Journal of Traumatic Stress October 2013, 26, 535–536
EDITORIAL
The Changed Face of PTSD Diagnosis Paula P. Schnurr National Center for PTSD, White River Junction, Vermont, USA and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
This issue of the Journal contains a special section on the new diagnostic criteria for posttraumatic stress disorder (PTSD) and related disorders in the recently published Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). In 2009, we published an editorial, “The Changing Face of PTSD Diagnosis” (Schnurr, 2009), describing the initial activities by the Journal of Traumatic Stress and the International Society for Traumatic Stress Studies to report on the revision of the DSM-IV (APA, 1994). Now, in 2013, the change—the changes, actually—have occurred. The most significant is that PTSD is no longer classified as an anxiety disorder. Instead, PTSD is included in a category of disorders related to traumatic and stressful events. This change reflects recognition of the fact not all traumatizing events are fear-based and that we needed to expand the categorization of serious reactions other than PTSD that can occur following stressor exposure. The special section begins with an article by Kilpatrick and colleagues (2013) on the differences in diagnostic outcome between the DSM-IV and the DSM-V. Several of the findings are particularly important. In general, the prevalence of PTSD appears to be somewhat lower according to the DSM-5 than according to the DSM-IV. Exploration of the reasons behind the lower prevalence suggests that the reduction is appropriate. The primary reason individuals who met diagnostic criteria according to the DSM-IV but not according to the DSM-5 is the elimination from Criterion A of sudden death of a loved one due to natural causes. Counting natural death as a Criterion A event had been a controversial issue since its introduction in DSM-IV.
In my experience, many trauma professionals interpreted DSMIV narrowly, considering only traumatic death to meet the criterion, but much research and practice was based on the broader interpretation. By excluding sudden natural death, the change in DSM-5 may help to stimulate further research on pronounced reactions to bereavement such as prolonged grief (Prigerson et al., 2009) and complicated grief (Shear et al., 2011). Kilpatrick et al. also found that the requirement of having at least one avoidance symptom is the other primary reason individuals who meet DSM-IV-based criteria do not meet DSM-5-based criteria. This change seems appropriate given the number of studies that have found avoidance and numbing symptoms are distinct from one another (e.g., Yufik & Simms, 2010). The article by Friedman (2013a) describes the reclassification of PTSD along with the changes to the diagnostic criteria and provides helpful insight into the processes by which decisions were made. As an advisor to the work group responsible for PTSD and the other disorders, I can attest to the process being open, rigorous, and collaborative. Many voices and differing ideas were given a chance to contribute to the deliberations. Ultimately, the group came to consensus, working under a conservative framework Friedman describes as requiring a high level of evidence for introducing any changes to the DSM-IVbased criteria. Retaining the broad criteria approach of the DSM-IV was a key decision that resulted in the diagnostic criteria differing markedly from the proposed narrow criteria for PTSD in the 11th edition of the International Classification of Diseases (ICD-11). According to the DSM-5, some of the symptoms of PTSD are distinctive to PTSD and some overlap with other mental disorders. Friedman (2013a) points out that including both distinctive and overlapping symptoms is a common approach to psychiatric and medical diagnosis. In contrast, PTSD according to the ICD-11 is defined by a much smaller set of distinctive symptoms. Commentaries by Brewin (2013) and Maercker and Perkonigg (2013) offer critiques of the DSM-5-based approach and argue for that used in the ICD-11. Kilpatrick (2013) argues that DSM-5 “got it right” but this is an empirical question,
The opinions stated in this article reflect those of the author and are not the official position of the U.S. Department of Veterans Affairs. Correspondence concerning this article should be addressed to Paula P. Schnurr, National Center for PTSD (116D), VA Medical Center, White River Junction, VT 05009. E-mail: [email protected] Published 2013. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21851
535
536
Schnurr
as Friedman (2013b) notes in his commentary. Research comparing the DSM-5-based and ICD-11-based criteria for PTSD is urgently needed. The two diagnostic systems may result in real differences in who receives a diagnosis. Such differences may further scientific understanding, but also may cause difficulties in comparing research findings across studies and in understanding of the burden of trauma in countries that use one versus the other system to diagnose PTSD. Nevertheless, the new diagnostic criteria in the DSM-5 and the ICD-11 present an opportunity. Formalization of the PTSD diagnosis in DSM-III (APA, 1980) is arguably the most important event that has occurred in the field of traumatic stress studies. Research increased substantially after 1980 (Blake, Albano, & Keane, 1992), leading to advances in awareness, scientific knowledge, and clinical care. The changed definitions in the DSM-5 and the ICD-11 not only reflect these advances, but also can lead to further advances as the new diagnoses are implemented in research and practice.
