The Impact of Changes to the DSM and ICD Criteria for PTSD

Transcription

1 The Impact of Changes to the DSM and ICD Criteria for PTSD Jonathan I Bisson Institute of Psychological Medicine and Clinical Neursociences Cardiff University

2 What is PTSD? Question

3 Diagnosing PTSD DSM-IV (2000) replaced by DSM-5 in 2013 ICD-10 (1992) to be replaced by ICD-11 in 2015 Definition challenged by heterogeneity of presentation and absence of diagnostic tests

4 Harmonisation of PTSD Diagnosis Opportunity to bring ICD and DSM closer together or make them identical ICD DSM Harmonisation Coordination Group led to optimism DSM-5 PTSD symptoms rise from 17 to 20 Six proposed ICD-11 PTSD symptom criteria plus a new parallel diagnosis of complex PTSD

5 Trauma and Stressor Related Disorder Exposure to traumatic event Re-experiencing Avoidance Negative alterations in cognitions and mood Alterations in arousal and reactivity DSM-5 PTSD

6 DSM-5 PTSD New Cluster Negative alterations in cognitions and mood that are associated with the traumatic event Based on confirmatory factor analysis Moves PTSD away from being a fear based disorder (unlike the proposal for ICD-11)

7 Questions What traumatic events cause PTSD?

8 DSM-IV PTSD Criterion A Exposure to a traumatic event 1. Involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. Response involved intense fear, helplessness, or horror

9 DSM-5 PTSD Criterion A Exposure to actual or threatened death, serious injury, or sexual violence through: 1. Direct experience 2. Witnessing, in person 3. Learning of event happening to a close family member or friend (actual or threatened death must be violent or accidental) 4. Repeated or extreme exposure to aversive details (e.g. Human remain collection, police and details of child abuse. Not TV, etc. unless work related)

10 Question Would the following traumas fulfil criterion A? Road traffic accident Assault Bullying at work Learning about father s heart attack Having acute appendicitis Watching people jumping to their deaths on TV

11 Question What do people report as their worst traumatic experience?

12 White et al (2014) Caerphilly health and social needs study 18 to 74 years old Worst traumatic event in life and TSQ 4,558 (50%) returned valid questionnaires 2,142 (47%) reported a traumatic event Epidemiology and Psychiatric Sciences

13 White et al (2014) 56.8%F & 43.2%M reported a DSM-IV qualifying event Life threatening illness or injuries and learned about traumas were the most common DSM-IV non-qualifying just <50% death of a parent (18.6%) most common NB DSM-5 criteria exclude learning about a long-term illness

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15 DSM-5 PTSD Criterion B Intrusion symptoms Recurrent, involuntary and intrusive distressing memories Recurrent distressing dreams (content and/or affect related) Dissociative reaction (acting or feeling as if event recurring) Intense or prolonged psychological distress to cues Marked physiological reactions to cues

16 DSM-5 PTSD Criterion C - Avoidance Avoidance or efforts to avoid distressing thoughts or feelings about or closely associated with the trauma Avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects, situations)

17 DSM-5 PTSD Criterion D - Negative Alterations in Cognitions and Mood (1) Inability to remember an important aspect (typically due to dissociative amnesia) Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g. I am bad, No one can be trusted, The world is completely dangerous ) Persistent, distorted cognitions about the cause or consequences that lead to selfblame or the blame of others

18 DSM-5 PTSD Criterion D - Negative Alterations in Cognitions and Mood (2) Persistent negative emotional state (e.g. fear, horror, anger, guilt, shame) Markedly diminished interest or participation in significant activities Feelings of detachment or estrangement from others Persistent inability to experience positive emotions (e.g. happiness, satisfaction, love)

19 DSM-5 PTSD Criterion E - Marked Alterations in Arousal and Reactivity Irritable behaviour and angry outbursts (with little or no provocation) Reckless or self-destructive behaviour Hypervigilance Exaggerated startle response Problems with concentration Sleep disturbance

20 DSM-5 PTSD Criteria F, G & H Duration of disturbance > one month The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Not attributable to a substance or another medical condition With or without dissociative symptoms Delayed expression if > six months

21 Question How would you diagnose PTSD with 6 symptoms?

22 Proposed ICD-11 Criteria WHO keen to use ICD-11 to improve the clinical utility of diagnosis Complexity of current diagnostic systems argued as a major problem Enhanced clinical utility can lead to improved care and reduced burden of disease

23 Features of Clinical Utility Communication facilitation practitioners, patients, families, administrators Implementation in clinical practice accuracy of description, ease of use time required to use it Usefulness in selecting interventions and making clinical management decisions

24 ICD-11 PTSD Proposal 2 Re-experiencing Flashbacks/powerful images & nightmares 2 Avoidance Thoughts & feelings Places, people, activities 2 Hyperarousal Startle & hypervigilance

25 Question How would you diagnose complex PTSD?

26 ICD-11 Complex PTSD Proposal Emotion Regulation Hyperactivation, de-activation Negative Self-Concept feeling diminished, defeated, worthless, shame, guilt, despair Disturbed Relationships difficulties in feeling close, little interest in relationships or social engagement

27 Question Which system (ICD-11 or DSM-5) is likely to diagnose most people with PTSD and why?

28 O Donnell et al (2014) Traumatic injury patients admitted to hospitals in Australia Assessed 72-months post trauma PTSD prevalence DSM-IV = 5.9% DSM-5 = 6.7% ICD-10 = 9.0% ICD-11 = 3.3%

29 Adults with suspected PTSD first % female, mean age 45.4 (11.7) 16.8 (12.6) years since various traumas Structured clinical interview CAPS 5 ICD-11 Questions PTSD Registry

30 Prevalence of PTSD

31 DSM-5 & ICD-11 13% 10% 24% 54%

32 DSM-5 & ICD-11 Complex 29% 45% 26%

33 Impact of Divergence of ICD-11 and DSM-5 Criteria will be met for ICD-11 but not DSM-5 PTSD and vice-versa Risk of interchangeable use depending on desirability of diagnosis Potential to cause confusion and reduce clinical (and other) utility high Fingers crossed for ICD-12 and DSM-6

34 Cardiff University Traumatic Stress Research Group Jon Bisson Hannah Colley Sarah Cosgrove Tony Downes Mat Hoskins Sandra Jumbe Neil Kitchiner Catrin Lewis Alice Piekarski Neil Roberts Ben Sessa