Major report challenges diagnostic criteria for PTSD
Professor Neil Greenberg from King’s College London has co-authored a major report challenging the DSM-5 diagnostic criteria for post-traumatic stress disorder (PTSD).
Published today in JAMA Psychiatry, the report sets out controversial changes, implications and rationale for immediate action, relating to revisions made in 2013 to the DSM-5 definition of PTSD.
DSM-5 (Diagnostic and Statistical Manual) is the standard classification of mental disorders used by mental health professionals across the world.
According to the authors, including leading researchers from King’s College London, Harvard University and Massachusetts General Hospital, a series of changes to DSM-IV were made based on ‘selective interpretations of evidence’ and the influence of cognitive theory. This lessened the emphasis of other well-established neurobiological models underlying evidence-based treatments.
The report highlights evidence that the revised definition of PTSD offers no improvement in clinical diagnosis and excludes many individuals who would have met previous criteria for the disorder.
Professor Greenberg, who is Professor of Defence Mental Health at King’s, said: 'This paper has been put together by many of the world’s leading experts on traumatic stress and post traumatic stress disorder. Collectively, we are truly concerned that there has not been enough thought put into the difficulties that moving from DSM-IV to DSM-5 will cause to frontline clinicians and patients. The publication of ICD 11, due in the near future, using yet another definition, will only make situation more complex. We believe that DSM and ICD expert panels should work more closely to ensure that the world is not having to battle with multiple definitions of the same disorder which is only going to cause confusion for all.'
The authors put forward criticisms of PTSD’s current diagnostic criteria under five broad headings:
‘Trauma Definition: Splitting Hairs’
DSM-5 tightened the scope of qualifying events for diagnosis, which ‘ties clinicians’ hands in applying the trauma-criterion when clinically appropriate.'
‘Symptom Criteria: Unsupported Changes’
Of the 17 original DSM-IV symptoms, eight underwent significant edits and three symptoms were added. These changes introduced complex phrasing, alterations in meaning and increased diagnostic permutations - sometimes replacing the DSM’s foundation of reportable, observable symptoms with subjective criteria and overlapping depressive cognitions/emotions.
‘Evidence of Flawed Consensus Processes’
No ‘a priori’ scientific standards for evaluating the many proposed changes or feedback received.
Studies comparing DSM-IV and DSM-5 criteria were conducted largely in non-representative research samples.
‘Clinical Evaluation: Reinventing the Wheel'
DSM-5 undermines researchers’ ability to generalise studies and creates a circular requirement for an entirely new foundation of instrumentation, neurobiological, genetic and interventions research.
In their concluding remarks, the authors write: ‘The purpose of revising a psychiatric definition is to enhance diagnostic accuracy, clinical utility and communication. The DSM-5 definition of PTSD provides no improvements in these areas.
‘This has profound implications for patients with PTSD per DSM-IV for whom well established treatments exist and for patients with impairment meeting DSM-5 criteria for whom treatments may not generalize.
‘Essentially, what the new definition appears to have accomplished is a disruption of the long chain of links, established through epidemiological, neurobiological and treatment studies, providing the foundation of current practice for patients with PTSD.’