PhD/PsyD PTSD criteria and other changes in the DSM-5

[WisNeuro]

They also significantly changed PTSD and the way that neurocognitive disorders are classified.

Mod note: Split this discussion out from the EPPP thread.

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[smalltownpsych]

Thanks for the head's up on the PTSD. It looks to me like they added negative alterations in cognition and mood to the criteria. I don't know if that makes much difference in actual clinical practice or if it would just help to clarify for research. In other words, the patient is usually coming to me because of the fact that they meet that criteria.

What was the shift in the way neurocognitive disorders are classified? Since I am not a neuropsychologist, I pay less attention to that.

 

[OneNeuroDoctor]

From my understanding via attending DSM 5 workshop there are significant changes. It might as well be a brand new diagnostic system rather than an update.

Many professionals are angry and upset about DSM 5, especially psychiatrist associated with prior editions. There are questions of if the DSM 5 is going to be recognized by insurance companies and some are speculating it will not be required by October 2014.


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[smalltownpsych]

From my understanding via attending DSM 5 workshop their are significant changes. It might as well be a brand new diagnostic system rather than an update.

Many professional are angry and upset about DSM 5, especially psychiatrist associated with prior editions. There are questions of if the DSM 5 is going to be recognized by insurance companies and some are speculating it will not be required by October 2014.


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I think you are referring to ICD-10 which was due to be implemented in Nov 2014, but our hospital just told us a couple of weeks ago that would not occur until 2015 now.

Getting rid of the multi-axial system was the biggest change from my perspective. I still don't feel comfortable with how I am going to document diagnosis appropriately and am still defaulting to the DSM-IV style that I was well-trained in, especially when dictating.

 

[OneNeuroDoctor]

I think you are referring to ICD-10 which was due to be implemented in Nov 2014, but our hospital just told us a couple of weeks ago that would not occur until 2015 now.

Getting rid of the multi-axial system was the biggest change from my perspective. I still don't feel comfortable with how I am going to document diagnosis appropriately and am still defaulting to the DSM-IV style that I was well-trained in, especially when dictating.

If you attend the APA authorized DSM 5 daylong workshops they will say the Multi axial system was never required in prior editions, it was just a teaching method of using prior DSM's.

There are already discussions of making additional changes, even after it was published.


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[WisNeuro]

Thanks for the head's up on the PTSD. It looks to me like they added negative alterations in cognition and mood to the criteria. I don't know if that makes much difference in actual clinical practice or if it would just help to clarify for research. In other words, the patient is usually coming to me because of the fact that they meet that criteria.

What was the shift in the way neurocognitive disorders are classified? Since I am not a neuropsychologist, I pay less attention to that.

Oh they made a much more significant change to PTSD than that. Now someone has only to "learn" of a traumatic event to a loved one to qualify. PTSD will become the disability du jour because of that change.

As for as neuro stuff, we can just classify something as minor or major neurocognitive disorder. Did away with dementia as a label prett ymuch, although you can still classify suspected etiology in the subtyping.

 

[smalltownpsych]

Oh they made a much more significant change to PTSD than that. Now someone has only to "learn" of a traumatic event to a loved one to qualify. PTSD will become the disability du jour because of that change.

As for as neuro stuff, we can just classify something as minor or major neurocognitive disorder. Did away with dementia as a label prett ymuch, although you can still classify suspected etiology in the subtyping.

I hear of traumatic events all the time! Maybe I have PTSD, too! Where's my check?
In all seriousness, helping people with trauma can be emotionally distressing, which I think is one reason why this was included but is it likely to lead to the other symptoms? Do we need to have a diagnosis for every human difficulty? Also, disability and the way that whole system works (or doesn't) is a whole other can of messy worms.
Oh, and thanks for the info on the neuro stuff.

 

[AcronymAllergy]

There were also some changes in ADHD with respect to the age of onset criteria (thankfully, considering the original one never had any empirical support). Additionally, the criteria are slightly different for folks who're 17+ in terms of both symptom counts and type (where they at least tried to capture some of the more executive-oriented deficits).

And yes, it all might end up being a moot point in a year and a half when things switch over to the ICD-10.

 

[perhaps11]

To my knowledge, the updated version also states that someone does not have to experience fear or any other intense emotions DURING the traumatic event to meet criteria for PTSD.

 

[WisNeuro]

To my knowledge, the updated version also states that someone does not have to experience fear or any other intense emotions DURING the traumatic event to meet criteria for PTSD.

