Brewin & Lanius (2009): Reformulating PTSD for DSM-V: Life After Criterion A Flashcards
3 criticisms of ptsd diagnosis
- pathologizing normal events
- criterion A is not valid
- symptom overlap with other disorders
3 proposed changes
- removing Criterion A
- focusing B criteria on core symptoms like flashbacks and nightmares (smaller set of symptoms)
- refining C and D criteria to reduce overlap with other disorders.
Criticism 1: PTSD pathologizes normal distress -> 3 ways this can be interpretated
- extreme stress reactions are temporary and ptsd symptoms will naturally go away (but; research contradicts this, indicating that intense stress can result into lasting mental issues. also research shows there is a difference between short-term symptoms in the general population not directly affected by a terrorist attack, and lasting disorders in those who are directly involved)
- symptoms of ptsd are common reactions to stress seen in people who experience normal distress (PTSD is often seen as a prolonged failure of adapting to extreme stress. Critics claiming it’s just normal distress should clarify how long symptoms can persist without being considered abnormal, which they haven’t done yet.)
- PTSD is not biologically different from normal distress (but: increasing evidence suggests that PTSD has a distinct biological profile. Brain imaging studies reveal different activation patterns in PTSD compared to other anxiety disorders and depression, even in patients with both conditions. Furthermore, there are unique cortisol feedback inhibition
patterns in PTSD as opposed to depression)
criticism 2: issues with criterion A
- How broadly or narrowly should trauma be defined?
- Can trauma be measured reliably and validly?
- What is the relationship between trauma and PTSD (because we know trauma is not exclusively associated with ptsd)?
Insufficient specificity of Criterion A/how broadly should trauma be defined?
- The DSM still includes situations where learning about someone else’s trauma (A3) qualifies as exposure to trauma. Critics say this broadening of criteria is resulting in (more) PTSD diagnoses for situations that
are far from the original idea of trauma.
It did lead to more PTSD cases, but many of these cases are linked to learning about the sudden unexpected death of a close relative or friend (which could quite reasonably be described as traumatic).
- Other situations, not clearly meeting the Criterion A threshold, but associated with
full PTSD, involve prolonged build-up stress over time.
Trauma of lower intensity would in fact be expected to provoke PTSD in vulnerable individuals with a limited capacity to dampen their physiological response to stress. The criteria should therefore account for the fact that people have varying responses to enduring stress, to take away criticism and confusion.
Insufficient specificity of Criterion A/how narrowly should trauma be defined?
The DSM-IV introduced criteria for diagnosing PTSD. It required individuals to have experienced a qualifying traumatic event (same as DSM-V) and responded with intense fear, helplessness, or horror (different than DSM-V).
But there is a lot of evidence showing a range of reactions to trauma beyond these emotions. Some studies found cases where trauma exposure didn’t have these specific emotional responses, yet individuals developed full PTSD (e.g. military personnel trained to handle trauma, some crime victims, survivors of traumatic brain injury).
The difference between DSM-IV assuming emotions stay the same over time and new psychological and biological knowledge suggesting emotions can change has influenced the development of diagnostic criteria in the transition to DSM-5 (Note that this criticism is now resolved due to the introduction of the DSM-V.)
most common comorbidities
- depression
- generalized anxiety
disorder (GAD) - panic disorder
- increased substance use
criticism 3. other disorders are linked to traumatic events
Different symptoms of PTSD are also common symptoms in other disorders (e.g. intrusive memories, images or thoughts in ocd, emotional and physiological arousal in phobias, social withdrawal, loss of interest, emotional numbing and hopelessness about the future in depression). The combination of those symptoms could determine with what disorder someone gets diagnosed.
But evidence suggests these traumatic events don’t increase the risk for other disorders unless PTSD develops. Conclusion: PTSD does indeed play a central role in the psychological response to trauma
E.g., a study found an increased risk of depression in those with PTSD but not in those exposed to trauma without developing PTSD. Conclusion: PTSD does indeed play a central role in the psychological response to trauma
2 reexperiencing symptoms that do appear to be distinctive to ptsd:
- flashbacks (a key factor that sets PTSD apart from depression. compared to to intrusive memories in depression, intrusive memories in PTSD involve a greater sense of reliving in the present)
- traumatic nightmares (70% of people with ptsd)
reasons for removing criterion a
- defining criterion A is challenging, past attempts have faced criticism and inconsistencies.
- evidence shows that specifying triggering events is not only difficult but also not ideal, considering individual differences in sensitization and vulnerability
- the full ptsd syndrome rarely happens without a traumatic event, making criterion a not ore beneficial for a precise diagnosis
reasons for focusing on a smaller set of core symptoms
- They propose that PTSD should center around the core experience of reliving traumatic events through vivid images, accompanied by intense fear or horror, indicating a perceived severe threat to a person’s well-being.
- there is evidence that short screening measures are just as effective as longer ones
- the intention is to highlight the features that are most salient to the individual with PTSD, that are the primary focus of psychological treatment, and that make PTSD distinct from other anxiety disorders and from depression.
welke core symptomen zouden we moeten hebben
- reexperiencing (dreams and images)
- avoidance (avoid internal reminders and external reminders)
- hyperarousal (hypervigilance, startle response)
- duration: more than 1 month
- clinically significant impairment
advantages removing criterion a
- Not requiring a specific trauma for PTSD aligns it with other psychiatric disorders, therefore it becomes more comparable to anxiety disorders and depression.
- The problem of deciding if an event qualifies for Criterion A or depending on reports about what emotions were felt prior to traumatic event is eliminated.
- Individual factors and training to face trauma won’t disqualify someone from a PTSD diagnosis. (Remember the military personel example)
- Clinicians can focus on symptoms and treatment without concerns about meeting specific criteria or emotions felt during the event
disadvantages removing criterion A
- It would deviate significantly from the original understanding of PTSD. (however: we should change the way we understand PTSD to match new research findings. we now see that a traumatic event doesn’t have the same significance as originally thought; it interacts in a complex way with the individual’s characteristics)
- It might make the suffering of those exposed to catastrophic life events seem less significant. (however: we now understand that events can severely affect mental health)
- Without Criterion A acting as a gatekeeper, PTSD could be diagnosed for almost any stressor, making the diagnosis meaningless. (however: existing data suggest that this is unlikely, and focusing on core symptoms and impairment criterion should prevent this from happening)
advantages of focusing on core symptoms
- Improved ease of identification and diagnosis outside specialist trauma centers.
- Greater homogeneity of cases and reduced overlap with other disorders by removing symptoms associated with general dysphoria.
- Increased flexibility for clinicians to identify reexperiencing during examination, accommodating highly avoidant patients.
- Explicit focus on the reexperiencing of fear and horror promotes better connections with basic psychological and neuroscience approaches to these emotions.
