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The future of ptsd

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The twentieth century was rife with war and catastrophic trauma. Anything lesser suffered during such time was considered trivial, dismissed as the sufferer's individual weakness, a failing in psychological fortitude.

Enter Post Traumatic Stress Disorder (PTSD), answering the demand to explain Vietnam veteran syndrome, combat stress reaction, concentration camp syndrome, rape trauma syndrome, battered woman syndrome, abused child syndrome and further associated labels.

The PTSD diagnosis was created to meet the need for symptoms arising from catastrophic trauma. Over time, however, the diagnosis seems to have lost its way in addressing this need.

A broken industry
The Diagnostic and Statistical Manual of Mental Disorders (DSM III) cited the PTSD qualifier as: Characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. The precipitating stressor must not be one which is usually well tolerated by most other members of the cultural group (e.g., death of a loved one, ordinary traffic accident).

The International Classification of Diseases (ICD 10 - Current version) uses what I believe to be the best description still to date: Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

There are key words in those statements, "outside the range of usual human experience" , "exceptionally threatening or catastrophic nature", "which is likely to cause pervasive distress in almost anyone." These are facts often dismissed when trying to explain one's specific circumstances around complete contextual meaning.

Unfortunately, due to today's perpetual need to find the next level of political correctness, the diagnosis is increasingly handed out like condolence cards, assigned for every one of life's bumps and bruises. Worse, this is done by the very people who are meant to work in the best interest of their client and society at large, ensuring to not pathologize society.

While fixing some of the holes created from the DSM 4, which made a mockery of PTSD criterion since the DSM 3, the DSM 5 (current version) still falls foul to this modality of political correctness, allowing society to be pathologized into this neat mental health model after what are, in essence, traumatic events.

No longer do we experience an event, talk about it and move on with our lives. Instead, we have a mental health disorder, are treated as guinea pigs using psychological therapies, then if we do not recover within this statistical timeframe, are guided towards the use of medication for treating this apparent disorder.

Now, let's not confuse this with legitimate cases where a person is debilitated by symptoms after experiencing horrific trauma.

If you want to call this process scientific evidence -- individuals self-reporting symptoms, followed by a psychological professional interpreting said report, mixed with their personality, experience and capacity of emotion, then apply a label based on a group of professionals who prior agreed on a majority statistical model which asserts people presenting a, b and c symptoms have x, y or z diagnoses -- then sure, you may convince yourself that mental health has scientific foundation.

Otherwise, the fact is that there is little valid science underlying mental health diagnoses, nor the prescribed medications to treat these fictitious disorders, beyond best guesses gleaned from statistics.

When something is special
What most people don't understand is that PTSD is special. It is the only diagnosis to contain a required event occur for diagnosis. PTSD diagnosis has a legal component attached to criterion A, being that a trauma professional is legally stating that trauma of significant distress has occurred. This variable impacts disability claims and legal circumstance.

As a result of PTSD's uniqueness, understandably it has been embroiled in controversy since inception. The only diagnosis close to PTSD's controversy is Dissociative Identity Disorder (DID), which is the new (politically correct) name for multiple personality disorder.

Muddy waters
Today, in the twenty-first century, we have people claiming PTSD for all sorts of events, such as wisdom tooth extraction, obnoxious jokes in the workplace, cheating spouses, relationship breakdowns and women who had uncomplicated births. PTSD is academically a diagnosis reserved for those who meet very specific traumatic criterion and severity. None of the above meet this criterion, yet professionals diagnose based on meeting a categorical symptom profile, loosely surrounding what the individual claims as traumatic to themselves.

This erosion of diagnostic stringency is called criterion creep. In other words, humans slowly broaden the definition of trauma, often self-justifying what they feel is traumatic enough.

Is a tooth extraction, obnoxious joke, uncomplicated birth, cheating partner or relationship breakdown equivalent to rape, torture, violent death, childhood abuse or war? That very question has certainly been met with diverse responses by those here who do meet the traumatic criterion for PTSD diagnosis.

