PhD/PsyD PTSD diagnosis and Criterion A

[EnPsychlopedia]

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I would highly encourage you to read David Healy's History of Mania for a counter opinion.

Thanks for the recommendation. For context, I am mostly referencing a Reddit thread where someone is claiming Criterion A for PTSD only exists because insurance and pharmaceutical companies want it to exist as a way to prevent helping people.

 

[ForensicPsychFightClub]

Any tips on differentiating between PE and CPT based on client's presenting concerns or other characteristics?

VA folks are going to have better insight since they use a whole decision matrix. But, I do a whole lot of trauma assessment and have gathered pieces from their decision matrix, professional organizations like AAFP and ISTSS, and trauma research.

From my understanding, you kind of make the decision based on what is the central and driving symptom in someone’s trauma case conceptualization: Avoidance, à la Criterion C, some Criterion E, and downstream/associated consequences like substance abuse - that’s best treated through exposure, and thus PE. If you are working with someone and you think the lynchpin issue that can explain much of their trauma symptomatology and functional impairment is an ingrained need to avoid, exposure is the way.

CPT is used when the lynchpin issue are more criterion D issues - entrenched negative beliefs, emotion dysregulation, a malaise-like state devoid of many positive emotions, and the strong presence of guilt, worthlessness, and self-blame. Some downstream consequences can be phenomological overlap with depression or an entrenched sense of hypervigilance making social withdrawal likely. These folks do best in restructuring their views and beliefs and dealing with stuck points to help improve their overall functioning.


I will say I also do recommend DBT-PE at times for folks who have a strong presence of DSO symptoms, including pervasive emotion dysregulation leading to significant consequences, interpersonal conflicts, and identity disruption. Anecdotally i also see a lot of suicidality and unrelenting crisis in folks who really need DBT-PE. I do recommend it cautiously as it is quite long and intensive - like, most often at least 20 sessions of DBT is recommended even before PE is integrated, so it is a year-plus therapy course for many.

Those are my thoughts but i am happy to be schooled by someone more in the know.

 

[R. Matey]

Thanks for the recommendation. For context, I am mostly referencing a Reddit thread where someone is claiming Criterion A for PTSD only exists because insurance and pharmaceutical companies want it to exist as a way to prevent helping people.

Yeah, totally fair. And a really important caveat to this conversation. I was thinking about it after I posted that but got busy, etc. IME, many master's level and FPPS psychologists repeat dumb versions of legitimate critiquesof psychiatry because they do not truly understand the research and the major players. They just read/hear the critiques and repeat them. There isn't some cabal of pharma/insurance plutocrats dictating the DSM criteria to committee members, but it also would be naive to assume that big pharma has no stake in psychiatric research.

With the context in mind, they're likely repeating what they read in TBKTS or heard repeated to them by someone who read it. VDK devoted an entire chapter in that book to whining about how Spitzer purportedly comissioned him to do a field trial of DPD (or what has come to be called CPTSD) only to reject the criteria later. He specifically whines about criterion A. He includes the rejection letter in the book, which to me sounded entirely reasonable. Basically, lots of people have traumatic childhoods, which can manifest in various forms of psychopathology and the criteria of DPD are nonspecific. There was also concern that DPD lacks any meaningful discriminate validity from BPD.

 

[Fan_of_Meehl]

Yeah, totally fair. And a really important caveat to this conversation. I was thinking about it after I posted that but got busy, etc. IME, many master's level and FPPS psychologists repeat dumb versions of legitimate critiquesof psychiatry because they do not truly understand the research and the major players. They just read/hear the critiques and repeat them. There isn't some cabal of pharma/insurance plutocrats dictating the DSM criteria to committee members, but it also would be naive to assume that big pharma has no stake in psychiatric research.

With the context in mind, they're likely repeating what they read in TBKTS or heard repeated to them by someone who read it. VDK devoted an entire chapter in that book to whining about how Spitzer purportedly comissioned him to do a field trial of DPD (or what has come to be called CPTSD) only to reject the criteria later. He specifically whines about criterion A. He includes the rejection letter in the book, which to me sounded entirely reasonable. Basically, lots of people have traumatic childhoods, which can manifest in various forms of psychopathology and the criteria of DPD are nonspecific. There was also concern that DPD lacks any meaningful discriminate validity from BPD.

In these contexts I think it's always useful to bear in mind that virtually EVERY single mental health disorder in the DSM/ICD is viewed through a diathesis-stress model/lens and that this isn't unique to trauma- and stressor-related disorders. If we do away with boundaries to Criterion A (which some people are proposing with a straight face) then we are basically arguing PTSD out of existence/meaningfulness as a distinct disorder. "Bad things happened to me, f$%$##@ed me up" model applies, arguably, to every mental disorder in existence--to say nothing of the issue of multifinality as applied, even, to clear Criterion A events.

