by Serena Nathaniel-James, Cognitive Behaviour Therapist & Psychologist
In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Post-Traumatic Stress Disorder (PTSD) is classed as a trauma and stressor related disorder, which can arise from exposure to actual or threatened death, serious injury or violence. The ‘exposure’ can be in the form of a direct experience, witnessing in person, learning of actual or threatened death of a family member or a friend (although the event must be violent or accidental), or experiencing repeated or extreme exposure, for example, of the kind some police officers experience when faced with the aversive details of traumatic events.
In contrast, the previous diagnostic criteria for PTSD on the basis of the DSM-IV-TR, included that the person was exposed by experiencing, witnessing or was confronted with the event/s involving the actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Furthermore, the person’s responses needed to involve a significant degree of intense fear, helplessness, or horror.
This change in PTSD criteria from DSM-IV-TR to DSM 5 has allowed the diagnosis to be expanded and over the last 5 years or so, there has been a sudden rise in the use (and abuse) in my view, of the term “PTSD.” In both my medico-legal and treatment work, I frequently come across for example, GP notes where patients’ symptoms are noted using terms and descriptors such as “flashbacks”, “nightmares,” “not sleeping since the accident”, “patient has PTSD.” The same gets repeated in referral letters to NHS psychological therapy services and private providers. To compound the problem, novice clinicians, or those with little knowledge and experience, tend to adopt a simple cause and effect approach leading to the idea that trauma is the only cause of these symptoms.
One important and major criticism of the DSM 5 diagnostic criteria for PTSD is the use of the word ‘traumatic’ as it is not clear what is meant by this (Breslau and Kessler, 2001).
Research in the area of illness belief indicates that diagnosis can lead to a misattribution of symptoms. Illness belief comprises individual’s views on identity, consequences, timeline, controllability and causal attribution of their health condition (Leventhal et al. 1998; Leventhal et al. 1980). Illness belief has been found to be positively correlated with over-reporting of symptoms. It is not surprising that an individual labeled as a PTSD sufferer by his GP or another clinician will incorrectly attribute his symptoms to PTSD which may or may not be the case. It can be easily envisaged how a person who is vulnerable to hypochondriacal worry would then develop a preoccupation with the diagnosis of PTSD, leading to a secondary problem.
From my experience many NHS services and private therapy providers heavily rely on the use of the Impact of Life of Events Scale–Revised (IES-R) in their assessment of possible PTSD. This scale was first introduced in 1997 and although it is only meant to be an aid in a clinical assessment, it is used incorrectly by many to diagnose PTSD. IES-R is the revision of the Impact of life of events scale (IES) which is based on Horowitz’s model of emotional processing following a trauma (Horowitz, 1976). Not so long after the publication of IES, PTSD was introduced into the DSMIII. However, the DSM-III conceptualisation of PTSD was rather different to Horowitz’s information processing model. The IES-R like its predecessor, continues to retain its main emphasis on assessing intrusions and avoidance, underlying the purpose of the development of this scale. A detailed critical review of the IES-R is beyond the scope of this article. Nonetheless, the key points to understand here are that this instrument is only meant to be an aid in clinical assessment and the differences in the conceptualisation of psychological symptoms and experiences associated with PTSD that exists between the IES-R and DSM. The use of IES-R as a “diagnostic instrument” for PTSD as I have come across in numerous medico-legal reports, betrays an expert’s poor understanding of what PTSD really is.
As aforementioned a diagnosis of PTSD cannot be made just on the basis of symptoms. An important reason for this is because some of the symptoms ‘associated’ with PTSD are also to be found in other conditions such as Borderline Personality Disorder, where childhood trauma is a common although not a universal feature of this disorder. Furthermore, these same people can experience symptoms of intrusion, avoidance and hyperarousal, despite not meeting the diagnostic criteria for co-morbid PTSD (Oldham et al, 2010). Symptoms such as intense anxiety, fear, avoidance and hypervigilance can also be part of other disorders such as specific phobia, agoraphobia and panic disorder (this list is not exhaustible) all of which can be a psychological consequence of other significant events such as a road traffic accident.
