How Important is a Diagnosis?

[anthony]

Bob, best place to find a trauma specialist is go to local veteran centres and ask them who the general therapists and doctors are that treat soldiers. They are trauma specialists. You don't need to be a veteran to ask, nor be one to use those people. Whilst military have their own specialists, they also use civilian, and once a veteran is discharged from the military, they then use civilians generally. Seek them and you will find your answers quickly.

The reason your current physicians have not given you a PTSD diagnosis is because of the method in which you have suffered your trauma, ie. bullying. Bullying does cause PTSD in some extreme cases, however; due to the nature of PTSD diagnosis, by itself it is not normally "traumatic enough" to meet the first two criteria, hence why most will not diagnose it for bullying.

The first two criteria which must be met, are:

1. Did you experience, witness, or were confronted with an event/s that involved actual or threatened death, serious injury, or a threat to the physical integrity of yourself or others?
2. Did your response involve intense fear, helplessness, or horror?

Now, what you explained does fit this in certain aspects, though to a physician, they are also looking for the event that was "traumatic enough" to cause it. Diagnosis is not just about symptoms, because simply having anxiety disorder, you can have all the same symptoms of a person with PTSD does, but it does not mean you have PTSD, it means you have severe anxiety.

If you read [DLMURL]http://www.ptsdforum.org/thread1114.html[/DLMURL] then you will get the general idea of what physicians are looking for in order to diagnose PTSD, because its not just about the symptoms you present, but the larger picture of your trauma experienced, how you feel about that, the events themselves, the extent of symptoms, your body language, and more. There are a lot of aspects measured for diagnosis of PTSD, beyond what is mentioned on paper. The paper criteria are that only a guide for diagnosis, and physicians are looking for other aspects in conjunction with those theory aspects for a diagnosis to be made. Otherwise, they go to the lesser diagnosis which is more often the correct one at that time, because not all physical attributes are being shown to them.

That doesn't mean you don't have PTSD, but it means they are not convinced you do, so they cannot make the diagnosis. You can't fake PTSD, trust me on that. If presented before a trauma specialist, they will know whether you have PTSD or you whether you simply have severe anxiety, which comes along with depression, etc etc... all the symptoms which may look like PTSD.

 

[bob]

Anthony, I agree 100% and I can assure you that I meet these two main diagnostic criteria as well as the other lesser ones. In fact, it was only after reading about the diagnostic criteria that I realised I have PTSD. Previously to that, I had thought I was going insane, which I gather this is pretty common with sufferers. Now I realise that is not the case.

After having a rather frustrating chat with my shrink, I have canceled my next appointment with her and asked her to refer me to a trauma specialist. Our chat basically involved me saying I want a diagnosis, and her saying she thinks I should get more exercise and go for CBT. We went round in circles from there, she ignored my request for a diagnosis. I didn't really like her anyway and hopefully my new specialist will be more helpful.

I would like to thank everyone who has replied to me so far for validating how I feel about the situation.

 

[bob]

RE the diagnostic criteria, I notice that bullying is absent from the list. I believe that bullying is significant enough to cause PTSD. After reading up on it, it seems that I am not the only one (bullyonline.org/stress/ptsd.htm#PTSD,%20PDSD%20and%20bullying). In my case the beatings I received were quite severe and I did fear for my life. As I mentioned, I was bullied in and out of school and also at home over a period of several years. I really thought the bullies were out to kill me and all efforts to get help went unrewarded. It is when the perceived threat to one's safety exceeds one's means of coping that I believe traumatic injury occurs. In my case, I had little or no means of coping and the perceived threat to myself was very real indeed and lasted for a number of years.

 

[bob]

I forgot to mention - the type of traumatic injury that I believe I am suffering from is known as Complex PTSD. See the wikipedia article on Complex PTSD for more info.

 

[Lisa]

Hey there Bob...Fellow brit, hi!

It is recognised that bullying can cause PTSD alone, if there is perceived or actual threat to life, or physical and/or psychological integrity...at least that is my understanding of it, but correct me if I am wrong. I read the other day that the new DSM IV due to come out will have more specified symptoms listed to make the diagnosis clearer, as well as some branches of complex PTSD with adjusted criterion to that also. So there is hope for people like your Psychiatrist who are not open minded enough to actually listen to their patients (which I find ridiculous!).