Are the academics of PTSD accurate? Can only those who experience catastrophic events have PTSD? Maybe the most interesting question of this entire discussion is: can the PTSD diagnosis sustain its criterion A traumatic requirement?

The way things are progressing, PTSD's future is going to get uglier. PTSD is the hip, cool, "in" diagnosis at present. It rolls off of the tongue -- post traumatic -- meaning anything prior that caused distress must befit this diagnosis! Right? That is very much the way many tend to view the diagnosis.

It's complicated; that much I know. I believe that reader comments for this article may broaden the opinion base relating to questions posed, but let's try to further understand what is happening with trauma diagnosis today and where this diagnosis, which is often so central to our lives, might be headed given the current diagnostic climate.

Who Said Trendy?

PTSD is the trendy diagnosis plagued with contentions and future growth problems. Does the industry continue to expand criterion so eventually everything but the kitchen sink can befit PTSD? Or decisions need to be made that curb the political influence and remove public pressures for political correctness upon organizations such as the World Health Organization and American Psychiatric Association in structuring mental health criterion?

To keep this article focused, we've excluded posting PTSD diagnostic version history. See: Third edition, Link Removed, Fifth edition.

Lets talk diagnostic problems
Criterion creep
is nothing new when discussing diagnostic scope, it simply means that trauma experts try to include more avenues to meet diagnosis with each diagnostic progression. This is often done to conclude a valid outcome that contains speculative data. What does that mean?

Well... valid data is found, yet limited when compared to speculative data. The problem with criterion creep is that practicing therapists transition speculative opinion and data within their diagnostic procedures. They then push their view, their opinion, beliefs even, upon their clients, who then perpetuate such knowledge as though factual.

This is how we see newcomers to MyPTSD claim their therapist diagnosed them with PTSD for their spouse cheating on them. A cheating spouse does not meet criterion A, yet here they appear nonetheless. Worse, they appear stating their therapist diagnosed them with PTSD purely because their spouse cheated on them.

Professionals are a diagnostic problem.

I like to think that Dead Link Removed hit the nail on the proverbial head and solved criterion creep adequately:

One unintended consequence of peace and prosperity is a liberalised definition of what counts as a traumatic stressor. The threshold for classifying an experience as traumatic is lower when times are good. In the absence of catastrophic stressors such as war, specialists in traumatic stress turn their attention elsewhere, discovering new sources of victims of hitherto unrecognised trauma.

The other side to this equation is that the very improvements in living standards and reduced violence we created make people sensitive to stressors that would not otherwise have affected previous generations. Maybe the better we make our lives, the more sensitive we become to what is traumatic?

Mental health diagnosis and application is what I would consider the largest problem. When you visit your doctor feeling unwell, physical tests more often than not will identify whether a physical issue exists. When you visit a therapist (psychiatrist downwards) you enter a world of philosophical diagnosis and theoretical hypothesis.

The industry is working with tools available at this time. Dr. Thomas Insel, former Director of the National Institute of Mental Health (NIMH) said it best at the 2015 Smithsonian "Future is Here" festival: "In 2015, I can’t tell you -- nor can anyone else -- how the brain functions as an information processing organ. How does it do it? What is meaning, how is it stored, where does it exist, what does it look like in the brain?"

Google "what we know about the brain and memory" and begin reading the different explanations of memory storage, encoding and retrieval from websites you would consider authoritative sources. You will immediately begin reading different theories. One should note such words, theories vs fact. Yet today's theory, one could argue, is today's fact.

See what I just did? Philosophical discussion. That is the basis of the mental health industry.

Link Removed of the NIMH, Steven E. Hyman, wondered whether the DSM diagnoses are more reifications, and not labels for genuine medical conditions. (Reifications are complex ideas when treating something immaterial -- like happiness, fear, or evil -- as a material thing. A wedding ring is the reification of a couple's love.)