I've been impressed by how much we've deviated in recent years from a stance of being appropriately critical of the PTSD construct to simply accepting it wholesale as applying to nearly everyone and explaining nearly everything all the while maintaining that society somehow suffers from a "lack of awareness" of PTSD/trauma. Go to Amazon and do a search for "ptsd" and sort by "most recent."

There was a 2007 special issue of Journal of Anxiety Disorders that makes for some fascinating reading on some of the very real critiques of the PTSD construct. Though somewhat outdated, the more central critiques have yet to be substantially addressed in the clinical and scientific literature...they just appear to have become extremely unpopular to raise or consider, passe, or taboo for what I believe are almost entirely arbitrary sociocultural/ideological reasons. Basically, it's 'mean, bad, uncaring, unempathetic or uncool' to critique the PTSD construct these days. However, that kind of thinking is leading to a resurgence of the whole DID/MPD, trauma-dissociation, dissociative amnesia, 'memory wars 2.0,' Breuer/Charcot, Jason Bourne model of trauma where "the body keeps the score."

 

[WisNeuro]

In these contexts I think it's always useful to bear in mind that virtually EVERY single mental health disorder in the DSM/ICD is viewed through a diathesis-stress model/lens and that this isn't unique to trauma- and stressor-related disorders. If we do away with boundaries to Criterion A (which some people are proposing with a straight face) then we are basically arguing PTSD out of existence/meaningfulness as a distinct disorder. "Bad things happened to me, f$%$##@ed me up" model applies, arguably, to every mental disorder in existence--to say nothing of the issue of multifinality as applied, even, to clear Criterion A events.

I've been impressed by how much we've deviated in recent years from a stance of being appropriately critical of the PTSD construct to simply accepting it wholesale as applying to nearly everyone and explaining nearly everything all the while maintaining that society somehow suffers from a "lack of awareness" of PTSD/trauma. Go to Amazon and do a search for "ptsd" and sort by "most recent."

There was a 2007 special issue of Journal of Anxiety Disorders that makes for some fascinating reading on some of the very real critiques of the PTSD construct. Though somewhat outdated, the more central critiques have yet to be substantially addressed in the clinical and scientific literature...they just appear to have become extremely unpopular to raise or consider, passe, or taboo for what I believe are almost entirely arbitrary sociocultural/ideological reasons. Basically, it's 'mean, bad, uncaring, unempathetic or uncool' to critique the PTSD construct these days. However, that kind of thinking is leading to a resurgence of the whole DID/MPD, trauma-dissociation, dissociative amnesia, 'memory wars 2.0,' Breuer/Charcot, Jason Bourne model of trauma where "the body keeps the score."

To add to this, there's an interesting interplay between development of PTSD and expectancy effects. Arising from the CISD lit and things following and related to that line of inquiry, we know that expectancy effects following a traumatic event greatly influences whether or not someone develops PTSD. This increase in "awareness" that coincides with telling everyone that they have trauma and that trauma will lead to negative effects, is likely leading to actually causing negative symptoms in individuals who otherwise would have responded with a modal; recovery trajectory. The midlevel community is generally shockingly ignorant of iatrogenesis, much to the detriment of their patients.

 

[cara susanna]

Ahh, such interesting discussions since I last read this thread!

Any tips on differentiating between PE and CPT based on client's presenting concerns or other characteristics?

One of the biggest things that we emphasize in the PTSD treatment world is patient agency, so the best treatment is the one that they choose. The VA calls it 'shared decision making," where you sit down with the patient, answer questions that they might have, explain the recommendations and options (this is when I also discuss the CPG and what the recommendations mean), and then have a discussion that results in their deciding. Sometimes patients ask me to choose for them, and I explain to them that research shows that they will generally do better if they choose the treatment rather than me choosing for them. Of course, there are some exceptions: if you don't have a clear trauma memory, PE and WET are out and you need to default to CPT. When explaining CPT vs. PE and WET to patients, I also tell them that CPT has more flexibility in terms of the index event and what to focus on in session. You choose an overall index event, but you can still work on things like current stressors and other negative past experiences that have impacted beliefs. That can be really nice with patients who have complex trauma and have trouble narrowing it down, or have ongoing stressors that are contributing to their issues. PE and WET, on the other hand, you have to pick a memory and stick with it, with not a lot of room to discuss other things.

