"Controversies in the evolving diagnosis of PTSD"
"Controversies in the evolving diagnosis of PTSD" By Lennis G. Echterling, Thomas A. Field and Anne L. StewartFebruary 29, 2016 Trauma is as old as humanity itself. In fact, for nearly 3,000 years, such epic poems as The Odyssey and The Iliad have given eloquent voice to the psychic scars of war. These “hidden wounds” of combat included overwhelming feelings of anxiety, horrific nightmares, heightened startle reactions, flashbacks of battle scenes and a profound sense of alienation years after the conflicts had ceased. Despite powerful accounts over the millennia of the psychic impact of trauma, it was only 35 years ago that the Diagnostic and Statistical Manual of Mental Disorders (DSM) introduced the condition known as posttraumatic stress disorder (PTSD). Since then, the evolving diagnosis of PTSD has generated numerous and intense controversies. Only dissociative identity disorder has stirred up more debates among researchers and practitioners. Now that counselors are playing an increasingly important role as service providers for both military and civilian survivors of trauma, it is vital that we become familiar with the historical context and current issues regarding PTSD. Conceptualizations of trauma The origins of the PTSD diagnosis stem from two dramatically different conceptualizations of its cause and symptoms. The psychological movement began in the 1790s and considered the syndrome to be primarily a mental one involving altered consciousness and amnesia, which later became known as dissociation. The somatic movement, which conceptualized a physiological basis for the syndrome, began in England during the 1860s, when researchers described “railway spine” as a consequence of the physical traumas of railroad accidents. During the past 150 years, wars have spurred health care providers to consider, to varying degrees, these contrasting perspectives in hopes of better understanding and treating the psychiatric casualties of combat. Trauma and wars From the U.S. Civil War to the recent conflicts in Iraq and Afghanistan, researchers and practitioners have returned again and again to the impact of war-related violence on the psyches of military troops. In the past, however, the prior lessons learned were largely abandoned and ignored in the decades of peacetime that followed wars. For example, many physicians who were followers of the somatic movement proposed that traumatized Civil War combat veterans were suffering from a cardiac injury, which they labeled “soldier’s heart.” At the same time, other health care providers relied on a psychological conceptualization of the condition, which they referred to as “nostalgia.” In World War I, psychiatrists originated the term “shell shock” because they considered the symptoms to be physiological reactions to the intense shock waves that emanated from artillery explosions. Other mental health practitioners, influenced by Sigmund Freud’s theories, diagnosed the condition as “war neurosis.” With the beginning of World War II, many service members once again experienced the horrors of combat. Initially, those who developed posttraumatic reactions were discharged. However, when psychiatrists found that the degree of relatedness in the military unit was a protective factor, they developed treatment strategies for what they termed “combat fatigue.” These treatment strategies emphasized emotional support and rapid return to active duty. Again, interest in trauma faded once World War II came to an end. Nevertheless, we should note that the first use of the term “posttraumatic” occurred in a follow-up study on veterans who had been diagnosed with combat fatigue. In the heat of battle in the Korean War, the American Psychiatric Association published the first edition of the DSM. The new manual briefly acknowledged that combatants experienced short-lived psychological reactions to war but did not label the syndrome a psychiatric disorder. Not until the Vietnam War did the demand for a combat-related trauma diagnosis reach a tipping point. In the early 1970s, many returning U.S. veterans exhibited problematic and life-threatening behaviors. At first these behaviors were attributed to noncombat-related neurosis or psychosis. However, with public war protests growing, veterans began advocating for a new disorder called “post-Vietnam syndrome.” Mental health professionals began holding “rap groups” with Vietnam veterans about their experiences and led panel discussions at professional conferences. These efforts led to the American Psychiatric Association’s decision in 1980 to formally accept PTSD as a legitimate diagnostic category in the DSM-III. The long-term conflicts in both Iraq and Afghanistan once again have focused attention on the traumas that combatants endure and the pervasive impact of PTSD on the lives of returning veterans. The Rand Corp. estimated the prevalence of PTSD in Iraq and Afghanistan war veterans to be 14 percent, which is twice the estimated lifetime prevalence rate for civilians. With multiple and longer deployments, the risk of military combatants developing PTSD is even greater. Trauma and the DSM In 1951, the DSM-I, which was a slim volume of 130 pages, introduced the syndrome “gross stress reaction.” Although not a disorder, the inclusion of this reaction proved to be both significant and influential for two reasons. First, it acknowledged that the syndrome was a risk not only for veterans of war but also for civilian survivors of catastrophic events. Second, it asserted that this syndrome applied to “normal” persons who experienced intolerable stress, thus disagreeing with the then-dominant psychodynamic assumption that these psychiatric casualties