Reformulating PTSD for DSM-V: Life after Criterion - a summary of an article by Brewin, Lanius, Novac, Schnyder and Galea (2009)

Reformulating PTSD for DSM-V: Life after Criterion
Brewin, C.R., Lanius, R.A., Novac, A., Schnyder, U., & Galea, S. (2009)
A. Journal of Traumatic Stress, 22, 366-373.


Abstract

The diagnosis of posttraumatic stress disorder has been criticised on three main reasons, namely: 1) the alleged pathologizing of normal events 2) the inadequacy of criterion A 3) symptom overlap with other disorders.

PTSD has a multifactorial etiology.

Evaluation of three criticisms of PTSD

Criticism 1: PTSD pathologizes normal distress

One criticism of PTSD is that it creates a medical condition out of normal distress.

Studies show that extreme stress sometimes leads to severe and long-lasting psychopathology, as well as to a variety of serious medical conditions.

A popular view currently is that PTSD reflects a failure of adaptation, whereby normal reactions to extreme stress do not correct themselves. What is pathological about PTSD is defined by the persistence of its symptoms.

Evidence supports a distinctive biological profile associated with PTSD.

Criticism 2: inadequacy of criterion A

Three fundamental issues with the A criterion are: 1) how broadly or narrowly should trauma be defined? 2) can trauma be measured reliably and validly? 3) what is the relationship between trauma and PTSD?

Trauma is not exclusively associated with PTSD.

Other disorders are linked to traumatic (criterion A) events

Trauma is associated with an increased prevalence of other disorders. If these can be diagnosed after a traumatic event, the question arises why the same could not be true of PTSD.

Trauma’s do not increase the risk for other disorders independently of the increased risk for PTSD. PTSD plays a central role in the psychological response to trauma.

Insufficient specificity of criterion A

The original conceptualization of PTSD was a response to an event ‘generally outside the range of usual human experience’. This was broadened, due to which there is a conceptual creep that is causing PTSD to be diagnosed in response to situations that are far removed from the original concept of trauma (according to critics).

There are few cases with PTSD after circumstances like divorce or money problems.

Trauma of lower intensity would be expected to provoke PTSD in vulnerable individuals with a limited capacity do dampen ther physiological response to stress. Such vulnerability may be genetic, interacting with lifetime exposure to trauma or epigenetic. It can also be related to greater levels of prior trauma.

Excessive specificity of criterion A

In the DSM-IV, to qualify for a PTSD diagnosis, individuals had to have experienced, witnessed, or been confronted with a qualifying event, and have responded with intense fear, helplessness or horror.

There is a wide range of reactions to trauma associated with PTSD. There are cases in which trauma is not accompanied by intense fear, helplessness or horror, although the full PTSD syndrome develops. Memories, and the emotions associated with them, can and change.

Criticism 3: symptom overlap with other disorders

The symptom overlap with depression and other anxiety disorders has been noted as a potential problem with the PTSD diagnosis. Symptom B1 refers to any kind of intrusive memory, image, or thought, a symptom that is common in many psychiatric disorders. Emotional and physiological arousal elicited by specific situations, and avoidance are part of phobias. Social withdrawal, loss of interest, emotional numbing, and hopelessness about the future are common features of depression.

The lack of specificity is of concern because there are so many different combinations of symptoms that will yield a diagnosis of PTSD.

PTSD symptoms fall into four factors: re-experiencing, avoidance, dysphoria and hyperarousal.

Flashbacks are specific to PTSD rather than mere trauma exposure (this distinguishes them from depression). Intrusive memories in PTSD involve a greater sense of reliving in the present than in depression.

Improving the diagnosis of PTSD

This article proposes that the way forward for the PTSD diagnosis is to abolish criterion A and refocus PTSD around a smaller set of core symptoms.

It is highly unlikely that any formulation for criterion A will be found that deals with all the problems and inconsistencies identified above. Specifying triggering events is also undesirable because of differences in vulnerability. The full PTSD syndrome hardly ever occurs in the absence of an event that could reasonably be described as traumatic. Criterion A simply describes the usual context of PTSD without contributing itself to diagnostic precision.

It is proposed that PTSD should be refocused around the core phenomenon of re-experiencing in the present, in the form of intrusive multisensory images accompanied by marked fear or horror, an event now perceived as having severely threatened a person’s physical or psychological well-being. The intention is to highlight the features that are most salient to the individual with PTSD, that are the primary focus of psychological treatment and that make PTSD distinct from other disorders.

Potential advantages and disadvantages of the proposed diagnostic criteria

Abolition of criteria A

Among the possible advantages of not requiring a trauma that is PTSD will immediately come into alignment with the other disorders. There will no longer be a problem deciding whether the re-experienced event qualifies for criterion A. Clinicians will be free to focus on the symptomatic presentation and the most appropriate treatment.

Objections to abolishing criterion A are: it would result in a substantial departure from the original conceptualization of PTSD, it would risk trivializing the suffering of those exposed to catastrophic events and a scope of PTSD will be widened to include reactions to almost any stressor and the diagnosis will become meaningless.

Focusing on core symptoms

The increased focus on a core disturbance, and the consequent simplification of the criteria, should lead to improved ease of identification and diagnosis in settings other than trauma centres. The removal of symptoms associated with general dysphoria should lead to greater homogeneity of cases and reduced overlap with other disorders. In keeping the emphasis on the underlying psychological process, the criteria give clinicians greater flexibility in identifying re-experiencing on examination. The explicit focus on re-experiencing of fear and horror should encourage better links with basic psychological and neuroscience approaches.

One disadvantage is that there may be disagreement about what constitutes the core of the disorder.

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