The Complexities of Diagnosing Posttraumatic Stress Disorder (PTSD)

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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11 Responses to The Complexities of Diagnosing Posttraumatic Stress Disorder (PTSD)

  1. Wendy says:

    Thanks for this post. My area of research is on whether complex trauma can be differentiated from acute PTSD, using psychophysiology and cognitive/affective neuroscience, so I am invested in this issue. You may be interested to know that it looks like Complex PTSD has made it into the ICD-11, thanks to the work of Marylene Cloitre and many others. It’s not surprising that it made it into the ICD, as the ICD is explicitly a clinical tool. What’s even more surprising are that “text book” complex trauma symptoms–shame, dissociation, risky behavior–are reportedly being incorporated into the DSM-5. That doesn’t address the issue of severity between complex and acute PTSD, but it does set the stage for opening up what we think of as “text book” responses to trauma.

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  2. Shaili Jain says:

    Yes, I was able to attend Dr Cloitre’s great talk on ICD 11 and the complex PTSD diagnosis at the recent 28th ISTSS meeting. It was wonderful to hear from her and others re: advancements in this regard….. Obviously, DSM V remains the predominant guiding manual for USA based psychiatrists and psychologists though….with ICD 11 being more relevant for international communties..

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  4. Jenny McClendon says:

    Dear Dr. Jain,

    I would really like to engage in a conversation about this. Veterans have been denied treatment at the VA based on having sustained “Too much trauma.”

    After ten years of protracted warfare this could take us to a whole new level of disregarding difficult cases.

    This is another way of dividing people that suffer up into categories of :Good and bad” “Treatable and not treatable.” This could add to the dismissal of countless veterans from these so-called specialized trauma services departments.

    Please consider hearing from people that have been abused for having sustained too much trauma.

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  5. Female PTSD says:

    I read this with interest, but from a clients perspective rather than a clinical one. I believe I suffer from complex ptsd but because, as I write this, there is no formal diagnosis for that, I have been saddled with a diagnosis of ptsd and borderline personality disorder. I am currently in the process I trying to refute the latter and in doing my research devised a Venn diagram to show the crossover of bpd with complex ptsd. It is on my blog if anyone is interested (BPD vs Complex PTSD) or I can provide a link if necessary.

    I just wanted to say I am glad there are professionals who know ptsd in its current diagnostical form, is just not enough.

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    • Jenny McClendon says:

      Borderline Personality Disorder is a troubling diagnosis. This is often given to clients that are considered difficult to treat or manipulative. This is especially troubling because then the client has trouble getting the treatment that they need.

      These diagnoses are highly subjective and damaging. Can’t we just treat trauma and focus on the symptoms at hand rather than labeling clients in ways that might make it difficult for them to be treated in the future?

      I was refused treatment at the Washington DC Trauma Clinic because I had been traumatized by too many men to be treated in the women’s clinic.

      What will we do with people that have witnessed too many explosions in Fallujah or Kandahar? We have been at war for 12 years and we are uncovering a culture of abuse in the military that has traumatized too many service members.

      When I see an article like this I begin to think that the names that we are called by the Diagnostic and Statistical Manual are more important that the treatment that we are given.

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    • Shaili Jain, MD says:

      thanks so much to you both for sharing your stories,
      i would strongly recommend Judith Hermann’s book (if you have not already read it) and, also, the work of Dr Marylene Cloitre– she has done excellent work on studying the effectivess of psychological treatment (STAIR) for complex PTSD.

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