were vulnerable individuals who possessed predisposing neurotic conditions. In the second edition of the DSM, published in 1968, the American Psychiatric Association revised the title of the syndrome to “transient situation disturbances,” a label with a more clearly negative term. Still, it was not considered a disorder. Finally, in 1980, PTSD was included as a mental disorder in the DSM-III. It also became the first disorder to include a diagnostic criterion — a traumatic event — that was entirely external to the individual and outside the range of usual human experience. Examples of traumatic events included rape, combat, accidents and disasters. If the event was a “normal” one, such as the loss of a job or divorce, the person’s reaction was diagnosed as an adjustment disorder. Other criteria for PTSD included re-experiencing symptoms, engaging in avoidance and having arousal symptoms. The addition of PTSD to the DSM-III was not without controversy. Given the disorder’s emphasis on combat-related trauma, there was concern the Vietnam War had politicized the decision with its emphasis on the hidden wounds of combat veterans. Because their dysfunction now was directly tied to military service and not to personality flaws, the Veterans Administration (now the Department of Veterans Affairs) was required to offer services to affected soldiers. In addition, PTSD was recognized as a disorder that merited disability status. Consequently, the Veterans Administration requested more government funding to meet the increased need for psychological services. Seven years later, the DSM-III-R (revision) appeared with several minor refinements to the diagnosis of PTSD, including operationalizing the symptom clusters. A major contribution of this edition was to identify, for the first time, age-specific features that children and adolescents exhibit in response to trauma. In 1994, the DSM-IV eliminated the requirement for the precipitating stressor for PTSD to be outside the range of normal human experience. It also expanded the definition of traumatic events to include the indirect experiences of observers and the loved ones of the victims. As a consequence of adding vicarious traumas, the number of qualifying events for PTSD increased by 59 percent. No other diagnosis in the history of the DSM had undergone such a drastic expansion (known as “conceptual bracket creep”) from one volume to another. The DSM-IV-TR (text revision) was introduced six years later and tightened the definition of a traumatic event to something that is “extreme” and “life threatening.” It also added several diagnostic specifiers, such as “acute,” “chronic” and “delayed onset.” After many postponements, the DSM-5 was finally released in 2013 in a massive volume of 947 pages. The most obvious change in this current edition is that PTSD is no longer classified as an anxiety disorder. Instead, it is included in a new chapter titled “Trauma- and Stressor-Related Disorders.” Another significant change is that the DSM-5 now places restrictions on the operational definition of a traumatic stressor. For example, witnessing an event no longer qualifies as a traumatic stressor unless the person is physically present. In most cases, observing an event through the media is excluded. The DSM-5 also no longer requires an intense emotional reaction to the event because this lacked predictive utility. A new specifier now includes dissociative symptoms such as depersonalization and derealization. Swinging pendulum Like a pendulum, the conceptualization of PTSD has swung back and forth over the past century. In the time of Freud, its cause was attributed largely to the individual’s character deficits. During World War II, it was understood to be a normal reaction to persistent combat exposure. Thus, the pendulum moved toward identifying the traumatic event itself as the chief culprit of dysfunction. Following the war, most mental health practitioners gave greater weight to the extreme stressor as the primary cause. This view was reflected in the first edition of the DSM, when it was posited that any “normal” individual would develop symptoms after exposure. As traumatized veterans returned from the Vietnam War, special interest groups began advocating for the addition of PTSD to the DSM-III to publicly acknowledge the hidden wounds of war. Perhaps most important, by requiring that the stressor had to be outside of normal human experience and so severe that any normal person could be affected, the DSM-III definition of PTSD reflected the farthest swing of the pendulum toward placing onus for dysfunction on the traumatic event. On the basis of new evidence that the majority of survivors did not develop PTSD after exposure to traumatic events, the DSM-IV represented the pendulum’s move back toward the interaction between internal and external causation, judging the individual’s emotional reaction to be just as crucial in the development of psychopathology. In other words, the event itself was no longer considered the sole cause of PTSD. Instead, traumatization was defined both as exposure to an event and an individual’s subsequent response of intense fear, helplessness or horror. During development of the DSM-5, some scholars suggested that the event should be removed entirely as a diagnostic criterion for PTSD, resembling a return to Freud’s conception of dysfunction being attributed solely to the individual. A developmental perspective One serious limitation of the first three editions of the DSM was the lack of consideration of any potential developmental differences in reactions to extreme stress. Therefore, a major contribution of the DSM-III-R was to identify age-specific features that children and adolescents