Tuesday, March 17, 2009

SciAm Mind Takes on PTSD Diagnosis

In a new article, Scientific American Mind presents a series of arguments against the PTSD diagnosis, particularly in veterans (this is being pushed by the Pentagon, which does not want to pay for the long-term treatment PTSD can sometimes require). Apparently, there are some prominent psychologists also arguing for the elimination (or, at the very least, a serious redefinition) of the PTSD diagnosis in the DSM-V.

Soldiers' Stress: What Doctors Get Wrong about PTSD

A growing number of experts insist that the concept of post-traumatic stress disorder is itself disordered and that soldiers are suffering as a result

By David Dobbs

DISTRESS CAN BE a normal response to pain and loss or a sign of a psychic wound that is failing to heal. Critics of PTSD diagnostic criteria, including many soldiers, feel that returning veterans’ natural process of adjustment is often mislabeled as a dysfunctional state.
TYLER HICKS New York Times

Key Concepts

  • The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.
  • The flawed PTSD concept may mistake soldiers' natural process of adjustment to civilian life for dysfunction.
  • Misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.

In 2006, soon after returning from military service in Ramadi, Iraq, during the bloodiest period of the war, Captain Matt Stevens of the Vermont National Guard began to have a problem with PTSD, or post-traumatic stress disorder. Stevens's problem was not that he had PTSD. It was that he began to have doubts about PTSD: the condition was real enough, but as a diagnosis he saw it being wildly, even dangerously, overextended.

Stevens led the medics tending an armored brigade of 800 soldiers, and his team patched together GIs and Iraqi citizens almost every day. He saw horrific things. Once home, he said he had his share of "nights where I'd wake up and it would be clear I wasn't going to sleep again."

He was not surprised: "I would expect people to have nightmares for a while when they came back." But as he kept track of his unit in the U.S., he saw troops greeted by both a larger culture and a medical culture especially in the Veterans Administration (VA) that seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.

"Clinicians aren't separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems or who are just taking some time getting over it," Stevens says. He worries that many of these men and women are being pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.

Stevens, now a major and still on reserve duty while he works as a physician's assistant, is far from alone in worrying about the reach of PTSD. Over the past five years or so, a long-simmering academic debate over PTSD's conceptual basis and incidence has begun to boil over. It is now splitting the practice of trauma psychology and roiling military culture. Critiques originally raised by military historians and a few psychologists are now advanced by a broad array of experts indeed, giants of psychology, psychiatry and epidemiology. They include Columbia University's Robert L. Spitzer and Michael B. First, who oversaw the last two editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, former chair of Johns Hopkins University's psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard J. McNally, a leading authority in the dynamics of memory and trauma and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they assert, represent a faulty, outdated construct that has been badly overstretched so that it routinely mistakes depression, anxiety or even normal adjustment for a unique and especially stubborn ailment.

This quest to scale back the definition of PTSD and its application stands to affect the expenditure of billions of dollars, the diagnostic framework of psychiatry, the effectiveness of a huge treatment and disability infrastructure, and, most important, the mental health and future lives of hundreds of thousands of U.S. combat veterans and other PTSD patients. Standing in the way of reform is conventional wisdom, deep cultural resistance and foundational concepts of trauma psychology. Nevertheless, it is time, as Spitzer recently argued, to "save PTSD from itself."

Casting a Wide Net
The overdiagnosis of PTSD, critics say, shows in the numbers, starting with the seminal study of PTSD prevalence, the 1990 National Vietnam Veterans Readjustment Survey (NVVRS). The NVVRS covered more than 1,000 male Vietnam vets in 1988 and reported that 15.4 percent of them had PTSD at the time and that 31 percent had suffered it at some point since the war. That 31 percent has been the standard estimate of PTSD incidence among veterans ever since.

In 2006, however, Columbia epidemiologist Bruce P. Dohrenwend, hoping to resolve nagging questions about the study, reworked the numbers. When he had culled the poorly documented diagnoses, he found that the 1988 rate was 9 percent and the lifetime rate 18 percent.

McNally shares the general admiration for Dohrenwend's careful work. Soon after it was published, however, McNally asserted that Dohrenwend's numbers were still too high because he counted as PTSD cases those veterans with only mild, subdiagnostic symptoms, people rated as "generally functioning pretty well." If you included only those suffering "clinically significant impairment" the level generally required for diagnosis and insurance compensation in most mental illness the rates fell yet further, to 5.4 percent at the time of the survey and 11 percent lifetime. It was not one in three veterans who eventually developed PTSD, but one in nine and only one in 18 had it at any given time. The NVVRS, in other words, appears to have overstated PTSD rates in Vietnam vets by almost 300 percent.

"PTSD is a real thing, without a doubt," McNally says. "But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them."

The idea that PTSD is overdiagnosed seems to contradict reports of resistance in the military and the VA to recognizing PTSD denials of PTSD diagnoses and disability benefits, military clinicians discharging soldiers instead of treating them, and a disturbing increase in suicides among veterans of the Middle East wars. Yet the two trends are consistent. The VA's PTSD caseload has more than doubled since 2000, mostly because of newly diagnosed Vietnam veterans. The poor and erratic response to current soldiers and recent vets, with some being pulled quickly into PTSD treatments and others discouraged or denied, may be the panicked stumbling of an overloaded system.

