I appreciated Jason Drwal’s recent Psych Central Professional article, “The Biggest Mistake Therapists Make When Diagnosing PTSD.”
Jason correctly wrote that according to the DSM-5, a qualifying trauma – referred to as a criterion A stressor – is generally considered a necessary condition for a PTSD diagnosis. Only trauma towards the extreme level, involving the direct or witnessed risk of death, serious injury or sexual violence, is considered worthy of a PTSD diagnosis. Herein lies a significant problem, a major medical inconsistency.
As a practicing physician for 35 years, I am not aware of any other medical diagnosis for which what happened to you defines what is wrong with you. If I have symptoms, signs and X-ray findings consistent with a fractured leg, the emergency room physician will not much care whether my injury was sustained by tripping over the dog or falling off a roof.
Emergency care physicians know that people can sustain the same injury from a wide range of events – some apparently trivial, others more obviously potentially serious. This principle holds true across all medical specialties.
Physicians are generally well aware that many factors affect a person’s risk of illness and injury, factors such as age and physical frailty. They make allowances for such increased risks when evaluating their patients. They know that the medical diagnostic process is far too nuanced to be governed by absolutist preconditions such as what happened to you.
This realistic medical logic does not apparently apply to PTSD. For example, according to an official British National Health Service (NHS) website, ‘PTSD isn’t usually related to situations that are simply upsetting, such as divorce, job loss or failing exams’ (National Health Service). People who have been through these difficult experiences regularly report how traumatic – rather than ‘simply upsetting’ – these can be.
Why is Trauma Approached Differently?
Why would trauma be approached by the medical profession is a way that is diametrically opposite to standard medical diagnostic practice? Why would a globally-recognised trauma expert psychiatrist consider it necessary to publish a YouTube video entitled Psychiatry must stop ignoring trauma? (van der Kolk, 2015). My answer – if the true place of trauma was properly recognised within mainstream mental health, including the psychiatric diagnoses, the dominance of the prevailing biologically-biased approach to mental health would be a much more difficult to justify.
Many medical and mental health heavyweights have raised serious questions about the validity of the DSM over the years. Here are just some examples;
In 2007, prominent psychiatrist Nancy Andreasen – recipient in 2000 of the National Medal of Science for Research on Mental Illness from Bill Clinton – wrote of the 1980 DSM-III: “‘Validity has been sacrificed to achieve reliability,” and “DSM diagnoses are not useful for research because of their lack of validity” (Andreasen, 2007).
Former director of the National Institute of Mental Health (NIMH) psychiatrist Thomas Insel wrote prior to DSM-5’s publication in 2013 that, “While DSM has been described as a `bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. . . The weakness is its lack of validity” (Insel, 2013).
Eight years earlier at an American Psychiatric Association meeting, Thomas Insel told his audience that the DSM-IV had “0 per cent validity” (Johnson).
Psychiatrist Steven Hyman – Thomas Insel’s predecessor as director of the National Institute of Mental Health – has stated that the creators of the DSM ‘Chose a model in which all psychiatric illnesses were represented as categories discontinuous with “normal”. But this is totally wrong in a way they couldn’t have imagined. What they produced was an absolute scientific nightmare’ (Belluck et al, 2013).
Regarding the 2013 DSM-5, DSM-IV Task Force lead psychiatrist Allen Frances has spoken of “DSM-5’s flawed process and reckless product;” “discredited and scientifically unsound;” “the gross incompetence of DSM-5” (Frances, 2013); “deeply flawed;” “untested” (Frances, 2012).
American physician and author Maria Angell MD, former editor-in-chief of the New England Journal of Medicine, senior lecturer, Department of Global Health & Social Medicine, Harvard Medical School: “‘Given its importance, you might think that the DSM represents the authoritative distillation of a large body of scientific evidence. It is instead the product of a complex of academic politics, personal ambition, ideology and, perhaps most important, the influence of the pharmaceutical industry. What the DSM lacks is evidence.
The problem with the DSM is that in all of its editions it has simply reflected the opinions of its writers. Not only did the DSM become the bible of psychiatry, but like the real Bible, it depends on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journals or books, statements of fact are supposed to be supported by citations of scientific studies” (Angell, 2009).
American psychiatrist Daniel Carlat has written that the DSM “has de-emphasized psychological-mindedness, and replaced it with the illusion that we understand our patients when all we are doing is assigning them labels’’ (Carlat, 2010, p. 60).
