2/8/2011

The Expanding Definition of PTSD

Since its introduction into the <i>DSM</i> in 1980, the symptoms of post-traumatic stress disorder have been repeatedly expanded. <i>DSM-V</i>, scheduled for release in 2013, continues the trend.

By David R. Price, Ph.D.

The diagnosis of post-traumatic stress disorder has undergone extensive professional debate. The disorder officially became a psychiatric diagnosis in 1980 in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). The inclusion of this diagnosis was not without controversy and/or political pressure. An excellent review of how this occurred can be found in W. J. Scott's article, "PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease," published in 1990. For readers interested in post-traumatic stress disorder, it is an excellent read.

Post-traumatic stress disorder was the first mental health condition recognized to be caused by a specific, and oftentimes compensable, event. When the DSM-III was published in 1980 with the diagnosis of post-traumatic stress disorder included, no one anticipated the impact such a diagnosis would have on the legal, insurance and disability arenas. Paul Lees-Haley commented in 1986, "If mental disorders were listed on the New York Exchange, PTSD would be a growth stock to watch." The disorder has been prone to abuse, and claims professionals need to work with mental health providers to ascertain the validity of PTSD claims, particularly when there are indications that a claimant has an incentive to manufacture symptoms.

Fourteen years after PTSD was originally introduced as a diagnosis, a warning concerning malingering associated with the condition was included in the DSM-IV (1994). In that iteration, the last sentence under "Differential Diagnosis" and immediately before the diagnostic criteria for PTSD stated: "Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role." [Editor's note: See the upcoming issue of Claims Advisor magazine for further treatment of the problem of malingering.]

The Changing Criteria
For comparison, since 1980 there have been only minor changes in the diagnostic criteria of most mental disorders, such as major depressive disorder, schizophrenia, dementia, the various personality disorders, and somatoform disorders. However, with each edition since the DSM-III, significant changes in the diagnostic criteria of PTSD have occurred, with even further anticipated changes in May of 2013 with the publication of DSM-V.
If we look at the diagnostic criteria of post-traumatic stress disorder, it is interesting to consider Criterion A, which defines the scope of the stressors necessary to produce post-traumatic stress disorder, and its transformation since 1980. According to Criterion A in DSM-III, the event necessary to cause PTSD was simply the "existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone." As we would see, though, in DSM-III-R (1987), the type of stressor necessary to cause a post-traumatic stress disorder was considerably modified. It did not require that a stressor be directly experienced; it could be the result of witnessing another person being killed or injured and also included such stressors as the sudden destruction of one's home or community. DSM-III-R extended the required stressor from being "directly experienced" to "in some cases, the trauma may be learning about a serious threat or harm to a close friend or relative, e.g., that one's child has been kidnapped, tortured or killed."

Interestingly, we find in DSM-IV (1994) that Criterion A, the gatekeeper to the diagnosis of post-traumatic stress disorder, had again been modified and extended, making the diagnosis applicable to more individuals. Instead of experiencing "an event outside the range of usual human experiences," one could now have an event in which one "witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others," and that involved a response of "intense fear, helplessness or horror." This has been expanded further in the proposed DSM-V to include "learning that the event occurred to a close relative or close friend" and "experiencing repeated or extreme exposure to aversive details of the event," which includes exposure through electronic media when that exposure is work-related.

Updates under consideration for PTSD symptoms in DSM-V, which is scheduled for publication in 2013, include other changes that would broaden diagnostic criteria for the disorder. Under the "intrusion" symptom (Criterion B), the word "cued" has been added in the first sub-criterion, meaning distressing memories would no longer have to be spontaneous. Also added is the consideration of a continuum of reactions, the range of which is left undefined.

Diagnostic Criterion C has been overhauled in the proposed update, with some of its sub-criteria being condensed and some being moved into a new Criterion D, "Negative alterations in cognitions and mood," which has additional, noteworthy sub-criteria. (The old Criterion D has been pushed to E.) Those include persistence in: negativity about self and others; distorted blame regarding the event; and a negative emotional state.

The further expansion of the diagnostic criteria for PTSD continues to widen the possibility for sustainable claims for compensation in a broad range of personal injury cases. Discussion by the revision working group is ongoing, and some of the drafted changes may still be altered based on feedback from the diagnostic community.
David R. Price, Ph.D., is president of The Forensic Network in Greenville, S.C. drpricephd@aol.com


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