Symptom overlap is prevalent within the DSM and ICD categorical structure, comorbidity is now the rule, instead of exception. The same symptoms (written the same or similarly) appearing across multiple disorders, for example, half the symptoms in the DSM IV are directly or indirectly connected when viewed through a network approach.
To put this as simple as possible -- if you inserted your cause and symptoms into an algorithm that searched current mental health diagnoses, you're more likely, than not, to be returned multiple valid diagnostic options. So does this mean you have all these diagnoses? According to doctrine, you certainly could be diagnosed with them all.

A person may meet anxiety, depression, sleep and social disorders uniquely, yet if we went back to that algorithm, PTSD would likely exist within the output list because it contains many of the symptoms in these very diagnoses. This brings us around to criterion A and whether its importance should be adhered at all costs.

Post traumatic stress disorder has little valid evidence to support itself. This conclusion was made by a traumatologist group assigned to aid in correcting the issues with the PTSD diagnosis for the DSM V. The problem though, is they also had no valid solutions to the problems. Still philosophical.

There are vast differences between the DSM and ICD versions for PTSD diagnosis. Why? The ICD does not include numbing symptoms. The ICD 11 is proposed to tighten PTSD criterion to such extent that it will become difficult to diagnose. PTSD is entered as a rare, severe, diagnosis for those having experienced catastrophic trauma that no person should reasonably expect to endure within their lifetime.

One of the largest issues is attempting to define specific traumatic events. Back to that criterion A problem. Is PTSD simply chasing its tail trying to implement any limit on "what is traumatic enough" for a diagnosis?

Diagnostic solutions are problems too
Problems are easy to discover -- viable solutions on the other hand? This is why we have diverse trauma therapy options. If things were simple, one-size-fits-all would work.

Criterion creep began the same day mental health doctrine was created. Every practitioner has an opinion on what is right for evaluation or diagnostic purpose. They're not wrong, either, as the entire industry is speculative, philosophical, trial and error on a per patient basis. Who says a small fringe method today won't be the primary treatment tomorrow?

Then we have progression, and that comes from the industry professionals. Precision medicine is needed more than ever to substantiate mental health, yet we lack the necessary biological knowledge for the brain, and thus we lack any associated tests to validate mental health diagnosis.

Maybe the solution is to remove criterion A? That would elate many industry experts. It would remove the pretense surrounding PTSD, making it available to everyone where trauma is relative to the individual and assessing physician, instead of meeting a specific type or threshold. This freedom would negate societal times being good, bad or otherwise.

Saying that, lessening PTSD traumatic requirement would likely void disability for PTSD diagnosis. PTSD is considered the mental equivalent of losing a limb. Is a relationship breakdown, cheating spouse or tooth extraction equivalent to losing a limb?

This legal and disability component must be factored towards any decision made forthwith. Open PTSD and you either collapse Governments from disability claims, or you collapse those persons lives legitimately disabled by PTSD from catastrophic trauma.

MyPTSD members contributed modifications to harden DSM V criterion (Modified Version), which may solve some problems with the ease PTSD is diagnosed, whilst including regulation for complex trauma sufferers.

Do we continue adding diagnoses to the literature, expanding diagnostic manuals specificity? Rosen, Spitzer and McHugh outline some of the new literature appearing in an attempt to fill such criterion creep void:

New diagnostic categories modeled on PTSD have been proposed, including prolonged duress stress disorder, post-traumatic grief disorder, post-traumatic relationship syndrome, post-traumatic dental care anxiety, and post-traumatic abortion syndrome. Most recently, a new disorder appeared in the professional literature to diagnose individuals impaired by insulting or humiliating events – post-traumatic embitterment disorder.

Does psychological diagnosis need be restricted to psychiatrists? They are the medical doctors who diagnose based on exclusion. Such a requirement may help reduce criterion creep, yet this creates diagnostic delays more than already exist, and psychiatrists are more likely to treat with pharmacology, whereas psychologists rely more on therapeutic technique. Maybe a top down screening process? Visit your GP, referral to psychiatrist, evaluated whether you need psychotherapy (diagnosed), and then you are pushed to a psychologist for psychotherapy.

