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Problems with the post-traumatic stress disorder diagnosis and its future in DSM-V

  • Gerald M. Rosen (a1), Robert L. Spitzer (a2) and Paul R. McHugh (a3)
Summary

Significant issues challenge the diagnosis of post-traumatic stress disorder (PTSD). Yet, applications of the PTSD ‘model’ have been extended to an increasing array of events and human reactions across diverse cultures. These issues have implications for clinical practice and for those who revise criteria in the DSM-V.

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Copyright
Corresponding author
Gerald M. Rosen, 117 East Louisa Street, PMB-229 Seattle 98102, Washington, USA. Email: grosen@u.washington.edu
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Breslau, N, Davis, GC. Posttraumatic stress disorder: the stressor criterion. J Nerv Ment Dis 1987; 175: 255–64.
2 Scott, MJ, Stradling, SG. Post-traumatic stress disorder without the trauma. Brit J Clin Psychol 1994; 33: 71–4.
3 Bodkin, JA, Pope, HG, Detke, MJ, Hudson, JI. Is PTSD caused by traumatic stress? J Anx Dis 2007; 21: 176–82.
4 Erwin, BA, Heimberg, RG, Marx, BP, Franklin, ME. Traumatic and socially stressful events among persons with social anxiety disorder. J Anx Dis 2006; 20: 896914.
5 Ozer, EJ, Best, SR, Lipsey, TL, Weiss, DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull 2003; 129: 5273.
6 Spitzer, RL, First, MB, Wakefield, JC. Saving PTSD from itself in DSM-V. J Anx Dis 2007; 21: 233–41.
7 Simons, D, Silveira, WR. Post-traumatic stress disorder in children after television programmes. BMJ 1994; 308: 389–90.
8 Rosen, GM. Traumatic events, criterion creep, and the creation of pretraumatic stress disorder. Sci Rev Ment Health Pract 2004; 3: 46–7.
9 Summerfield, D. Cross-cultural Perspectives on the Medicalization of Human Suffering. In Posttraumatic Stress Disorder: Issues and Controversies (ed Rosen, GM): 233–44. John Wiley & Sons, 2004.
10 McHugh, PR, Treisman, G. PTSD: A problematic diagnostic construct. J Anx Dis 2007; 21: 211–22.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Problems with the post-traumatic stress disorder diagnosis and its future in DSM-V

  • Gerald M. Rosen (a1), Robert L. Spitzer (a2) and Paul R. McHugh (a3)
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eLetters

A proposal for a new disorder to replace PTSD in DSM-V

Olav Nielssen, psychiatrist
30 January 2008

Dear Sir,

In their recent article, Rosen, Spitzer and McHugh observed that the clinical presentation of post traumatic stress disorder (PSTD) is not restricted tothose who have experienced severe trauma, that traumatised patients do not necessarily develop PTSD and that PTSD is often misdiagnosed (1). We would

like to add that there is almost no evidence that PTSD is reliably diagnosed in ordinary clinical settings.

In our naturalistic study of expert reports about psychological injury after motor vehicle accidents we that found that the agreement about the presence of PTSD by experts engaged by the same side in the court case was little better than by chance (2). Most of this disagreement seemed to be due to selective use of the diagnostic criteria, although there was also difference in opinion about the severity of the patients experiences and hence whether they met the “A” criteria.

A search of [PubMed] [Psych Lit] and [CINHAL] did not locate any studies to show that PTSD can be reliably diagnosed without the use of a structured or semi-structured interview. The DSM-III and ICD-10 field trials did not report the inter-rater reliability of PTSD (3,4) and the DSM-IV trials restrictedthe examination of the reliability to the rating of audio-tapes of 25 patients’ responses to the PTSD module of the SCID (5). Furthermore, we have not been able to ascertain whether the very high kappa scores reported in the DSM-IV trials (k = 0.85) included a correction for the loss of degrees of freedom arising from the use of the same ratings in multiple rating pairs.

Although there are numerous studies confirming the inter-rater reliability of various diagnostic instruments, many of the instruments are only administered when the patient is suspected of having the disorder and their ability to reliably distinguish PTSD from other disorders is not well established. Despite their limitations, we support the call of Miller (6) for the routine use of diagnostic interviews, as there is no evidence the disordercan be reliably diagnosed in any other way.

Rosen, Spitzer and McHugh call for DSM–V criteria that reflect research findings and limit the potential for misuse of the diagnosis. We believe that the logical step would be the complete removal of the A criteria. This would separate the clinical assessment of the patients’ psychological state from

issues of causation and minimise pre-emptive decisions about the cause and

nature of the patient’s distress. This new disorder, called Phobic Memory

Disorder or another name that does not imply a particular cause, could then be diagnosed in the usual way. As there are likely to be few objective features of the disorder, the diagnosis should be made using a semi-structured interview for the new criteria. Causative factors, including the role trauma, premorbid conditions and litigation, would be considered in the same way as other disorders.

1. Rosen GM, Spitzer RL, McHugh PR.Problems with the post-traumatic stress disorder diagnosis and its future in DSM V.Br J Psychiatry. 2008;192:3-4

2. Large M, Nielssen O.An audit of medico-legal reports prepared for claims of psychiatric injury

following motor vehicle accidents.Aust N Z J Psychiatry. 2001;35:535-40.

3. Spitzer RL, Forman JBW, Nee J : DSM-III field trials I. Initial Interater Diagnostic Reliability. Am J Psychiatry 1979 ; 136:815-817

4. Sartorius N, Ustun TB, Korten A, Cooper JE, van Drimmelen J.Progress toward achieving a common language in psychiatry, II: Results from the international field trials of the ICD-10 diagnostic criteria for research for mental and behavioral disorders.Am J Psychiatry. 1995;152:1427-37.

5. Kilpatrick, D.G., Resnick, H.S., Freedy, J.R., Pelcovitz, D., Resick, P.A., Roth, S., & van der Kolk, B. (1998). In T.Widiger, A. Frances, H. Pincus, R.Ross, M. First, W. Davis, M. Kline (Eds.), The posttraumatic stress disorder field trial: Emphasis on Criterion A and overall PTSD diagnosis, pp. 303-344. DSM-IV Sourcebook Vol. 4 , Washington, DC: American Psychiatric Press.

6. Miller PR. Inpatient diagnostic assessments: 2. Interrater reliability and outcomes of structured vs. unstructured interviews.Psychiatry Res. 2001;105:265-71.

Dr Olav Nielssen, Dr Matthew Large
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Conflict of interest: None Declared

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