The Complexities of Diagnosing Posttraumatic Stress Disorder (PTSD)

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When I was in medical school, senior physicians would frequently usher a group of us students into a patient’s room so we might hear them tell the story of their illness.  It seemed that the more classic the story was for a particular illness the more intense was their ushering.  We would huddle around the patient’s bed all of us transfixed by the doctor interviewing the patient. I remember hanging on the patient’s every last word and, simultaneously, shifting through the textbook data stored in my brain in search of a diagnostic match.  When done, the senior doctor would turn around and challenge us to diagnose what ailed the patient and we would respond with a flurry of answers. I still remember the thrill of solving the puzzle, of making a “textbook diagnosis”.

Image courtesy of coalitionforveterans.org

These days, almost 20 years later, it seems I rarely meet a patient with a “text book diagnosis” and the patients I care for in real life clinical practice are more complex than those described in the pages of thick medical texts.  Perhaps, nowhere does this complexity become more apparent than when I meet patients who have experienced a severe psychological trauma.

In my work as a psychiatrist that go to “text book” is called the DSM IV, the diagnostic and statistical Manual of Mental Disorders which is currently in its fourth version.  This is the standard diagnostic manual used by psychiatrists and psychologists all over the USA.

In this 943 paged book, under chapter 7 titled, Anxiety Disorders, one can find several pages devoted to Posttraumatic Stress Disorder (PTSD).  Page after page documents all one could possibly need to know about diagnosing PTSD: the core clinical features, associated features and disorders, specific cultural and age features, prevalence of PTSD, clinical course of PTSD, familial patterns and Differential Diagnoses (i.e. other disorders that look like PTSD but are not)

Yet, as valuable as these pages are, this diagnosis of PTSD still appears dissatisfying to many.

In her 1992 landmark text, Trauma and Recovery, Judith Herman M.D., a Harvard psychiatrist, argued that “the diagnosis of posttraumatic stress disorder as it is presently defined does not fit accurately enough the complicated symptoms seen in survivors of prolonged repeated trauma”.  She proposed that the syndrome that follows upon exposure to prolonged repeated trauma needs its own name and offered the new term, “complex PTSD”.

I find myself thinking of Dr. Herman’s complex PTSD diagnosis often these days—I think complex PTSD better explains some of the symptoms I see in my patients who have experienced severe trauma. In such cases I find the DSM IV wanting and instead find that the complex PTSD diagnosis holds more real life value or clinical utility.

The DSM IV is currently undergoing a revision with the latest version, the DSM 5¸slated to come out in May of 2013. This has raised the possibility that complex PTSD would be included as a separate diagnostic entity in the DSM-5.  But it is not so easy to get into the DSM­, for a new disorder to be considered for entry a strict set of criteria need to be met: Is there a clear definition of the disorder? Are there reliable methods to diagnose the disorder? In the case of complex PTSD, is it truly distinct from PTSD or just a different, perhaps more severe, type of PTSD? What is the value of adding a new diagnosis—how will it change the way we care for those living with PTSD?

In fact, vigorous discussion over this very question was recently published in the Journal of Traumatic Stress, an academic journal published by the International Society for Traumatic Stress Studies. Leaders and experts in the field of traumatic case articulately state their arguments for and against the inclusion of complex PTSD in the DSM 5.

One issue fundamental to my specialty that is no doubt fueling this controversy is the lack of objective biomarkers available to mental health professionals to diagnose mental disorders such as PTSD.  A limitation of much of our diagnosis in psychiatry is that we base our diagnosis on the self report of our patient and have limited blood tests or scans at our disposal to make an “objective” diagnosis.

On a positive note we can be reassured that psychiatry is in the midst of a biological revolution, hurtling toward a time when it will soon be able to diagnose with blood tests and brain scans and offer tailored treatments to patients. Still, this does not obviate me from my duty to heal the pain of those suffering today and though I work with a diagnostic system that is imperfect, I know that that does not make such a system invalid when used properly.

The diagnostic status of complex PTSD is controversial and not likely to be resolved soon, in the meantime, I will have to get used to living in a world where patients with “text book diagnoses” appear to be scarce, and, instead, venture into more ambiguous territory. Textbooks aside, I try instead to make sense of the mental dysfunction I am witnessing in the hope that it offers some meaning to the person seeking help from me and, through this validation, perhaps an improved sense of their overall well being.

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.

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