By Brenda L. Mooney
SILVER SPRING, MD – A new study raises critical questions about the change in the definition of post-traumatic stress disorder (PTSD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and how that will affect diagnosis and clinical care of servicemembers and veterans now and in the future.
The direct comparison of screening questionnaires, published recently in The Lancet Psychiatry journal, uncovered some vexing problems related to the shift from the PTSD definition in DSM-IV to DSM-5, which was released in 2013.1
For example, the research from Walter Reed Army Institute of Research found that 30% of servicemembers screening positive for PTSD under the old DSM-IV criteria were excluded when DSM-5 criteria were used, and about 20% of those who met criteria under DSM-5 would not have been identified using the older DSM-IV criteria.
The study directly compared the original DSM-IV and DSM-5 checklists by surveying a group of 1,822 U.S. soldiers, 946 of them who had been deployed in Iraq and Afghanistan.
In an analysis of all respondents, 224 (13%) screened positive for PTSD by DSM-IV-TR criteria and 216 (12%) screened positive by DSM-5 criteria. In soldiers exposed to combat, 177 (19%) screened positive by DSM-IV-TR, and 165 (18%) screened positive by DSM-5 criteria.
Of the 221 soldiers with complete data who met DSM-IV-TR criteria, however, 67 (30%) did not meet DSM-5 criteria, and 59 additional soldiers met only DSM-5 criteria, according to the results.
“After 12 years of war and over 25 years of solid clinical and research experience with the previous definition, the reclassification of the PTSD diagnosis in DSM-5 presents concerns for the evaluation and treatment of servicemembers and veterans who have served in Iraq and Afghanistan,” according to lead author Charles W. Hoge, MD. “Although we found that roughly the same percentage of soldiers met criteria for PTSD according to the two definitions, and the new PTSD screening tool was equivalent to the one we’ve used for many years, we also found that the two PTSD definitions did not identify the same individuals. The new definition also did not appear to have greater clinical utility than the previous one.”
The study noted that the diagnosis of PTSD underwent many more changes than other mental disorder diagnoses affecting adults prior to the publication of DSM-5, with the number of symptoms increasing from 17 to 20 and eight of the original 17 symptoms substantially reworded.
“Both the DoD and VA have indicated that any servicemember or veteran who is undergoing treatment or disability evaluation for PTSD based on the old criteria will not have their diagnosis changed as a result of the new criteria,” Hoge told U.S. Medicine. “Thus, the DSM-5 definition mostly pertains to those newly seeking care or benefits.”
Hoge suggested that one key dilemma military and VA clinicians will face is what diagnosis should be used for patients who clearly would have met the previous definition, which was around for 25 years, but don’t meet the new one.
“This could include, for example, individuals who meet all of the previous criteria but do not report one of the two active avoidance symptoms of the new criteria,” he pointed out.
In addition, he raised the issue of what diagnosis should be used for sub-threshold cases, essentially those servicemembers and veterans who have many of the symptoms of PTSD without meeting full criteria yet would obviously benefit from PTSD-specific trauma-focused treatment, such as prolonged exposure therapy, cognitive processing therapy, eye movement desensitization and other evidence-based treatments.
As part of the DSM-5 changes, a diagnosis of PTSD was reclassified from an anxiety disorder to a trauma and stress disorder with the recommendation that patients whose symptom pattern falls below the diagnostic threshold for PTSD be diagnosed with adjustment disorder.
Hoge noted that the DSM-5 actually tells clinicians to use the adjustment disorder diagnosis for subthreshold cases because of that reclassification.
“However, both the National Center for PTSD, which was instrumental in crafting the new definition, and our team at WRAIR who conducted this research, have expressed concern with this decision,” he recounted. “Adjustment disorder carries a potentially negative connotation in the military. Adjustment disorder is a diagnosis of exclusion that lacks any standardized set of symptom criteria. Furthermore, adjustment disorder lasting less than six months can lead to administrative separation from the military without medical benefits. As a result, the NC-PTSD is now recommending that the ICD-9 code 309.89 be used instead of adjustment disorder for subthreshold cases.”
