How is post-traumatic stress disorder defined today, and why has it been a moving target?
When the American Psychiatric Association published its first Diagnostic and Statistical Manual of Mental Disorders in 1952, what we now know as PTSD was called "stress response syndrome." It wasn't until 1980 that the organization officially added the term PTSD to the psychiatric lexicon.
Criteria for PTSD remain in flux as the diagnostic manual now enters its fifth reworking.
Under the old definition, in order to qualify for the diagnosis, a person's response must have involved "intense fear, helplessness, or horror." That criterion is missing from the proposed DSM-V.
Dr. Matthew J. Friedman, executive director of the Department of Veterans Affairs' National Center for PTSD, likes to think of the revision process in the same way he views the evolution of our laws.
"It's a living construct," says Friedman, a professor of psychiatry at Dartmouth Medical School and member of the anxiety disorder working group for DSM-V. "It's constantly changing as new scientific information pours in."
So fast, indeed, that regulators sometimes have a hard time keeping up.
The VA is considering a rule change that would make it easier for noncombat troops to qualify for PTSD benefits. The proposed regulation, published in August, still cites the old "fear, helplessness, or horror" requirement.
Other proposed changes in the diagnostic criteria would lower the threshold for PTSD.
For instance, under the old definition, a person must have "experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." Under the proposed revision, it would be enough if a person "learned" that a traumatic event had occurred to a close friend or relative or had experienced "repeated or extreme exposure to aversive details of the event(s)" — such as a police officer "repeatedly exposed to details of child abuse."
None of this changes the fact that, as a constellation of self-reported symptoms, PTSD is very subjective.
"We don't have a laboratory test for PTSD," says Bruce Dohrenwend, a psychiatric epidemiologist at Columbia University and part of a team that re-examined results of the landmark National Vietnam Veterans Readjustment Study, which helped introduce the term PTSD to the masses.
Still, the challenge of diagnosing the disorder remains. In 2008, Dr. Norma Perez suggested in an e-mail to staff at the VA hospital in Temple, Texas, that they "refrain from giving a diagnosis of PTSD straight out." Perez, a clinical psychologist and leader of the PTSD treatment team there, felt the staff lacked the "time to do the extensive testing that should be done to determine PTSD," and asked employees to "consider a diagnosis of Adjustment Disorder, R/O (rule out) PTSD."
A probe by the VA's inspector general determined there was no intent to misdiagnose, though some veterans' groups accused the federal government of clamping down on PTSD in order to save money.
Maj. C. Alan Hopewell, an Army neuropsychologist and head of the Traumatic Brain Injury Clinic at Fort Hood, Texas, believes the PTSD diagnosis is "abused and overused."
In nine months with the 785th Medical Company (Combat Stress Control) during the Iraq troop surge, Hopewell and his colleagues saw more than 25,000 patients. Of those he saw for potential PTSD, he estimates that one third were actually troubled by something happening on the home front, and another third had "just general adjustment problems."
"I am the first person to make an accurate diagnosis and to help people have whatever treatment or whatever benefits they deserve," says Hopewell. "When our emphasis is on giving everybody disability, it creates people who HAVE disabilities."