That was actually the one move that was backed up by the research. The A2 criterion of PTSD was a terrible predictor of symptom development.

 

[futureapppsy2]

Oh they made a much more significant change to PTSD than that. Now someone has only to "learn" of a traumatic event to a loved one to qualify. PTSD will become the disability du jour because of that change.

As for as neuro stuff, we can just classify something as minor or major neurocognitive disorder. Did away with dementia as a label prett ymuch, although you can still classify suspected etiology in the subtyping.

I've seen a lot of outrage over this particular change, but I don't get it, tbh. There's plenty of research demonstrating that intense, vicarious experiences can be traumatizing (see, for example, the research showing that parents whose children have cancer show more PTSD symptomotology than their children or the research on parents who have infants in the NICU), and it specifically excludes most media exposure, so it's not like you can just say "oh, yeah, was watching CNN, now have PTSD."

On another note, an issue that we've seen in our clinic is that the new ASD criteria basically leave us with no way to diagnosis children with intense fixated interests and repetitive behaviors but no real language impairment.

 

[erg923]

I recently asked a presenter why they did not just rename PTSD since we are now trying to conceptulize its presentation as being so hetergenous.

For PTSD variants/presentation that is less fear based, it seems like "depressive disorder with post-traumtric reaction/origion" or something like that would be much more informative.

 

[WisNeuro]

I've seen a lot of outrage over this particular change, but I don't get it, tbh. There's plenty of research demonstrating that intense, vicarious experiences can be traumatizing (see, for example, the research showing that parents whose children have cancer show more PTSD symptomotology than their children or the research on parents who have infants in the NICU), and it specifically excludes most media exposure, so it's not like you can just say "oh, yeah, was watching CNN, now have PTSD."
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I don't think these are great examples of how bad the change is. In your examples, you are still directly experiencing the the potential loss of a loved one. The new criteria allows just learning that a close friend or relative was in a traumatic event. In a hypothetical example, say my best friend was in a car accident, had some serious injuries, but fully recovered. I can now qualify for PTSD. There is no good research for this type of PTSD, and it opens up the door for a multitude of frivolous disability claims.

 

[perhaps11]

Anecdotally, I have known of clinicians who worked in trauma clinics (e.g. VA PTSD clinics) and began experiencing PTSD symptoms after hearing in great detail, day in and day out, about these horrific events experienced by their clients. Not saying this justifies such a huge change to the DSM (without much research backing it up), but apparently, it does happen. In any case, there should be a clear, definitive line drawn by the APA as to what qualifies as "PTSD-by-association" and whether or not such a diagnosis truly falls within the same construct as PTSD experienced by individuals who experienced trauma directly. As it stands now, I do not agree with this specific change to the criteria.

 

[WisNeuro]

Well, there are those that would even do away with PTSD as a whole (Spitzer, Rosen, McHugh) and characterize it more as an expression of other disorders. And yes, "trauma fatigue" is interesting and I have seen people exhibit time limited symptoms, but I have never seen anyone develop the full spectrum for the time required for a full blown diagnosis.

 

[southernpsych7]

Long time reader, first time poster. Admittedly this is an area that I have a research and clinical interest, so it drew me out.
Many of the points that have been brought up (particularly about Criterion A) were discussed during the refinement of PTSD for DSM-5. Is anything perfect.. no.. but in this instance I believe they got this right. I would have still liked something speaking more to complex trauma but hey, change doesn't happen overnight.

As noted previously, there was not much debate about DSM-IV criterion A2 being removed, the research seemed solid on that. As for opening up the perceived definition of a "traumatic event", I ask you to please re-read DSM-5 criteria, the examples and notations are pretty specific. For example, the notation following A4 that noted that exposure should not have occurred through electronic media unless job related. The foundation of A4 (as I understand it) was borne out of much of the first responder research. I think anyone who has worked with medics, trauma surgeons, and paramedics can appreciate this expansion (where this "trauma" did not always fit under DSM-IV). There are valid concerns of A3 as I think this is the criterion most upon to mis or reinterpretation. I think a major threat here is that this can be lumped in with acute bereavement reactions (the bereavement vs. depression discussion is for another day). The "this will open up disability claim" argument I view as a red herring at this time. As having discussed with my lawyer friends, PTSD is already thrown around in the disability world. I have not seen any evidence that these changes would/are increasing this yet. I am open to changing this opinion when the research supports it.
As for the restructuring of system clusters, I think many people will agree that this was helpful for having a clearer clinical picture of what "PTSD" is made out of. Note that in DSM-IV you could meet PTSD criteria without avoidance symptoms (which were lumped in more depressive symptoms).
Since I have observed some of the posters on this board prefer to have empiricism be part of the debate (which I note I have not seen yet in this thread) please consider Kilpatrick, et al. 2013 (http://onlinelibrary.wiley.com/doi/10.1002/jts.21848/full)

