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Researchers critique DSM-5 changes to PTSD, call for action

The 2013 DSM-5 definition of PTSD, which includes revisions to the DSM-IV definition, is not an improvement and has consequences for clinicians and patients, according to a recent editorial in JAMA Psychiatry.

“Although many important evidence-based changes resulted, core criteria and diagnostic language for most common conditions affecting adults remained unchanged, safeguarding continued use of treatments validated over decades,” Charles W. Hoge, MD, of Walter Reed Army Institute of Research, US Army Medical Research and Material Command, Silver Spring, Maryland, and colleagues wrote. “A notable exception was [PTSD].”

Charles W. Hoge

Criteria were added and major word changes were made to symptoms that have been fundamental clinical indicators of PTSD, according to Hoge and colleagues.

While DSM-5 removed the DSM-IV requirement for a fear-based response to a traumatic event, a positive change according to Hoge and colleagues, the scope of qualifying events was significantly limited to reduce “bracket creep” and “frivolous tort or compensation claims.”

This change may limit clinicians from properly applying the criteria for trauma.

Eight of the 17 original DSM-IV symptoms were revised. Changes included complex phrasing, alterations in meaning and increased diagnostic variations, according to Hoge and colleagues.

They report that the most problematic changes included:

• Replacing the “re-experiencing” term with “intrusion” and requiring intrusive memories to be “involuntary;”
• Rewording “restricted range of affect” to “persistent inability to experience positive emotions;”
• Replacing “foreshortened sense of future” with “persistent and exaggerated negative beliefs or expectations about oneself, others, or the world;”
• Adding “persistent distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself or others;”
• Adding “persistent negative emotional state (eg, fear, horror, anger, guilt, or shame) as a catch-all symptom criterion; and
• Adding “reckless or self-destructive behavior” as a PTSD-specific symptom.

“The revision undermines our ability to generalize the extensive research base and creates a circular requirement for an entirely new foundation of instrumentation, neurobiological, genetic, and interventions research,” Hoge and colleagues wrote. “Furthermore, 3 years after the publication of DSM-5, validation studies remain absent for the Clinician- Administered PTSD Scale (CAPS-5) compared with the original CAPS or other diagnostic instruments.”

In addition, the researchers claim there were no priori scientific standards for evaluating proposed changes or feedback.

“The purpose of revising a psychiatric definition is to enhance diagnostic accuracy, clinical utility, and communication. The DSM-5 definition of PTSD provides no improvement 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,” the researchers wrote. – by Amanda Oldt

Disclosure: Hoge reports no relevant financial disclosures. Please see the full study for a list of all authors’ relevant financial disclosures.