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Saturday, December 06, 2008

Defining PTSD: Update on Our Way to DSM-V

Interesting developments in the the current updating of the DSM-IV, or Diagnostic and Statistical Manual of Mental Health Disorders (generally considered the "Bible of Psychiatry"), and the ongoing push to make the process as transparent as possible.

Concerns have begun swirling about regarding a number of entries, post-traumatic stress disorder [PTSD] among them. It would be wise to keep our eye out on these developments, especially if you are in the field's research and/or medical professions, as the early draft of the new DSM-V is due out in the coming year. A period for comment will follow before the final version is published in 2012. (Follow the latest back-and-forth over at Psychiatric Times' DSM-V page.)

First, a look at the desk reference's history via Wikipedia:

The DSM [official site | select contents] is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used in the United States and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers.

The DSM has attracted controversy and criticism as well as praise. There have been five revisions since it was first published in 1952, gradually including more disorders. It initially evolved out of systems for collecting census and psychiatric hospital statistics, and from a manual developed by the US Army.

The last major revision was the DSM-IV published in 1994, although a "text revision" was produced in 2000. The DSM-V is currently in consultation, planning and preparation, due for publication in May 2012. An early draft will be released for comment in 2009.

In educational interest, article(s) quoted from extensively.

Last month, Christopher Lane, a professor of English at Northwestern University and the author of "Shyness: How Normal Behavior Became a Sickness," penned a searing LA Times opinion piece on the wrangling going on around the update process:

Over the summer, a wrangle between eminent psychiatrists that had been brewing for months erupted in print. Startled readers of Psychiatric News saw the spectacle unfold in the journal's normally less-dramatic pages. The bone of contention: whether the next revision of America's psychiatric bible...should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.

This may sound like an arcane, insignificant spat about nomenclature. But the manual is in fact terribly important, and the debates taking place have far-reaching consequences. ...

A clear explanation follows. Continuing:

Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmaceutical companies and agencies that regulate drugs. Because large numbers of countries, including the United States, treat the DSM as gospel, it's no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world.

Behind the dispute about transparency is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full-scale mental illnesses in their own right. Also, because so many participants in the process of defining new disorders have ties to pharmaceutical companies, some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.

The more you know about how psychiatrists defined dozens of disorders in the recent past, the more you can appreciate Spitzer's concern that the process should not be done in private. Although a new disorder is supposed to meet a host of criteria before being accepted into the manual, one consultant to the manual's third edition -- they're now working on the fifth -- explained to the New Yorker magazine that editorial meetings over the changes were often chaotic. "There was very little systematic research," he said, "and much of the research that existed was really a hodgepodge -- scattered, inconsistent and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest."

Things are different today, the new consultants insist, because hard science now drives their debates. ...Spitzer is bothered by the prospect of "science by committee." Others, like forensics expert Karen Franklin, writing in American Chronicle, warn that advocacy groups are pressing for the inclusion of dubious terms that simply don't belong in a manual of mental illnesses.

Franklin's Am Chronicle piece offers more on the personalities and problems wound up in the process. She specifically mentions Lane, author of the above LA Times op-ed:

In writing his book, Lane was able to get unprecedented access to internal memos and letters of the American Psychiatric Association's DSM-III task force. Based on these primary sources, he credits the rise of the DSM from an obscure tract used mainly by state hospital hacks to an international bible to one man - Robert Spitzer - who chaired the task force and handpicked its members from people he considered "kindred spirits." (Spitzer is perhaps better known among the general public for his controversial stance that gay people could be turned heterosexual through reparative therapy.)

Over the years, the DSM has expanded from just 106 pages to its current 886. The severe mental disorders that once formed the book's core are still in there. There's just so much fluff that it's harder to find them.

And now, the American Psychiatric Association is at it again, working on the fifth edition that is set to launch in May 2012. But this time, perhaps in response to exposes such as Lane's, there will be no telltale memos and letters to document the process. Task force members are sworn to complete secrecy; they must sign a "confidentiality agreement" prohibiting them from disclosing anything to anyone.

Pasadena Therapist shared his latest entreaty, "Update on Making DSM-V Transparent," at the end of November. In it, Spitzer makes specific mention of his concern involving transparency around the PTSD definition discussions:


Robert L. Spitzer, M.D.
Professor of Psychiatry, Columbia University
Former Chair of Work Group to Develop DSM-III and DSM-III-R

...Pressure on APA leadership to increase transparency culminated in the drafting of an Action Paper by some members of the APA Assembly. ...In addition, each of the 13 Workgroups have been asked to prepare a report every 4 months summarizing their progress. Reports of the 13 Workgroups were posted on the DSM-V web site in the week prior to the Assembly vote.