I just want to point out that it would be impossible for Anthony to type up a list listing every possible trauma, so don't take that list as definitive because I don't think it was intended that way!

Bullying comes in many forms and many of us here have PTSD due to it at least in part - domestic abuse, work related bullying, school bullying, sibling abuse...

I understand your need to be validated. At times sometimes I have found myself up against the 'everyone gets teased at school' line and I find it the most offensive sentence anyone could ever give me. I often find I don't bother talking about the bullying so I just pick a different trauma to talk about from my list! Though I now have a therapist who is actually sensible for once.

But there is the world of a difference between 'natural' teasing children give and take in and outside of school, and bullying -which is abuse (and nobody ever belittles the effects of the word 'abuse'). Bullying not only causes PTSD, but also death by suicide in a proportion of those suffering at the hands of their bullies. They give it the word 'bullying' but I think it has a negative connotation to it these days, and isn't taken seriously enough by the government in the UK, that is for sure. I have heard too many sad stories of people connected to me where bullying has ended tragically. I had a friend in school hang herself (though she luckily lived). When she was back, the kids all walked around holding their ties up. So the school advised my friend to move schools... check out the irony there.

Anyway, there is a website on bullying and PTSD by Tim Field, I think its bullyonline... i think he relates some of it to work bullying but there's obviously school bullying and PTSD and stuff on there too... I don't have the link right now, but I'm sure if you search him up you'll find him. I just thought that it may be good for you to read up on some bullying specific PTSD websites so that you know that they are there and it is recognised generally know that bullying comes in different forms, different places and causes PTSD. Since you've felt invalidated by your psychiatrist (who sounds very similar to some I have had!), you might find as much validation as you can find helpful until your own validation is enough....

I was bullied similarly. It wasn't the only cause of PTSD for me, but I'm sure if there was only that I'd have PTSD anyway. I feared for my life under threat of being stabbed, alongside being beat up, humiliated, controlled etc.. Looking back, I doubt they ever would have stabbed me, though having said that I really don't put anything past them so, no I don't doubt they would have...but the important point is the PERCEIVED threat was most definitely there. I would be classed as complex PTSD too and a part of the trauma was consistently never being helped or believed, which only compounded it.

By the way - well done ditching the Psychiatrist and going for a trauma specialist! Good luck!

Sorry for the ramble... I have strong feelings on this subject!

 

[anthony]

Bob, I believe the best thing you have just done is made a decision for a second opinion. Again, if a trauma specialist says you don't have PTSD, then you need to listen to them and begin treatment for what they do believe you have, not what you believe you have. If that fails, then they will look further, have no doubt. Yes, some shrinks are idiots, especially towards bullying because of its nature. They want hard core physical abuse.

Now, whilst bullying is being recognised for some who have PTSD, is actually is a very limited percentage of those bullied who actually get PTSD vs. an anxiety disorder. You have to understand the difference of PTSD diagnosis compared to just what your reading. No, the list you read is not exhaustive, as Lisa pointed out above, thanks Lisa. What you must understand is the shrinks DO NOT look at the worst end of the scale, being PTSD, for something like bullying because whilst you believe it fits the first two criteria, I am going to give you what they work from, being the full understanding of "traumatic enough." You see, you can meet all the criteria theoretically, you can meet the criteria symptom wise, however; where some people confuse having PTSD vs. a near equal diagnosis of severe anxiety disorder, the that magical two words, "traumatic enough" and another two words that must be met are, "abnormal trauma."

