The Subjectivity of PTSD

Traumatic stress is a very natural phenomenon that has affected people for centuries. It has been implicated as a cause of both physical and psychological problems, examples of which have been recorded by historians. During ancient Greek civilization, Homer wrote about a Greek soldier who went blind after witnessing the death of his friend in battle.1 During the American Civil War, after the battle of Gettysburg; a physician described a common syndrome suffered by soldiers who experienced the trauma of combat characterized by shortness of breath, chest pain and palpitations. He called it “cardiorespiritory syndrome.”1 Later, after World War I, veterans of battle were described as having tremors, ataxia and amnesia. These symptoms characterized what was later called “shell shock” or “combat neurosis.”1 In addition to the mental and physical trauma of war, there have been non-combat causes of trauma resulting in similar symptoms. Rape victims were said to suffer from “rape trauma syndrome” and railroad workers in the 1800’s who suffered both physical and mental trauma from occupational accidents were often diagnosed with “nervous shock” and “posttraumatic neurosis.”9 The discussion of malingered or legitimate conditions associated with traumatic stress became a debated topic in the 1870’s when insurance companies began to compensate injured railroad workers.9 Since then an increasing number of patients have presented with similar signs and symptoms, reportedly due to traumatic stress, resulting in the establishment of criteria for diagnosing Post Traumatic Stress Disorder (PTSD) with strict guidelines published in the DSM III by the American Psychiatric Association.

With diagnostic legitimacy, PTSD has become more prevalent and its application has broadened. Originally the DSM III diagnostic criteria was relatively objective, specifying what constituted a traumatic event, clearly differentiating such events from other stressors that constitute normal life such as: divorce, failure, serious illness, financial hardships, etc. Instead, these experiences would be characterized as Adjustment Disorders. The framers of the original PTSD diagnosis criteria considered a traumatic event to be a “catastrophic stressor that was outside the range of usual human experience,” for example, events such as torture, rape, the Nazi Holocaust, and the atomic bombings of Japan.3 Today the application of the term “traumatic event” has become flexible and subjective. According to the current definition in the DSM IV a person doesn’t have to be in any physical danger or even be present during the traumatic event to develop the disorder.9 The trauma can occur by a third-persons retelling of events to another individual. In a recent study by Breslau and Kessler the broader DSM IV definition of exposure to trauma led to a 59% increase in the number of events considered appropriate for meeting exposure criteria and a 39% increase in the number of people meeting diagnostic criteria.9 Further supporting these findings are the results of an epidemiologic study which reveals that the lifetime population prevalence of PTSD in the United States has increased since using the DSM IV criteria for diagnosis instead of the DSM III criteria.6

Since current diagnostic criteria are purely subjective and based only on an individual’s report, trial lawyers have used PTSD commonly as the disorder du jour for those seeking financial gain. In 1989 PTSD was called the “diagnosis of choice” in civil litigation, and during that time about 15% of all work related injury claims in the United States were based on PTSD related diagnoses.9 It has been estimated that up to 50% of post-injury psychological symptoms are malingered depending on whether rates are reported by insurance companies, psychiatric studies or attorneys.9 Both scientific studies and anecdotal reports have shown that many veterans have blatantly misrepresented their involvement in combat and other trauma with the intention of obtaining benefits or financial compensation.9 The subjective criteria for diagnosing PTSD only perpetuates this problem, and the validity of the mental health profession is being diminished by its abuse. More importantly, the significance of the disorder that truly affects some individuals is being minimized. It is essential that the mental health community come together to tighten the criteria and make all efforts to stop the abuse of this diagnosis in order to isolate and treat the true sufferers of PTSD.

Differentiating the individuals with true PTSD from the malingerers using current DSM IV criteria is difficult. Many of the symptoms such as reexperiencing, suicidal ideation, emotional detachment, anxiety, avoidance, and the content of dreams, are difficult to verify.9 In a consultation setting, most physicians want to believe their patients and take their reported symptoms at face value. It is assumed that it is in the patient’s best interest to be honest with their doctors in order to benefit from treatment. However, when patients claiming PTSD are in a situation where financial gain or some other benefit may be involved, the physician is cautioned by the DSM-IV to rule out malingering before the diagnosis of PTSD is made. Herein lies the problem, how does one rule out this disease? If a malingering patient does their research and complains of all the right things it is nearly impossible for a physician to make a distinction between malingering and legitimacy. To complicate this even further, the current health care situation doesn’t allow enough time for a physician to effectively “investigate” the claims. For time sake many physicians will err on behalf of the patient and simply grant the diagnosis. Consider the ramifications of this in the context of veterans; if Military and VA employed physicians err on behalf of the patient they inevitably grant a diagnosis to every military veteran claiming symptoms of PTSD. This can result in 100% disability benefits and perpetuates the high costs of our healthcare system. With the recent wars in Iraq and Afghanistan and the increasing number of veterans being diagnosed with PTSD our system could quickly deteriorate. A study conducted by Stanford University in 2009 found that rates of PTSD among veterans of Iraq and Afghanistan may be as high as 35% with an estimated 700,000 veterans suffering from PTSD.8 Currently over 200,000 Veterans have applied for VA service connected benefits on the basis of PTSD and to date it is the most common psychiatric condition for which veterans seek VA service connected benefits.6 Many of these cases are haphazardly diagnosed during out-processing physical and mental exams that take place rapidly. For example, often times the exams consist of a questionnaire asking explicit questions related to PTSD-associated symptoms to which the patient simply checks ‘yes’ or ‘no.’ Obviously, this method of screening makes it easy for the well-informed and well-rehearsed malingerer to be falsely granted the diagnosis of PTSD.

