Psychopathology

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a mental disorder manual that describes all known mental illnesses, how mental health practitioners can diagnose them, and how they can be treated. The DSM series, published by the American Psychological Association, has been updated and changed to include an expanding number of events and human reactions from throughout the world's different cultures (American Psychiatric Association, 2013). DSM 5, which replaced DSM 4 on May 18, 2013, is now used for standardizing mental diagnostic categories and criteria.
Posttraumatic Stress Disorder (PTSD) has been reclassified in DSM 5 from an Anxiety disorder in DSM 4 to a new Trauma and Stressor associated disorder. In DSM 5 PTSD is termed as the development of characteristic symptoms following exposure to one or more traumatic events and is noted that Posttraumatic Stress Disorder can occur at any age, beginning after the first year of life. On the other hand, anxiety disorders are defined by DSM 5 to be a group of mental disorders characterized by feelings of anxiety and fear (Friedman et.al, 2007)

The purpose of this paper is to look in deeper and understand why the American Psychological Association effected this change and try to justify their reasons by looking at what implications this change has had. To clearly understand what this change is really about, we have to look at the notable differences between the two DSMs regarding PTSD that we will assess.

Table 1

Differences in PTSD criteria

DSM 4

DSM 5

1. PTSD is classified as Anxiety Disorder

1. PTSD is classified as a Trauma and Stressor-related disorder

2. Specify on whether PTSD is acute or chronic

2. Doesn’t address PTSD criterion under these specifications

3. Has 3 symptom clusters

a. Intrusive recollection

b. Avoidant numbering

c. Hyper arousal



























3. Has 4 symptom clusters

a. Re experience

b. Avoidance

c. Arousal

d. Negative cognition and mood (new)

4. Has subtypes

a. For children under 6 years

b. Adults and children over the age of 6

The above table clearly illustrates that there have been adjustments to how PTSD is now viewed. All these issues cumulatively led to the reclassification of PTSD. Addressing the first issue and our main issue, classification of PTSD has been a major thorn in mental disorders definition.

Since its inception into DSM 3 by Davidson and Foa (1991) who concluded that it was better classifying PTSD as an anxiety disorder rather than a depressive and dissociate disorder. DSM 4 being published in 1994 adopted this classification and that was what was used by the mental health professionals till DSM 5 was published. However, it is worth noting that during the almost 20-year gap, critics had questioned this classification. In 2009, (Resick and Miller,2009) presented a case to classify PTSD on its own. They argued that a number of negative emotions some of which include anger, guilt and shame are triggered by trauma exposure and they play an important role in development and maintenance of PTSD.

It has been a journey to get PTSD classification from an anxiety disorder. It is clear that an important factor that makes one be allegeable to the PTSD diagnosis is trauma. Infact this is tackled in the first criterion in the diagnosis of PTSD. Criterion A has undergone changes too but the most significant is the expansion of this criteria to a 2-part criterion. Earlier, in DSM 3 formulation, a traumatic event was conceptualized to be a catastrophic stressor outside the normal range of human experience. This were events such as war, rape, torture etc. and painful stressors such as divorce were seen as ordinary stressors that one had the ability to cope with and adapt to.

In 1980 when PTSD was recognized as a disorder, it was found that it was fairly common in the population. This prompted for DSM 4 to include a history of exposure to a traumatic event and symptoms from each of the 3 clusters above mentioned in the table. The onset of every disorder under this category has been preceded by exposure to a traumatic or otherwise adverse environment. According to (Friedman et.al, 2013) emotional reactions to the traumatic event (e.g., fear, helplessness, horror) are no longer a part of Criterion A unlike in the DSM 4 person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2)

Another aspect that has undergone change is the specifiers criterion (criteria F). In DSM 4 diagnosis were expected to specify the onset and duration of symptoms of Posttraumatic Stress Disorder using: acute (less than 3 months’ symptom duration), chronic (3 months or longer) and with delayed onset (6 months have passed since the traumatic event and the onset of the symptoms). However, in DSM 5, it is generalized as the duration of disturbance. It is indicated to last for at least a month. Reducing the duration of the diagnosis has led to faster detection of the onset of PTSD as it develops through the acute and chronic stress disorder stages.