The National Center for PTSD White Board videos are really awesome to use when discussing treatment options with patients: VA.gov | Veterans Affairs There is also a PTSD Treatment Decision Aid that they can go through on their own to see what treatment might be best for them. PTSD Treatment Decision Aid

To add to this, there's an interesting interplay between development of PTSD and expectancy effects. Arising from the CISD lit and things following and related to that line of inquiry, we know that expectancy effects following a traumatic event greatly influences whether or not someone develops PTSD. This increase in "awareness" that coincides with telling everyone that they have trauma and that trauma will lead to negative effects, is likely leading to actually causing negative symptoms in individuals who otherwise would have responded with a modal; recovery trajectory. The midlevel community is generally shockingly ignorant of iatrogenesis, much to the detriment of their patients.

That makes a lot of sense, especially given what we know about trauma centrality being associated with a poorer response to treatment.

In these contexts I think it's always useful to bear in mind that virtually EVERY single mental health disorder in the DSM/ICD is viewed through a diathesis-stress model/lens and that this isn't unique to trauma- and stressor-related disorders. If we do away with boundaries to Criterion A (which some people are proposing with a straight face) then we are basically arguing PTSD out of existence/meaningfulness as a distinct disorder. "Bad things happened to me, f$%$##@ed me up" model applies, arguably, to every mental disorder in existence--to say nothing of the issue of multifinality as applied, even, to clear Criterion A events.

I've been impressed by how much we've deviated in recent years from a stance of being appropriately critical of the PTSD construct to simply accepting it wholesale as applying to nearly everyone and explaining nearly everything all the while maintaining that society somehow suffers from a "lack of awareness" of PTSD/trauma. Go to Amazon and do a search for "ptsd" and sort by "most recent."

There was a 2007 special issue of Journal of Anxiety Disorders that makes for some fascinating reading on some of the very real critiques of the PTSD construct. Though somewhat outdated, the more central critiques have yet to be substantially addressed in the clinical and scientific literature...they just appear to have become extremely unpopular to raise or consider, passe, or taboo for what I believe are almost entirely arbitrary sociocultural/ideological reasons. Basically, it's 'mean, bad, uncaring, unempathetic or uncool' to critique the PTSD construct these days. However, that kind of thinking is leading to a resurgence of the whole DID/MPD, trauma-dissociation, dissociative amnesia, 'memory wars 2.0,' Breuer/Charcot, Jason Bourne model of trauma where "the body keeps the score."

Do you remember any of the specific critiques that they made? I'm quite curious.

 

[Sanman]

In these contexts I think it's always useful to bear in mind that virtually EVERY single mental health disorder in the DSM/ICD is viewed through a diathesis-stress model/lens and that this isn't unique to trauma- and stressor-related disorders. If we do away with boundaries to Criterion A (which some people are proposing with a straight face) then we are basically arguing PTSD out of existence/meaningfulness as a distinct disorder. "Bad things happened to me, f$%$##@ed me up" model applies, arguably, to every mental disorder in existence--to say nothing of the issue of multifinality as applied, even, to clear Criterion A events.

I've been impressed by how much we've deviated in recent years from a stance of being appropriately critical of the PTSD construct to simply accepting it wholesale as applying to nearly everyone and explaining nearly everything all the while maintaining that society somehow suffers from a "lack of awareness" of PTSD/trauma. Go to Amazon and do a search for "ptsd" and sort by "most recent."

There was a 2007 special issue of Journal of Anxiety Disorders that makes for some fascinating reading on some of the very real critiques of the PTSD construct. Though somewhat outdated, the more central critiques have yet to be substantially addressed in the clinical and scientific literature...they just appear to have become extremely unpopular to raise or consider, passe, or taboo for what I believe are almost entirely arbitrary sociocultural/ideological reasons. Basically, it's 'mean, bad, uncaring, unempathetic or uncool' to critique the PTSD construct these days. However, that kind of thinking is leading to a resurgence of the whole DID/MPD, trauma-dissociation, dissociative amnesia, 'memory wars 2.0,' Breuer/Charcot, Jason Bourne model of trauma where "the body bodycount keeps the score."

Fixed that for you, couldn't resist. That needs to be a movie title.

To add to this, there's an interesting interplay between development of PTSD and expectancy effects. Arising from the CISD lit and things following and related to that line of inquiry, we know that expectancy effects following a traumatic event greatly influences whether or not someone develops PTSD. This increase in "awareness" that coincides with telling everyone that they have trauma and that trauma will lead to negative effects, is likely leading to actually causing negative symptoms in individuals who otherwise would have responded with a modal; recovery trajectory. The midlevel community is generally shockingly ignorant of iatrogenesis, much to the detriment of their patients.

