Lets Create A Ptsd Diagnosis

[Kintsugi]

I purposely stayed away from this thread because I knew it would be some crazy shit. I was right. It's hard to follow. I like arguing about the nitty-gritty of words, and it's giving me a headache. :bored:

Also, I think y'all got past this, but I saw "non-voluntary" somewhere. I think it was amended to "involuntary," but just a heads up in case it wasn't. :barefoot:

 

[anthony]

Why then is Sexual Violence specified

Because sexual violence is the single largest trauma against women. Domestic violence often means being beaten and raped by your partner / person living with in a domestic situation.

Also, I think y'all got past this, but I saw "non-voluntary" somewhere. I think it was amended to "involuntary," but just a heads up in case it wasn't.

Yer, we have used nonvoluntary based on its definition, as involuntary is inaccurate and opens holes.
Ok, no disagreement, I have locked in criterion A into the first post of the thread.

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Line drawn, criterion A discussion done. We can come back to it at the end, so if you have more with it then please add it in the off-topic side thread for your later referencing.

Before we get into symptoms themselves, we need to create a structured symptom category profile. I would like to try and fit complex trauma into this.

Feel free if you have a better way of doing this, yet based on what I thought would happen with this discussion, it has happened. It takes a lot of discussion to do something like this, and so it should. So I figure the best way to the outcome is:

> Build structured symptom categories first
> Begin sorting symptoms and classifying within relevant categories
> Allocate a stricter symptom requirement
> Add any additional criterion that are not symptom categories
> Review, discuss and make final changes

If this sounds good, and nobody has a better way to do this -- then structuring a symptom category profile is really the first point of call.

 

[lostforgottensoul]

If this sounds good, and nobody has a better way to do this -- then structuring a symptom category profile is really the first point of call

I think thats a way to do it. If not then you'll have symptoms of all sorts all over the place.

How sharp should these catigories be?

Like flashbacks would say be under, i dont know 'reliving trauma' or even maybe 'dissociation' though unsure as thats a symptom in of itself.

Im just wondering how like narrow to make them but not too narrow as a symptom would fit if its A but we made it B so it doesnt sort of thing.

Also i guess the lesser narrow then is not specified enough as well enough and too much goes into it, and it would seem too all over the place.

I do think that psysical symptoms needs to be a catigory has i have a crap load and though other disorders are in that, they are mainly due to my PTSD stuff.

Unsure of having dissociation by itself but because it varies, maybe?

Also anxieties & fears should be one and seem better together. Maybe even throw in there phobias? So anxiety (or anxieties), fears, and phobias?

My red hot rage/explosions w/o knowing what im doing or saying, i think, should go under this one of anxiety(ies), fears & phobias since its due to anxiety.

Also def a catigory for sleep disfunction (nightmares, sleep walking, insomnia, and id even mention like waking up running ect in here.)

Not sure if suicidal ideations should be by itself.

Maybe make a catigory as like other or miscellaneous as theres gonna be plenty that wont happen enough to have its own catigory. Just my opinion.

Not sure if addictions, SI ect would be symptoms but if it is, thats the one, I think, it should be under the miscellaneous/other though unsure of SI as thats normally a personality disorder thing i think.

Just throwing some out there.

 

[Deleted member 28740]

@anthony. Crit A refinement was unnecessarily messy process.

From a project management background, the Diagnosis refining process will be a unwieldy octopus.

You have identified the key (may expand) items to refine and this process needs refinement before starting. Items clearly defined should each have their own thread, subthread, though with the "offshoot" that becomes ungainly. Leave those in and they sink on their own if not of substance or appropriate.

Questions will always be of inclusion and exclusion, and based on current study data, which is not conclusive to begin with. Example, why 8% of general population exposed to ABCD results in a PTSD impact to mental health or diagnosis will always be open to interpretation of the causative and the person.

Links attached discuss process used to address mental health response issues during a catastrophic event 9/11, Katrina, etc. How the states and agencies had to refine their response. The process of input flowing and being sorted to a unifying consensus is of interest to this task. I am still trying to find one link that includes the process in detail. Good reads before embarking. The structure for reducing "noise" has to be both channeled and flowing. Set that up first. Flow chart style. Subject line clear for each discussion and input. And the off topic creation was IMHO disruptive. In attitude of spoilers etc. You ended up with a small pool of contributors and their chatter. IMHO.

Plan this next phase first. Then implement process of refinement. Good reads on process to achieve coherency.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1854990/ Katrina/Darwin

Dead Link Removed

 

[Deleted member 28740]

Because sexual violence is the single largest trauma against women. Domestic violence often means being beaten and raped by your partner / person living with in a domestic situation.

