Download PTSD in DSM-5: Understanding the Changes

PTSD in DSM-5: Understanding the Changes
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
PTSD in DSM-5: Understanding the Changes
September 25, 2015 | PTSD [1], DSM-5 [2]
By James Phillips, MD [3]
Despite the efforts of a dedicated Work Group, DSM-5 has not significantly changed the problems
with PTSD that beset DSM-IV.
© Mariya Lavchieva/shutterstock.com If your concern as a clinician is
how to code PTSD when we move to ICD-10-CM codes in October of this year, you need not fret.
Simply go to the DSM-5 manual, find the PTSD diagnosis, and switch from the DSM-IV/ICD-9 309.81
to the ICD-10 F43.10. Do the same for acute stress disorder.
That simple maneuver, useful as it is for clinical practice, does hide some of the complexity of the
new version of the manual. To begin with, DSM-5 has shuffled the deck and moved PTSD out of the
anxiety disorders section, as in DSM-IV, and into a newly created section, trauma- and stress-related
disorders. PTSD now keeps company with acute stress disorder, reactive attachment disorder,
disinhibited social engagement disorder, all the adjustment disorders, other specified trauma- and
stressor-related disorder, and unspecified trauma- and stressor-related disorder. Odd company,
indeed. It’s as if the DSM-5 Work Group got stuck on the word “stress” in the PTSD acronym and
decided that any diagnosis that includes this word belongs in the same section. Someone who
experiences clinical anxiety in the context of a new job is now lumped into the same super-category
as someone who has experienced a near-death on the battlefield.
What then is the reason for moving PTSD out of anxiety disorders and into the new trauma and
stress disorders section? The main rationale is that PTSD often manifests with non-anxiety symptoms
such as dissociative experiences, anger outbursts, and self-destructive behavior. As discussed below,
however, patients with “complex PTSD” usually experience anxiety along with other symptoms.
Given the imperfect fit of PTSD under anxiety or stress, we might conclude that the decision to
choose one or the other is to some degree arbitrary.
Diagnostic criteria
The coding change is simple. What about the diagnostic criteria? By way of difference, DSM-5
specifies that the criteria apply to adults and children over age 6 (and includes another set of criteria
for children under 6); eliminates the immediate response to the trauma as involving fear,
helplessness, or horror; and splits the avoidance symptoms into 2 clusters (ie, distressing memories
and external reminders). In addition to these changes, virtually all the symptoms of each cluster are
elaborated or written differently, and for each cluster extra symptoms are added. More about this
later.
Complex PTSD
In the years of DSM-5 development, one point of controversy in the work on PTSD was whether to
include symptoms of complex PTSD (also called disorders of extreme stress not otherwise specified)
in the diagnosis.1 The argument for inclusion was that many sufferers of trauma and chronic trauma
do not experience the standard symptoms of PTSD but rather symptoms of depression, anxiety, or
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PTSD in DSM-5: Understanding the Changes
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
dissociation, or of borderline personality disorder. The authors of DSM-5 have handled this issue in a
curious manner.2 To begin with, they eliminated criterion A2, which included the words “. . . response
involved intense fear, helplessness, or horror,” explaining that “Emotional reactions to the traumatic
event (eg, fear, helplessness, horror) are no longer a part of criterion A. The clinical presentation of
PTSD varies.”3 The new criterion A does not, however, describe other possible reactions.
Where are the symptoms of complex PTSD? In the introductory paragraph to the trauma- and
stressor-related disorders section, the authors write: “It is clear, however, that many individuals who
have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than
anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and
dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms.”3 So
again, where in the manual are these symptoms? They get a one-sentence mention in the PTSD text
but do not appear in the diagnostic criteria. Nor are they mentioned in the criteria or discussion
section of either other specified trauma- and stressor-related disorder or unspecified trauma- and
stressor- related disorder, in either of which we might expect them to appear. But finally, depression
and aggression show up in reactive attachment disorder, another of the stress disorders. The
problem is that this is defined as a diagnosis of children. We must conclude, therefore, that DSM-5
has hinted at symptoms of complex PTSD, but in the end has left them out of the manual. DSM-5
continues to opt for a universal reaction to stress, as presented in the diagnostic criteria.