The question becomes how long before the conversation swings back the opposite way? That a certain amount of trauma is normal and going through it does not make you special? Short of a few truly lucky people, bad things happen to everyone, including some level of trauma. Most people still function.

 

[WisNeuro]

1) At what level does the split become financially exploitative/unethical?

2) If employers drive down the salaries of every psychologist, then those numbers will be used to reduce the overall income of every psychologist (i.e., the "F you, I got mine" approach espoused by every 70+ year old psychologist touting AI).

3) APA should probably address the financial exploitation ethics for tuition for programs, at some point.

1) I'm fine with the market regulating itself on this one. Practice owners generally have no special or exclusive trick here. Everything they do, an individual clinician can do for themselves. They don't like the split, go somewhere else or do it yourself. If I were going to hire, I'd be on the higher end of splits to the provider, but that's because I like my reputation and it'd be worth it, personally and financially, to only hire very high quality people, as opposed to quantity at a higher split for me. But, to each their own. People are not forced to accept these positions, and with unemployment rates for doctoral level clinical psychologists being near zero, it's not like they don't have other options.

2) Definitely a possibility, yet a self-inflicted wound

3) I'm always a fan of cracking down on the diploma mills.

 

[WisNeuro]

The question becomes how long before the conversation swings back the opposite way? That a certain amount of trauma is normal and going through it does not make you special? Short of a few truly lucky people, bad things happen to everyone, including some level of trauma. Most people still function.

Good question. I wouldn't imagine it's going to be anytime soon. I think we're going to see the pendulum swing much further into the "everyone's traumatized" and "everyone's disabled" direction before there is a swing back. Which, is unfortunate for those who truly do have PTSD and disability, as it waters down the concept and everyone will be questioned about their legitimate status.,

 

[WisNeuro]

This really mirrors many of the cultural questions we have discussed with regard to sex and race in recent years. Who in society does not have some level of privilege? Similarly, who doesn't have some level of trauma?

Indeed, as with privilege, "trauma" is not a binary variable in practice, though many treat it as such.

 

[Fan_of_Meehl]

Indeed, as with privilege, "trauma" is not a binary variable in practice, though many treat it as such.

Excerpt from a recent article in the Journal of Traumatic Stress by Wolf, Marx, Keane and others:

"These results provide a parsimonious account of the transdiagnostic effects of trauma exposure. Traumatic experiences likely increase the risk for all 'distress disorders' by increasing levels of nonspecific negative emotionality."

They're even flirting with the idea of a 'trauma-related specifier' one could tack on to primary diagnoses in that domain (MDD, GAD, PDD) rather than having a separate standalone PTSD category.

 

[futureapppsy2]

Excerpt from a recent article in the Journal of Traumatic Stress by Wolf, Marx, Keane and others:

"These results provide a parsimonious account of the transdiagnostic effects of trauma exposure. Traumatic experiences likely increase the risk for all 'distress disorders' by increasing levels of nonspecific negative emotionality."

They're even flirting with the idea of a 'trauma-related specifier' one could tack on to primary diagnoses in that domain (MDD, GAD, PDD) rather than having a separate standalone PTSD category.

I get where this is coming from, but it seems like it's ignoring a lot of PTSD-specific symptoms and also that this would firmly entrench the idea of "justified v. unjustified" or "sympathetic v. unsympathetic" mental illness.

 

[aim-agm]

One way I explain why Criterion A is so important is that the same presentation can represent different conditions depending on what caused it.
For example:
If you fracture hip by falling out of a tree, we don't suspect a larger problem with your skeletal system.
If you fracture your hip by falling to the floor, we worry about osteoporosis.
If you fracture your hip by standing up, we worry about cancer (with osteolytic bone mets)


If you experience an extreme event (i.e. Criterion A event) and develop an extreme response congruent with that event (i.e. Criteria B-F), then (to oversimplify) your problem is a product of the trauma.
If you don't experience an extreme event but still experience those symptoms, you have a different problem (even if the expression of that problem is influenced by a non-Criterion A event).

 

[Fan_of_Meehl]

One way I explain why Criterion A is so important is that the same presentation can represent different conditions depending on what caused it.
For example:
If you fracture hip by falling out of a tree, we don't suspect a larger problem with your skeletal system.
If you fracture your hip by falling to the floor, we worry about osteoporosis.
If you fracture your hip by standing up, we worry about cancer (with osteolytic bone mets)


If you experience an extreme event (i.e. Criterion A event) and develop an extreme response congruent with that event (i.e. Criteria B-F), then (to oversimplify) your problem is a product of the trauma.
If you don't experience an extreme event but still experience those symptoms, you have a different problem (even if the expression of that problem is influenced by a non-Criterion A event).

