Toward Validation of the Diagnosis of Posttraumatic Stress Disorder
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: Studies of survivors of the September 11, 2001 attacks on the World Trade Center in New York City suggest that postdisaster depressive disorders may be at least as prevalent, or even more prevalent, than posttraumatic stress disorder (PTSD), unlike findings from most other disaster studies. The relative prevalence and incidence of major depressive disorder (MDD) and PTSD were examined after the 9/11 attacks relative to trauma exposures. This study used full diagnostic assessment methods and careful categorization of exposure groups based on DSM-IV-TR criteria for PTSD to examine 373 employees of 9/11-affected New York City workplaces. Postdisaster new MDD episode (26%) in the entire sample was significantly more prevalent (p<.001) than 9/11-related PTSD (14%). Limiting the comparison to participants with 9/11 trauma exposures, the prevalence of postdisaster new MDD episode and 9/11-related PTSD did not differ (p=.446). The only 9/11 trauma exposure group with a significant difference in relative prevalence of MDD and PTSD were those with a 9/11 trauma-exposed close associate, for whom postdisaster new MDD episode (45%) was more prevalent (p=.046) than 9/11-related PTSD (31%). Because of the conditional definition of PTSD requiring trauma exposure that is not part of MDD criteria, prevalence comparisons of these two disorders must be limited to groups with qualifying trauma exposures to be meaningful. Findings from this study suggest distinct mechanisms underlying these two disorders that differentially relate to direct exposure to trauma vs. the magnitude of the disaster and personal connectedness to disaster and community-wide effects. Copyright © 2015. Published by Elsevier Inc.Comprehensive Psychiatry 02/2015; DOI:10.1016/j.comppsych.2015.02.009 · 2.26 Impact Factor
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ABSTRACT: Purpose Much of the mental health research that has emerged from the September 11 (9/11) attacks has been focused on posttraumatic stress disorder and its symptoms. To better understand the broader experience of individuals following a disaster, focus groups were conducted with individuals from affected companies both at Ground Zero and elsewhere in New York City. Methods Twenty-one focus groups with a total of 140 participants were conducted in the second post-9/11 year. Areas of identified concern were coded into the following themes: Disaster Experience, Emotional Responses, Workplace Issues, Coping, and Issues of Public Concern. Results Discussions of focus groups included material represented in all five themes in companies both at Ground Zero and elsewhere. The emphasis and the content within these themes varied between the Ground Zero and other companies. Content suggesting symptoms of PTSD represented only a minority of the material, especially in the company groups not at Ground Zero. Conclusions This study’s findings revealed an array of psychosocial concerns following the 9/11 attacks among employees of companies in New York City that extended far beyond PTSD. This study’s results provide further evidence that trauma exposure is central to individuals’ post-disaster experience and focus, and to individuals’ adjustment and experience after disaster.Social Psychiatry and Psychiatric Epidemiology 10/2014; 50(4). DOI:10.1007/s00127-014-0970-5 · 2.58 Impact Factor
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ABSTRACT: of-fered recommendations concerning refinement and valida-tion of the diagnosis of posttraumatic stress disorder (PTSD). The authors concluded that "avoidance and numbing symp-toms represent the core of psychopathology as currently writ-ten in the DSM-IV-TR" (1, p. 39). These conclusions have im-portant implications for DSM-V. However, there are other considerations about avoidance and numbing relevant to the criteria set for PTSD that the authors did not discuss. First, there is a growing body of factor analytic research showing that effortful avoidance (i.e., deliberate attempts to avoid trauma reminders) and numbing are distinct groups of PTSD symptoms (2). If factors identified by factor analysis corre-spond to distinct groups of causal mechanisms (3), then re-search into the etiology of PTSD would be hindered by blur-ring the distinction between effortful avoidance and numbing. Second, DSM-IV-TR criteria for PTSD include five numbing symptoms but only two effortful avoidance symp-toms. In order to reliably assess various manifestations of ef-fortful avoidance, more of these symptoms need to be in-cluded in DSM-V. Third, based on DSM-IV-TR criteria, PTSD can be diagnosed even in the absence of effortful avoidance. If effortful avoidance is one of the core features of PTSD, then such symptoms should be required to diagnose PTSD. Fourth, the existence of trauma-related, psychogenic amnesia is con-troversial (4), thereby undermining validity of the PTSD diag-nosis. Even if such amnesia is a clinical reality, it is different than effortful avoidance of trauma memories and, more likely than not, distinct from numbing. This latter point is under-scored by reanalysis of data from 60 PTSD patients in one of our recent studies (5) in which a 5-item numbing scale was created from scores on the Clinician-Administered PTSD Scale. Amnesia had a corrected item-total correlation that was no different from zero (r=–0.08) compared with a range of 0.16–0.54 for the other numbing items. In short, amnesia was unrelated to other numbing items. It seems prudent to omit this symptom from DSM-V. Finally, if avoidance and numbing are the core features, is PTSD simply a combination of spe-cific phobia and depression (6)? An important step in validat-ing PTSD is to demonstrate that it has incremental validity over specific phobia and depression—that is, to show that the diagnosis of PTSD conveys important information relevant to understanding the etiology and treatment of trauma-related psychopathology that is not conveyed by a combination of these other diagnoses.American Journal of Psychiatry 06/2009; 166(6):726. DOI:10.1176/appi.ajp.2009.08121799) · 13.56 Impact Factor