As a seasoned psychiatrist, I try to take most events in stride. My main reaction to unsettling events is to flatten down and take my own pulse.
However, when I saw the article in the Lancet Psychiatry (2014 Aug. 14 [doi:10.1016/S2215-0366(14)70235-4]) by my longtime colleague, Col. (Ret.) Charles W. Hoge, M.D., and his coauthors, my pulse went way up, and "Oh, my God" was my very unscientific reaction.
Col. (Ret.) Charles W. Hoge
As readers may recall, the new definition of posttraumatic stress disorder raises the number of symptoms from 17 to 20, and 8 of those original symptoms were substantially reworded. In addition, PTSD was moved in the new manual from an anxiety disorder to disorders related to trauma and stressors.
In their study, Dr. Hoge and his coauthors administered surveys to soldiers looking at DSM-IV-TR and DSM-5 criteria. In brief, about a third of soldiers who met DSM-IV-TR criteria for PTSD did not meet DSM-5 criteria. Almost a third were in the opposite camp, meeting DSM-5 but not the older criteria, wrote Dr. Hoge of the Center for Psychiatry and Neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md. The main issue is about criterion C and the splitting up of avoidance symptoms from depressive symptoms.
Why was my reaction so strong? I had thought that the new criteria would widen those eligible for the diagnosis. Instead, it eliminates almost a third of them, mainly because they did not meet the avoidant criteria. (Please read the article for the full complex details.)
In the disability system in the military and Veterans Affairs system, the diagnosis of PTSD carries major weight. So what will happen if the criteria exclude them?
Dr. Elspeth Cameron Ritchie
The good news is that both Veterans Affairs and the Department of Defense have made it clear that service members and veterans who already have the diagnosis according to the DSM-IV will not have it changed as a result of DSM-5, so the new definition mostly pertains to those newly seeking care or benefits now. It remains unclear what diagnosis should be used for those veterans who clearly would have met the previous definition (which has been used for more than 25 years), but not the new one. The DSM-5 recommends the use of adjustment disorder in this case, but some experts are concerned that the use of this diagnosis for this purpose will have negative effects. A major issue is that service members can be separated without benefits for an adjustment disorder. Questions also remain about whether adjustment disorder should have even been paired with PTSD in the same chapter in the new DSM-5.
In the accompanying commentary, Dr. Alexander C. McFarlane, of the Centre for Traumatic Studies at the University of Adelaide, Australia, warns about the negative consequences of the change in definition (Lancet Psychiatry 2014 Aug. 14 [doi:10.1016/S2215-0366(14)70321-9]. He also urges caution when the new diagnosis is used in forensic or disability evaluations.
I recommend that readers review this important article and commentary, and that the military and the VA also take a cautious approach.
Dr. Ritchie is former chief of psychiatry for the U.S. Army and current chief clinical officer in the behavioral health department for the District of Columbia.