The death of a loved one, whilst traumatic and can give a person all the symptoms of PTSD, is not classified by context as "traumatic enough" and/or "abnormal trauma", which is the difference as to why physicians DO NOT easily diagnose PTSD for bullying. Bullying is seen as a "normal" part of growing up in society, and that is the factual orientation of what bullying is, it is classed as "normal". Most children get bullied at some point during their childhood lives, for years, months or the entire time, it is classified as "normal trauma" of life. This is why you cannot be diagnosed with PTSD for having all the signs and symptoms if your partner dies. Death under fairly normal circumstances cannot be classified as "abnormal trauma" and/or "traumatic enough" and this is where sites such as bullyonline confuse listing PTSD, because they leave out those little facts within the diagnostic criteria, instead they go looking for everything around those facts, ie. if they discard that, it makes their statement / cause look better.

Again though, I will state, a very small percentage of people bullied do get PTSD and can be diagnosed from a trauma specialist. You may, you may not, have PTSD. You may simply have a severe anxiety disorder, and if so, you must accept that your trauma, whilst still very valid is trauma to you, may simply not be classified as either "traumatic enough" and/or "abnormal trauma" by the guidelines for diagnosis. You may find it is exactly "traumatic enough" or "abnormal trauma" when advised by a trauma specialist, but only they can tell you that.

I think you have probably sparked my mind a little now though, in that maybe I should include something about those two aspects which specialists are looking for, and not just the theoretical and physical symptoms that go with a diagnosis.

I don't believe many people truly believe just how serious PTSD is if diagnosed, and as society becomes more PC, they believe a little anxiety attack gives them PTSD, which we all know does not. This is how severe a diagnosis of PTSD is, and the extent of trauma one must suffer in order to get PTSD itself:

• Revert again from what you know as a civilian, and now look at the Governments around world, which are the military.
• A diagnosis of PTSD is that severe when looked upon as "traumatic enough" and/or "abnormal trauma" that PTSD is the only illness that military around the world rate equally too losing an actual limb.
• You read that correctly, that is how severe the diagnosis is. Military around the world DO NOT provide pensions for anything lesser. You either lose a limb or have PTSD. By definition, have PTSD is actually defined as worse than only losing half a leg. Losing both legs is worse than having PTSD, both physically and mentally attributed.

That is how severe a trauma one must endure for a physician to diagnose PTSD, because that is the very level they are comparing your trauma against, or equal to the level off the loss of an actual limb.

This is why there is a unique different to diagnosis towards death. Natural is simply not looked at, period. If your partner hung themselves, though you did not find them, you would not get diagnosed with PTSD, because whilst their death is traumatic to you, you did not witness, where confronted with or your physical integrity where not affected. Your partner simply hung themselves and you will have a natural anxiety affect as a result.

Now if you found your partner who had hung themselves, that changes everything in your response. You where confronted with their death, you found them, thus you now meet the means off "abnormal trauma" in relation to the first two criteria. The second is a given if you found someone hung. The immediate response would be helplessness.

Now, back to bullying. Some bullying has been recorded to the same extent as a child who was physically and emotionally abused by their parents their entire youth. It is rare, but it is recorded. These are usually the few who meet the full criteria. In relation to yours Bob, you have mentioned physical abuse, and this may/may not meet the criteria because it depends on the length of time and extent, beyond what is classified as "normal" school yard bullying, fighting, etc. We have all been bullied, most have been in fights at school, even sustaining stitches, broken bones, etc... I have, and my brothers, though none of which gave me PTSD. That does not mean it wasn't a pre-cursor to my own PTSD, ie. the straw that broke the camels back.

It really is a developing issue within the diagnostic criteria, being bullying, and one which will see more light no doubt as the years pass and society becomes more PC. But the undisputed facts must still be reviewed, and that is for someone to be diagnosed with PTSD, it cannot be lessened to what the intent of the diagnosis is, being the extreme end of all scales and incurable. A person diagnosed has met "abnormal trauma" and "traumatic enough", met all theoretical and physical impairment guidelines, obviously met the first two criteria though the traumatic enough instances.

I think you have done the right thing though Bob, being to seek a second opinion to find out once and for all what a trauma specialist believes, because there is a huge difference between a know it all shrink using personal bias vs. a trauma specialist who knows trauma inside out, back to front, and excludes personal judgement or bias from their diagnosis. Well done Bob.

