difficulties in introspecting and judging whether they have persistent and exaggerated negative beliefs or cognitions about the cause or consequence of traumatic experience. In view of the intensity of an individual’s beliefs after a trauma exposure and the reality of their negative appraisals, it is likely that the judgment of these matters using self-report instruments will be questionable. DSM5 would have been better served if these abstract psychopathological constructs had not been included ahead of more objectively observed behaviours or physiologically measurable reactivity. www.thelancet.com/psychiatry Vol 1 September 2014
It seems that the PTSD criteria in DSM-5 have faltered on the assumption that individuals can tell more than they know. Avoidance presumes that individuals understand their primary motivation, which can be disrupted in PTSD. People with PTSD struggle to report and reflect on their inner world yet this has become an increased focus of these diagnostic criteria. Hoge and colleagues’ findings draw attention to the hazards that these changes in diagnostic criteria will introduce in the administration of veterans’ benefits and access to care. We think there should be a period of transition between legal use of DSM-IV and DSM-5 so that potential effects of these changes can be examined and that deserving individuals are not denied their legal rights. There is an obligation not to let this unintended consequence of a fashion of psychopathological formulation prevail. Alexander C McFarlane Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, SA 5062, Australia [email protected] I declare no competing interests. 1
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Kilpatrick D, McFarlane A. PTSD and the law: forensic considerations. In: eds Friedman MJ, Keane TM, Resick P. Handbook of PTSD: science and practice. New York: Guilford Press, 2014: 540–54. Hoge CW, Riviere LA, Wilk JE, Herrell RK, Weathers FW. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. Lancet Psychiatry 2014; published online Aug 14. http://dx.doi.org/10.1016/S2215-0366(14)70235-4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, DSM-5. Washington DC: American Psychiatric Association, 2013. O’Donnell ML, Alkemade N, Nickerson A, et al. Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11. Br J Psychiatry 2014; published online May 8. DOI:10.1192/bjp.bp.113.135285 Benish S, Imel A, Wampold B. The relative efficacy of bona fide psychotherapies for treating posttraumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychool Rev 2008; 28: 746–58. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition, DSM-III. Washington DC: American Psychiatric Association, 1980. Adler A, Wright K, Bliese P, Echford R, Hoge C. A2 diagnostic criterion for combat-related post-traumatic stress disorder. J Traumatic Stress 2008; 21: 301–08. Friedman M, Resick P, Bryant R et al. Considering PTSD for DSM-5. Depress Anxiety 2011; 28: 750–69. McFarlane A and Van Hooff M. Impact of childhood exposure to a natural disaster on adult mental health: 20 year longitudinal follow-up study. BJ of Psych 2009; 195: 142–48. Lanius R, Vermetten E, Loewenstein R, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry 2010; 167: 640–47. MacNamara A, Post D, Kennedy A, Rabinak C, Phan K. Electrocortical processing of social signals of threat in combat-related post-traumatic stress disorder. Biol Psychol 2013; 94: 441–49. Marshall G, Schell T, Miles J. A multi-sample confirmatory factor analysis of PTSD symptoms: what exactly is wrong with the DSM-IV structure? Clin Psychol Rev 2013; 33: 54–66.