Tough call. In most countries it is subjective. Not to the victim, no. But to society and law and justice, still subjective and to mental health professionals also. How violent was it, etc. I'm not opposed to it being in the CA. Not at all, would broaden to included domestic violence. IMHO. External evidence of trauma inflicted is documentable. Rape is in the realm of whiplash in the courts and health treatment, with much less objective evidence in terms of impact trauma and subsequent justice.

 

[EveHarrington]

Just sticking my head back in here to see where you are.... Criterion A looks good.

The sexual part must be included @Changeling because millions of women, men, and children have 100% legitimate PTSD from non violent non consensual sexual encounters. Please understand that it is not the violence in and of itself that causes PTSD in these cases. It is the unwanted sexual violation of ones body. I am finding your arguments to be very tangential to the task at hand (throughout the thread). I'm not sure why you're arguing legalities. IMHO legal arguments need to be left out of a diagnostic criterion discussion altogether. The task at hand is to create an accurate diagnosis. Symptoms follow no "law" and need to be described exactly as they are. The law needs to mold to the diagnosis (where needed) and not the other way around. Introducing legalities into this argument does us all injustice.

I've stayed out of this discussion for the most part up to this point but felt the need to say something as I am a survivor of a non violent sexual assault that has caused my PTSD. I think this is one of those things that should be accepted even if you cannot fathom a non violent rape causing PTSD.

 

[anthony]

You ended up with a small pool of contributors and their chatter. IMHO.

And posts such as this are exactly what need to cease in this thread. So please stop posting noise. Off-topic thread exists for this.

@lostforgottensoul this applies to you too. Stop posting noise in this thread. If you do not have a clear idea to present, then use the off-topic discussion. Both threads have a purpose -- put the noise in off-topic and the specifics here. Keeping both related to PTSD diagnosis.

 

[anthony]

I will have my categorical structure proposal in a day or two -- still doing a little research -- if anyone has their own, feel free to share for discussion.

 

[anthony]

Been doing a bunch of reading of studies on the diagnosis, issues with it, blah blah blah.... all of which tend to mimic the same issues, yet no real solutions. Many also tend to highlight the symptom categories for the DSM V are pretty good. Sure, everything can be improved.

So... my only thing, is this complex PTSD debate. Complex PTSD has been attempted several different ways for inclusion, all have failed. The reasons vary from already existing diagnoses (BPD, DID, Dissociative Disorders, mood disorders) being present and able to be used as comorbid. Saying that, anything personality has to based on you fitting that symptom profile prior to adulthood -- that rules out nearly ever combat veteran, POW and such, where their trauma happens in adulthood, yet for sustained periods of time. There have been issues nailing down the diagnostic specifics, so much symptom cross-over (not sure why they worried about that one considering half the book crosses symptoms already) and many other issues.

The one common theme, to me anyway, is that the complex aspect isn't actually much different from PTSD, it's more that the complex sufferer endures regulation issues in relation to symptoms that the DSM V pretty much already covers. I think somatisation was the only one not included, but I could be wrong, as the wording for that may even fit when viewed backwards as a definition.

So... looking at this from all different ways, I think the structure is pretty tight. I think the nightmare of trying to create a unique diagnosis for complex trauma can be averted by adding a sub-type of complex by meeting a single symptom category set, called "regulation."

B. Intrusive symptoms:
C. Avoidance symptoms:
D. Affect & mood symptoms:
E. Arousal symptoms:
F. Regulation symptoms (3 or more and diagnose as complex):

I believe the issue may lay a little more in some wording, however; they did tighten the symptom wording a lot between version 4 and 5, as this is where they made it harder to meet PTSD. I also believe, to be perfectly honest, that the number of symptoms to be met should be increased... meeting one symptom in a set of 5 or 6 is just ridiculous. With such symptom crossover now, and really the figure is around 50% from a study done on the DSM, that there are better diagnoses for those who just meet criterion if they only have one symptom from 5 or 6 to choose. I've never spoken to someone here in depth that had one symptom from a category. So why make it a criterion?

I think by introducing a simple F category for regulation, you can target the specifics that already exist in PTSD diagnosis, and its merely a matter of whether the person is struggling to regulate those symptoms, such as what is seen in complex trauma sufferers. The majority do not meet BPD or DID, but PTSD itself does not really cover the regulation problems they experience.

It can be discarded otherwise for those not meeting them, PTSD is diagnosed. Those who do (complex sufferers), then PTSD-complex type is used.

IMHO, it removes so much of the nonsense going on with this diagnosis, yet doesn't exclude the complex sufferer when trying to explain their regulation problems with certain symptoms.

Thoughts? Stupidity? Stick with the basics? Go for gold? It's all philosophical and toss it to the wind?