The DSM IV is also not the latest version of the DSM, you must actually look at the DSM IV (TR), which is a text revision of the manual. The DSM V is scheduled to break apart PTSD into multiple categories, in that you will be diagnosed with: Combat PTSD, Childhood PTSD, etc etc... labels that allow physicians to know what your trauma was, or close enough too. That was the initial statement made in relation to the next revision of DSM. Whether that will occur or not, yet to be seen. I will tell you when it comes out, as I will purchase a copy for myself.

 

[Lisa]

Apology for mentioning the wrong DSM version... I didn't have the book I was referring to (where I got the information, not the actual DSM whatsit) handy so I obviously got it wrong. Anyway, Anthony clearly has the diagnostic criteria firmly in his head, as opposed to me!

I have to reply with my personal opinion on this, I hope this is okay.

Personally - I think mainly on a psychological viewpoint when it comes to thinking around PTSD, but I am still learning myself. I hate disagreeing with people (and admittedly I am scared to disagree with you Anthony!) but I come from things differently in relation to whether or not bullying is 'normal trauma' or 'abnormal' trauma. To me, trauma is trauma. If the effects are the same as 'abnormal trauma', then what does it matter whether it's considered normal or abnormal by a psychiatric professional body based on the fact that it is not a rare enough occurrence to be considered traumatic? Sexual abuse happens a lot... but that is not considered 'normal' trauma. As I said, there is a difference between every day teasing, and severe bullying where a child is left victimised, psychologically and physically injured, terrified, emotionally, mentally and sometimes physically tortured, and, effectively, traumatised by it years later. However, as Anthony touched on, this is a developing issue and could all change as the criteria is being constantly adjusted.

But that is just my personal opinion, and this is about diagnosis, which is purely a psychiatric issue... therefore my post and psychological viewpoint doesn't really belong in this discussion!

But I do agree that you cannot be diagnosed with something lesser than the diagnostic criteria, and that the best thing to do is to get a second opinion.

 

[bob]

Lisa and Anthony, thankyou for your posts. You both make some excellent points and have given me lots of food for thought.

Anthony, you make the point of PTSD only being considered if there is evidence of "abnormal trauma". I would like to point out the difference between the diagnosis for PTSD and Complex PTSD. To quote wikipedia, Complex PTSD is a clinically-recognized condition that results from exposure to prolonged interpersonal trauma. The keyword here is prolonged. Arguably there is no single incident that I have encountered that would cause PTSD, although some do come close*. Instead, my problems are caused by lots and lots of lesser traumatic incidents over several years. I believe that Complex PTSD is not included in DSM IV but is under consideration for inclusion in DSM V, so getting a diagnosis thereof may be tricky without a very good doctor.

Whilst I agree with Anthony that the doctors are looking for abnormal trauma in a PTSD diagnosis, I believe that traumatic injury is sustained when the trauma experienced exceeds one's ability to cope with it. There are two very important points to consider here. Firstly, (Complex) PTSD can be caused by situations that are less traumatic than considered necessarry for PTSD, as long as they are prolonged in nature. Secondly, the point at which traumatic injury is sustained is subjective. That is to say it varies from person to person depending on how well they are able to cope with trauma. For someone with limited coping resources, traumatic injury may be sustained from incidents that someone with better coping resouces would be able to deal with. At any rate, the net result is the same whether PTSD or Complex PTSD - it's all traumatic injury.

I was going to write some more about bullying and emotional abuse but I've worn myself out and my mind has gone blank.

* the ones that come to mind are being beaten in the head with a spanner needing stitches, being punched by a guy with a sovereign ring and then having my head slammed in a door needing stitches, being beaten by two police officers in the back of a police car, being shut in a bin by children at school, setting off a trap that spiked me in the head requiring stiches, seeing a friend beaten with a baseball bat and lots of blood coming from his head, witnessing a woman killed by a bus and bleeding lots

 

[Claire]

Hello Bob, I recommend you read a book called PTSD, the invisible injury. I cant remember who its by but I think its the guy that Lisa mentions Tim Field or a collegue of his. Its written by a policeman. its very good and was a real awakening for me when I found it.

I hope you get an answer one way or the other from the new specialist.

 

[anthony]

I hate disagreeing with people (and admittedly I am scared to disagree with you Anthony!)