 

[WisNeuro]

. The "this will open up disability claim" argument I view as a red herring at this time. As having discussed with my lawyer friends, PTSD is already thrown around in the disability world. I have not seen any evidence that these changes would/are increasing this yet. I am open to changing this opinion when the research supports it.

Context is everything. In the VA system, it has historically been much harder to get a PTSD SC if they were never in a combat zone, this was something that could be verified in the C-file. Now, there are technically no limitations considering almost every Veteran has a friend who was deployed at some point even if they were not.

As you said, the A2 change makes sense because the research was pretty clear on it. The A3 change, as far as my knowledge of the literature, does not have the same empirical foundation at all.

I'm fine with the leaving out of Complex PTSD. Sparse literature and little has been done to differentiate it from simply being PTSD in individuals with cluster B traits.

 

[southernpsych7]

I agree context is important (I shy away from "everything", sorry, I am CBT through and through). The context I work in is also the VA system. In this context, SC will always be an issue, no matter the criteria for a diagnosis (particularly PTSD). The concern I seem to hear from researchers/clinicians on this issues is that it is "adding more people to the pot" that experience a criterion A trauma (see previous article I posted) . What we must keep in mind (and I hope VA clinicans in particularly remember with a higher proportion of trauma exposure in this mileu) is that exposure alone does not constitute PTSD. Most people will experience a "trauma" in their lifetime but most people will not develop PTSD (if they are being honest). In focusing in on criterion A we sometimes forget B-H must also be met (which hopefully a thorough albeit probably short/pressured C&P exam can establish). There will always be the person who is SC-seeking, who is going to present in anyway possible to attain their desired goal. Does this open a door to them that is harder to verify through record review? Probably. Do C&P psychologists have time for a MMPI-2 or PAI, No. So I understand the skepticism, but I want to wait to see what happens. If service connection rates sky rocket and it can be tied to a change in diagnostic criteria (and not because we have a new era of veteran entering the VA)... Then I will be right there with everyone. But we don't that evidence ... yet...

 

[WisNeuro]

No, not yet. There hasn't been enough time for this to play out. It's just worrisome given the lack of adequate justification for the change IMO. I don't believe the rise will be all that noticeable given the rates of people getting connected for "traumatic brain disease" in the absence of any actual brain damage.

Luckily, it's still a small percentage of the overall Veteran population, but, just like the general population with regards to disability, there will always be the few that take advantage of system and soak up valuable time, money, and resources. I just see this as another way to achieve that goal without actually doing anything to help those who truly need it.

 

[perhaps11]

And I have seen the problem on the other side of things - where us clinicians (I also work in the VA system) diagnose military-related PTSD that we feel should absolutely qualify for some SC, but the vet gets denied. Other times we do not believe military-related PTSD is an appropriate diagnosis for a vet and yet for some reason they end up receiving SC. You'd think that the C&P psychologists would do some sort of effort testing, but at least in my VA, this does not happen. So what's with the disconnect in clinical opinion?

 

[WisNeuro]

And I have seen the problem on the other side of things - where us clinicians (I also work in the VA system) diagnose military-related PTSD that we feel should absolutely qualify for some SC, but the vet gets denied. Other times we do not believe military-related PTSD is an appropriate diagnosis for a vet and yet for some reason they end up receiving SC. You'd think that the C&P psychologists would do some sort of effort testing, but at least in my VA, this does not happen. So what's with the disconnect in clinical opinion?

Yeah, the C&P thing is dicey since examiners vary wildly in their methods. We have one we call the "stamper." I've read his reports and it's ridiculous what he accepts. We have other examiners who actually do SVT/PVT testing, the failure rate is exorbitantly high. But even that is dicey. You probably have several categories that include frank malingers, those with actual symptoms who think they have to exaggerate it to get noticed, and a small number of false positives.

No easy answer for a somewhat broken system.