Agree. Exact same logic Richard McNally argues regarding background-foreground inversion.

To the extent that you have someone exhibiting serious psychopathology consistent with 'PTSD' due to non-criterion A stressors, then those non-stressor factors (e.g., personality dysfunction, other vulnerability factors) advance into the 'causal foreground' in terms of explaining the symptoms while the putative 'traumatic events' recede into the 'causal background.'

I like the way you put it, though. It's a lot easier to explain.

 

[EnPsychlopedia]

If you experience an extreme event (i.e. Criterion A event) and develop an extreme response congruent with that event (i.e. Criteria B-F), then (to oversimplify) your problem is a product of the trauma.
If you don't experience an extreme event but still experience those symptoms, you have a different problem (even if the expression of that problem is influenced by a non-Criterion A event).

This is an interesting way to frame it. I don't have any radical opinions on Criterion A except that I am in favor of the "Keep but maybe moderately expand" camp. This perspective might make me return to the "Keep as is" camp.

That said, I wonder what you think about the argument that PTSD is the only DSM disorder (not counting neurodevelopmental, intellectual, and cognitive disorders) for which we have an etiological or index event criterion. (Maybe prolonged grief fits this definition?) We don't require that someone have an index event to explain a specific phobia, or eschew an MDD diagnosis because the symptoms appear to be driven by some one cause rather than another. I guess it's arguable that PTSD is just different because the construct demands it to be different, but I can also somewhat understand the perspective of folks who say that someone who has the same sx without the Criterion A event should be conceptualized as having the same diagnosis.

 

[aim-agm]

This is an interesting way to frame it. I don't have any radical opinions on Criterion A except that I am in favor of the "Keep but maybe moderately expand" camp. This perspective might make me return to the "Keep as is" camp.

That said, I wonder what you think about the argument that PTSD is the only DSM disorder (not counting neurodevelopmental, intellectual, and cognitive disorders) for which we have an etiological or index event criterion. (Maybe prolonged grief fits this definition?) We don't require that someone have an index event to explain a specific phobia, or eschew an MDD diagnosis because the symptoms appear to be driven by some one cause rather than another. I guess it's arguable that PTSD is just different because the construct demands it to be different, but I can also somewhat understand the perspective of folks who say that someone who has the same sx without the Criterion A event should be conceptualized as having the same diagnosis.

The larger category is "Trauma- and Stressor-Related Disorders", each of which require a "index" precipitant. If someone has PTSD symptoms but in response to a non-Criterion A event you could consider it as an "other specified trauma- and stressor-related disorder", which may or may not respond to the same treatments. But yes, the disorders caused by events require events.

But think about it: many disorders are conceptualized as a product of something else. I don't just mean things like substance-relatef disorders.* If someone has poor sleep and this is causing low energy (because they are tired), impaired concentration (because they are also deprived), low interest in activities (because they are tired), and appetite changes (because sleep impairment has hormonal effects) we don't say that they have MDD even though they have 5 of the SIGECAPS symptoms, because these symptoms are not the product of depressed mood.


*: Writing this, the thought struck me that having PTSD syndrome without a Criterion A event is like having cravings for a substance with no history of use. It can happen, but it represents a different condition.

 

[cara susanna]

I’ve mentioned before that I’m in the camp of expanding it. Criterion A shouldn’t be the go-no go if we have research which suggests that ambiguous experiences that do not clearly meet Criterion A do not differ in any symptom cluster, effective treatment, or prognosis with those that clearly do. However, that same research contends that there is a significant difference between clear Criterion A and those that do not meet it in terms of trauma symptomatology. So it serves a role, but the dogma is it - as is - is the role. Like without it, it ain’t trauma. That’s too narrow minded IMO.

A2 was stripped from the IV under the belief it is was too subjective, which i think is crappy rationale from a medical community which espouses rigorous inclusion/exclusion standards. “It feels too subjective” is, IMO, just a vibes thing.

Anyway, in other news, finally some definitive recent proof that should hopefully kill the myth of “PhD is for research, PsyD is for clinical” stuff. Particularly the camp that asserts you somehow get more intervention experience in a PsyD.

But symptoms in relation to non-Criterion A events DON'T respond as well to PTSD treatment, at least CPT. Also, A2 wasn't stripped because it was too subjective, but because it didn't actually predict anything.

I am a big believer in keeping Criterion A because my concern is that, if we call everything trauma, we risk losing the original meaning. Like, being cheated on is incredibly stressful and negatively impactful, but it's not the same sort of acute experience as almost getting killed or being sexually assaulted, etc. Even the "learning about a loved one" expansion FEELS different when you're doing treatment, imo.

