Response to a Rather Chowder Headed Article on PTSD

By Doug Bremner On July 16, 2009 · 11 Comments

This rather chowder-headed article (“PTSD has Unreliable Diagnostic Criteria“) by David Wilson and Peter Barglow has several weak points that I thought I would address. First of all the use of the term “Unreliable”. Reliability in science doesn’t refer to whether or not you can count on your brother-in-law to return the lawn mower he borrowed. It means whether two clinicians will come up with the same diagnosis (Inter-rater reliability) or whether the same diagnosis will come up when the person is assessed at two different time points (test-retest reliability). The authors use the term in neither of these senses, but rather just throw it out there and hope that it sticks to something.

Their first critique is that the diagnosis is based on human judgment and the criteria have changed several times in different versions of the DSM.

Like so what? And isn’t that true for other diagnoses?

The next set up the straw man that there is a high degree of overlap with other mental disorders in terms of symptomatology. As I have written in my book Does Stress Damage the Brain? it shouldn’t be surprising that mental disorders, including depression, borderline personality disorder, dissociative disorders, and depression, that have in common a link to psychological trauma, shouldn’t have overlapping symptomatology. That is why I call them trauma spectrum disorders.

The authors refer to a study of patients being treated with medication for depression where those with and without a history of trauma had similar rates of co-morbid PTSD at 78%. Given the overlap of symptoms between PTSD and depression and the strong link between depression and trauma this really isn’t all that surprising. They cite another study in which healthy college students were divided into those with a DSM defined trauma and those without. The ones in the group without trauma had higher levels of PTSD. A traumatic event is defined in DSM as a threat to self or or personal integrity, or the sudden death or injury of someone close to you, experienced with intense fear, horror or helplessness. Obviously an event like a death of a parent can be very traumatic for a child, even if it doesn’t happen suddenly. In fact, in this second study, 2/3 of the students noted death of a parent or someone close to them as a ‘non-congruent’ trauma. Furthermore the paper did not specify whether the required “fear, horror or helplessness” was assessed, so we have to assume that it wasn’t. These papers were in an issue of the Journal of Anxiety which ran a series of troll-ish articles which I have previously taken on here.

The authors go on to tackle some other non-issues, like the fact that a re-analysis of data from the Vietnam War showed lower rates of PTSD than previous estimates. So what? This was largely because DSMIII did not require functional disability for the diagnosis. There are still 236,000 veterans with PTSD, as we wrote in a letter to the Editor of Science in 2007.

The authors go on to set up the straw man that not all veterans with PTSD can be confirmed to have been in combat. So what? There are other possible traumatic events that occurred in Vietnam, and some may have experienced PTSD from other events. It stands to reason that this could happen in some instances.

The authors go on to claim that cases of PTSD are related to searching for financial gain. To state that all veterans are faking their symptoms to make money is ridiculous. If they don’t like psychiatry, why don’t they go work in a different field?

11 Responses to Response to a Rather Chowder Headed Article on PTSD

Virginia S. Wood, Psy.D. says:

July 16, 2009 at 6:34 am

“Chowder-headed” is charitable.

Any time compensation is an issue, the evaluator will need to assess whether the patient is exaggerating. This is true whether the person is schizophrenic and seeking Social Security benefits or a veteran seeking VA benefits, and no one writes articles suggesting that these other disorders are completely ephemeral. What we do in those situations is not give the schiz or PTSD or whatever diagnosis, but one of the factitious disorders.

Differential diagnosis is a major part of our jobs. And of course there’s some subjectivity to the process. We’re professionals. If it were completely objective, a technician (or a computer) could do it. This is such a bizarre little article. I could understand it coming from a med student who lacks experience and perspective, but the 2nd author, a professor, should know better.

Similarly, coaching occurs in many venues around many diagnoses. Attorneys coach their clients on how to “pass” DUI evals. Attorneys even coach providers on how to fill out the paperwork for their patients’ SSI applications. You can Google “Mental Status Examination” and find sites that coach you to pass (or fail, depending on your point of view) your MSE. So what? You could, following the article to its logical conclusion, invalidate the whole DSM that way.