In spite of the many false claims, PTSD still remains a legitimate disorder, with some studies suggesting a genetic link. Interestingly though, not all individuals experiencing identical trauma develop PTSD. While some studies indicate that approximately 60% of men and 50% of women report exposure to at least one lifetime traumatic event only 8% of those men and 20% of those women actually developed PTSD.6 This concept of individual resilience and susceptibility is being researched in animal models aiding in our understanding of the basic psychophysiology of an individual’s response to stress. Neurobiolological research directed at identifying factors influencing susceptibility and resilience to PTSD have revealed that increased stress hormones may cause hippocampal damage and that some individuals with PTSD have a smaller hippocampus than those without. Additional studies suggest increased activity of the amygdala in patients with PTSD, particularly when recalling a traumatic event.7 Endocrinological events are also being explored as a possible explanation for susceptibility/resilience to PTSD. Unfortunately, in spite of current scientific research we still lack any objective elements that allow physicians to ensure an accurate diagnosis. Objectivity is essential and with current the research underway we may one day be able to identify the true PTSD sufferers.

Through biological and epidemiological research it has become clear that PTSD is a real disorder. Research and anecdotal evidence also reveals that the flexible and subjective nature of its diagnostic criteria lends its use to malingerers. Scientific research has not caught up with the field of psychiatry and is yet unable to produce objective data to allow a physician to accurately diagnose PTSD. Until then, differentiating malingerers from legitimate sufferers will be an intricate game of wit between the psychiatrist and patient. The physician will continue to act in the best interest of their patients, as they are ethically bound. With current DSM criteria in place they have no choice but to default diagnose every patient that presents with reported signs and symptoms outlined in the DSM and err on the side of the patient. This is the only guarantee that the physician will live up to their creed. All the while perpetuating the problem of abuse and over diagnosis of PTSD, minimizing the mental health profession, and diminishing the significance of a real disorder that affects many people. One can only hope that the upcoming DSM V addresses this issue and finds a less subjective way to diagnose this very serious disorder.

REFRENCES

1. Ornstein RD, Pitman RK. Trauma and post-traumatic stress disorder. In: Stern TA, Herman JB, eds.
Psychiatry Update & Board Preparation. 2nd ed. New York, NY: McGraw-Hill; 2004:127–136

2. Henderson DC, Kunkel L, Goff DC. Psychosis and schizophrenia. In: Stern TA, Herman JB, eds.
Psychiatry Update & Board Preparation. 2nd ed. New York, NY: McGraw-Hill; 2004:100

3. Matthews J, Papakostas G. Mood disorders: depression. In: Stern TA, Herman JB, eds. Psychiatry
Update & Board Preparation. 2nd ed. New York, NY: McGraw-Hill; 2004:105

4. Perlis TH, Ghaemi SN. Bipolar disorder. In: Stern TA, Herman JB, eds. Psychiatry Update & Board
Preparation. 2nd ed. New York, NY: McGraw-Hill; 2004:115

5. True WR, Rice J, Eisen SA, et al. A twin study of genetic and environmental contributions to liability
for posttraumatic stress symptoms. Arch Gen Psychiatry 1993;50:257–264

6. Ramaswamy, Sriram. "A Primary Care Perspective of Posttraumatic Stress Disorder for the
Department of Veterans Affairs." Prim Care Companion J Clin Psychiatry. 7.4 (2005).

7. Hedges DW, Allen S, Tate DF, et al. Reduced hippocampal volume in alcohol and substance naïve
Vietnam combat veterans with posttraumatic stress disorder. Cogn Behav Neurol 2003; 16:219–
224

8. Corliss, Colleen. "Staggering Rates of PTSD: Iraq & Afghanistan Veterans." Swords to Plowshares
2009: n. pag. Web. 25 Jul 2010. .

9. Hall, Ryan. "Malingering of PTSD: forensic and diagnostic considerations, characteristics of
malingerers and clinical presentations." General Hospital Psychiatry. 26.2008 (2008): 525-535.