Overhauling both the diagnosis and the VA's care system, critics say, will ensure better care for genuine PTSD patients as well as those being misdiagnosed. But the would-be reformers face fierce opposition. "This argument," McNally notes, "tends to really piss some people off." Veterans send him threatening e-mails. Colleagues accuse him of dishonoring veterans, dismissing suffering, discounting the costs of war. Dean G. Kilpatrick, a University of South Carolina traumatologist and former president of the Inter national Society for Traumatic Stress Studies (ISTSS), once essentially called McNally a liar.

A Problematic Diagnosis
The DSM-IV, the most recent edition (published in 1994), defines PTSD as the presence of three symptom clusters reexperiencing via nightmares or flashbacks; avoidance by numbing or withdrawal; and hyperarousal, evident in irritability, insomnia, aggression or poor concentration that arise in response to a life-threatening event [To see related sidebar please purchase the digital edition].

The construction of this definition is suspect. To start with, the link to a traumatic event, which makes PTSD almost unique among complex psychiatric diagnoses in being defined by an external cause, also makes it uniquely problematic, for the tie is really to the memory of an event. When PTSD was first added to the DSM-III in 1980, traumatic memories were considered reasonably faithful recordings of actual events. But as research since then has repeatedly shown, memory is spectacularly unreliable and malleable. We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit.

In one study by Washington University memory researcher Elizabeth F. Loftus, one out of four adults who were told they were lost in a shopping mall as children came to believe it. Some insisted the event happened even after the ruse was exposed. Subsequently, bounteous research has confirmed that such false memories are common [see "Creating False Memories," by Elizabeth F. Loftus; Scientific American, September 1997].

Read the rest of the article.

* Just to provide some balance, PTSD has a genetic link: here, here, and here. Based on this, trauma is necessary but not sufficient to create PTSD. The second study listed here also suggests that the number of incidents (# of combat experiences for veterans) increases the tendency to experience PTSD.

* There is a definite "re-wiring" of the brain in those suffering from PTSD: here, here, and here. Basically, the amygdala grows and hypocampus shrinks, seemingly in response to prolonged exposure to cortisol (a stress hormone).

* The notion that PTSD is the only psychological diagnosis dependent on an exterior etiology (the experience of a traumatic event) is false. Addictions, cutting, depression, obsessive-complusive disorder, and DID all have environmental factors.

This is an interesting debate that should be more public. It's sadly discouraging that the folks working on the DSM-V have been sworn to secrecy and that there is no real consensus in the community about the addition or subtraction of diagnoses.

5 comments:

teeny yogini said...

Interesting subject, not only in and of itself, but because it raises good questions what happens when psychological research collides with political agendas.

The thing is it may be that PTSD IS too broadly defined and that some soldiers would be better off being treated for other disorders or even by getting basic reintegration help -- but the bottom line is that the soldiers should receive ADEQUATE help. One worries that articles like this will be used to simply cut services and abandon those who served and now suffer.

Will now watch this issue -- thanks for bringing it to light.

David Dobbs said...

teeny yogini wrote:

"One worries that articles like this will be used to simply cut services and abandon those who served and now suffer."

I can understand the worry -- but refer readers to the Sci Amm article itself, which essentially proposes, toward its end, a different disability system that would ensure that soldiers got the care they needed regardless of their diagnosis (i.e., PTSD v depression or anxiety-related issues). The present system encourages PTSD overdiagnosis because PTSD offers a unique path of access to health-care benefits and financial help (presently structured in a countertherapeutic fashion) that vets and soldiers should have access to as a matter of course.

teeny yogini said...

David,

Thank you for responding! I agree with what you wrote above and hope that people will understand your very well-written article in that way. I did not mean to cast any aspersions on the article itself -- and apologize if it might have come off that way -- but rather on a potentially facile reading of it. Since, as you write, PTSD has become almost a "catch-all" term for a soldier suffering any psychological difficulty, I still fear that changing the definition (without concurrently changing our veteran's system as you suggest) could put care at risk.

I look forward to reading more of your work.

WH said...

David,

Thanks for sharing your thoughts here - same to you, Teeny Yogini.

I understand the need for a clearer diagnosis, and with the ability to scan brains, the changes in the amygdala and hypocampus will likely become the diagnostic criteria at some point, assuming the PTSD diagnosis isn't completely eliminated (hard to say, since the DSM-V is not an open process).

I agree with the suggestions at the end of the article that veterans should get quality treatment no matter the diagnosis - that's only fair considering what we have asked of them.

BUT, if we treat people with actual PTSD misdiagnosed as something else, the outcomes will not be good in terms of making them functional again. Conversely, if we treat depression and anxiety as PTSD, the outcome is much more likely to be a functional human being.

Perhaps if some lesser accepted treatments (EMDR, parts work, etc) were implemented and evaluated, we might have more options than long-term treatment - it would be in the VA's interest to do so (and they are currently funding Dr. Richard Schwartz's Internal Family Systems Model in a small-scale study for PTSD).

Anyway, thanks again for stopping by the offer your position - much appreciated.

Peace,
Bill

Dr.G said...

My impression of the article is that it is heavily biased, placing too much reliance on the views of only one psychologist (Dr. Richard McNally) who, Dobb acknowledges, is "perhaps the most forceful of the (PTSD) critics". For a really thorough critique please see Mike Dunford's blog at scienceblogs.com/authority/2009/03/ptsd_mental_health_and_the_mil.php