Jul 11, 2009

PTSD Lives a Long Life

When discussing Post Traumatic Stress Disorder (PTSD), one wishes to be precise and careful in refuting the political forces challenging this diagnosis of a malady that is pervasive in our veterans.

Col. Dan Cedusky, USA (Ret) sends a piece entitled Valid Diagnosis Who Benefits From Challenging Its Existence from the Psychiatric Times written by Rachel Yehuda, PhD and Alexander C. McFarlane, MD. See below.

So to the neocons and specifically the rightwing VA Inspector General's office that is giving our Wisconsin veterans such a hard time, let me be precise and careful in my lay-medical advice to you: Go fuck yourselves.

July 9, 2009 Psychiatric Times. Vol. 26 No. 7

PTSD Is a Valid Diagnosis: Who Benefits From Challenging Its Existence?

Rachel Yehuda, PhD and Alexander C. McFarlane, MD

PTSD filled a nosological gap by providing a way to characterize the long-lasting effects of trauma exposure.1 This led to a plethora of previously lacking scientific observations. Now the existence of PTSD is being called into question because some of the original assumptions that helped make the case for it have proved to be incorrect.2-4 However, it is possible to update some of the flawed assumptions of PTSD without rescinding the diagnosis. There is no reason to throw the baby out with the bathwater.

It is true that when advocates argued for the centrality of trauma exposure as a cause of PTSD, they lacked the perspective that PTSD is only one of many possible outcomes following trauma exposure—including resil­ience.1 However, the diagnosis is not invalidated by the fact that trauma exposure does not always—but sometimes does—result in PTSD.5 In medicine, diagnoses are not invalidated when not all persons express symptoms associated with a pathogen. Not all persons who are infected with Mycobacterium tuberculosis get clinically manifested pulmonary disease. Yet this does not call into question the role of the bacterium. Nor do we call into question the diagnoses of pulmonary tuberculosis because it shares symptoms with pneumonia and sarcoidosis.

The PTSD construct is valid independent of symptoms of overlapping disorders.5,6 The argument that 'symptom overlap' calls the PTSD diagnosis into question reflects a fundamental misunderstanding of the purpose of diagnostic categories—which is to organize symptoms around a common cause to effectively provide the needed intervention. Treating specific symptoms outside the framework of a diagnosis is problematic.7 The idea here is that one arguably treats behavioral manifestations of panic attacks that come 'out of the blue' differently from similar physiological reactivity provoked by traumatic reminders in PTSD. The PTSD diagnosis implies a failure of homeostatic mechanisms involved in stress recovery.8 In the absence of trauma exposure, some of the same symptoms might reflect a different neurobiological process and treatment intervention.

We agree that the diagnosis of PTSD almost entered a cul-de-sac when it initially postulated—back in the days before functional neuroimaging in psychiatric research—that symptoms resulted from an organic brain change occurring secondary to stress-induced arousal. Fortunately, advances in neuroscience disconfirmed this, while providing the constructs for a more nuanced way of understanding enduring brain ef­fects resulting from environmental per­turbations—including gene-environment interactions, epigenetic mod­ifications, and other molecular mechanisms.9-11 These advances have not only explained mechanisms involved in enduring stress effects but have also revealed individual differences that explain why long-term illness develops in only some traumaexposed persons.9 That initial theories about pathophysiology may have been erroneous does not jeopardize the validity of the PTSD construct any more than the concept of schizophrenia was jeopardized when its cause was considered to be the 'schizophrenogenic mother.'12

So too, the “errors” that can be made in the diagnosis of PTSD underscore the need for better training. Also, there is every reason to believe that scientific advances will yield PTSD biomarkers that differentiate this condition from others, particularly, those with overlapping symptoms. Progress in this area has already been made, and the yield from the rapid develop­ment of methodologies for unbiased genome-wide genotyping, gene expression, and molecular approaches are only beginning to be realized.9-11 Soon it will be more difficult for those who have never seen PTSD clinically to dismiss the “validity” of the PTSD diagnosis.

What is it that really bothers people? Could it be the high price tag of caring for persons disabled with PTSD? Could it be resentment that some persons fake symptoms for secondary gain? “Malingerophobia” is a strong fear for doctors, but being able to fake an illness does not invalidate it as a diagnostic entity.13 Could it be that if we continue to assert that trauma exposure really can result in a mental health syndrome, our society will need to shoulder some of the responsibility for primary prevention and start making the world safer from violence, accidents, and disasters that threaten our citizens? [Emphasis added by all of us.]

The fact that many persons choose not to continue mental health treatment for PTSD after they become service-connected is often used to 'prove' that the injury was never really there and that the diagnosis was only a vehicle for compensation. Anyone who works with veterans or civilians battling the courts in an attempt to obtain compensation for PTSD would understand that severity of PTSD would be high during this process. It is stressful to recount explicit details of traumatic material—even with appropriate support, corrective information, and anxiety-reduction techniques in therapy. Imagine needing to do so in the context of an adversarial process in which the veracity of one’s report of trauma or level of distress is questioned. It is unfortunate that some veterans link the experiences of seeking
compensation with mental health treatment at the VA and do not return. It is also true that the compensation- seeking process promotes avoidance behavior, accounting for more drop­outs. Because there are still barriers to care, it is important not to draw conclusions about the prevalence, sever­ity, or reality of any mental illness based on treatment-seeking behavior. Indeed, only a minority of those with PTSD seek any treatment.14,15

A constructive solution to the problem of the high cost of PTSD-related disability is to invest in the development of novel PTSD treatments and strategies for its prevention. One of the benefits of asserting that PTSD is not a result of brain damage secondary to stress exposure is that this opens up many new vistas for intervention. The validity of PTSD does not depend on its being a permanent condition—this is another assumption that could be corrected without even altering the diagnostic criteria. When treatment options based on a more precise characterization of the cause and biology of PTSD become available, the price tag associated with PTSD disability will be reduced. Rescinding the di­agnosis will stand in the way of these developments.

It seems disingenuous, invoking DSM-V to use the convenience of having been wrong about some things to obliterate a diagnosis that has been so on-target in so many ways for so many trauma survivors. It is not clear why the dialogue is set up in a binary manner to either confirm or deny the existence of PTSD as currently formulated. The question going into DSM-V is whether we can restructure a more precise diagnosis that will be more resis­tant to the superficial criticisms currently used to challenge its existence. Once we acknowledge that PTSD is a specific type of response to trauma, many of the conceptual 'problems' related to refining Criterion A, bracket creep, or symptom overlap dissipate.

The issues regarding PTSD have faced other diagnoses that are also sometimes difficult to delineate as a result of symptom overlap or because some patients fall into the cracks of often arbitrary and dichotomously parsed diagnostic criteria. That PTSD has become the whipping post for the challenges that emerging knowledge brings to the classification of mental disorders suggests it has had a strong cultural impact . . . let’s not shoot the messenger.

Dr Yehuda is director of the PTSD Program at James J. Peters Veterans Affairs Medical Center in the Bronx, and professor of psychiatry at Mount Sinai School of Medicine in New York City. Dr McFarlane is professor of psychiatry and head of CMVH University of Adelaide Node at the Centre for Military and Veterans’ Health at the University of Adelaide, Australia.

Acknowledgments: This work was supported by funding from Veterans Affairs, Department of Defense, and NIMH.

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