Furthermore, it is a logical error to conflate co-morbidity with reliability/validity problems. PTSD is a known risk factor for chemical abuse/dependence, for example, and we don’t question whether A&D disorders really exist. Of course they do. Again, you can apply that illogic to any number of clusters of disorders and invalidate most of the DSM. Sometimes it’s hard to distinguish bipolar from schizoaffective–let’s toss them out, too. It can be hard to tell ADHD from bipolar in a child–whoops, there goes another.

Nor does symptom overlap invalidate a diagnosis unless and until it becomes impossible for experts to reliably distinguish patients with one disorder from another. For example, depression as a symptom is present in many disorders, including schizophrenia. That invalidates neither schizophrenia nor the major depressive disorders as diagnoses. They remain reliably diagnosed as independent syndromes. It is not possible, nor would it be desirable, to require that each and every diagnosis be completely different from every other any more than it would be to insist that if more than one medical diagnosis has “fever” in its criteria that they are somehow unreliable.

Finally, it is 7:08 a.m. in my zone, and I have to get ready for work. So I don’t have time to check their reference list just now. A brief scan of the reference list, however, reveals that (a) they are totally ignoring massive amounts of excellent research into PTSD and (b) what they do cite is oddball stuff out of the mainstream of PTSD work. Only two appear to be from reputable peer-reviewed journals; one, for heaven’s sake, is from an “alternative” publication.

No, wait, one more thing; the issue of non-traumatized (by DSM definitions) PTSD sufferers would seem to indicate a problem with the first criteria, not the diagnosis as a whole. Clinicians have long noted (and complained) that the definition of trauma is too restrictive. That is perhaps as much a political issue as a scientific one: Snorts of derision accompanied early attempts to apply the diagnosis to rape survivors. That was a combat veteran’s diagnosis, and nobody else was to be allowed to tread on that sacred ground.

I treat a lot of PTSD and so really appreciate your calling our attention to this. It’s a very odd little piece, and I’m wondering if it’s a first salvo in some kind of campaign to tinker with the diagnosis in DSM-V.
Virginia S. Wood, Psy.D. says:

July 16, 2009 at 6:41 am

P.S. Trauma does change brain chemistry and the authors toss that off as if it had turned out not to be true. There is plenty of research, much of it by VA itself, to support that. That is what is behind such vegetative signs in PTSD as changes in sleep/dream patterns, exaggerated startle responses, and so forth.
Dan says:

July 16, 2009 at 7:28 am

As a veteran from the Navy and Marine Corps myself, these idiots suggesting a veteran would fake PTSD for financial gain pisses me off, quite frankly.

Most ex-military have more honor and integrity than your average middle class citizen. And, more honesty and character as well.

I’ll be happy to give them both PTSD of a different nature- if I ever have an opportunity to find them and have a little talk with them.
Henry Greenspan, Ph.D. says:

July 16, 2009 at 4:07 pm

Hi Friends,

Well, as a clinical psychologist who’s been working with Holocaust survivors for the past thirty years, this is an issue of particular interest.

Among the many things that get confused is aetiology versus signs/symptoms. As far as aetiology, I have found Henry Krystal (himself a Holocaust survivor) to have been most useful in my own work. His definition of trauma itself is narrow relative to the almost all-compassing way it has come to stand for “extreme hardship” in pop psych and even professional psych at times. The element of helplessness in the face of imminent threat is the key for Krystal, an “inner surrender” to an inescapable of dissolution (which can mean one’s own death, the death of “trust in the world,” those who _are_ one’s world, and more).

On the other hand, there is the PTSD symptom list–the various forms of dissociated and intrusive memories, etc.

The extent to which PTSD symptoms correlate with traumatic experience (defined as Krystal does) remains a question as far as I am concerned. It is not about malingering, etc. It is about the complexity of people and of life experience.

