Chris Freeman UKPTS 2nd Annual meeting Edinburgh Feb 2010

Went live 10th feb.2010

How many people use DSM 1V system in their work with trauma sufferers?

DSM PTSD criteria have been, on balance, a positive development in the trauma field

DSM PTSD criteria, on balance, have not been an advance for the trauma field

DSM PTSD criteria have been the most damaging development in the trauma field since Freud's aphorism

Penis dosum repetitative

DSM 1 DSM 11 DSM 111 DSM111 R DSM1V DSM1V TR DSM V

(1952) ( 1968 ) (1980) ( 1987 ) (1994) (2000) (2013)

DSM 1 DSM 11 DSM 111 DSM111 R DSM1V DSM1V TR DSM V

106 diagnoses 130 pages 182 diagnoses 134 pages 265 diagnoses 494 pages 292 diagnoses 567 pages 297 diagnoses 886 pages no extra diagnoses ???????

Medical 203 1943 issued by war department Army Navy and Veterans Dept. adopted it 1949 WHO released ICD 6 Spurred APA into action Circulated 203 to its members 1952 DSM I published which was essentially 203 with some minor changes.

Very similar to DSM 1 Debate about neurosis was active but term still retained Homosexuality still a disorder Large protests by Gay activists at APA conferences from 1970-73 diagnosis was dropped in 1974 printing Replaced by sexual orientation disturbance

Robert Spitzer elected chair of task force. Completely different format Adopted Research Diagnostic Criteria All psychodynamic terminology dropped Had to reintroduce neurosis in brackets after a few disorders to get it approved by APA Introduced multi axial system Sexual orientation disturbance became ego dystonic homosexuality

Axis 1 Clinical disorders including learning and developmental disorders Axis 11 Personality disorders Axis 111 Medical conditions and physical disorders Axis 1V Psychosocial and environmental factors Axis V Global assessment of functioning

Introduced ADHD for first time Introduced concept of clinically significant distress or impairment in social, occupational or other important areas of functioning

Developed in 1970,s in response to post Vietnam reactions Incorporated in to DSM 111 in 1980 First published RCT in 1989 (Keane Small study CBT in Vietnam Vets) Appeared in UK textbooks mid 1990,s

DSM 1 had gross stress reaction DSM11 dropped this and had nothing DSM 111 introduced PTSD with concept of stressor that would evoke significant symptoms of distress in almost everyone DSM111R altered this to an event that is outside the range of normal human experience and would be markedly distressing to almost everyone

DSM1V dropped these Currently have The person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others

Three symptom clusters Reexperiencing (intrusive) Avoidance Hypervigiliance (arousal). The clusters consist of items that are descriptive; so are the clusters and there are no expectations about the inherent dynamics

Also managed without Social Phobia, Panic disorder, GAD and Bulimia Nervosa Only had Anxiety Neurosis and OCD Subdivsion produced by specialists and drug companies needing something to treat

Also managed without Social Phobia, Panic disorder, GAD and Bulimia Nervosa Only had Anxiety Neurosis and OCD Subdivsion produced by specialists and drug companies needing something to treat

No diagnosis has caused more debate No disorder has been altered as much between various editions of DSM No disorder has differed so much between ICD 10 and DSM Almost every criterion from A-F has been argued about

Other DSM diagnoses agnostic to aetiology but PTSD has built in assumption about causation Bockin et al 2007 showed PTSD can follow a variety of non life threatening events. (Divorce, financial difficulties) Irwin 2006 found PTSD in social phobics who had significance performance failures Most if not nearly all Criterion A events do not produce PTSD

Dropping Criterion A altogether Removing from anxiety disorders Adding new trauma related diagnoses

Not necessary Not sufficient

Yes but not commonest psychological reaction

PTSD 16 Depress 11 Anxiety 18

211 consecutive admissions to Hadassah ER 4 months later 2/3rds had no disorder 17% had PTSD, 15% other anxiety disorder and 14% major depression

OTHER

PTSD

ANXIETY
DEPRESSION

174 motor vehicle accident victims with no past psychiatric history 6 month and 18 month follow up 42% no disorder 19% PTSD, 17% major depression, 37% anxiety disorder, 22% some other disorder

447 Southeast Asian refugees Cambodian, Vietnamese, Laotian, and Hmong

PTSD
16% 1%

Other

44%

39%

Anxiety

Depression

Nicholson, BL 1997

Launched On 10th Feb.2010 Chair of task force is David Kupfer 13 working groups that reflect DSM1V groupings All vetted twice for conflicts of interest

Katharine A. Phillips, M.D. Chair Professor of Psychiatry and Human Behavior Director of Residency Training for Research Department of Psychiatry and Human Behavior The Alpert Medical School of Brown University Butler Hospital Providence, RI

Gavin Andrews (Australia) Robert Lewis Fernandez Dan Stein (South Africa) Susan Bogels (Netherlands) Michelle Craske Scott Rauch Mathew Friedman Eric Hollander Robert Ursano Hans Ulrich Wittchen (Germany)

Checked twice by two different bodies All agrees no more than $ 10,000 year in industry grants from 2007 onwards

Details on Website from 10/02/10 Feedback and comments until April 10th Field trials will start May 2010 Will appear in 2013 (date put back)

Proposal to change from 5 axis to 3 Proposal to form new category of Trauma and related disorders Proposal to completely restructure personality disorders Reduce from 10 to 5 Prototypical approach

Currently a pentaxial system Axis 1 Psychiatric diagnosis Axis 2 Personality disorder diagnosis Axis 3 Medical diagnosis Axis 4 Psychosocial factors Axis 5 Global assessment of functioning Condense axes 1-3 All diagnoses will be axis 1 (psychiatric, personality and medical) Brings in line with ICD 10

Substance- Induced tic disorder (specify substance) Tic disorder due to a general medical condition Hoarding disorder Olfactory reference syndrome Skin picking disorder

OCD moved out of anxiety disorders Complicated agoraphobia with and without panic attacks abandoned

Proposal to move this to a new Category of trauma and stress related disorders Number of subtypes can be specified such as depressed anxious mixed Proposal that one be with PTSD like or ASD like symptoms

New definition of Criterion A1 No electronic exposure Criterion A2 dropped Dissociative reactions now in cluster B New E cluster including Reckless or self destructive behaviour

The person was exposed to the following event(s) death or threatened death, actual or threatened serious injury, actual or threatened sexual violation in one or more of the following ways: 1. Experiencing the event(s) 2. Witnessing the event(s) as they occurred to other. 3. Learning that the event(s) occurred to a close relative or close friend 4. Experiencing repeated or extreme exposure to aversive details of the event(s)

Witnessing or exposure to aversive details does not include electronic media unless this is part of ones vocational role

Dissociative amnesia Persistent and negative evaluations about self others or the world Persistent distorted blame of self or others Pervasive negative emotional state for example fear, horror, anger, guilt , shame

Irritable, angry or aggressive behaviour Reckless or self destructive behaviour

Criterion A1 as PTSD Criteria A2 dropped Duration increased min 2days to 3 days Now have to have at least 8 B symptoms Avoidance criteria strengthened

Complicated grief disorder Developmental trauma disorder Disorders of extreme distress not otherwise specified

Disorders of extreme distress not otherwise specified Affect regulation Somatization Dissociative symptoms

How many people will use DSM V system in their work with trauma sufferers?

DSM PTSD criteria have been on balance a positive development in the trauma field

DSM concept of PTSD on balance has not been an advance for the trauma field

DSM PTSD criteria have been the most damaging development in the trauma field since Freud's aphorism

Penis dosum repetitative