RDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Impact of Events Scale-Revised: esponse

RDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Impact of Events Scale-Revised: esponse

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Impact of Events Scale-Revised To the Editor: We read with great interes...

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Impact of Events Scale-Revised To the Editor: We read with great interest the article by Bienvenu et al1 in a recent issue of CHEST (July 2013) and would like to compliment them on the development and validation of the Impact of Events Scale-Revised (IES-R) for patients with posttraumatic stress disorder (PTSD) after acute lung injury. Psychiatric nosology and diagnostic classification systems are always dynamic and in a state of flux. The authors developed the screening questionnaire and validated it against the Clinician-Administered PTSD Scale (CAPS), which is based on Diagnostic and Statistical Manual of Mental Disorders (DSM), fourth edition, diagnostic criteria. However, the recently introduced fifth edition (DSM-5) has revised the conceptualization as well as the diagnostic criteria for PTSD, which has definite implications for the screening instrument proposed in the study. PTSD was moved from the class of anxiety disorders into a new class of trauma and stressor-related disorders. The cluster of symptoms in the fourth edition has been expanded in DSM-5 to include intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. DSM-5 now requires at least one avoidance symptom for a PTSD diagnosis. Three new symptoms were added: two in criteria D (negative alterations in cognitions and mood) to include persistent, distorted blame of self or others and persistent negative emotional state and one in criteria E (alterations in arousal and reactivity) to include reckless or destructive behavior.2 Criterion A2 (requiring fear, helplessness, or horror happening right after the trauma) was removed in DSM-5 because research suggested that this criterion does not improve diagnostic accuracy.3 A clinical subtype with dissociative symptoms was added for those who meet the criteria for PTSD and experience additional depersonalization and derealization symptoms. CAPS, the psychometric instrument against which the IES-R was validated, is currently being revised to ensure its compatibility with DSM-5 diagnostic criteria for PTSD. These changes lead to the inference that the IES-R would require substantial revision and validation against the revised CAPS to ensure its clinical utility in the future. Sundar Gnanavel, MD Ruby Stella Robert, MBBS New Delhi, India Affiliations: From the Department of Psychiatry (Dr Gnanavel), All India Institute of Medical Sciences; and Department of Physiology and Cardiopulmonary Rehabilitation (Dr Robert), Vallabhbhai Patel Chest Institute. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Sundar Gnanavel, MD, Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1691

References 1. Bienvenu OJ, Williams JB, Yang A, Hopkins RO, Needham DM. Posttraumatic stress disorder in survivors of acute lung injury: 1974

evaluating the Impact of Event Scale-Revised. Chest. 2013; 144(1):24-31. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013. 3. Friedman MJ, Resick PA, Bryant RA, Brewin CR. Considering PTSD for DSM-5. Depress Anxiety. 2011;28(9):750-769.

Response To the Editor: We thank Drs Gnanavel and Robert for their comments on our recent article in CHEST,1 and we appreciate the opportunity to respond. Importantly, we cannot take credit for developing the Impact of Event Scale-Revised (IES-R).2 We simply assessed its measurement properties against a “gold standard” clinical interview, the Clinician-Administered Posttraumatic Stress Disorder Scale, in survivors of acute lung injury. Drs Gnanavel and Robert highlight the shifting nature of psychiatric diagnosis with successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). We conducted our study during the era of the fourth edition (DSM-IV), but the fifth edition (DSM-5) was published a few months ago. Notably, the definition of ARDS has changed since we conducted our study, and the previous umbrella term “acute lung injury” has been eliminated.3 Where we may disagree with Drs Gnanavel and Robert is in their statement that DSM-5 changes necessitate substantial revisions to the IES-R to ensure its future clinical utility. To us, a posttraumatic stress disorder (PTSD) measurement tool has clinical utility if it addresses whether a person has substantial PTSD symptoms and whether symptom levels measured using the tool correlate with symptom levels measured using a clinical interview. Although there are changes in the DSM-5 definition, which include separation of the avoidance and numbing criteria and expansion of the potential associated symptoms from 17 to 20, in our view, the phenotype for PTSD is very similar in DSM-IV and DSM-5. Thus, regardless of whether the authors of the IES-R or other researchers further revise the instrument, it already meets our standard for clinical utility, whether PTSD is defined using DSM-IV or DSM-5. As highlighted by Schelling and Kapfhammer4 in the editorial accompanying our article, tools such as the IES-R have a potentially important role to play in research and clinical practice because critical illness/intensive care-related PTSD symptoms are common5 but often overlooked. We encourage ongoing discussion and research in this area and thank Drs Gnanavel and Robert for raising these issues. O. Joseph Bienvenu, MD, PhD Dale M. Needham, MD, PhD Baltimore, MD Ramona O. Hopkins, PhD Salt Lake City, UT Affiliations: From the Department of Psychiatry and Behavioral Sciences (Drs Bienvenu), and Division of Pulmonary and Critical Care Medicine (Dr Needham), Johns Hopkins University School of Medicine; and the Psychology and Neuroscience Center (Dr Hopkins), Brigham Young University. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence

Correspondence to: O. Joseph Bienvenu, MD, PhD, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 115, Baltimore, MD 21287; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1940

References 1. Bienvenu OJ, Williams JB, Yang A, Hopkins RO, Needham DM. Posttraumatic stress disorder in survivors of acute lung injury: evaluating the Impact of Event Scale-Revised. Chest. 2013; 144(1):24-31. 2. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD: A Practitioner’s Handbook. New York, NY: Guilford Press; 1997:399-411. 3. Ranieri VM, Rubenfeld GD, Thompson BT, et al; ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533. 4. Schelling G, Kapfhammer H-P. Surviving the ICU does not mean that the war is over. Chest. 2013;144(1):1-3. 5. Davydow DS, Desai SV, Needham DM, Bienvenu OJ. Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review. Psychosom Med. 2008;70(4):512-519.