247
NARONG SANGNAK/epa/Corbis
PTSD and DSM-5: unintended consequences of change
Published Online August 14, 2014 http://dx.doi.org/10.1016/ S2215-0366(14)70321-9 See Articles page 269
246
The choice of diagnostic criteria for post-traumatic stress disorder (PTSD) is especially important because these criteria are used in legal jurisdictions and for the determination of pensions.1 Charles Hoge and colleagues’ Article2 in The Lancet Psychiatry draws attention to the worrying discordance between DSM-IV and DSM-5 criteria3 for the diagnosis of PTSD in veterans, substantiating similar findings from previous studies.4 Specifically, Hoge and colleagues’ findings showed that, of soldiers who met DSM-IV-TR symptom criteria, 30% did not meet DSM-5 criteria and that 45% of those meeting either criteria had a discordant classification when the two sets of criteria were compared.2 The fact that this observation is mostly accounted for by the redefinition of the criterion C in DSM-5 is a matter of concern. A question that needs to be answered is whether the DSM-5 criteria have been excessively influenced by theoretical cognitive behavioural constructs due to the dominance of this treatment in field, despite the specific effectiveness being questioned,5 at the expense of other domains of evidence. Paradoxically, one of the major advances of DSM-III was to adopt an atheoretical position, renounce the psychoanalytic theory of neurosis and move to a scientific approach to phenomenology.6 Has this issue been forgotten? The dominance of the cognitive behavioural model has led to the separation of avoidance symptoms from numbing, with both persistent effortful avoidance and negative alterations in cognition and mood now being required for the diagnosis.3 There is a confused logic in requiring avoidance symptoms to be present to reach the diagnostic threshold because their manifestation can be substantially affected by an individual’s professional training. Military and emergency services personnel learn to override their avoidance and fear reactivity to do their duties. Military training makes people suppress their emotional reactivity during exposure to traumatic events7 yet they still develop PTSD. Hoge and colleagues’ finding of diagnostic discordance between DSM-IV and DSM-5 due the reformulation of the C criterion draws attention to the importance of the issue. Veterans’ training means they use techniques to ignore their desire for avoidance or alternatively use dissociative strategies to minimise awareness of traumatic triggers, which leads to numbing. These
strategies do not mean the psychophysiological abnormalities of PTSD are not present and therefore do not need treatment. Furthermore, people with PTSD are at times not aware of the traumatic origins of their physiological arousal,8 and are hence unable to mount an avoidant response or report the disorder. For example, the inability of individuals to recognise the traumatic origins of their avoidance behaviour led to the under-diagnosis of PTSD in children exposed to a bushfire disaster when reassessed in adulthood.9 Rather they were diagnosed with weather phobia in a structured interview. The participants did not understand how the extreme wind that occurred before and during the fire led to their fear of storms. In military populations a further issue is that avoidance strategies can drive alcohol and substance abuse, both of which are not reflected in the criteria. Also, DSM-5 specifies PTSD with dissociative symptoms and this pattern of reactivity might lead to a predominant pattern of numbing that overrides avoidance behaviours,3 and is also disruptive to interpersonal relationships. The reformulation of emotional numbing in DSM-5 is also problematic and can lead to further diagnostic discordance, particularly because this is a fundamental emotional state in veterans’ adaptation to the extended exposure to the threat of combat and reinforced in the training environment. While DSM-IV characterised numbing as a restricted range of affect indicative of a substantially reduced ability to feel emotions, in DSM-5 it has been changed to the persistent inability to experience positive emotions. 2,3 The DSM-5 construct is at variance with the neurobiological research into this phenomenon, despite DSM-5 supposedly being an update to incorporate the use of such evidence.3 Findings from neuroimaging studies have defined two distinct patterns of reactivity in PTSD, namely where there is emotional undermodulation and overmodulation.10 Overmodulation is associated with excessive corticolimbic inhibition mediated by structures including the dorsal anterior cingulate and the medial prefrontal cortex. This pattern of activation underpins a sense of emotional disengagement that is marked by numbing and the constriction of ideation, a general occurence10 that is not restricted to positive emotion as would be suggested by the new criteria of DSM-5. Furthermore, findings from electrophysiological studies www.thelancet.com/psychiatry Vol 1 September 2014
Comment
