Dr. Friedman did not say whether this necessarily was the result of one’s crisis response training but noted that based on an evidence review, his work group dropped the criterion, and that now many people previously considered subclinical receive a PTSD diagnosis. “Had the A criteria been included in [Dr. Hoge’s] exploration, then a soldier who would not have met the A criteria in DSM-VI would make it in DSM-5, so it becomes a different ball game,” said Dr. Friedman, senior adviser at the National Center for PTSD, and professor of psychiatry and of pharmacology and toxicology at the Geisel School of Medicine at Dartmouth, Hanover, N.H.
In the study, Dr. Hoge and his coauthors wrote, “there is good evidence lending support to removal of the criterion A2,” yet during his presentation, he emphasized that just as service members learn to override fear, hopelessness, or horror, “they also learn to override avoidance symptoms as part of their training.” He concluded that because the prevalence rates are virtually the same between the fourth and fifth editions of the DSM, but for different reasons, there is no clinical utility in the new criteria. “Technically, [these soldiers] don’t meet the new definition, but clearly, they are individuals who need trauma-focused therapy and would have met the previous definition.”
Former Army psychiatrist Col. (Ret.) Elspeth Cameron Ritchie, meanwhile, said in an interview that Dr. Hoge and Dr. Friedman are “both world-renowned researchers in the field of PTSD and other related injuries of war.”
“All of us are struggling with the right way to diagnose PTSD, especially after almost 14 years of war and hundreds of thousands of wounded service members,” Dr. Ritchie said. “In addition, PTSD is not a simple, uniform diagnosis. It probably is many overlapping diagnoses.”
She has warned clinicians to proceed with caution, since how military personnel are diagnosed can have serious implications for their careers and benefits.
Currently, the VA and the Department of Defense support the status quo for any personnel previously diagnosed according to DSM-IV criteria, but how subclinical cases should be handled is still at issue. The DSM-5 recommendation for subthreshold symptoms is to consider them an adjustment disorder.
Dr. Hoge rejected this as unhelpful, noting that a failure to adjust or adapt in the military setting has a “pejorative connotation.”
Dr. Friedman and the National Center for PTSD currently recommend using 308.89 from the DSM-5, which is “other specified trauma and stressor-related disorder.” Using “chronic adjustment disorder” is not appropriate, said Dr. Friedman, “because it has a 6-month time limit.” Dr. Friedman also noted that 308.89 in the DSM-5 is the same as the DSM-IV anxiety not otherwise specified, which prior to the DSM-5 was what was used for subthreshold PTSD. According to Dr. Hoge, however, 308.89 is linked in military electronic health records to “adjustment reaction with aggression antisocial behavior/destructiveness” and “aggressor identified syndrome,” both of which could have similar deleterious effects to a soldier as an “adjustment disorder.”
The current U.S. Army Medical Command policy allows physicians to continue diagnosing PTSD according to DSM-IV standards or to apply an unspecified anxiety code (ICD-9 300.00) for any subthreshold PTSD patients.
The fractious approach to diagnosis, according to Dr. Hoge, might be simplified by implementation later this year of the ICD-10, although he said early indications of the ICD-11 in Europe do not show better specificity when compared with the DSM-IV. He noted that the ICD-11 is simpler and has fewer symptom criteria. Here in the United States, he said, “We are not going in the right direction.”
Dr. Hoge said his presentation was based on his own findings and does not represent the opinions or policies of the U.S. Army.
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*Correction, 6/2/2014: An earlier version of this article misattributed a reference to Lancet Psychiatry.