Although clearly a move in the right direction, I believe that these reports fall far short of providing the requisite transparency. The Workgroup reports are quite variable in terms of the amount of detail they provide regarding possible directions for change in the DSM-V. Some are quite detailed (e.g., Eating Disorders) and provide a good window into the process. Others, like the summary for Anxiety Disorders, is so general as to provide almost no information about problematic issues that the workgroup has identified.

For example, although there has been considerable criticism of the criteria for PTSD (including a special issue of the Journal of Anxiety Disorders devoted to that topic), there is no information provided about possible directions for change – simply that PTSD is one of the subjects of the literature review.

One possible new direction, something called evolution theory, is presented in Clinical Psychology: Science and Practice's "Anxiety and Posttraumatic Stress Disorder in the Context of Human Brain Evolution: A Role for Theory in DSM-V?" Intro and summary grafs from the February 2008 article:

The published research agenda (Kupfer, First, & Regier, 2002) for the [DSM-V] advocated the "development of a physiologically based classification system in the DSM-V" (Charney et al., 2002). Psychophysiological research on PTSD is expanding at all levels of inquiry; for example, neuron counting methods (adopted from Parkinsonism research) have shown damage to the locus ceruleus in chronic PTSD (Bracha, Garcia-Rill, Mrak, & Skinner, 2005). The DSM-III, DSM-IV, DSM-IV-TR (American Psychiatric Association, 1980, 1994, 2004), and ICD-10 (World Health Organization, 2004) have judiciously minimized discussion of etiologies to distance clinical psychology and psychiatry from Freudian psychoanalysis. This goal has been largely achieved, and several authors now argue that sufficient empirical evidence has accumulated to re-introduce etiological factors into DSM-V (Akiskal & Akiskal, 2005; Bracha, 2006; Bracha, Ralston, et al., 2005, 2007; Cosmides & Tooby, 1999; Nesse, Stearns, & Omenn, 2006; Tooby & Cosmides, 1990). A related problem in DSM-IV-TR and ICD-10 is that the classification of anxiety disorders is neither mode-of-acquisition-based nor brain-evolution-based (Bracha, 2006). ...

With regard to anxiety disorders and PTSD, there is ample evidence for neurobiological underpinnings (Charney, Barlow, et al., 2002; Bracha, Garcia-Rill, et al., 2005); however, linking anxiety disorders to their evolutionary origins has had limited success in attracting the mainstream interests of mental health clinicians, Marx et al. (2008) being a rare exception. For example, Seligman's preparedness theory attempted to do this for specific phobias (Mineka & Öhman, 2002a, 2002b; Öhman & Mineka, 2001; Seligman, 1971). Bracha and colleagues have focused on PTSD, other anxiety disorders, and acute stress-induced conversive disorders (Bracha, 2006; Bracha, Williams, Haynes, et al., 2004, 2006d; Bracha & Hayashi, 2006; Bracha, Vega, & Vega, 2006; Bracha, Yoshioka, et al., 2005). Marx et al. comprehensively explain a previously misunderstood motor behavior, reported by victims of sexual assault, as an evolved predator defense. In so doing they eloquently highlight the clinical insights that evolution theory brings to clinical traumatology.

Although DSM revisions have moved toward empirical findings, there is still no mention of linkage between psychopathology and evolution. DSM-III was a paradigm shift in psychiatry and clinical psychology (Klerman, 1990; Maser et al., in press), but it continues to lack an overarching and unifying theory within which its symptoms and etiologies can be understood. While evolution theory has brought considerable clarity and unification to other specialties in biology and even to internal medicine (Nesse et al., 2006), it has not done so for psychopathology. Nesse's editorial stressed the need for an evolutionary approach to psychopathology (Nesse et al., 2006), and Bracha has made similar arguments for a host of anxiety disorders.

There may now be enough data in certain areas that the inclusion of theory should be reconsidered for DSM-V. The theory does not have to be perfectly correct, if it serves to stimulate research. Anxiety and its disorders could easily be a testing ground for inclusion of evolution theory in DSM-V, since those forms of psychopathology have the most empirical data. Along with the many changes that are being suggested for DSM-V, we urge the planners to seek out empirical studies and/or theories that place psychopathology in an evolutionary context. The field will then have a connection to broader issues in biology, the data on psychopathology can be placed within a widely accepted concept, and clinicians will have the possibility of developing more effective behavioral treatments (e.g., Levine, 1997).

A November 2007 Clinical Psychiatry News article by Damian McNamara explores another possible change being considered for PTSD's clinical definition:

"Does presence of a PTSD syndrome automatically imply exposure to severe trauma? That is true only if PTSD can arise as a specific response to severe trauma," [Michael First, professor of clinical psychiatry at Columbia University, said at the annual meeting of the American Academy of Psychiatry and the Law]. "However, if there are cases where PTSD develops in absence of severe trauma, it is not a valid assumption," added Dr. First.