Culture and PTSD
In 2010 I wrote a blog4 on PTSD as illustrative of DSM problems in cultural diversity. In that blog, I
focused on research on the effects of political violence in Peru.5,6 In those studies, the McGill
University researchers found a 25% incidence of classic PTSD symptoms among their victim research
group but also a high incidence of depression and anxiety. Their findings were consistent with those
of Hinton and Lewis-Fernandez,7 who reviewed the extensive research on PTSD in 2011 and
concluded that the DSM-IV symptom cluster does have a degree of validity on its own, but that
DSM-IV does not do justice to the great cultural variety of every aspect of response to trauma. In the
DSM-5 discussion of PTSD, there is a small subsection, culture-related diagnostic issues, devoted to
cultural differences. While this subsection does recognize cultural variation, and while DSM-5 also
has an entire section III dedicated to “cultural formulation,” these commentaries do not alter the
core diagnostic criteria of PTSD, which continue to convey the sense of a universal response to
trauma. Thus, as with complex PTSD, DSM-5 has not significantly changed the problems with PTSD
that beset DSM-IV.
Conclusion
What can we conclude about PTSD in DSM-5? Despite the efforts of a dedicated Work Group, DSM-5
has not fixed such major concerns of DSM-IV as complex PTSD and cultural variance; and these
issues are in turn related to the DSM-5 insistence on a universal response to trauma as framed by
the PTSD diagnostic criteria.
DSM-5 has introduced many changes in the wording of the PTSD diagnostic criteria, so many that the
manual evokes an almost obsessive need to make things more precise, as if, in the uncertain area of
psychological trauma and its consequences, DSM-5 will at all costs pin it down.
For the clinician who tries to diagnose using DSM, this could involve a time-consuming effort to get
the criteria right. And given that experienced clinicians mostly diagnose through prototypes and not
by counting criteria, and that there is no significant change in PTSD from DSM-IV, it is hard to
imagine that the experienced clinician will pay much attention to the changes the Work Group has
made.
Disclosures:
Dr Phillips is Clinical Professor of Psychiatry in the department of social and behavioral health at the
Yale Global Mental Health Program at the Yale School of Medicine in New Haven, CT.
References:
1. US Department of Veterans Affairs. PTSD: National Center for PTSD: Complex PTSD.
http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp. Accessed August 24, 2015.
2. American Psychiatric Association. DSM-5 Development. G 03 Posttraumatic Stress Disorder.
http://web.archive.org/web/20120504205134/http://www.dsm5.org/ProposedRevision/Pages/
proposedrevision.aspx?rid=165#PTSD. Accessed August 24, 2015.
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PTSD in DSM-5: Understanding the Changes
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. Washington, DC: American Psychiatric Association; 2013.
4. Phillips J. The cultural dimension of DSM-5: PTSD. Psychiatric Times. 2010.
http://www.psychiatrictimes.com/dsm-5-0/cultural-dimension-dsm-5-ptsd. Accessed August 24, 2015.
5. Pedersen D. Political violence, ethnic conflict, and contemporary wars: broad implications for
health and social well-being. Soc Sci Med. 2002;55:175-190.
6. Pedersen D, Tremblay J, Errazuriz C, Gamarra J. The sequelae of political violence: assessing
trauma, suffering and dislocation in the Peruvian highlands. Soc Sci Med. 2008;67:205-217.
7. Hinton DE, Lewis-Fernandez R. The cross-cultural validity of posttraumatic stress disorder:
implications for DSM-5. Depress Anxiety. 2011;28:783-801.
Source URL: http://www.psychiatrictimes.com/ptsd/ptsd-dsm-5-understanding-changes
Links:
[1] http://www.psychiatrictimes.com/ptsd
[2] http://www.psychiatrictimes.com/dsm-5-0
[3] http://www.psychiatrictimes.com/authors/james-phillips-md
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