PTSD: It’s Not What It Used to Be

Mental health diagnoses are like no other type of medical diagnosis. They shift and change, are difficult to objectively define, and are subjected to non-medical variables, unlike any other medical concerns. Within the military (and everywhere else, really, but my posts are focused on the military community) Posttraumatic Stress Disorder (PTSD) is a significant example of this. In recognition of PTSD Awareness Month, I thought it might be interesting to look at the evolution of the diagnosis of PTSD.

When the initial Diagnostic and Statistical Manual (DSM) of Mental Disorders was released in 1952 by the American Psychiatric Association it included a diagnosis called Gross Stress Reaction. This was to be used after exposure to extreme emotional stress such as that experienced in combat or a civilian catastrophe. The diagnosis was conceptualized as frequently transient, reversible, and not pathologic, noting “under conditions of great or unusual stress, a normal personality may utilize established patterns of reaction to deal with overwhelming fear." This was a good conceptualization as it normalized psychological reactions to trauma and provided a caution about giving a more serious diagnosis too soon, while also acknowledging that some individuals would not regain full functioning without clinical intervention.

The DSM-II (American Psychiatric Association, 1968) dropped this diagnosis and replaced it with Adjustment Reaction of Adult Life. This category of diagnoses continued to acknowledge that the symptoms occurred in individuals without an underlying mental health disorder and that the symptoms were transient. This was considered a step back for the conceptualization of military trauma, however, as all adult stressors were lumped together. An unwanted pregnancy and fear of combat were both used as examples of stressors within the DSM-II that might lead to this diagnosis. Thus, this was an insufficient way in which to describe the psychological reaction to combat and operational trauma.

With the impetus of the Vietnam War and the women’s rights movement, PTSD debuted in 1980 in the DSM-III. The push for a PTSD diagnostic category was an effort primarily of Vietnam War veterans and survivors of rape to have a diagnosis that accurately encompassed the post-traumatic sequelae of life-threatening trauma. At its inception, it was already problematic, as those experiencing clinical symptoms following war trauma and those experiencing rape exhibit varying symptom profiles due to these inherently different experiences and the context in which they occur. However, at its core it was a needed effort to assist individuals who had survived horrible experiences. The initial creation of the diagnosis of PTSD increased research into this area, provided legitimacy to individuals suffering from posttraumatic symptoms, and increased societal awareness.

Since 1980, the PTSD diagnosis has been changed three times (DSM-III-Revised; DSM-IV; DSM-5) and with each change the diagnostic criteria have expanded. Using criteria provided by the DSM-5 (American Psychiatric Association, 2013), there are 636,120 symptom combinations that may produce a diagnosis of PTSD (Galatzer-Levy & Bryant, 2013). This is significantly problematic in that the diagnosis has become less specific over time. PTSD is an unusual diagnosis because two people, both with the same diagnosis, can share none of the same symptoms. PTSD is also an ambiguous diagnosis in that none of the symptoms are specific to the diagnosis, as all PTSD symptoms overlap with other psychiatric conditions such as depression and anxiety disorders. An additional complication is that PTSD symptoms are things that we all experience when under “normal” stress. As the diagnosis has evolved, it has become more nebulous.

If you are experiencing déjà vu, you know your history. During World War II, there was a diagnosis, War Neurosis, which incorporated any mental health presentation related to war experiences and that didn’t resolve fairly quickly. Our current diagnosis of PTSD is now about as useful as the term War Neurosis. PTSD has become almost a default diagnosis for anyone experiencing trauma, despite the fact that unresolved trauma can result in a number of more precise clinical manifestations—such as Major Depressive Disorder, Phobia, Generalized Anxiety Disorder, Substance Use Disorder, Adjustment Disorder, and Bereavement.

Does this matter? It does. Diagnosis drives treatment recommendations and different clinical manifestations require different approaches. We must make the diagnosis of PTSD more, not less, precise and we must be careful about defaulting to it simply because the individual in question has a trauma in their past. Emotional trauma related to warfare is a constant and our ability to provide the best services for our service members and veterans hinges on a reliable and accurate diagnosis. How we define PTSD drives our ability to effectively and accurately identify, prevent, intervene, and treat our military.