References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
Brewin, C. R. (2013). “I wouldn’t start from here”—An alternative perspective on PTSD from ICD-11: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 557–559. doi:10.1002/jts.21843 Friedman, M. J. (2013a). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26(5), 548–556. doi:10.1002/jts.21840 Friedman, M. J. (2013b). PTSD in DSM-5: Response to Brewin, Kilpatrick, and Maerker and Perkonigg. Journal of Traumatic Stress, 26(5), 567–569. doi:10.1002/jts.21847 Kilpatrick, D. (2013). PTSD—The DSM-5 got it right: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 563–566. doi:10.1002/jts.21844 Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV-based and DSM-5-based criteria. Journal of Traumatic Stress, 26(5), 537–547. doi:10.1002/jts.21847 Maercker, A., & Perkonigg, A. (2013). Applying an international perspective in defining PTSD and related disorders: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 560–562. doi:10.1002/jts.21852 Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., . . . Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), 1. doi:10.1371/journal.pmed.1000121
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Shear, M. K., Simon, N. M., Wall, M. M., Zisook, S., Neimeyer, R. A., Duan, N., . . . Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28, 103–117. doi:10.1002/da.20780
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Schnurr, P. P. (2009). The changing face of PTSD diagnosis. Journal of Traumatic Stress, 22, 1–2. doi:10.1002/jts.20387
Blake, D. D., Albano, A. M., & Keane, T. M. (1992). Twenty years of trauma: Psychological Abstracts 1970 through 1989. Journal of Traumatic Stress, 5, 477–484. doi:10.1002/jts.2490050310
Yufik, T., & Simms, L. J. (2010). A meta-analytic investigation of the structure of posttraumatic stress disorder symptoms. Journal of Abnormal Psychology, 119, 764–776. doi:10.1037/a0020981
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
EDITORIAL
The Changed Face of PTSD Diagnosis Paula P. Schnurr National Center for PTSD, White River Junction, Vermont, USA and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
This issue of the Journal contains a special section on the new diagnostic criteria for posttraumatic stress disorder (PTSD) and related disorders in the recently published Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). In 2009, we published an editorial, “The Changing Face of PTSD Diagnosis” (Schnurr, 2009), describing the initial activities by the Journal of Traumatic Stress and the International Society for Traumatic Stress Studies to report on the revision of the DSM-IV (APA, 1994). Now, in 2013, the change—the changes, actually—have occurred. The most significant is that PTSD is no longer classified as an anxiety disorder. Instead, PTSD is included in a category of disorders related to traumatic and stressful events. This change reflects recognition of the fact not all traumatizing events are fear-based and that we needed to expand the categorization of serious reactions other than PTSD that can occur following stressor exposure. The special section begins with an article by Kilpatrick and colleagues (2013) on the differences in diagnostic outcome between the DSM-IV and the DSM-V. Several of the findings are particularly important. In general, the prevalence of PTSD appears to be somewhat lower according to the DSM-5 than according to the DSM-IV. Exploration of the reasons behind the lower prevalence suggests that the reduction is appropriate. The primary reason individuals who met diagnostic criteria according to the DSM-IV but not according to the DSM-5 is the elimination from Criterion A of sudden death of a loved one due to natural causes. Counting natural death as a Criterion A event had been a controversial issue since its introduction in DSM-IV.