Lisa, no need to ever be scared of me, I don't bite. I like people to disagree with me, because I value others opinions. Some things I write here may be my opinion, which I usually use IMO or IMHO, and some are facts that I have studied / self educated about. Please do disagree with though Lisa, because I am certainly not always right, nobody is. I would rather someone correct me if I am wrong, or if they have a better way of doing things, I certainly love change.

Anthony, you make the point of PTSD only being considered if there is evidence of "abnormal trauma". I would like to point out the difference between the diagnosis for PTSD and Complex PTSD. To quote wikipedia, Complex PTSD is a clinically-recognized condition that results from exposure to prolonged interpersonal trauma. The keyword here is prolonged.

You are correct Bob in what you state, though complex PTSD is more an in-house diagnostic assessment label, and yes, again correct that it is not in the DSM IV (TR) though this is the topic on how the PTSD diagnosis will be broken down in the DSM V. You are correct in that aspect, absolutely.

What I think your missing here though, is that regardless what your looking for in relation to the labelling, the outside characteristics for the further labelling are only part of the diagnosis once a person meets the actual PTSD diagnosis itself. PTSD is diagnosed as acute or chronic only, at present by the DSM criteria, however; what I must add here, is that the DSM is only a "guide" to diagnosis, and is not by any means a "legal" bible for the mental health industry. Some think it is, but it is not, and this is why we have in-house diagnostic criteria such as "severe PTSD" and "Combat PTSD" and "Complex PTSD" etc. This is why the industry is calling for a more standardized approach I believe, in that from what I have read about the topic, so far the additions will be made to help standardize the PTSD diagnostic labels instead of some working only from the DSM, others working from the in-house word of mouth rules, and so forth.

Regardless of all this, the actual basics for PTSD as defined by the DSM IV (TR) must all be first met, including "abnormal trauma" and/or "traumatic enough". Again though, my list does not rule out bullying because its not mentioned, as several trauma types are not within it, though can be used for PTSD diagnosis. The list is not exclusive, that is for sure. I know two people with PTSD diagnosed from bullying, though I will add, the bullying they had to actually prove, go figure, then it was proved as being so severe the diagnosis from anxiety disorder to PTSD was made, from what I am aware in these two cases.

Bullying can be "traumatic enough" to cause PTSD, no doubt about it. The only issue I believe they had to prove was that it was not classified as "normal" type playground bullying as part of growing up. I believe that was the issue. For example, I had fights at school, even though I hated fighting and avoided it at all costs, and did injure myself, though have no traumatic recollections beyond them being a normal aspect of growing up and school yard bullying / pissing contests that go on. I could certainly think back though to one, maybe two kids, that could likely have PTSD from school yard bullying that I attended school with, in that the typical bullies of the school honed in on them constantly, and with what I know now, could undoubtedly state they should have PTSD because their near entire high school years would off been hell, and no doubt caused more conflict when taken home, the typical teen mentality of keeping it all in, not talking with parents, etc; all the things we know are wrong now, but still occur regardless.

Firstly, (Complex) PTSD can be caused by situations that are less traumatic than considered necessary for PTSD, as long as they are prolonged in nature. Secondly, the point at which traumatic injury is sustained is subjective.

I would have to agree and disagree with this. As already stated, even to meet complex PTSD you must meet the PTSD diagnosis, which already encompasses and is recognised for long standing trauma, ie. childhood abuse, molestation, bullying, etc. From my understanding, and I will have Dr. Roerich have a look at this thread if he has time, is that the label of "complex" is just that, a label after diagnostic criteria has been met, basically saying that the extent of trauma is from the prolonged duration of events, constant events, and off a significant nature to "compound" and become over-whelming for the mind.

I think you are correct, though I am pretty sure you must still first meet the actual diagnostic criteria. Again though, I will ask Dr Roerich if he can read this thread and clarify, as he would be a better person to outline due to being a traumatic specialist.

That is to say it varies from person to person depending on how well they are able to cope with trauma.

