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PTSD: To Be Or Not To Be? Part I

Oct 04

G’day all!  First another tip of your Stetson (if I might?) to our foreign visitors.  I remain amazed at the great distances between us here in Canada and some of the far off places from which we draw readers; and in addition, to how police persons from around the globe share similar concerns.

Today’s topic is a sensitive one, as I know many of you have received a diagnosis of “PTSD”.  You may have sensed from the tone of the two previous pieces that I was leading up to an article like this one.  I have always been uncomfortable with the history (derivation?) of this “diagnosis”.  For what is about to follow, you must take some responsibility.  It was you who taught me to be an investigator during my time at “Depot Division”, where by the way (chest puffed out) I was the Valedictorian of my Troop.

Anyway, I have followed the leads and investigated this controversial disorder.  The comments I will make in this piece, although well supported, commonly held and controversial at the same time, are not meant to erode your confidence in health care providers that disagree with me and my like-minded colleagues.  Most importantly my comments are not made to serve as therapy, only to provide another perspective; and to get you thinking like an investigator again.  I want you to grasp that human emotional pain may be universal but suffering is not.  My mission is to get you out of your head and into your life!!

So, away we go!  I’m sure that it will be no surprise to you that the US’s Veteran’s Administration (VA) is the world’s largest recipient of per patient funding for “PTSD”.  The VA cares for between 250 and 300,000 combat veterans, each year, who have received a diagnosis of “PTSD”.  The total annual cost is approximately $4.25 billion.  However, strangely enough extant (current) research does not support the existence of such a distinct and discrete syndrome.  In other words, “PTSD’s” diagnostic formulation, from its’ inception to this very day, continues to remain invalid.  Please believe me, those of you who have experienced traumatic exposures, my intention is not to diminish your pain, or the needs you feel for comfort and understanding.  My objective is to educate you as to the quality of the research evidence; the impact of culture on diagnosis; to get you to understand and perhaps re-consider the consequences of a traumatic exposure; and maybe even get your employer to find a less conflictual way of caring for you, and returning to you, your autonomy.

Ready for a little (largely disregarded) history?  In the earliest days of the diagnosis (1980) the DSM 3 (Diagnostic and Statistical Manual Third Edition) included the diagnosis of “PTSD” after its’ authors were lobbied by Vietnam Veteran’s Associations, and anti-war social workers, psychologists, and psychiatrists.  The argument for the recognition of a special disorder related to traumatic combat exposures, was that memories associated with these exposures were persistent and emerged in the form of a “PTSD”.  While interesting, this argument focuses on the fallout from a traumatic exposure, rather than the psychology that lays behind the suffering experienced by the patient.  A huge assumption was made, and it was suggested that an organic brain injury was suffered concomitant to the arousal of extreme stress.  Unfortunately this “wild ass” hypothesizing was coupled with the secondary assumption that the patient was destined to become chronically disabled.  (All with absolutely no proof!!).

Initially the American Psychiatric Association (APA) entered the fray under some pressure from the VA, and began by using the military’s diagnostic criteria.  The purpose of the DSM is to provide health care professionals with the research behind the diagnoses that they apply to their patients.  The diagnostic process is complex, and as with all decisions made by humans there is a subjective component involved.  The APA (composed of M.D’s specializing in Psychiatry), to its’ credit, wanted to respond to criticism and made changes.  There were 11 changes made in the revision of the DSM 3 (1987); followed by 15 in the DSM 4 (1994).  In the latter edition there were nearly 200 symptom combinations that could equal a diagnosis of “PTSD”.  With the DSM 5 (2013) when the “new and improved” criteria were applied by researchers, 30% fewer patients received a diagnosis of “PTSD” than they would have using the old DSM 4 criteria. (Are you investigators following this?  It’s all right there in black and white…..all you have to do is educate yourself……call me).  Now get this, when the researchers used BOTH sets of diagnostic criteria (i.e. from both the DSM 4 and the DSM 5), and an equivalent sample size, more subjects received the diagnosis under the DSM 5 criteria than the DSM 4.  You think you’re confused?  Dr. W. Hoge, Director of Research at the Walter Reed Army Hospital concluded “……the new criteria do not have greater clinical utility” than those of the DSM 4.  Remember them?  They are the ones that can produce 200 different symptom combinations that equal a diagnosis of “PTSD”.  Sorry, but that is like me looking out the window and telling you we have “weather” today!!

Another problem for the diagnostician arises in that the symptom profile associated with “PTSD” overlaps with several other mental conditions e.g. mood disorders, anxiety disorders, and substance abuse.  In one study I read, published in 1995, the authors reported that 88% of men and 79% of women with a diagnosis of “PTSD” had at least one other diagnosis along with it.  Any clinician could tell you (subjectively) that depression would be the most common comorbid (goes along with) diagnosis; it was detected in nearly 50% of those with a diagnosis of “PTSD”.  The “PTSD” cluster contains so many nonspecific indicators of psychological distress common to other conditions, the validity of the diagnostic category (i.e. “PTSD”) remains in question.

A much more critical concern (and then I’ll stop for now……OK M’lady?).  Crazy as it sounds, “PTSD” symptoms may not even be related to the experiencing of trauma.  Another group of researchers have demonstrated that when a cohort of patients, who were being considered for the pharmacological treatment of depression, were tested, 78% of them, traumatic history or not, met the diagnostic requirements for a diagnosis of “PTSD”.  In another interesting piece of research, the investigators demonstrated that their subjects (university students) without a traumatic history were more likely to meet some diagnostic criteria for a diagnosis of “PTSD” , than those with a verified traumatic history.

As long ago as 1988 a Vietnam Veterans Readjustment Study discovered that 31% of their subjects met all criteria necessary for a diagnosis, however only 15% of them had been assigned to actual combat.  When narrower diagnostic criteria were employed (similar to DSM 5?) and the veracity of reported trauma exposure was investigated, rates reported ranged from 3-15.5%.

I’ll stop for now and let you chew on Part I.  Next time (Part II) we will look at the tenuous position the patient is put in when he/she is confronted with the relationship between illness and financial benefit.

” DON’T PUSH THE RIVER, IT FLOWS BY ITSELF”

Dr. Mike Webster

Reg’d Psych.

(#0655)

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