Here is my favorite article on the subject of Criterion A, btw: https://pubmed.ncbi.nlm.nih.gov/38123526/

 

[Fan_of_Meehl]

This is an interesting way to frame it. I don't have any radical opinions on Criterion A except that I am in favor of the "Keep but maybe moderately expand" camp. This perspective might make me return to the "Keep as is" camp.

That said, I wonder what you think about the argument that PTSD is the only DSM disorder (not counting neurodevelopmental, intellectual, and cognitive disorders) for which we have an etiological or index event criterion. (Maybe prolonged grief fits this definition?) We don't require that someone have an index event to explain a specific phobia, or eschew an MDD diagnosis because the symptoms appear to be driven by some one cause rather than another. I guess it's arguable that PTSD is just different because the construct demands it to be different, but I can also somewhat understand the perspective of folks who say that someone who has the same sx without the Criterion A event should be conceptualized as having the same diagnosis.

But symptoms in relation to non-Criterion A events DON'T respond as well to PTSD treatment, at least CPT. Also, A2 wasn't stripped because it was too subjective, but because it didn't actually predict anything.

I am a big believer in keeping Criterion A because my concern is that, if we call everything trauma, we risk losing the original meaning. Like, being cheated on is incredibly stressful and negatively impactful, but it's not the same sort of acute experience as almost getting killed or being sexually assaulted, etc. Even the "learning about a loved one" expansion FEELS different when you're doing treatment, imo.

Here is my favorite article on the subject of Criterion A, btw: https://pubmed.ncbi.nlm.nih.gov/38123526/

I just can't even wrap my head around the logic of arguing we should remove the requirement of having experienced trauma from the criterion set of a 'postTRAUMATIC stress disorder.' Wouldn't you at least have to change the name to something like 'postEVENT stress disorder?' Which would pretty much imply an un- or other-specified trauma/distress-related disorder which--in effect--eliminates PTSD, per se, from the DSM.

A FUNDAMENTAL issue with PTSD as a diagnosis is that it moves beyond the task of scientific DESCRIPTION and into the realm of scientific EXPLANATION (theory, etiology, causality) in ways that other categories that are nosologically-adjacent and extremely similar in their cross-sectional (descriptive) symptom profiles (MDD, GAD) do not.

Scientific description vs. explanation are two entirely different tasks/paradigms. The PTSD diagnosis, if rendered properly, requires a much higher level of inference (causal inference) as compared to the other disorders. Therefore, its definitional boundaries as well as its implementation in individual cases will always be bedeviled by issues beyond those applying to other disorders in the DSM framework. As long as it exists near to its current form it will always be problematic to apply.

 

[ForensicPsychFightClub]

But symptoms in relation to non-Criterion A events DON'T respond as well to PTSD treatment, at least CPT. Also, A2 wasn't stripped because it was too subjective, but because it didn't actually predict anything.

I am a big believer in keeping Criterion A because my concern is that, if we call everything trauma, we risk losing the original meaning. Like, being cheated on is incredibly stressful and negatively impactful, but it's not the same sort of acute experience as almost getting killed or being sexually assaulted, etc. Even the "learning about a loved one" expansion FEELS different when you're doing treatment, imo.

Here is my favorite article on the subject of Criterion A, btw: https://pubmed.ncbi.nlm.nih.gov/38123526/

Oh, I agree. I am not arguing for removing some sort of traumatic event as a prerequisite. I do inherently believe the diagnosis is related to maladaptive responses following an intense fear reaction, so you take the fear out, you are talking about a different thing entirely. I also like the Marx article and am not in the camp that criterion A should be entirely subjective.

But, I do find myself swayed by the arguments listed by Marx for expanding it, along with many articles like this one , this one, or this one, among others , which have continually found that significantly impactful and distressing experiences which run close to, but do not exceed, criterion A - there’s no difference. In symptom severity, impairment, or course. This, to me, falls short of the current conceptualization of criterion A - as the gatekeeper. If A2 didn’t predict anything, what do we call this when A is not seeming to be the arbiter of what is trauma and what isn’t - at least as currently written? The argument is always “If we take away Criterion A, then what are we even talking about when it comes to trauma?” which is sort of the nuclear option. Criterion A could be expanded or reworked without scrapping it entirely.

