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PTSD criteria
examined
(June
2007 Issue)
By Ami Albernaz
Since it was first described in the Diagnostic and Statistical
Manual (DSM-III) in 1980, posttraumatic stress disorder has provided
an important framework for helping war veterans and others who have
experienced a catastrophic, life-altering event make sense of their
suffering and find relief. Over the years, the diagnostic criteria
for the disorder have been modified slightly, and a recent McLean
Hospital study suggests that the current criteria might not accurately
capture the disorder.
The finding comes at a time when experts are revisiting notions
of some psychological disorders with the belief that focusing on
broader dimensions of temperament and personality, rather than specific
features, might allow for better insight into a person's psychology
and lead to more effective treatment.
The McLean study, conceived by J. Alexander Bodkin, M.D., director
of the hospital's Clinical Psychopharmacology Research program,
involved extensive questioning of more than 100 patients seeking
treatment for major depression. The patients were asked to recall
a traumatic event in their lives (those who could recall none were
asked to choose one event that served as a "proxy for trauma").
A pair of researchers not involved in the questioning, acting independently
from each other, then rated each of the experiences in terms of
severity. Subjects who had not experienced trauma were found just
as likely as those who had experienced substantial trauma to show
PTSD symptoms.
"This study does not support the specificity of symptoms attributed
to PTSD," Bodkin says. "It shows that a person in tumult shows PTSD
symptoms."
The criteria for PTSD, besides the initial traumatic experience,
includes a person reliving the event, whether through flashbacks
or hallucinations; avoiding reminders of the trauma; experiencing
emotional numbing; and showing symptoms of anxiety and arousal.
If the symptoms attributed to PTSD can occur in people who have
not faced a major trauma, perhaps the course of therapy should be
revisited in some cases, Bodkin believes. "If these problems that
people come to a therapist with really do not originate from a trauma
… then maybe it's better to focus on symptoms rather than the event.
The risk of focusing on a trauma during therapy is that a person
could be identified with the trauma and not receive the best treatment."
David Barlow, Ph.D, director of the Center for Anxiety and Related
Disorders at Boston University, served on the task force that made
the final decisions on PTSD criteria for the DSM IV. He says advances
since the manual's release in 1994, particularly within neurobiology,
have led to the need to rework how disorders are considered.
"Any diagnostic system in any field is a snapshot in time. It's
always in a state of flux," he says. "The DSM IV emphasizes features
that distinguish disorders. But now we're beginning to group them
together - the new trend is to consider similarities."
It is now known that many disorders, including anxiety and depressive
disorders, are highly comorbid and share many key attributes, while
having distinguishing features as well.
"The question is - are the key features as important as we'd thought
or is it more productive to look at broader things like temperament
and vulnerabilities?" Barlow says. "A lot of people have experienced
[traumatic] events, but don't report them or have panic attacks
and talk about something at work instead… I think we need to take
a step back and look at all this."
As soldiers return from tours in Iraq, PTSD is likely to become
a focus of discussion. Bodkin emphasizes his research was not intended
to discount the anguish and upheaval experienced by many who have
been through combat. PTSD was, after all, first introduced to describe
the experience of some soldiers who had served in Vietnam.
"This is not about military personnel. This does not imply that
many are not burdened by problems," he says. "We're not questioning
the severity of the condition within which they find themselves,
but the causes."
Requests to interview Veterans Affairs personnel who work with
PTSD were declined.
Bodkin also acknowledges that the results of his study need to
be replicated before firmer conclusions can be drawn. For now, he
suggests, PTSD diagnoses should be delivered with a degree of caution.
"If you get a PTSD diagnosis and really have it, that's one thing,"
he says. "But it's another if a treatment provider has a PTSD bias.
It may be counterproductive to focus on the trauma, when the provider
instead should be helping to work through the symptoms."
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