Toward Validation of the Diagnosis of Posttraumatic Stress Disorder

Massachusetts General Hospital, Boston, Massachusetts, United States
American Journal of Psychiatry (Impact Factor: 13.56). 01/2009; 166(1):34-41. DOI: 10.1176/appi.ajp.2008.08050644
Source: PubMed

ABSTRACT Unlike most psychiatric diagnoses, posttraumatic stress disorder (PTSD) is defined in relation to a potentially etiologic event (the traumatic "stressor criterion") that is fundamental to its conceptualization. The diagnosis of PTSD thus inherently depends on two separate but confounded processes: exposure to trauma and development of a specific pattern of symptoms that appear following the trauma. Attempts to define the range of trauma exposure inherent in the diagnosis of PTSD have generated controversy, as reflected in successive revisions of the criterion from DSM-III onward. It is still not established whether or not there are specific types of traumatic events and levels of exposure to them that are associated with a syndrome that is cohesive in clinical characteristics, biological correlates, familial patterns, and longitudinal diagnostic stability. On the other hand, the symptomatic description of PTSD is becoming more clear. Of three categories of symptoms associated with PTSD--intrusive memories, avoidance and numbing, and hyperarousal--avoidance and numbing appear to be the most specific for identification of PTSD. Research is now poised to answer questions about the relevance of traumatic events based on their relationship to symptomatic outcome. The authors recommend that future research begin with existing diagnostic criteria, testing and further refining them in accordance with the classic Robins and Guze strategy for validation of psychiatric diagnoses. In this process, diligent adherence to the criteria under examination is paramount to successful PTSD research, and changes in criteria are driven by empirical data rather than theory. Collaborations among trauma research biologists, epidemiologists, and nosologists to map the correspondence between the clinical and biological indicators of psychopathology are necessary to advance validation and further understanding of PTSD.

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    • ") are divided into three clusters: reexperiencing, avoidance/numbing, and hyperarousal. The validity of the current conceptualization of PTSD described in DSM-IV has been questioned because of the often heterogeneous presentation of PTSD; the overlap in symptom criteria between PTSD, other anxiety disorders, and major depressive disorder; and the high comorbidity rate among these disorders (North et al. 2009). A number of factor analyses have been conducted, most suggesting alternative two-, three-, or four-factor models of PTSD that provide different conceptualizations of PTSD: including additional symptom clusters such as dysphoria, or distinguishing between an active avoidance and passive numbing factor (Foa et al. 1995; Buckley et al. 1998; King et al. 1998; Asmundson et al. 2000; Amdur and Liberzon 2001; Gaffney 2003; Baschnagel et al. 2005; Elhai et al. 2009). "
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    ABSTRACT: Confirmatory factor analysis (CFA) of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) three-factor posttraumatic stress disorder (PTSD) diagnostic criteria was conducted to determine fit for this patient population. An exploratory factor analysis (EFA) of alternate symptom structures was planned to identify symptoms that cluster in this population. The response of symptom factors to treatment with venlafaxine extended release (ER) was explored. Baseline 17-item Clinician-Administered PTSD Scale (CAPS-SX17) data were pooled from patients enrolled in two double-blind, randomized, placebo-controlled trials. The CFA was conducted using maximum likelihood and weighted, least-squares factor extraction methods. The EFA was performed using a polychoric correlation covariance matrix and Pearson correlation matrix. Data from a pooled population of 685 patients (venlafaxine ER: n = 339; placebo: n = 346) were analyzed. CFA rejected the DSM-IV three-factor structure. The EFA identified a different three-factor structure as the best fit: factor 1 included reexperiencing symptoms, factor 2 included symptoms of altered mood and cognition, whereas factor 3 comprised avoidance and arousal symptoms. All DSM-IV symptom factors and all factors in the identified three-factor model responded positively to venlafaxine ER treatment. Data are consistent with literature failing to confirm the three-factor structure of DSM-IV PTSD, and they support the DSM-5 inclusion of a symptom cluster addressing altered mood and cognition in PTSD. The efficacy of venlafaxine ER in reducing a range of symptom clusters in PTSD is consistent with its multiple mechanisms of action.
    Brain and Behavior 11/2013; 3(6):738-46. DOI:10.1002/brb3.183
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    • "trauma, so that most people are regarded as having experienced posttraumatic stress at some time during their lives [11]. PTSD has sometimes been confused with nonspecific psychological distress characterized by anxiety and depression [13] [14] [15]. Anxiety and depression can be nonspecific responses to stress even in people who do not have the avoidance behaviors and numbing symptoms characteristic of PTSD [16]. "
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    ABSTRACT: Background. Few disaster studies have specifically examined personality and resilience in association with disaster exposure, posttraumatic stress disorder (PTSD), and major depression. Methods. 151 directly-exposed survivors of the Oklahoma City bombing randomly selected from a bombing survivor registry completed PTSD, major depression, and personality assessments using the Diagnostic Interview Schedule for DSM-IV and the Temperament and Character Inventory, respectively. Results. The most prevalent postdisaster psychiatric disorder was bombing-related PTSD (32%); major depression was second in prevalence (21%). Bombing-related PTSD was associated with the combination of low self-directedness and low cooperativeness and also with high self-transcendence and high harm avoidance in most configurations. Postdisaster major depression was significantly more prevalent among those with (56%) than without (5%) bombing-related PTSD (P < .001) and those with (72%) than without (14%) predisaster major depression (P < .001). Incident major depression was not associated with the combination of low self-directedness and low cooperativeness. Conclusions. Personality features can distinguish resilience to a specific life-threatening stressor from general indicators of well-being. Unlike bombing-related PTSD, major depression was not a robust marker of low resilience. Development and validation of measures of resilience should utilize well-defined diagnoses whenever possible, rather than relying on nonspecific measures of psychological distress.
    Depression research and treatment 09/2012; 2012:204741. DOI:10.1155/2012/204741
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    • "In DSM-IV-TR, the event must have caused a response involving feelings of horror, intense fear, or hopelessness. The accident would have to result in a pathological response involving a number of cognitive, psychological, and behavioral processes, including symptoms of numbing and avoidance, increased arousal and re-experiencing of the event (Brewin and Holmes 2003; North et al. 2009). However, previous research has questioned DSM criteria for PTSD, with many criticisms surrounding the utility of Criterion A (Kilpatrick et al. 2009). "
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    ABSTRACT: This study examined 1,500 New Zealand community-residing adults for involvement in serious motor vehicle accident (MVA) and the development of trauma-related symptomatology. The incidence of MVA was 11 %. More than 50 % of the accident victim sub-sample reported hyperarousal, with exaggerated startle, intrusive recollections, situational avoidance, emotional reactivity, and cognitive avoidance. The high incidence of trauma-related symptoms is noteworthy given 59 % of victims reported sustaining no or mild accident injury, and only 27 % were admitted to hospital for severe injury. Trauma-related symptoms were related to measures of injury severity, psychological and social functioning, and persistent medical problems. Pre- and post-accident factors, that is, experience of additional trauma, experience of stressful life events and post-accident social contact were the most important predictors of trauma-related symptoms severity. This study discusses the importance of examining trauma-related symptoms rather than using categorical diagnostic criteria (i.e., post-traumatic stress disorder, PTSD) as a sole means of characterizing the psychological impact of MVA.
    Culture Medicine and Psychiatry 04/2012; 36(3):442-64. DOI:10.1007/s11013-012-9265-z · 1.29 Impact Factor
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