Problems with the post-traumatic stress disorder diagnosis…

…and its future in DSM-V. This editorial from the January 2008 British Journal of Psychiatry from Gerald Rosen, Robert Spitzer and Paul McHugh is music to my ears. It questions the validity and the future of the post-traumatic stress disorder (PTSD) diagnosis because the symptoms it describes are already covered by other depressive and anxiety disorder diagnoses. THe concept of PTSD emerged as a diagnosis with DSM-III in the context of the ’60’s feminist and antiwar movements. I believe it was an expression of the sentiment that victims of abuse and returning Vietnam veterans had experienced something more extraordinary than other sufferers, and therefore that the extremity of their reactions needed to be codified in a new diagnosis. Very quickly, then, insensitivity to the PTSD diagnosis came to seem like insensitivity to the plights of various classes of the downtrodden and oppressed. And, from the patients’ point of view, it has been a very appealing diagnosis to carry, given that it serves to remove the stigma of mental illness from the person and locate the defect in the horrendous external event that befell them.

So, since the inception of the diagnosis in the early 1980’s, there has been a momentum to apply it from both clinicians and patients. As FmH readers will be aware, this bandwagon effect is one of my pet peeves. I have opined that the diagnosis has come to be applied sloppily and indiscriminately whenever an inexperienced, earnest and naive clinician felt that something terrible, deserving of empathy, had happened to their patient. The orthodox adherents of PTSD have claimed that horrendous traumatic experience beyond the pale of what the human nervous system was designed to endure altered neurophysiological functioning in distinct and specific ways, accounting for the defining symptoms of PTSD and justifying the need for such a diagnosis. When the diagnosis was handed out nonchalantly to anyone who had suffered a stress or a loss, in contrast, it lost its specificity, as the sufferer really did not embody such a profound alteration in neurophysiological functioning. What was being described was more run-of-the-mill depression or anxiety in response to expectable stresses and losses. The indiscriminate use of the PTSD diagnosis has also reinforced rampant victim culture in our society.

But this new editorial may represent even a more profound objection to the diagnosis of PTSD than I have been making. It may not be invalidated by being applied too broadly; it may be entirely invalid in the first place. Whwere in the diagnostic pigeonholes were the PTSD sufferers before there was PTSD? They carried depression and/or anxiety diagnoses. Should they be there again? This makes sense to me for several reasons.

First, the description of PTSD involves three symptom clusters — intrusive recollections of the trauma, exaggerated emotional and physiological reactivity when triggered by memories or reminders of what has happened, and self-protective avoidance and constriction of emotion in reaction. In learning and teaching about this diagnosis, I have felt hardpressed to explain how these are different from anxiety, depression, and compensatory efforts. So, in terms of the severity of a trauma, exactly where are we to draw the line between those that merely bum one out, those that cause depression, and those that cause PTSD?

Secondly, it has long been known that resilient individuals do not necessarily develop PTSD symptoms in response to traumatic experiences similar to those that produce the syndrome in others. Since it is shaped by constitutional factors in the suffferer, the concept of a distinctive response to extreme trauma is further watered down.

Thirdly, some argue that there are depressive disorders, there are anxiety disorders, and there is the somewhat unusual fusion of the two symptom complexes in PTSD. But many psychiatrists, myself included, feel we have rarely seen a ‘pure’ depressive or anxiety disorder case, that patients always embody a combination of the two, and that the depressive and anxiety disorders are not as distinct as the diagnostic scheme would have use believe. Among other lines of evidence contributing to this impression is the fact of the overlap in efficacy of therapeutic agents for depression and anxiety. Antidepressants are good anxiolytics (perhaps better than Valium and its modern family of anti-anxiety derivatives, the benzodiazepines). Anti-anxiety medications have a venerable history for the treatment of depression. Treatment for PTSD, in any case, is little more than targeting some combination of anxiety and depressive symptoms, anyway.

Finally, most of the neurobiological explanations for the etiology of PTSD emphasize the impact of activation of the fight-or-flight response, and the bathing of the brain in stress hormones, at the time the trauma is experienced. This supposedly damages the brain and changes its emotional reactivity, its memory processing, etc. thereafter. But, increasingly, depression too has come to be understood as a syndrome of altered brain function and tissue damage from the physiological effects of stress, in a similar way. One interesting trend throughout the mental health field, as it has emphasized biological factors more and more to the exclusion of psychological and emotional, is arguably the lessening separation of heretofore distinctive diagnoses. I have recently heard theoretical speculation that schizophrenic and bipolar (manic depressive) psychoses may not be separate entities either. Indeed, the central distinction in diagnostic psychiatry between disorders of mood and of thought makes less and less sense than we have thought.

In psychiatric epistemology, there has always been a tension between the ‘lumpers’ and the ‘splitters’. Modern developments in diagnostic nomelnclature embodied in recent editions of the Diagnostic and Statistical Manual (“DSM”) have clearly been in the hands of the splitters, to a sometimes baroque and ridiculous extent. Distinctions have proliferated, pigeonholes have multiplied. Interestingly, one of the co-authors of this editorial, Robert Spitzer, has been the maven of the DSM process for the past several decades. The reconsideration of PTSD signified by this editorial may represent a long-overdue resurgence of lumping. As a generalist and synthesist in the field, this is very appealing to me…

So, in a sense, it may not be that all or most post-traumatic stress is really depression and anxiety; it may be that all or most depression and anxiety disorders may really be post-traumatic. Much has been written about Freud’s betrayal of the trauma concept. In early vesions of psychoanalytic theory, he had recognized the impact of external events in the etiology of neuroses, but in revising his theory he increasingly focused on internal fantasies. Critics have suggested he was avoiding his own irresolvable conflicts about his relationships with the women in his life. In any case, this was the first of two major betrayals of the patient’s reality in mental health treatment which has shaped the conception of mental disorders and the approach to treatment for the ensuing century or more; the second has been the reductionistic biological focus of the last two decades, removing us even more from the core reality of the patient’s experience. Arguably, it has gotten to the point that third party payors, in a sense, only want to pay for “endogenous” disorders that do not arise from life events, relegating “reactive” syndromes to lesser diagnostic categories which are less reimbursable. In a way, I may have been dead wrong in complaining that PTSD was diagnosed too often and arguing for the more precise use of the concept. The impact of trauma may not be recognized or acknowledged nearly enough.