The PTSD academic literature firstly suggests that most people, even when exposed to severe trauma, never develop PTSD (e.g. Paris, 2000, McNally, 2009). McNally also suggest that those who do, usually have past symptomology. Of particular note is the finding that PTSD reflects more about the intrinsic sensitivity than a reaction to a life-threatening event (Robert et al. 2012). This is supported by the much earlier work of McFarlane (1989) who showed that PTSD in firefighters was best predicted by neuroticism traits prior to the exposure rather than by the severity of fires. This indicates the importance of personality factors and within that, the possible role of personality traits which make up psychological resilience.
It is not incomprehensible that most people do not develop PTSD after traumatic experiences. For example, childbirth could prove extremely traumatic for the mother as it can be potentially life threatening and yet most women do not develop PTSD despite experiencing significant anxiety about the delivery. A review and meta-analysis of 59 studies of the prevalence of PTSD during pregnancy and postpartum showed that only 4% of women develop PTSD after birth (Dikmen Yildez et al.). This every day phenomena says a lot about the inbuilt strength of human beings to be able to cope with potentially life-threatening experiences and individual differences in response to life events.
Being described as sustaining PTSD as a psychological consequence in litigation can prove to be advantageous as it offers strong support for psychological injuries (Gold, 2003; Gold & Simon 2001). However, the problem is PTSD is also perceived by laymen and experts alike as the most “severe” form of psychological injury and thus will unsurprisingly, likely encourage Claimants to either falsely report or over-report their symptoms as it will validate their experience of being a victim to an adverse life event. Another important factor is secondary gain of receiving higher compensation. In the US, a 2013 analysis of 1369 civil jury cases, 2/3 of the plaintiffs received compensation for PTSD and approximately a 1/3 received a million dollars or more in settlement of their claim. The importance of secondary gains cannot be overlooked. For example, McNally (2003) found that rates of PTSD diagnosis in the veteran population were grossly overestimated and some veterans who claimed benefits because of PTSD had never been in combat!
In summary, the diagnostic criteria for PTSD has changed in every edition of DSM and this has not escaped criticism (McNally 2009). In the context of litigation (and those instructing them) need to keep an open mind about the Claimants’ psychological symptoms as what is being reported could be due to another psychological condition and not PTSD!
Breslau, N., Kessler, R.C. (2001): The Stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation. Biographical Psychiatry; 50;699-704.
Leventhal, H., Leventhal, E.A., & Contrada, R.J. (1998). Self-regulation, health and behavior. A perceptual -cognitive approach. Psychology and health, 13 (4) 717-733.
Leventhal, H., Meyer, D. (1980). The common sense model of illness danger. In S. Rachman(Ed.), Medical Psychology, Vol 2 (pp. 7-30). New York: Pergamon.
Paris, J. (2000): Predispositions, personality traits and posttraumatic stress disorder. Harvard Review of Psychiatry 8:175-183.
McNally, R. (2009): Can we fix PTSD? Depression and Anxiety. 26:597-600.
Roberts, A.L., Dorhend, B., Aiello., A.A. (2012): The stressor criterion for post-traumatic stress disorder-does it matter? Journal of Psychiatry 73:264-270.
McFarlane, A.C., (1989): The aetiology of post-traumatic morbidity: predisposing, precipitating and perpetuating factors. British Journal of Psychiatry 154:221-228.
McNally, R.J., (2003): Remembering Trauma. Cambridge, MA: Belknap Press/Harvard University Press.
Dikmen Y.P., Ayers S., & Philips, L. (2017). The prevalence of post-traumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. Journal of Affective Disorders, 208: 634-645
Zarins, Jury Verdict Review & Analysis at https://www.jvra.com/verdict_trak/professional.aspx?=1&se arch=55&verdict=1&jurisdiction.
Oldham, J., Gabbard, G., & Goin, M. (2010). Practice Guidelines for the treatment of patients with Borderline Personality Disorder: APA
Mrs Serena Nathaniel-James
Cognitive Behaviour Therapist & Psychologist
B.Sc, M.Sc, M.Sc, MBPsS
Mrs Nathaniel-James has diverse experience in the application of CBT in the fields of general adult mental health and the specialist field of neuropsychology. Her extensive experience comprises of the treatment of depression, anxiety, PTSD and other emotional difficulties. She has experience in the assessment and treatment of emotional problems in people who have suffered an acquired head/brain injury.
Contact: Mrs Nathaniel-James
Tel: 0207 467 8300 - 07904 570 272