According to Hoge, the code has been given the label of “other specified trauma- and stressor-related disorders” in DSM-5, but, in some electronic medical records systems, appears simply as another adjustment disorder code. Because of that, he said, the code “is not necessarily a better option, at least until EMRs are updated with the new DSM-5 language, or ICD-10 replaces ICD-9. Previously, clinicians would often use the label of “anxiety disorder not otherwise specified” (ICD-9 300.00) for subthreshold PTSD, which at least had the advantage of being considered a legitimate anxiety disorder that could result in medical benefits, if indicated.”
A federal deadline for the transition from ICD-0 to ICD-10 is this month.
In a linked comment accompanying the article, Alexander McFarlane, a professor at the Centre for Traumatic Stress Studies at the University of Adelaide in Australia, wrote, “We think there should be a period of transition between legal use of DSM-IV and DSM-5 so that potential effects of these changes can be examined and that deserving individuals are not denied their legal rights.”2
Hoge said he agreed with McFarlane’s concerns but considers it unlikely that either the VA or DoD will delay the full implementation of the DSM-5 classification of PTSD.
In terms of how clinicians should handle the transition, he pointed to advice offered in the study: “In addition to relying on clinical judgment, clinicians should recognize the subjectivity involved in developing consensus-based diagnoses, gather relevant assessment and clinical data and document which diagnostic criteria they apply.”
As for his own practice, Hoge said he will likely continue to give the diagnosis of PTSD if individuals meet the previous definition and require trauma-focused treatment and will likely continue to use the 300.00 anxiety code for other subthreshold cases until EMRs are updated with the new terminology.
“Overall, I think the DSM-5 provides critical improvements that will enhance psychiatric practice, such as in the areas of developmental, neurocognitive, somatic symptom, and substance use disorders; it is also not difficult for clinicians treating servicemembers and veterans to make the transition to DSM-5, since most of the common mental disorders that affect adults did not undergo significant changes,” he emphasized. “However, PTSD is exception; it underwent such profound changes in wording of many symptoms that there are greater concerns for this diagnosis than others. I believe that the decision to include PTSD and adjustment disorder in the same chapter in DSM-5 is a fundamental problem. I also believe, based in part of our research, that many of the changes that were made to the PTSD definition in DSM-5 did not actually improve the clinical utility of the definition.”
1Hoge CW, Riviere L, Wilk JE, Herrell RK, Weathers, FW. The prevalence of post-traumatic stress disorder (PTSD) in US combat soldiers: a head-to-head comparison of DSM-5 versus DSM-IV-TR symptom criteria with the PTSD checklist. The Lancet Psychiatry, 2014; DOI: 10.1016/S2215-0366(14)70235-4
2McFarlane AC. PTSD and DSM-5: unintended consequences of change. The Lancet Psychiatry, Early Online Publication, 14 August 2014. doi:10.1016/S2215-0366(14)70321-9
Overall, the symptoms of PTSD are mostly the same in DSM-5 as compared to DSM-IV. A few key alterations include: • The three clusters of DSM-IV symptoms are divided into four clusters in DSM-5: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. DSM-IV Criterion C, avoidance and numbing, was separated into two criteria: Criteria C (avoidance) and Criteria D (negative alterations in cognitions and mood). The rationale for this change was based upon factor analytic studies, and now requires at least one avoidance symptom for PTSD diagnosis. • Three new symptoms were added: • Criteria D (negative alterations in cognitions and mood): persistent and distorted blame of self or others, and persistent negative emotional state • Criteria E (alterations in arousal and reactivity): reckless or destructive behavior • Other symptoms were revised to clarify symptom expression. • Criterion A2 (requiring fear, helplessness, or horror happen right after the trauma) was removed in DSM-5. Research suggests that Criterion A2 did not improve diagnostic accuracy (2). • A clinical subtype “with dissociative symptoms” was added. The dissociative subtype is applicable to individuals who meet the criteria for PTSD and experience additional depersonalization and derealization symptoms (3). • Separate diagnostic criteria are included for children ages 6 years or younger (preschool subtype) (4). Source: The National Center for PTSD
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