Physical Activity vs Psychomotor Activity Prognostication of COPD

Sundar Gnanavel, MD Ruby Stella Robert, MBBS New Delhi, India Affiliations: From the Department of Psychiatry (Dr Gnanavel), All India Institute of Medical Sciences, New Delhi; and Physiology and Cardiopulmonary Rehabilitation (Dr Robert), Vallabhbhai Patel Chest Institute. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Sundar Gnanavel, MD, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, Ansari Nagar, New Delhi 110029, India; e-mail: sundar221103@ yahoo.com © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1732

References 1. Nguyen HQ, Fan VS, Herting J, et al. Patients with COPD with higher levels of anxiety are more physically active. Chest. 2013;144(1):145-151. 2. Sadock BJ, Kaplan HI, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Philadelphia, PA: Wolter Kluwer/Lippincott Williams & Wilkins; 2007. 3. Grös DF, Antony MM, Simms LJ, McCabe RE. Psychometric properties of the State-Trait Inventory for Cognitive And Somatic Anxiety (STICSA): comparison to the State-Trait Anxiety Inventory (STAI). Psychol Assess. 2007;19(4):369-381.

To the Editor: We read with interest the recent article by Nguyen et al1 in CHEST (July 2013), which demonstrated novel findings. However, we would like to draw attention to certain conceptual issues that could effectively question the crux of those findings. As the authors mentioned, objectively measured physical activity is an excellent predictor of prognosis for patients with COPD. However, physical activity is distinct from psychomotor activity. Psychomotor activity is defined as motor/physical activity that is secondary to or dependent on a psychic component and is mostly non-goal-directed.2 For example, manic, psychotic, and anxious patients would demonstrate increased psychomotor activity. This is generally state-dependent, that is, it lasts during the course of psychiatric symptoms and normalizes on effective treatment. Furthermore, comorbid anxiety symptoms have never been implicated as a good prognostic factor in either COPD or any other chronic illnesses, to our knowledge. If anything, mild anxiety symptoms predict positive outcome negating a sedentary lifestyle; it has to be trait anxiety symptoms that refer to those individuals with anxious predisposition or temperament from adolescence. Considering that the Nguyen et al1 study used a cross-sectional design, state and trait anxiety symptoms could have been discerned using an anxiety inventory like the State-Trait Anxiety Inventory.3 An anxious state resulting in increased step counts per day is expected and logical even in a patient with COPD. This cannot be erroneously interpreted as an increase in physical activity and predictor of good prognosis in patients with COPD. The authors propose no strong hypothesis to explain the better prognosis of mild anxiety symptoms. In fact, we would consider anxiety symptoms as a confounding factor in assessment of physical activity in patients with COPD. A longitudinal study of physical activity in patients with COPD accounting for anxiety or use of an anxiety inventory like the State-Trait Anxiety Inventory (additionally in a cross-sectional study) would better clarify the picture. journal.publications.chestnet.org

Predicting Community-Acquired Pneumonia Etiology To the Editor: We read with interest the recent study by Cillóniz et al1 in CHEST (September 2013), in which several associations between the cause and outcome of community-acquired pneumonia (CAP) were reported in patients . 65 years of age, studied over a period of 12 years. The authors mention that the nonhomogeneous assessment of microbial cause is a potential limitation. In our opinion, this is an understatement of the bias that may have resulted from this approach, and this limitation precludes the conclusion that was reached. The most important finding of the study was that the presence of comorbidities was associated more with potential multidrugresistant (MDR) pathogens as a cause of CAP than was age. Thus, the authors concluded that “comorbidities rather than age should be considered in the selection of antibiotic treatment.” However, the outcome (in this case, a microbial cause) was not assessed uniformly in all included patients, which is a well-known cause of bias in predictive research.2 Apparently, microbial testing was left to the discretion of the treating physician. This is at least suggested by the pattern of microbial testing: serologic tests in 1,537 patients (44%), sputum cultures in 1,913 patients (54%), and blood cultures in 2,753 patients (78%).3 By ignoring the fact that microbial tests could be different across patients, the authors implicitly assumed that the tests were missing at random. However, in clinical practice, the choice for microbial testing is often influenced by patient and disease characteristics. Therefore, more extensive diagnostic testing in patients with comorbidities may well explain the higher prevalence of potential MDR pathogens in this patient group. Demonstration of comparable diagnostic procedures in patients with and CHEST / 144 / 6 / DECEMBER 2013

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