exhibit. For example, the DSM-III-R noted that young children were more likely to relive the trauma in repetitive play. Still, researchers and clinicians working with children noted that the PTSD criteria in the DSM were not developmentally sensitive and did not capture clinically relevant symptoms for children living in chronically unsafe conditions. A proposal to include a new diagnosis, developmental trauma disorder (DTD), was considered for inclusion in the DSM-5. This diagnosis was proposed on the basis of findings from developmental psychopathology, clinical presentations of children exposed to chronic interpersonal violence and emerging evidence from the field of neurobiology regarding the impact of trauma on brain development. Ultimately, the proposal for DTD was not accepted for inclusion in the DSM-5. The discussion of the merits of an alternative classification system for children experiencing complex trauma is continuing. Current issues In addition to the controversies regarding the definition and criteria of PTSD, criticisms have continued to emerge regarding the transparency, representation and integrity of the DSM revision process. Critics have cited the secrecy of the DSM-5 development process and the apparent lingering presence of pharmaceutical company influence on DSM task force members as factors affecting the process. Many advocates are worried that PTSD is underdiagnosed and undertreated among veterans of both current and past conflicts. For example, an estimated 271,000 Vietnam veterans continue to suffer from PTSD, according to a recent study by Charles Marmar published in JAMA Psychiatry. The New York Times reported that the incidence of PTSD among current military personnel more than doubled between 2005 and 2010, resulting in an overburdened Veterans Affairs (VA) health system. In 2011, the 9th U.S. Circuit Court of Appeals demanded that the VA overhaul its mental health services because delayed and inadequate services were being provided to returning U.S. veterans with PTSD. Harkening back to the conceptualization of “shell shock” in World War I, there now is growing recognition that primary blast waves have caused serious and permanent traumatic brain injuries among veterans of the Iraq and Afghanistan wars. The prevalence of PTSD among civilians is also a serious problem. The National Sexual Violence Resource Center reported that half of the survivors of sexual assault are estimated to meet diagnostic criteria for PTSD. The high incidence of wide-ranging traumatic events among both children and adults has led many to recommend the use of trauma-informed care involving collaborative, supportive and skill-based interventions that address the pervasive impact of trauma. Recent research also has underscored the need to refine our conceptualization of PTSD by recognizing the crucial role that shame can play in its dynamics. Anxiety regarding external dangers has long been considered the primary emotion of PTSD, but the perceived internal threat of exposing one’s shame often predominates for many survivors, especially among those who have experienced interpersonal violence. In marked contrast to the issue of underdiagnosis of PTSD, many professionals who intervene after disasters typically provide public education that normalizes reactions to catastrophes. Their criticism of the DSM is that broadening PTSD diagnostic criteria may have the unintended consequence of pathologizing natural human reactions to highly disturbing incidents. A related current issue is that many researchers and practitioners are calling for greater awareness of the phenomenon of posttraumatic growth, suggesting that the majority of trauma survivors eventually achieve higher levels of personal maturity, wisdom and well-being. In our current environment, PTSD remains a diagnosis that involves controversies. As promoters of human growth and development, counselors are in a unique position to be active participants in this conversation. We can engage most effectively by contributing to refinements in conceptualization, discoveries through research, innovations in practice and empowerment through advocacy efforts that promote the resilience of trauma survivors. Given the prevalence of PTSD and the severity of its impact on individuals, families, relationships and communities, it is our duty as counselors to play a crucial role in alleviating the anguish and pain of those who suffer the consequences of this disorder. Yes, trauma is as old as humanity. But as our theory, research and practices continue to evolve in the midst of PTSD controversies, we can envision a more humane future in which the diagnosis and treatment of trauma survivors offers healing and hope. **** Knowledge Share articles are developed from sessions presented at American Counseling Association conferences Lennis G. Echterling is a professor of counselor education and director of the Ph.D. in counseling and supervision program at James Madison University in Harrisonburg, Virginia. His most recent book is Thriving! A Manual for Students in the Helping Professions. Contact him at firstname.lastname@example.org. Thomas A. Field is an associate professor and associate program director in the master’s counseling program at City University of Seattle. He also works as an independent contractor at a private practice in the Seattle area. Contact him at email@example.com. Anne L. Stewart is a professor in the Department of Graduate Psychology at James Madison University. She is the president of the Virginia Play Therapy Association, and her most recent book is Play Therapy: A Comprehensive Guide to Theory and Practice. Contact her at firstname.lastname@example.org. Letters to the editor: email@example.com