Accuracy of DSM-5 PTSD Criteria Questioned

Megan Brooks

October 01, 2014

New research has called into question the accuracy of new diagnostic criteria for posttraumatic stress disorder (PTSD), as outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

In the first direct comparison of PTSD diagnostic criteria from DSM-5 and the prior DSM-IV-TR in US infantry soldiers, including many soldiers who served in Iraq and Afghanistan, substantial discordance was found between the two manuals.

The researchers note that their findings "raise fundamental concerns as to whether changing the PTSD definition (a definition proven to be highly useful in guiding treatment for more than 25 years) will enhance diagnosis and clinical care, and what this means for current and future generations of veterans."

The study, which was led by Charles Hoge, MD, senior scientist at the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, was published online August 14 in the Lancet Psychiatry.

Discordant Outcomes

The definition of PTSD underwent substantial changes in the DSM-5. But it is not entirely clear how these changes affect prevalence and clinical utility. In addition, the updated PTSD checklist (PCL-5) has not been compared with the previously validated PCL-S in a head-to-head comparison, the authors note.

The investigators compared the DSM-5 and DSM-IV-TR PTSD symptom criteria in 1822 US infantry soldiers, including 946 who had served in Iraq and Afghanistan.

They found that the PCL-5 was equivalent to the validated PCL-S. However, the DSM-5 PTSD symptom criteria did not appear to have greater clinical utility compared with DSM-IV-TR, "a conclusion based on nearly identical overlap with other psychiatric disorders and functional impairment."

More than 30% of soldiers who met criteria for PTSD under DSM-IV-TR did not meet DSM-5 criteria, and an equal number met criteria only under DSM-5, they note.

"Clinicians need to consider how to manage discordant outcomes, particularly for service members and veterans with PTSD who no longer meet criteria under DSM-5," the researchers conclude.

They add that an important limitation of the study was the absence of a comparison with a structured diagnostic interview.

In an accompanying commentary, Alexander McFarlane, MD, of the Center for Traumatic Stress Studies, University of Adelaide, in Australia, notes that the choice of diagnostic criteria for PTSD is "especially important because these criteria are used in legal jurisdictions and for the determination of pensions."

Dr McFarlane notes the study "draws attention to the worrying discordance between DSM-IV and DSM-5 criteria for the diagnosis of PTSD in veterans, substantiating similar findings from previous studies."

The study also highlights "hazards that these changes in diagnostic criteria will introduce in the administration of veterans' benefits and access to care," Dr McFarlane writes.

He believes there should be a "period of transition between legal use of DSM-IV and DSM-5 so that potential effects of these changes can be examined and that deserving individuals are not denied their legal rights."

APA Weighs In

Darrel A. Regier, MD, MPH, vice-chair for the DSM-5 Task Force and senior scientific consultant for the American Psychiatric Association, told Medscape Medical News that he is "well aware" of the article by Dr Hoge and colleagues and that he has discussed it with the authors and with the chair of the PTSD-related DSM-5 work group.

"Although we will be doing additional analyses of our DSM-5 field trials in the two VA hospitals in Dallas and Houston, we don't believe that the changes in the diagnostic criteria from DSM-IV to DSM-5 constitute a cause for fundamental concerns," said Dr Regier, who is also senior scientist, Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, Maryland.

"The changes were based on two decades of research in this area, and we expect that additional research will continue to evaluate the best criteria for characterizing individuals affected by these disorders," said Dr Regier.

He added that it is "important to note that it is the level of disability associated with any diagnosis that is most important for determinations of ability to serve in the military and to receive compensation for a service-connected disability. Diagnoses may include PTSD (309.81), an 'other specified' trauma- and stressor-related disorder (309.89), persistent depressive disorder (300.4), or a chronic adjustment disorder (309.28) — all of which can have various levels of severity and disability associated with them."

The study was funded by the US Army Military Operational Medicine Research Program. The authors, Dr McFarlane, and Dr Regier report no relevant financial relationships.

Lancet Psychiatry. Published online August 14, 2014. Abstract, Commentary

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