The network approach adequately demonstrates a broken categorical system of diagnosis currently used. We splash around labels and medication based on reusing the same symptoms for these diagnostic labels. Disorders are a network of interacting symptoms, even self-reinforcing, and not underlying disease entities (categorical) that produce symptoms.

When you suffer symptoms, period, you suffer them. However, looking at symptoms via a network approach may be more beneficial towards therapeutic solutions than diagnostic evaluation?

To understand this conundrum in its simplest form, let's use depression as an example. Rumination, insomnia, fatigue and concentration difficulties seem causally interconnected. If you ruminate, you're most likely to experience insomnia. Lack of sleep produces fatigue the following day, which is most likely going to affect your concentration.

Do you really have depression or do you simply ruminate? The cause has become lost in an attempt to label. Do the symptoms sustain themselves uniquely, or are they connected, based on individual situations?

One solution I don't see right now, is what surrounds our daily lives. Technology. Where is technology in diagnosis? We fill out forms, we have written books with defined limits, we have industry professionals who use emotion as part of their decision process. We have a diagnostic categorical structure with a 50% symptom overlap. Why? There are astounding mathematical minds today putting that math to use within algorithms. Google is a direct example of mathematical genius resulting in an accurate algorithmic outcome.

Would we not obtain a far more accurate diagnostic outcome from a computer system where we input symptoms, environmental effects, what is happening in our lives, using a HD camera assessing our body language, etc, and then calculate an accurate single diagnostic outcome, if not direction to look at what our issue is? Computers are not emotional: they're going to look at the facts, not be empathetic or sympathetic with self beliefs and complicating contextual factors. The snowball effect is limited, if not removed.

Google already uses a limited AI system in their search algorithm. We already have camer-based lie detector software that uses an algorithm to measure facial and body movements. Such technology already exists and would take mental health diagnosis from best guess to 95% plus accuracy.

Such an approach unites the world towards a single system, with all heads providing the content for an algorithm with which to work. I'm sure Google would love to put their name to a global medical system. Diagnostic delays would be removed, especially if you feed personal data over a period of time to provide the most accurate diagnostic outcome. Such process can all be self performed anywhere with Internet access.

Just add cost to access, and the industry maintains its big business hold on mental health.

Enthusiastic mixed with scary
It's 2017, and PTSD is seemingly becoming far more complicated than it ever should. Media are not helping by disseminating emotionally charged half-truths for statistical readership. Groups are banding together for change, and when enough noise is made, mixed with half-truths, politicians are being involved in mental health processes. Just look at the American marijuana accessibility laws for PTSD. There are more political decisions being made in its approval than are being based in medical evidence.

What I know is that PTSD, like most mental health disorders, is over-diagnosed and lacks diagnostic consistency. There is too much individualism in diagnostic application, which is what an AI-based networking algorithm would remove entirely, let alone the mis-diagnosis and comorbid over-diagnostic occurrences. Whether or not such a move is the answer to PTSD's criterion creep crisis is up for debate. What does seem clear is that if nothing is done to stem the flow of its current popularity as a diagnosis for all of life's natural bumps and bruises, the legitimacy of PTSD, and its legal implications, will be gravely endangered.
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I absolutely love the idea of diagnosis based on algorithm, not only for the reason mentioned above. I think even people who clearly meet all of the diagnostic criteria second guess their diagnosis from time to time. There is the hope that it is not PTSD and instead something far easier to treat. I would love to under go such a test for that.

It seem that percentage of people I know offline who have been diagnosed with PTSD is larger than is statistically probable.
I think Google could really revolutionise the diagnostic outcome for mental health, even the WHO in combination with such organisations. Anyone with a mobile phone with camera could live feed into an AI system for analysis, anywhere, anytime. They would have an accurate mental health system then.

Result: you’re having some anxiety which can be lessened .

Result: you’re having some anxiety which is considered severe and possibly unhealthy for you, we have emailed you a prescription for to turn in at your pharmacy to take regularly. Please login in every day with feedback and scanning to ascertain whether the medication is right for you.

