A new paper in Perspectives in Psychological Science looked at all the possible combinations of symptoms that could achieve a DSM-5 diagnosis of posttraumatic stress disorder and found there are now 636,120 ways to have PTSD.
This shows one of the many drawbacks of having a ‘check-list’ approach to classifying mental disorder.
636,120 Ways to Have Posttraumatic Stress Disorder
Perspectives in Psychological Science
November 2013 vol. 8 no. 6 651-662
Isaac R. Galatzer-Levy
Richard A. Bryant
In an attempt to capture the variety of symptoms that emerge following traumatic stress, the revision of posttraumatic stress disorder (PTSD) criteria in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) has expanded to include additional symptom presentations. One consequence of this expansion is that it increases the amorphous nature of the classification. Using a binomial equation to elucidate possible symptom combinations, we demonstrate that the DSM–IV criteria listed for PTSD have a high level of symptom profile heterogeneity (79,794 combinations); the changes result in an eightfold expansion in the DSM–5, to 636,120 combinations. In this article, we use the example of PTSD to discuss the limitations of DSM-based diagnostic entities for classification in research by elucidating inherent flaws that are either specific artifacts from the history of the DSM or intrinsic to the underlying logic of the DSM’s method of classification. We discuss new directions in research that can provide better information regarding both clinical and nonclinical behavioral heterogeneity in response to potentially traumatic and common stressful life events. These empirical alternatives to an a priori classification system hold promise for answering questions about why diversity occurs in response to stressors.
Many argue that psychiatric diagnoses are mostly just descriptions of syndromes: groups of signs and symptoms that tend to group together rather than the result of a single underlying disorder.
Sometimes they are better thought of a convenient classifications for testing treatments against.
When diagnoses are developed, however, there is always the temptation to continually tweak the definition to allow the inclusion or exclusion of different experiences as valid targets for treatment.
These changes are usually well-intentioned but can lead to unintended consequences – as this study shows.
Link to locked paper from Perspectives in Psychological Science.
4 thoughts on “A multitude of PTSDs”
Reblogged this on Beyond Meds and commented:
This article on Mind Hacks speaks to the notion that having 636,120 ways to manifest PTSD is a problem. I’d argue it’s not a large enough number. There are as many ways to manifest trauma as there are human beings. And this is exactly why diagnosis can never be precise and why labeling narrowly is always an assault on individuality. Healing too, requires a unique path for everyone.
Another way of thinking about it is that there are 8 elements in the syndromic cluster which define the disease, which as Monica points out can be manifested in many ways by distinct symptoms in distinct people, but which presumably share some qualitative similarity.
The issue may not be that the definition is too loose, but that the symptoms may be too finely graded (in the text, not in life). For example, the five ‘reexperiencing’ symptoms could be simply collapsed into two broader symptom descriptions- involuntary dreams, memories, and flashbacks are pretty similar, as are the two cuing symptoms, which separate psychological from physiological distress on re=encounter. 5 down to 2. Do that on multiple categories and your number of combinations collapses precipitously.
The authors of the paper point out that the degree of plasticity allowed in the definition of the syndrome is much greater than that of other entities in the DSM, such as major depression (hundreds), which may indicate a need for splitting apart the PTSD definition at some point (as dysthymia is separated from major depression in the mood disorders), or simply that the relevant committees had different approaches to their work, which is a problem from a consistency standpoint but not necessarily a nosological one.
All of this assumes that the construct validity of the disorders described in the DSM is good, which is probably true for some disorders and not for others. But, that’s a larger problem of psychiatry, not necessarily one of the DSM. The deliberate avoidance of etiology and a focus on interobserver consistency has been the approach of the DSM from DSM-III on, so it seems odd to blame it for doing its job. The emperor may, in some cases, have no clothes, but at least we are all able to consistently talk about his finery.
Let me suggest that 636,120 combinations for Posttraumatic Stress Disorder reflects a far deeper problem with the DSM5 than simply unintended consequences of well-intentioned tweaking. The entire edifice is absurdly cumbersome and off-base. Has the DSM5 ever heard of Occam’s razor? (Roughly translated, the simplest explanation for some phenomenon is more likely to be accurate than more complicated and convoluted explanations.)
In fact it is Trauma, i.e., deprivation and abuse, when sufficiently powerful that writes our character plays and rewrites them later in life. Trauma is the universal cause of creating symptoms in people of different temperaments. All symptoms are post traumatic by definition. The treatment for all trauma is through psychotherapy where the patient mourns the trauma in the context of engagement and trust in psychotherapy.
The full range of problematic human character presents a host of different symptoms that generate very different experiences of suffering. The varieties and types of plays show the entire symptomatology of psychiatric conditions. The arcane complexity of the DSM5 has arisen due to the misguided beliefs in pharmaceutical psychiatry and its ungrounded phantom diagnoses. It is a house of cards.
I would suggest the following as an alternative to the DSMs. (Please note that I do not use the demeaning term psychopathology.) We can break down the degree of formative trauma on the development of character into roughly three groups: (1) In the context of moderate problematic mothering, with some good-enough mothering, we have four major types of character worlds, depending on which temperaments are in ascendancy— obsessional, phobic, compulsive, and dissociative characters. (2) In the context of severe maternal
damage, the different array of temperaments generate schizoid and paranoid characters, sadistic and masochistic characters, narcissistic and echoistic characters, borderlinism, affective characters, anorexia, germ phobias, psychopathy, and psychotic depression. (3) Finally, we have the psychotic character worlds in which there is a fragmentation of the intactness of the self persona and a rupture of the cohesion of the play itself. This derives from a damaged Authentic-Being, due to some combination of extremely early maternal damage, with some genetic predisposition, and possibly epigenetic effects, all still forged through the different temperamental orientations. The psychotic character worlds are hebephrenia, catatonic schizophrenia, paranoid schizophrenia, schizoaffective schizophrenia, manic depression, and paranoid state. We don’t even see hebephrenia and catatonia mentioned much anymore because they don’t fit contemporary models. But they did not disappear and are still there.
Dr. Berezin, your theory is rather interesting, eclectic, esoteric and worthy of consideration. Do you have data ready to present to support your conclusions? Double-blind and controlled data would be helpful if we are to embrace your alternative treatment.