I’ve also just seen, worked with, and assessed many cases with these ambiguous cases to say that when people come with full criteria, but they went through, say, significant workplace sexual harassment, racial discrimination involving life threats, a person who watched their loved one die an agonizing death from Stage 4 stomach cancer but it took two weeks for them to die instead of suddenly and “unexpectedly”, of a sexual relationship where the person was a 12 year old abused by thier teacher who beleived it was consensual at the time and only later labeled their experiences as statutory rape - all of those fall outside of the bounds of Criterion A, as currently written. So the thinking would be that these people can’t meet criteria for PTSD no matter what symptoms they are found to have, even if they had most or all of them. That just seems strange to me and would only line up if lacking clearly meeting Criterion A predicted something clinically - either their symptom acuity, prognosis, or effective treatment. But it doesn’t seem like it would, based on my view of the research.

I do want to say for posterity that professionally, I stick to how Criterion A is written and do not go beyond it. This is my personal opinion, but I do believe professionally we have an obligation to stick to the prevailing opinion of the field, and what is in the DSM.

 

[R. Matey]

A FUNDAMENTAL issue with PTSD as a diagnosis is that it moves beyond the task of scientific DESCRIPTION and into the realm of scientific EXPLANATION (theory, etiology, causality) in ways that other categories that are nosologically-adjacent and extremely similar in their cross-sectional (descriptive) symptom profiles (MDD, GAD) do not.

You could make an argument for implicit causality in MDD and GAD. In an MDE, criterion A notes that items 1 or 2 must be present for the remaining vegetative symptoms to be valid indicators (similar to what @aim-agm said upthread). In GAD, criteria A and B are implicitly casual to arousal symptoms in criterion C. These are some of the many reasons why interpreting the PHQ-9 and GAD-7 total scores is fraught. Sure, they may all load on the same factor (provided you don't introduce convergent validity items or impose an oblique rotation) and that's all fine and good so long as we don't really care too much about predictive validity.

 

[futureapppsy2]

I split the Criterion A discussion into its own thread.

 

[PsyDr]

IMO:
1) PTSD is important from a medicolegal perspective, as it is one of the few diagnoses that requires a cause. Societal narratives rely upon a cause. Potentially, there is no cause. However, the social narrative structure will provoke the question, "so what causes that?".
2) The natural history of PTSD seems to be recovery. Without permanence, you can claim disability. There's a LOT of people whose income depends on the idea that PTSD is permanent. Cultures have crumbled when military aged men have limited income options.
3) The incidence of PTSD symptoms in individuals without Criterion A events compared to individuals who experience a Criterion A event= the potential that the symptoms are an exacerbation of trait neuroticism.


No one wants to know. It's better to say that someone's symptoms were caused by XYZ. There is a social reason why CBT for AUD is evidence based, yet the self medication hypothesis persists.

 

[EnPsychlopedia]

I’m not suggesting we remove Criterion A. I’m firmly in the pro-Criterion A camp. Of course there must be traumatic events for a trauma disorder. I’m simply saying that there are potentially compelling arguments for expanding it. It’s my understanding that there’s good evidence that events can cause all the PTSD symptoms while not meeting the threshold for Criterion A.

 

[PsyDr]

I’m not suggesting we remove Criterion A. I’m firmly in the pro-Criterion A camp. Of course there must be traumatic events for a trauma disorder. I’m simply saying that there are potentially compelling arguments for expanding it. It’s my understanding that there’s good evidence that events can cause all the PTSD symptoms while not meeting the threshold for Criterion A.

Not sure if you're referring to me. But:

True, W. R., et al. (1993). "A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms." Arch Gen Psychiatry 50(4): 257-264.

 

[WisNeuro]

A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms

Pitman and colleagues have also looked at this

https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1196/annals.1364.019

 

[EnPsychlopedia]

Not sure if you're referring to me. But:

True, W. R., et al. (1993). "A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms." Arch Gen Psychiatry 50(4): 257-264.

It was not a response to anyone in particular.

 

[DynamicDidactic]

so I do not spend a lot of cognitive energy, what am I supposed to take away from the 2 studies cited by @PsyDr and @WisNeuro ?

no evidence that shared environment contributes to the development of posttraumatic stress disorder symptoms

latter abnormalities represent antecedent, familial vulnerability factors for developing chronic PTSD upon exposure to a traumatic event.

Is it that PTSD is much more about underlying (e.g., genetic, biological) factors rather than an event of some sort? 😕

Also, what thread has this been separated out of?

 

[PsyDr]

so I do not spend a lot of cognitive energy, what am I supposed to take away from the 2 studies cited by @PsyDr and @WisNeuro ?





Is it that PTSD is much more about underlying (e.g., genetic, biological) factors rather than an event of some sort? 😕

Also, what thread has this been separated out of?

Some people think that Criterion A should be broadened to anything that hurts your feelings. Presumably that validates feelings.

