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PSYCHIATRY: Mission Creep – Posttraumatic Stress Disorder and The DSM-5

For more than thirty years, the Diagnostic and Statistical Manual of the American Psychiatric Association has been the “bible” of psychiatry. This book has become the major guideline for making diagnoses and evaluating emotional distress in most civi

by Dr. S.S.S., MD, MPH.

 

For more than thirty years, the Diagnostic and Statistical Manual of the American Psychiatric Association has been the “bible” of psychiatry. This book has become the major guideline for making diagnoses and evaluating emotional distress in most civil litigation. There are literally hundreds of diagnoses that are listed, but posttraumatic stress disorder (PTSD) has become the favorite of many lawyers. 

In the simplest terms, PTSD means that an otherwise normal individual develops disabling psychiatric symptoms after he or she is exposed to overwhelming trauma. This idea has been around for a long time and historically had its widest applicability during wartime. For example, a soldier exposed to an enemy attack develops overwhelming and lasting anxiety, even though he or she is not physically harmed. Perhaps the soldier saw his buddy die or feared that she was going to be killed herself. That soldier would typically reenact the battle scene through daytime “flashbacks” or terrifying nightmares. This condition went under such names as shell shock or traumatic neurosis. 

In 1980 the diagnosis of posttraumatic stress disorder was introduced into the newly reformulated third edition of the Diagnostic and Statistical Manual – the DSM-III. PTSD included the old wartime conditions, but also expanded the concept to include horrific situations in civilian life, such as rape, torture or mass casualty. The DSM-III limited this diagnosis to “a catastrophic stressor that was outside the range of normal human experience.” Individuals with PTSD showed a broad range of symptoms from three different groups: intrusive recollections (flashbacks and nightmares), avoidant and numbing symptoms (withdrawal from friends and family) and hyper-arousal (startle reactions). 

Posttraumatic stress disorder is the only serious, chronic mental health condition that is caused by a specific event (adjustment disorder and acute stress reaction are time-limited). Compare that to generic anxiety or depression, which may be the result of family history, childhood development or many other longstanding factors. Since the specific event in PTSD can be identified, its consequences are the natural subject of compensation. No wonder PTSD became so popular in civil litigation. 

As lawyers tried to expand the scope of posttraumatic stress, the psychiatric profession accomplished the same thing in its periodic revisions of the diagnostic manual. One commentator noted as early as 1986, “If mental disorders were listed on the New York Stock Exchange, PTSD would be a growth stock to watch.” In the DSM-III-R (revised) published in 1987, the stressor did not have to be directly experienced, but could be the result of simply witnessing a catastrophe. In the DSM-IV published in 1994, the event no longer had to be “outside normal human experience,” but just had to involve “actual or threatened death or serious injury or a threat to the physical integrity of self or others.” The basic criterion for PTSD has been broadened even more in the DSM-5 to include “learning that the event occurred to a close relative or close friend.” 

The recognition of PTSD was in many ways a positive development. I have seen patients for medical evaluations and for ongoing therapy who were victims of rapes or beatings. I have examined survivors of concentration camps. When I was in the army, I treated many soldiers returning from Viet Nam. More recently, I saw survivors of the 9/11 terror attack in New York. These individuals suffered from ongoing clinical symptoms, which severely limited their lives. For example, it is not uncommon for a woman rape victim to have unrelieved anxiety and to withdraw from everyone, including her loving husband and family. The ability to diagnose true PTSD helped develop early recognition and effective treatment. 

On the other hand, the concept of PTSD has been trivialized, especially in the legal system, to include almost every adverse event that can happen to anyone. I recently evaluated a woman who quit her job after she was denied a promotion, then sued her employer for workplace harassment and gender discrimination.  In her lawsuit, she claimed that she was constructively discharged. She may or may not have had a valid cause of action in terms of her employment situation. She claimed a variety of economic losses, but also added an allegation of emotional damages. Her psychiatrist opined that she suffered from posttraumatic stress disorder because she lost her job.

No one doubts that job issues can be upsetting. But are employment problems really outside the range of normal human experience? Do they involve death or serious injury or threat to physical integrity? The plaintiff in this case claimed that when she was denied promotion, she had no choice but to quit, and without the income, she feared she might “starve to death” (she did not mention that she already had new job lined up). Worse than that, her psychiatrist described her job experience as “her own personal 9/11.” The insurance adjustor authorized the defense attorney to fight it to the end. The adjustor revealed that he had lost a relative in the World Trade Center disaster and was personally offended by this claim. 

It is important to recognize the phenomenon of posttraumatic stress, but at the same time avoid trivializing it. I believe that the suffering of rape or terror victims is diminished when every slip-and-fall is diagnosed with PTSD. Even with the looser criteria in the new DSM-5, it is important for doctors and lawyers to apply the concept carefully. PTSD may be a convenient diagnosis because it points to a specific causative agent, but it is not the only psychiatric diagnosis that can form the basis of a claim for emotional damages. 

Plaintiff lawyers should seek honest mental health professionals and avoid those who trivialize posttraumatic stress disorder by applying it to every adverse life event. Defense lawyers should be aware of diagnostic hyper-inflation, especially for claims of PTSD. They should hire mental health practitioners who are able to separate true claims of posttraumatic stress from phony ones and have the ability to express their opinions clearly and unambiguously.