Hell… you can even take blood tests now with a phone. Once that is readily available, you could have one of those taken and analysed at the same time to ensure the medication is working correctly for your system. Technology is the solution — not people with individual, emotional, philosophical views and opinions on every person self reporting to them. Psychiatrists are just looking for people to be mentally unhealthy and needing their treatment.
I had to remove myself from the subjectivity of the current Diagnostic manual because of a massive conflict of interest on the part of insurance companies. I have what I have – it has not gone away and I have blood and urine tests that align with combat veteran style PTSD and not MDD . So even if the subjective methods exist legally and in the field of psychology and psychiatry the future is here medically in the fields of neurology and endocrinology research…Its just a shame those of us currently suffering have to wait the 17 years for the non subjective methods that are known now to be aligned with the subjective tests-proven as more reliable and adopted . Maybe technology is what can help get the manuals and practitioners to adopt proven research quicker than a lag time of 17 years – sadly not so much in the way of treatments but think there is already heaps to verify diagnosis. Once a biological basis for symptoms is mapped maybe better cause effect analysis will lead to effective treatments if not cures.
Yep. Those diagnoses are factually nothing more than observations agreed by a group, based on skewed statistically published data, dismissing the majority of actual data, as it does not get published. Mental health diagnosis has BIG problems.
I have Complex PTSD, with a bunch of other symptoms from bipolar disorder and anxiety disorders such as GAD, SAD and OCD. Honestly, my docs can’t fit me into a diagnosis, they think it all stems from trauma so I’m treating it in therapy, meanwhile I take a small amount of medication for my symptoms.
As much as I agree that for most of the population an algorythm and AI could revolutionize the mental health field, and I do agree, I think while the diagnostic criteria for schizophrenia for example is not updated, or bipolar, or any other mental illness for that matter, that is stuck in the past 100 years of fixed beliefs, nothing will change.
The truth of the matter is that we’re all different and express our symptoms in different ways, once the mental health field starts looking at us holistically and not as groups of people with exactly the same manifestations of symtpoms, things will start to change.

Other than that particular pet peeve of mine with the mental health field, I thouroughly enjoyed this piece and do agree that technology is the future.
I much appreciate this article series, thank you. I also always appreciate the discourse here on myPTSD for attempting these sorts of questions. I agree that neurology and endocrinology can offer a lot diagnostically, and agree that there are serious problems with mental health diagnoses. I have never seen an in-person copy of the DSM so I don’t know if this is in there, but with regards to mental health, it would also be helpful for there to be differentiators between one condition and another. Therapists and GPs rely on the DSM because they may not know exactly what they’re looking at in a patient and use the DSM descriptors to aid them. But I can tell you from personal experience, there is a very obvious difference between BP, BPD, PTSD, etc. in real life. Secondly, Google skews its algorithm intentionally all the time. You would have to know people in the industry to know this, but how the search functions and what it returns is skewed by zip code, and other things, like what it knows of you from your email or search habits. Imagine an algorithm that assumed all people living in northern states statistically were more likely to suffer depression or get MS, and then skewing its answers to diagnosis based on statistical data. How many times does Google give you crap answers? And if this is relied upon as a method, then how difficult would it be to fight the algorithm’s decision if it was wrong? IMHO, medicine (with it’s scans, bloodwork, etc.) is the diagnostic future.
I think some of your worries though are more in comparing Google marketing with an aspect of their algorithm. The AI component. Yes, Google mine data from all areas you use, but that is what a FREE service does. People don’t usually understand — they’re the cost when its free. I’m not advocating that Google be involved. They are simply one example company used who have the best algorithm AI in the world, is all. I totally agree, I would also love to see scans and physical medicine define whether a person is suffering a mental health condition, but I think that is further off than a logical networked approach with the help of an AI algorithm. Biomarkers just aren’t there in 95% of mental health conditions that aren’t hereditary, thus could be measured.
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