According to renowned British-based psychologist and author Dorothy Rowe, “Apart from where it deals with demonstrable brain injury, the DSM is not a valid document. The DSM is a collection of opinions. Believing in the DSM is much the same as believing in, say, the doctrines of the Presbyterian Church. Neither can point to evidence that supports the doctrine that lies outside the doctrine itself. When our ideas are supported by evidence, we can regard them as truths. Ideas unsupported by evidence are fantasies” (Rowe, 2010, p.130).
American psychologist, social justice and human rights activist Dr. Paula Caplan is a former professor of psychology, assistant professor in psychiatry and director of the Centre for Women’s Studies at the University of Toronto. Dr. Caplan was an invited consultant to two committees involved in the creation of the DSM-IV.
In 2014 she wrote: “I resigned from those committees after two years because I was appalled by the way I saw that good scientific research was often being ignored, distorted, or lied about and the way that junk science was being used as though it were of high quality, if that suited the aims of those in charge” (Caplan, 2014).
In 1995, she wrote, “As a former consultant to those who construct the world’s most influential manual of alleged mental illness . . . I have been able to assess and monitor the truly astonishing extent to which scientific methods and evidence are disregarded as the handbook is being developed and revised. I could not attempt in a single book to address the vast array of its biases, examples of its sloppiness and illogical thinking, and just plain silliness. Mental disorders are established without scientific basis or procedure” (Caplan, 1995, xv, 90).
According to Jason Drwal, the biggest mistake therapists make when diagnosing PTSD is to err in relation to what constitutes a criterion A traumatic event. Perhaps a greater mistake is for mental health professionals to accept without question the validity of DSM-5 and its contents and regularly impose these on their clients, including those relating to PTSD.
In relation to trauma, perhaps it is a major mistake for mental health practitioners to accept the faith-based – rather than evidence-based – DSM position on trauma. Trauma and its consequences are far more common occurrences that the DSM would have us believe.
Failing to appreciate this reality is not in the interest of the clients that we serve.
Andreasen, A. (2007). DSM and the Death of Phenomenology in America: An Example of Unintended Consequences. Schizophrenia Bulletin. 2007 Jan; 33(1): 108–112. Retrieved on 03 August 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2632284/.
Belluck P, Carey, B. (May 6, 2013). Psychiatry’s guide is out of touch with science, experts say. New York Times. Retrieved on 03 August 2018 from http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html
Caplan, P.J. (1995). They say you’re crazy: how the world’s most powerful psychiatrists decide who’s normal. New York: Addison-Wellesley Publishing Company.
Caplan, P.J. (2014, 2, 17). The great ‘crazy’ cover-up: Harm results from rewriting the history of DSM. Mad in America blog. Retrieved on 03 August 2018 from https://www.madinamerica.com/2014/02/great-crazy-cover-harm-results-rewriting-history-DSM/
Carlat, D. (2010). Unhinged: The trouble with psychiatry—a doctor’s revelations about a profession in crisis. London: Free Press.
Frances, A. (2012, 3, 12). DSM-5 Is a Guide, Not a Bible: Simply Ignore Its 10 Worst Changes. Huffington Post. Retrieved on 03 August 2018 from https://www.huffingtonpost.com/allen-frances/DSM-5_b_2227626.html
Frances, A. (2013, 1, 23). Price Gouging: Why will DSM-5 Cost $199 a Copy? Psychology Today. Retrieved on 03 August 2018 from https://www.psychologytoday.com/us/blog/DSM5-in-distress/201301/price-gouging-why-will-DSM-5-cost-199-copy
Insel T. (2013, 4, 29). Transforming diagnosis. National Institute of Mental Health. Retrieved on 03 August 2018 from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.
Johnson, R. The Role of Neuroimaging in Psychiatry and Addiction Medicine. Retrieved on 03 August 2018 from https://www.tomf.org/gd-resources/downloads/Johnson.pdf.
National Health Service (NHS, Britain) website. Causes: Post Traumatic Stress Disorder. Retrieved on 03 August 2018 from https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/causes/
Rowe, D. (2010). Why We Lie, London: Fourth Estate.
van der Kolk, B. (2015). Psychiatry must stop ignoring trauma. YouTube. Retrieved from http://bigthink.com/think-tank/dr-bessel-van-der-kolk-psychiatry-has-a-long-stubborn-history-with-trauma/
Dr. Terry Lynch is a mental health specialist. For nine years (2003-12) he served on Irish Government-appointed expert mental health groups. A physician, psychotherapist, mental health educator and best-selling mental health author, Terry provides a recovery-oriented mental health service. Terry works primarily with people who have been given psychiatric diagnoses. He provides online mental health courses for mental health professionals and the general public. When he is not working, Terry especially enjoys being with his wife and family, their two delightful dogs, and being creative on piano. Terry’s website – https://doctorterrylynch.com/ ‘