 

[joeylittle]

E. Arousal symptoms:
F. Regulation symptoms (3 or more and diagnose as complex):

Can you help me understand the difference between arousal and regulation, in a category sense? - or, rather, is there enough difference to warrant having both. I wonder if arousal can be covered inside any of the others - or if it could be merged into this idea of Regulation?

It's tough, because I get the fine distinction between arousal and regulation - and maybe, the answer will present itself in listing out the regulation piece of it. I think that adding on the regulation piece is a smart way to address the issue.

The only other thought I've been having is whether there would ever be a use for a sort of 'all across the board' set of criteria for Trauma and Stress Related Disorders, the same way the Personality Disorders have. The advantage to such a thing is that it creates a different kind of flow through the diagnosis itself - so, first you have to have the markers of a trauma/stress disorder, then you proceed through the specifics, depending on age, length of symptoms, etc. It might speak to creating more symptom requirements, in a good way. It could also get people off of assuming that PTSD is the catch-all.

Edit to add: in the DSM, there are four defining features of a personality disorder: distorted thinking patterns, problematic emotional responses, over or underregulated impulse control, and interpersonal difficulties. A person must demonstrate significant and enduring difficulties in two of the four, before they can be considered for a personality disorder diagnosis. Those difficulties also have to be demonstrated over time. It's an entirely different type of condition, but the structure is interesting, and perhaps useful here. It came into being specifically to re-direct the way diagnoses were happening.

Thoughts?

 

[anthony]

Can you help me understand the difference between arousal and regulation, in a category sense?

Based on the current criterion for Arousal, which maybe I shortened too much, being arousal and reactivity:

Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

I am looking towards the regulation aspect based upon the original and modified cPTSD diagnostic aspects:

Experiences in these areas may include:

• Difficulties regulating emotions, including symptoms such as persistent dysphoria, chronic suicidal preoccupation, self injury, explosive or extremely inhibited anger (may alternate), or compulsive or extremely inhibited sexuality (may alternate).
• Variations in consciousness, including forgetting traumatic events (i.e., psychogenic amnesia), reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation), or having episodes of dissociation.
• Changes in self-perception, such as a chronic and pervasive sense of helplessness, paralysis of initiative, shame, guilt, self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings
• Varied changes in the perception of the perpetrator, such as attributing total power to the perpetrator (caution: victim's assessment of power realities may be more realistic than clinician's), becoming preoccupied with the relationship to the perpetrator, including a preoccupation with revenge, idealization or paradoxical gratitude, a sense of a special relationship with the perpetrator or acceptance of the perpetrator's belief system or rationalizations.
• Alterations in relations with others, including isolation and withdrawal, persistent distrust, a repeated search for a rescuer, disruption in intimate relationships and repeated failures of self-protection.
• Loss of, or changes in, one's system of meanings, which may include a loss of sustaining faith or a sense of hopelessness and despair.

Purely my own looking through existing symptoms vs proposed cptsd clusters:

1. Chronic fear of abandonment and trust.
2. Inability to regulate feelings of guilt or shame.
3. Recurrent suicidal behavior, self-mutilation or threats off.
4. Severe dissociative / depersonalization episodes.
5. Inability to regulate self-destructive behavior.
6. Perception of the perpetrator, including incorporation of his or her belief system.

Most of the symptoms are already in PTSD, it's really more that cptsd tries to extend ptsd via symptoms that are more severe, yet are still the same as ptsd listing, or that the symptoms are difficult to regulate is the theme I see in looking through existing proposed complex criterion sets.

This consistent (extreme) or (regulation) aspect sticks to near all complex attributes. So if the symptoms are already contained in ptsd, then really its just a matter of extending those with specific regulation aspects to make them more severe, thus the complex nature. The DSM IV didn't really cater this well as they hadn't associated as much dissociative or derealisation to ptsd, but 5 does, and this (to me anyway) opens the door more freely to simply add a regulation cluster to cover what is otherwise an unwieldily beast called cPTSD otherwise, which it seems nobody has had great success in focusing to a structured disorder.

Whilst some are excited about the ICD 11 doing so... at present they only have it in name, redirected to an existing personality disorder. Even if they come up with its own clusters, will they be symptom clusters or just A to F and make it another personality diagnosis? That is all unknown at this time.

 

[Sideways]

Seperating "complex" ptsd based on arousal and reactivity symptoms sounds good to me, but the original basis for the "complex" trauma being different was that the trauma itself was also endured for a prolonged period, rather than being a single event. Maybe that's not relevant to diagnosis anymore? But it was used to explain why the brain might react differently in those situations, causing different symptoms.

That's perhaps just a causation issue which doesn't belong in diagnosis, but it is absent...is that what we're proposing?