Toward Validation of the Diagnosis of Posttraumatic Stress Disorder

Massachusetts General Hospital, Boston, Massachusetts, United States
American Journal of Psychiatry (Impact Factor: 12.3). 01/2009; 166(1):34-41. DOI: 10.1176/appi.ajp.2008.08050644
Source: PubMed


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.


Available from: Rebecca Pringle Smith, Nov 14, 2015
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    • "Summarizing the literature, Whitman and colleagues [29] noted that, in the absence of meeting criterion C (avoidance and numbing), criterion B (intrusion) and criterion D (hyperarousal) symptoms do not signify psychopathology, and that the majority of individuals who satisfy criterion C (avoidance and numbing) meet full diagnostic criteria. In their paper on validating the diagnosis of PTSD, North and colleagues [30] concluded that avoidance and numbing symptoms emerge as " the core pathology " for identifying PTSD (p. 39). "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: This study explored the effects of media coverage of a terrorist incident in individuals remote from the location of a major attack who had directly experienced a prior terrorist incident. Method: Directly-exposed survivors of the 1995 Oklahoma City bombing, initially studied six months after the incident, and indirectly-affected Oklahoma City community residents were assessed two to seven months after the September 11, 2001, attacks. Survivors were assessed for a diagnosis of bombing-related posttraumatic stress disorder (PTSD) at index and follow up, and emotional reactions and September 11 media behavior were assessed in all participants. Results: Among the three investigated forms of media (television, radio, and newspaper), only television viewing was associated with 9/11-related posttraumatic stress reactions. Exposure to the Oklahoma City bombing was associated with greater arousal in relation to the September 11 attacks, and among survivors, having developed bombing-related PTSD was associated with higher scores on all three September 11 posttraumatic stress response clusters (intrusion, avoidance, and arousal). Although time spent watching television coverage of the September 11 attacks and fear-related discontinuation of media contact were not associated with Oklahoma City bombing exposure, discontinuing September 11 media contact due to fear was associated with avoidance/numbing in the full sample and in the analysis restricted to the bombing survivors. Conclusion: Surviving a prior terrorist incident and developing PTSD in relation to that incident may predispose individuals to adverse reactions to media coverage of a future terrorist attack.
    Full-text · Article · Sep 2015 · Comprehensive Psychiatry
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    • "Recently, there has been a growing recognition of the importance of reward processing and in understanding its neural basis in PTSD. Emotional numbing has been shown to be the symptom that is most characteristic of chronic PTSD [4], and is strongly associated with functional and interpersonal impair- ment [5,6]. Two behavioral studies have reported deficient reward function in PTSD. "
    [Show abstract] [Hide abstract] ABSTRACT: There has been a growing recognition of the importance of reward processing in PTSD, yet little is known of the underlying neural networks. This study tested the predictions that (1) individuals with PTSD would display reduced responses to happy facial expressions in ventral striatal reward networks, and (2) that this reduction would be associated with emotional numbing symptoms. 23 treatment-seeking patients with Posttraumatic Stress Disorder were recruited from the treatment clinic at the Centre for Traumatic Stress Studies, Westmead Hospital, and 20 trauma-exposed controls were recruited from a community sample. We examined functional magnetic resonance imaging responses during the presentation of happy and neutral facial expressions in a passive viewing task. PTSD participants rated happy facial expression as less intense than trauma-exposed controls. Relative to controls, PTSD participants revealed lower activation to happy (-neutral) faces in ventral striatum and and a trend for reduced activation in left amygdala. A significant negative correlation was found between emotional numbing symptoms in PTSD and right ventral striatal regions after controlling for depression, anxiety and PTSD severity. This study provides initial evidence that individuals with PTSD have lower reactivity to happy facial expressions, and that lower activation in ventral striatal-limbic reward networks may be associated with symptoms of emotional numbing.
    Full-text · Article · Sep 2014 · PLoS ONE
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    • "The PTSD symptoms described in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) (American Psychiatric Association 1994) 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). "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Nov 2013 · Brain and Behavior
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