in PTSD have shown abnormalites in processing of angry, fearful, and happy faces, indicative of disrupted affect registration that is not limited to positive emotion.11 This disruption of affect registration is a major source of social impairment that needs to be addressed in treatment. Therefore, the new definition of numbing is at variance with a body of neurobiological data contrary to the broader aims of DSM-5. From a statistical standpoint, the decision to separate the C criterion of DSM-IV into separate avoidance and dysphoria components was based on the published confirmatory factor analyses. 8 However the methodological approach used in these analyses has been critiqued and it has been suggested that the acceptance of the four-factor solution that DSM-5 has adopted is based on a methodological artefact arising from the order in which the symptoms of PTSD are typically assessed.12 This modification has also been criticised from a conceptual standpoint with the suggestion that the differentiation of numbing and the dysphoria constructs has been exaggerated despite empirical evidence to the contrary.12 These substantial points further strip away one of the primary foundations of the case for the revision of PTSD in DSM-5 that separated avoidance and numbing. Clinicians’ inter-rater reliability when interpreting the reworded symptoms is a further concern that needs urgent investigation. The D criteria involving negative alterations in mood require subtle interpretation of the meaning and content of an individual’s thoughts and beliefs, and these are liable to substantial differences in interpretation because they depend on the appraisal of the risk of further trauma exposure and the cultural context. Another reason for the diagnostic discordance reported by Hoge and colleagues might arise from the participants’ difficulties in introspecting and judging whether they have persistent and exaggerated negative beliefs or cognitions about the cause or consequence of traumatic experience. In view of the intensity of an individual’s beliefs after a trauma exposure and the reality of their negative appraisals, it is likely that the judgment of these matters using self-report instruments will be questionable. DSM5 would have been better served if these abstract psychopathological constructs had not been included ahead of more objectively observed behaviours or physiologically measurable reactivity. www.thelancet.com/psychiatry Vol 1 September 2014
It seems that the PTSD criteria in DSM-5 have faltered on the assumption that individuals can tell more than they know. Avoidance presumes that individuals understand their primary motivation, which can be disrupted in PTSD. People with PTSD struggle to report and reflect on their inner world yet this has become an increased focus of these diagnostic criteria. Hoge and colleagues’ findings draw attention to the hazards that these changes in diagnostic criteria will introduce in the administration of veterans’ benefits and access to care. We think there should be a period of transition between legal use of DSM-IV and DSM-5 so that potential effects of these changes can be examined and that deserving individuals are not denied their legal rights. There is an obligation not to let this unintended consequence of a fashion of psychopathological formulation prevail. Alexander C McFarlane Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, SA 5062, Australia [email protected] I declare no competing interests. 1
2
3
4
5
6
7
8 9
10
11
12
Kilpatrick D, McFarlane A. PTSD and the law: forensic considerations. In: eds Friedman MJ, Keane TM, Resick P. Handbook of PTSD: science and practice. New York: Guilford Press, 2014: 540–54. Hoge CW, Riviere LA, Wilk JE, Herrell RK, Weathers FW. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. Lancet Psychiatry 2014; published online Aug 14. http://dx.doi.org/10.1016/S2215-0366(14)70235-4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition, DSM-5. Washington DC: American Psychiatric Association, 2013. O’Donnell ML, Alkemade N, Nickerson A, et al. Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11. Br J Psychiatry 2014; published online May 8. DOI:10.1192/bjp.bp.113.135285 Benish S, Imel A, Wampold B. The relative efficacy of bona fide psychotherapies for treating posttraumatic stress disorder: a meta-analysis of direct comparisons. Clin Psychool Rev 2008; 28: 746–58. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition, DSM-III. Washington DC: American Psychiatric Association, 1980. Adler A, Wright K, Bliese P, Echford R, Hoge C. A2 diagnostic criterion for combat-related post-traumatic stress disorder. J Traumatic Stress 2008; 21: 301–08. Friedman M, Resick P, Bryant R et al. Considering PTSD for DSM-5. Depress Anxiety 2011; 28: 750–69. McFarlane A and Van Hooff M. Impact of childhood exposure to a natural disaster on adult mental health: 20 year longitudinal follow-up study. BJ of Psych 2009; 195: 142–48. Lanius R, Vermetten E, Loewenstein R, et al. Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry 2010; 167: 640–47. MacNamara A, Post D, Kennedy A, Rabinak C, Phan K. Electrocortical processing of social signals of threat in combat-related post-traumatic stress disorder. Biol Psychol 2013; 94: 441–49. Marshall G, Schell T, Miles J. A multi-sample confirmatory factor analysis of PTSD symptoms: what exactly is wrong with the DSM-IV structure? Clin Psychol Rev 2013; 33: 54–66.
247