In my experience, many trauma professionals interpreted DSMIV narrowly, considering only traumatic death to meet the criterion, but much research and practice was based on the broader interpretation. By excluding sudden natural death, the change in DSM-5 may help to stimulate further research on pronounced reactions to bereavement such as prolonged grief (Prigerson et al., 2009) and complicated grief (Shear et al., 2011). Kilpatrick et al. also found that the requirement of having at least one avoidance symptom is the other primary reason individuals who meet DSM-IV-based criteria do not meet DSM-5-based criteria. This change seems appropriate given the number of studies that have found avoidance and numbing symptoms are distinct from one another (e.g., Yufik & Simms, 2010). The article by Friedman (2013a) describes the reclassification of PTSD along with the changes to the diagnostic criteria and provides helpful insight into the processes by which decisions were made. As an advisor to the work group responsible for PTSD and the other disorders, I can attest to the process being open, rigorous, and collaborative. Many voices and differing ideas were given a chance to contribute to the deliberations. Ultimately, the group came to consensus, working under a conservative framework Friedman describes as requiring a high level of evidence for introducing any changes to the DSM-IVbased criteria. Retaining the broad criteria approach of the DSM-IV was a key decision that resulted in the diagnostic criteria differing markedly from the proposed narrow criteria for PTSD in the 11th edition of the International Classification of Diseases (ICD-11). According to the DSM-5, some of the symptoms of PTSD are distinctive to PTSD and some overlap with other mental disorders. Friedman (2013a) points out that including both distinctive and overlapping symptoms is a common approach to psychiatric and medical diagnosis. In contrast, PTSD according to the ICD-11 is defined by a much smaller set of distinctive symptoms. Commentaries by Brewin (2013) and Maercker and Perkonigg (2013) offer critiques of the DSM-5-based approach and argue for that used in the ICD-11. Kilpatrick (2013) argues that DSM-5 “got it right” but this is an empirical question,
The opinions stated in this article reflect those of the author and are not the official position of the U.S. Department of Veterans Affairs. Correspondence concerning this article should be addressed to Paula P. Schnurr, National Center for PTSD (116D), VA Medical Center, White River Junction, VT 05009. E-mail: [email protected] Published 2013. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21851
535
536
Schnurr
as Friedman (2013b) notes in his commentary. Research comparing the DSM-5-based and ICD-11-based criteria for PTSD is urgently needed. The two diagnostic systems may result in real differences in who receives a diagnosis. Such differences may further scientific understanding, but also may cause difficulties in comparing research findings across studies and in understanding of the burden of trauma in countries that use one versus the other system to diagnose PTSD. Nevertheless, the new diagnostic criteria in the DSM-5 and the ICD-11 present an opportunity. Formalization of the PTSD diagnosis in DSM-III (APA, 1980) is arguably the most important event that has occurred in the field of traumatic stress studies. Research increased substantially after 1980 (Blake, Albano, & Keane, 1992), leading to advances in awareness, scientific knowledge, and clinical care. The changed definitions in the DSM-5 and the ICD-11 not only reflect these advances, but also can lead to further advances as the new diagnoses are implemented in research and practice.
References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
Brewin, C. R. (2013). “I wouldn’t start from here”—An alternative perspective on PTSD from ICD-11: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 557–559. doi:10.1002/jts.21843 Friedman, M. J. (2013a). Finalizing PTSD in DSM-5: Getting here from there and where to go next. Journal of Traumatic Stress, 26(5), 548–556. doi:10.1002/jts.21840 Friedman, M. J. (2013b). PTSD in DSM-5: Response to Brewin, Kilpatrick, and Maerker and Perkonigg. Journal of Traumatic Stress, 26(5), 567–569. doi:10.1002/jts.21847 Kilpatrick, D. (2013). PTSD—The DSM-5 got it right: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 563–566. doi:10.1002/jts.21844 Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV-based and DSM-5-based criteria. Journal of Traumatic Stress, 26(5), 537–547. doi:10.1002/jts.21847 Maercker, A., & Perkonigg, A. (2013). Applying an international perspective in defining PTSD and related disorders: Comment on Friedman (2013). Journal of Traumatic Stress, 26(5), 560–562. doi:10.1002/jts.21852 Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., . . . Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), 1. doi:10.1371/journal.pmed.1000121
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Shear, M. K., Simon, N. M., Wall, M. M., Zisook, S., Neimeyer, R. A., Duan, N., . . . Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28, 103–117. doi:10.1002/da.20780
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Schnurr, P. P. (2009). The changing face of PTSD diagnosis. Journal of Traumatic Stress, 22, 1–2. doi:10.1002/jts.20387
Blake, D. D., Albano, A. M., & Keane, T. M. (1992). Twenty years of trauma: Psychological Abstracts 1970 through 1989. Journal of Traumatic Stress, 5, 477–484. doi:10.1002/jts.2490050310
Yufik, T., & Simms, L. J. (2010). A meta-analytic investigation of the structure of posttraumatic stress disorder symptoms. Journal of Abnormal Psychology, 119, 764–776. doi:10.1037/a0020981
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