The science since the last major revision--the DSM-IV Text Revision in 1992--suggests exposure to traumatic stress might not be required in all cases of PTSD, he said.Initially, case reports suggested PTSD could arise following sub-threshold events such as divorce, bereavement, or the end of a romantic relationship. More recent scientific studies have supported the findings. For example, PTSD was equally present in traumatized, equivocally traumatized, and nontraumatized participants in a study by researchers at McLean Hospital, Belmont, Mass. (J. Anxiety Disord. 2007;21:176-82). They assessed 103 adults enrolled in a depression study instead of using a traditional design that would assess only people who had experienced a trauma for subsequent PTSD.

"Investigators on this study decided to look at PTSD whether there was trauma or not," said Dr. First, who is also a research psychiatrist at the New York State Psychiatric Institute.

There were 198 traumatic events of any severity. A total of 54 participants rated the trauma as an A1 event (meeting DSM-IV-TR Al criteria), 13 reported equivocal trauma, and 36 reported never having experienced trauma. Without regard to trauma history, 81 participants met criteria for PTSD, which was equally prevalent (around 80%) in each of the three groups, he said. "This study raises major questions about major trauma being required to cause PTSD," Dr. First said.

In another study, researchers surveyed a large cohort in the Netherlands that had experienced a traumatic or life-altering event (Br. J. Psych. 2005;186:494-9). A total of 299 individuals reported a lifetime traumatic event, such as an accident or abuse, compared with 533 who reported life events such as relationship problems or the sudden death of loved one.

"The scores for traumatic and nontraumatic life events were about the same for PTSD, the exception being those individuals whose trauma was physical or sexual abuse," Dr. First said. "So this is another study supporting [the idea] that it does not have to be a severe, A1-level trauma to qualify for PTSD." ...

Before publication of the DSM-IV, "there was a huge debate over how broad versus how narrow criterion A should be." One of the problems is that the some of the criteria, such as irritability, insomnia, and a marked disinterest in activities, also occur in depression.

Even items that do not overlap with other disorders might not be pathologic for PTSD. A possible solution is to evaluate criteria B, C, and D for diagnostic specificity to differentiate PTSD from other mood and anxiety disorders. Then only symptoms related to exposure to extreme stress would be retained, Dr. First added.

A different entry for PTSD in the DSM-V is all but certain if history is any indication. Since the first publication of the DSM, the entry has changed with each update. In the DSM-I, the precursor to PTSD was called "traumatic neurosis." In DSM-II, it became "transient situational disturbances." This vague definition became more specific in the DSM-III, which introduced PTSD-qualifying stressors--a recognizable stressor that would evoke significant symptoms of distress in almost everyone, distress that is generally outside the usual human experience. The DSM-III-R updated this to refer to an event outside of normal human experience. "The manual gave examples for the first time, suggesting only severe stressors lead to PTSD," Dr. First said. The sudden destruction of one's home or community was an example.

PTSD stands out as one of those few disorders in the DSM with an etiology that is included in the definition with a specificity regarding trigger events. "This idea of specificity hung around with the DSM, even though the definition changed," he said. Prior to publication of DSM-IV, a field trial of the PTSD criteria was conducted, part of which determined the prevalence and magnitude of stressful events.

Among 400 treatment-seeking outpatients and 128 community participants, for example, investigators found a huge prevalence of high-magnitude events: 84% of treatment seekers and 93% of community participants had at least one lifetime, high-magnitude event. "It's part of human experience at some point to be exposed to traumatic stress, so the requirement that it be outside the range of normal human experience was eliminated from the DSMIV," Dr. First said.

Only 66 people, 13% of cases, reported that they had experienced a past-year low-magnitude event, "so the conclusion was that PTSD occurs very rarely in absence of high-magnitude events," he said.

Now the matter is up for debate prior to release of DSM-V.

Years earlier, in July 2004, McNamara shared changes being considered at the time to PTSD's definition:

Major changes that are expected in DSM-V include:

* Posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) may be removed from the anxiety disorders grouping. ...

The proposal to remove PTSD from the anxiety grouping raises the question of where to put it, Dr. First said. DSM editors will reconsider a DSM-IV proposal to create a category called Stress-Induced and Fear Circuitry Disorders. Such a grouping might also include acute stress disorder, adjustment disorders, and "disorder of extreme stress not otherwise specified." This last group could include some patients exposed to extreme stress who do not meet current criteria for any DSM-IV categories.

The diagnostic criterion for PTSD may change, Dr. First said. The question is whether the condition should be defined by the nature of the stressor or by the phenomenology of reexperiencing the trauma. Another goal will be to simplify the 19 criteria for the disorder--for both practical and legal reasons. "We are trying to stop the floodgates of new lawsuits, with everyone claiming they suffer from PTSD."

No matter how things eventually shake out, it looks like we can expect to see some changes to the current DSM definition for PTSD.

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