Absolutely agree mate, and that is a definite, in that two people can be exposed to the same trauma, one get PTSD, one not, all because of their unique individuality perceptions in how their mind interprets the event.

I was going to write some more about bullying and emotional abuse but I've worn myself out and my mind has gone blank.

* the ones that come to mind are being beaten in the head with a spanner needing stitches, being punched by a guy with a sovereign ring and then having my head slammed in a door needing stitches, being beaten by two police officers in the back of a police car, being shut in a bin by children at school, setting off a trap that spiked me in the head requiring stiches, seeing a friend beaten with a baseball bat and lots of blood coming from his head, witnessing a woman killed by a bus and bleeding lots

Bob, this is exactly what I mean mate, when I say its not just about bullying itself, but you have now been physically injured with the mental compounding nature of bullying. You witnessed a women killed by a bus, nothing to do with bullying. You have been beaten by police, etc. You very likely may have PTSD because of these events, where the bullying may off been the pre-existing issues, though seeing a women get killed by a bus was the one that just tipped the scale for your mind.

I definitely believe you need that second opinion though, and the more you mention about the injuries sustained and especially the witnessing of the women killed, you need to be telling this to a trauma specialist so they can help make an accurate diagnosis. Again, they will know just by looking at your actions, reactions, the way you walk, talk, sit, everything, whether you have PTSD or not.

Either way mate, I truly do hope you atleast get the answers you need, being you have it or severe anxiety, whichever it is, both must be treated immediately, because even the severe anxiety left untreated could manifest to PTSD if you don't have it already. Not good though, that is for sure, and I definitely agree that your last physician likely took things a little too lightly. Again though, they can see you, I cannot.

 

[anthony]

Ok, I have spoken with Dr Roerich in relation to this issue, and whilst he cannot give specific information to you Bob as personal advice, I can give you a break down of what I interpret our conversation to determine. In point form, it goes something like this:

• A diagnosis has been made, anxiety disorder, yet the causes of it can be many and varied.
• Besides anxiety what else is going on and what is the cause of the anxiety. Is it situational?
• When did it occur and when did it get worse that you sought treatment from a psychiatrist?
• Have you received treatment for anxiety before?
• Have you been hospitalized for depression or psychosis? What about family members?
• Have you been screened for bipolar disorder or PTSD? While you may feel you have all the symptoms, those very symptoms described can be from many causes. How open are you to detailing your problems?
• How detailed is the psychiatrist in asking for signs and symptoms in a differential diagnosis?
• A psychiatrist who prescribes Zyprexa is thinking of paranoia, hypomanic or manic state of bipolar disorder, psychosis, or a need to temper aggressive behavior towards self or others.
• The correct diagnosis is always based on doctor and patient working together to piece together the pieces of a puzzle: what is causing distress or dysfunction? What is causing anxiety?

Is a diagnosis important? Yes, but unless there is an honest exchange of what is being experienced and what is being reported to the psychiatrist, the correct diagnosis may be elusive. The doctor should screen for bipolar disorder and PTSD. An organic workup for physical causes of anxiety should be done:

Acute Coronary Syndrome
Alcohol and Substance Abuse Evaluation
Congestive Heart Failure and Pulmonary Edema
Costochondritis
Depression and Suicide
Hyperthyroidism, Thyroid Storm, and Graves Disease
Hyperventilation Syndrome
Hypoglycemia
Mitral Valve Prolapse
Myocardial Infarction
Neoplasms, Brain
Pneumonia, Bacterial
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
Pulmonary Embolism
Schizophrenia
Toxicity, Benzodiazepine
Toxicity, Narcotics
Toxicity, Sympathomimetic
Toxicity, Thyroid Hormone
Withdrawal Syndromes

Other Problems to be Considered

Neuropathies
Pheochromocytoma
Sinus tachycardia
Brugada syndrome

Source: emedicine

Bob, in the above referenced material, Zyprexa is not mentioned as a medicine used for treatment, which typically outlines something more is going on with you than meets the eye.

 

[bob]

Hi Anthony. I have sent you a PM with some responses to the questions. I didn't post it here because some of it feels a bit personal.

Many thanks for your help, I'm really greatful to you.