And then, indeed, there is the political history of the DX (and the events with which it is associated) and, as above, the “inflation” of trauma in cultural lingo.
Evelyn Pringle says:

July 19, 2009 at 7:34 am

PSTD is another valid mental disorder that has fallen prey to disease mongering campaigns to the detriment of the true sufferers.

A sad state of affairs, considering the high number of people serving in the military who will develop PSTD due to the senseless “war for profit” in Iraq.
captain sunshine says:

July 20, 2009 at 2:48 pm

Rats ! I see that the price is now $0.01, and I just paid $0.05 ! But OK ! It is well worth the extra and as a matter of fact, the book is priceless ! ‘already a big help to me .
Jennifer Gathercole, M.A. says:

July 25, 2009 at 9:11 am

As a mental health clinician who works primarily with individuals who suffer from PTSD, I am appalled by the lack of professionalism and logic in this article. One must be either inexperienced or incompetent to make some of the very ridiculous claims made by the authors. First, if that had even spent a moment at any Vet Center they would know how hard it is to convince a veteran suffering PTSD to enter the therapy room, much less apply for financial assistance due to their disability. To imply that the diagnosis of PTSD is simply a money ploy is a dishonor to the men and woman who have honorably served this country. In addition, the seeming incongruity of identifying that non-combat veterans have PTSD symptoms would have been answered when faced with the judgement criteria that the military uses to determine who has been in combat and who hasn’t. An Army medic running through gunfire to patch together countless bloodied bodies missing limbs, and screaming in agony, may not count as being in “combat” for the military, because the medic doesn’t cary a gun. However, I doubt that any reasonable person could argue the traumatic value and potential catalyst for PTSD in the medics experience. In defense of many Vietnam veterans, due to missing record many can not prove where they were in combat and are denied VA coverage because they can not be idenitified as having been “in combat.” Worse still are the veterans who were on the sidelines but witnessed horror such as fighter jets crashing and burning on the decks of carriers and being unable to save the pilots.

I love my field for the good it can do if we listen to the needs of our clients. People need to decide whether they are trying to be therapists or politicians before they make broad assumptions and seek to prove their hypothesis without the benefit of researching the source.
Virginia S. Wood, Psy.D. says:

July 25, 2009 at 9:26 am

“…listen to the needs of our clients. People need to decide whether they are trying to be therapists or politicians…”

or detectives. Wow: Beautifully said. Thank you.
Amy Philo says:

July 25, 2009 at 9:51 pm

My grandfather was in WWII – a medic, and saw his friends blown up right next to him. My husband’s cousin has been in Iraq a few times, and also has had friends blown up right next to him. My grandfather was never given any drugs for his traumatic experience and I certainly am glad for that. I hate that our troops are being drugged. Excuse me if I have a problem with people being put at even greater risk because of an attempt to guilt everyone into supporting the treatment of their PTSD. Yes, trauma and its effects on people are very profound. But even more so, the life-altering, risky effects of antidepressants and antipsychotic drugs being fed to our troops are profound, and can lead to death. I would much rather get counseling or other treatments for trauma than drugs, and at that I would like to be able to do so without being labeled as disordered. Just because I went through a trauma does not mean that I have a defective brain or an illness. Nor does it justify any drug or combination of drugs being given to me which could either cover up or worsen my feelings, not allowing me to get better, and possibly driving me psychotic. How is being psychotic and robotic and numb better than learning to live with trauma and try to find a way to get through it?

The last thing we need is to mistreat our troops after they served us to protect us, regardless of the motives of the administrations forcing them to conduct their operations.
Amy Philo says:

July 25, 2009 at 10:19 pm

Hey maybe we should “treat” this PTSD case with drugs. What do you think? Is she diseased because her baby died from Effexor? Or is she simply traumatized like nobody should ever have to be? http://twohours.wordpress.com/2009/07/24/ptsd/#comment-17
Extremely Lame-O Article on the “Consensus” of Repressed Memories | Before You Take That Pill says:

September 13, 2009 at 8:18 am

[...] article which was cited in a chowder-headed review paper on PTSD which I previously picked apart here, Pope really hasn’t done much research on PTSD. My guess is that he has profited handsomely [...]