Some research shows that some demonstrate PTSD symptoms before a Criterion A event. Some research shows that there is a genetic component to who develops PTSD after a Criterion A event.

TL; DR: It's a cluster f of a diagnosis, attributing symptoms to an index trauma is probably wrong, the abbreactive model was discarded 120+ years ago, prince of tides was silly, and we should help people overcome their struggles.

 

[cara susanna]

Some people think that Criterion A should be broadened to anything that hurts your feelings. Presumably that validates feelings.

Some research shows that some demonstrate PTSD symptoms before a Criterion A event. Some research shows that there is a genetic component to who develops PTSD after a Criterion A event.

TL; DR: It's a cluster f of a diagnosis, attributing symptoms to an index trauma is probably wrong, the abbreactive model was discarded 120+ years ago, prince of tides was silly, and we should help people overcome their struggles.

But if they didn't have sx prior to the Criterion A event and now they do, how can we not attribute it?

 

[PsyDr]

But if they didn't have sx prior to the Criterion A event and now they do, how can we not attribute it?

You're asking about the fundamental method of evaluating causation, for which a time based relationship is insufficient.

1) If I didn't have grey hair before I joined SDN, how can I not attribute it?
2) If someone is high on trait neuroticism, and becomes more neurotic after an event: is the event the "cause"?
3) If someone had a BMI of 50+ for 40 years due to excessive caloric intake, was exposed to Agent Orange 50 years ago, and developed DMII, is the Agent Orange the cause?

 

[MCParent]

A thought experiment I would give to my grad students about criterion A.

A person goes to a Halloween spooky house and gets scared out of their wits by some of the stuff there. Every year there are urban legends that x spooky house used real dead bodies. Person and their therapist hear this, think patient saw mutilated dead body (meets criterion a). Pt is dxed with ptsd even though there was no dead body and no criterion a event. But patient is disturbed. Does PE work on the event and symptoms?

Variant. The house actually did contain real dead bodies. Therapist thinks all rumors of that are urban legends. Patient was exposed to real criterion a event but is not dxed and not treated for Sx.

Also related: if the purpose of dx is treatment and not just label slapping, how does expanding criterion a to an event like persistent racism inform treatment? Can you do PE on an event that is going to recur, probably that day?

 

[WisNeuro]

A thought experiment I would give to my grad students about criterion A.

A person goes to a Halloween spooky house and gets scared out of their wits by some of the stuff there. Every year there are urban legends that x spooky house used real dead bodies. Person and their therapist hear this, think patient saw mutilated dead body (meets criterion a). Pt is dxed with ptsd even though there was no dead body and no criterion a event. But patient is disturbed. Does PE work on the event and symptoms?

Variant. The house actually did contain real dead bodies. Therapist thinks all rumors of that are urban legends. Patient was exposed to real criterion a event but is not dxed and not treated for Sx.

Also related: if the purpose of dx is treatment and not just label slapping, how does expanding criterion a to an event like persistent racism inform treatment? Can you do PE on an event that is going to recur, probably that day?

PTSD and concussion/MTBI/PCS are interesting and similar. To a great extent, ones pre-existing mental health sx, trait neuroticism, and their expectations of sxs/recovery soak up a huge amount of variance in sx frequency and severity. They are also both highly compensable, relative to other things, and thus the mere presence of litigation/clear secondary gain adds a substantial amount of more unique variance.

 

[cara susanna]

A thought experiment I would give to my grad students about criterion A.

A person goes to a Halloween spooky house and gets scared out of their wits by some of the stuff there. Every year there are urban legends that x spooky house used real dead bodies. Person and their therapist hear this, think patient saw mutilated dead body (meets criterion a). Pt is dxed with ptsd even though there was no dead body and no criterion a event. But patient is disturbed. Does PE work on the event and symptoms?

Variant. The house actually did contain real dead bodies. Therapist thinks all rumors of that are urban legends. Patient was exposed to real criterion a event but is not dxed and not treated for Sx.

Also related: if the purpose of dx is treatment and not just label slapping, how does expanding criterion a to an event like persistent racism inform treatment? Can you do PE on an event that is going to recur, probably that day?

It's all about reasonable and credible perception, so technically that could meet Criterion A even if they weren't dead bodies.

And, yes, you can do PTSD treatment on an event that is going to recur, even that day. There's a famous study where they delivered CPT to people in the Republic of Congo, which still had ongoing violence. You can also do PTSD treatment with IPV survivors who are still in the IPV situation.

I'm not disagreeing that Criterion A has a lot of flaws and isn't as pretty as it is on paper in real life, but I don't know what PTSD even means if there isn't some sort of "traumatic" event. What are the intrusive symptoms reflecting?