As development is clearly visible, the elimination of acute and chronic PTSD allowed for Acute Stress Disorder to be defined. Despite the symptoms of both being closely similar, there are various distinctions that led the American Psychological Association to classify them separately. One being, acute stress persists from one day to 1 month after the traumatic event while PTSD lasts for months to years. According to (Bryant, et al., 2011) another difference being that dissociative symptoms associated to PTSD are believed to impede the victim’s ability to deal with the problem, even when treated shortly after the trauma. Analyzing these distinctions leads to better and accurate diagnosis from the mental health professionals and thus proving that the changes made were fundamental in healthcare delivery.

Furthermore, negative cognition and numbing cluster has also undergone some modification. Negative cognition was created from the separation of avoidance/ numbing in DSM 4. New symptoms including distorted cognition leading to blame of self or other and exaggerated negative beliefs about self and others or world and inability to experience positive emotions are added to the previous DSM 4 numbing cluster. According to Kilpatrick et al. (2013) and Miller et al. (2004) study, their second confirmatory factor analyses (CFA) indicated that the proposed 4-factor DSM-5 symptom structure provided better fit to the data than the DSM 4 3-factor model of the criterion D, negative alterations in cognitions and mood.

These symptoms were found to be universally acceptable as it concurred to the find that negative emotions some of which include anger, guilt and shame are triggered by trauma exposure and they play an important role in development and maintenance of PTSD. Amnesia’s dissociative nature is clarified and is not to be attributed to head injury or intoxication.

Notwithstanding, we have also seen an introduction of a criterion that was added for children 6 years old and younger. This is observed to be different from the in-text specifications that DSN 4 had about children. This criterion generally follows the primary criteria for adults, adolescents and children over six as it tends to sensitize on age and there to be undertaken clinical features. It is important to note for children under the age of 6 (preschool children) that avoidance and numbing are not separated into distinct clusters, amnesia, exaggerated negative beliefs, and distorted cognitions leading to blame alterations in cognition and mood are excluded.

According to Egger et al. (2006) and Scheeringa & Haslett (2010) the need for accurately detecting young children with severe PTSD-related symptoms and impairment is increasingly pertinent as new evidence-based treatments and diagnostic interviews. From their data research it was found that, adoption in DSM-5 of a developmental subtype of PTSD in young children, as all three of the proposed criteria sets resulted in significantly more cases than the DSM 4 criteria. The rest of criterions are largely unchanged these include the criterion E: Arousal and reactivity, hypervigilance, exaggerated startle and concentration problems, sleep disturbance.

Posttraumatic symptoms overlap in diagnoses with those of other disorders, a wide variety of diagnoses often needs to be considered to avoid misidentifying other disorders as PTSD and vice versa. A trained and experienced mental health professional is advised to weigh differential diagnoses before commencing treatment. Observing the advancements that had been made in order to change the classification, it is evident that DSM 5 has come to be more precise and addresses issues that were in DSM 4 with all the symptoms of each cluster written differently, and for each cluster extra symptoms are added.

This is going to help the professionals in understanding PTSD further and also assist in correct diagnosis and treatment thus justifying the problem statement of this paper: the classification change was necessary to the American Psychology Association, the mental health professionals, patients and the world. These criteria cumulatively effected caused the PTSD to be classified as Trauma and Stressor related disorder rather than an anxiety disorder.























References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bryant, R.A., Friedman, M.J., Spiegal, D., Ursano, R. & Strain, J. (2011) A review of acute stress disorder in DSM-5 Depression and Anxiety. 28 (9): 802-817

Egger, H. L., Erkanli, A., Keeler, G., Potts, E., Walter, B. K., & Angold, A. (2006). Test-retest reliability of the Preschool Age Psychiatric Assessment (PAPA). Journal of the American Academy of Child and Adolescent Psychiatry, 45, 538–549. doi:10.1097/01.chi.0000205705.71194.b8

Foa, E. B., Skeketee, G., & Rothbaum, B. O. (1989). Behavioral cognitive conceptualizations of post-traumatic stress disorder. Behaviour Therapy, 20, 155–176. doi:10.1016/S0005-7894(89)80067-X

Friedman, M. J. (2013). Finalizing PTSD in DSM‐5: Getting here from there and where to go next. Journal of Traumatic Stress, 26(5), 548-556.

Friedman, M. J., Keane, T. M., & Resick, P. A. (Eds.). (2007). Handbook of PTSD: Science and practice. Guilford Press.

Kilpatrick, D., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and proposed DSM-5 criteria. Journal of Traumatic Stress, 26, 537–547. doi:10.1002/jts.21848