Toward validation of the diagnosis of posttraumatic stress disorder.

Program in Trauma and Disaster, Dallas VAMC, 4500 S. Lancaster Rd., Dallas, TX 75216, USA.
American Journal of Psychiatry (Impact Factor: 14.72). 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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    ABSTRACT: The inclusion of post-traumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual III (DSM-III) was a considerable achievement that has vastly enriched our knowledge of reactions to traumatic events and our ability to offer appropriate care to survivors. Nevertheless, limitations created by the way in which PTSD belatedly entered the diagnostic canon continue to create problems today. One problem was created by the assumption, subsequently proven incor-rect, that PTSD was fully explained by exposure to an event outside the range of usual human experience. This resulted in the stressor criterion, Criterion A, assuming a central role in the diagnosis. The realisation that PTSD can follow more mundane traumatic events such as motor-vehicle accidents that nevertheless have the potential to create intense fear and helplessness, and the confirmation that individual vulnerability is as important in PTSD as in other psychiatric dis-orders, has led inevitably to subsequent problems in defining exactly what does and does not comprise a traumatic event. In the late 1970s there was also far less appreciation than there is today con-cerning the role of stressful life events in the onset and maintenance of many psychiatric disorders. In seeking to introduce a condition that was defined in terms of the aetiological role of extreme stress, it may therefore not have been so evident to those crafting the DSM-III definition that traumatic stressors would produce a range of psychopathological reactions, and that it would be necessary Post-traumatic Stress Disorder, First Edition. Edited by Dan Stein, Matthew Friedman, and Carlos Blanco.
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