The light went on in my head during a debate over PTSD nomenclature last year.
Then-president of the American Psychiatric Association, John Oldham, was chairing a session entitled Combat-Related PTSD: Injury or Disorder?
A stellar panel of trauma experts — retired generals, senior researchers and key framers of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — debated whether the term, post-traumatic stress disorder (PTSD) should be changed to post-traumatic stress injury (PTSI).
Supporters of the change to “injury” argued that it might help overcome the stigma that many military members and veterans associate with seeking treatment for PTSD.
Service members aren’t happy to report “a disorder” but might be willing to admit an injury. Those in opposition argued that “injury” is too imprecise a term for psychiatric diagnosis and treatment.
As I sat through the heated session, it struck me that they were also implying that the term, disorder, is somehow “more scientific” and, therefore, “more psychiatric.”
From the perspective of science, it seemed to me that the real question here was whether there is any evidence that changing the name of PTSD would actually promote health: neither side seemed interested in researching that very answerable question.
This made me wonder if we were actually debating about science or, perhaps, whether we were arguing about something else.
Following up on this year’s APA session in San Francisco last month (and, in particular, its 45-session Military Psychiatry track organized by Elspeth Cameron Ritchie, M.D., MPH, retired U.S. Army colonel and now chief medical officer for the District of Columbia’s Department of Mental Health) triggered that recollection, and others connecting to the vexing challenge of PTSD, or whatever you want to call it.
Among the key questions that occurred to me was “Who is DSM, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, actually written for?”
If for patients, shouldn’t its language be crafted to serve them best (and shouldn’t we be doing research to find out how it might best serve them)? If for professionals, do we psychiatrists really believe that treating injuries is less consistent with science or with the practice of medicine (or is somehow beneath our dignity) than the treatment of disorders?
Don’t most physicians treat injuries? And might we be conflating medicine with science in worrying about being “precise” in describing mental disorders? While I’m all for precision, we don’t really know enough about the basic science of any mental disorder to be very precise in diagnosing or treating it. This is particularly so with PTSD, a complex clinical problem in which a stressful life experience perceived by the mind becomes an intricate and enduring problem of mind, body and society.
Stepping back a bit, these considerations raise the question of whether DSM is a clinical document or a research document. While based on a good deal of research, DSM is primarily meant to help clinicians make sense of their patients’ symptoms and signs by providing a basis for diagnosis and subsequent treatment. Am I a scientist or a clinician?
For that matter, if I were ill, would I seek medical care from a scientist? Would anybody?
Controversy about DSM V
One of the highlights of the 2013 meeting of the APA was the release of DSM V, the long awaited, much debated revision of our diagnostic system. In the run up to the May meeting, many psychiatrists had noted the words of an April 29 blog post by Thomas Insel, Director of the National Institute of Mental Health (NIMH):
In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders…. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength… of DSM has been “reliability”… The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure…
Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system… we cannot succeed if we use DSM categories as the “gold standard.” The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories.
… We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.
That is why NIMH will be re-orienting its research away from DSM categories…
In this connection, it’s important to point out that when NIMH, one of the major funders of mental health research in the U.S. and around the world, says that it is going to shift away from research on the DSM categories, this means that a great many projects and careers are about to be affected. Since the 1980s, most psychiatric research has been cast precisely in terms of DSM categories — the ability to do so was the strongest argument for the modern structure of DSM. If the funds are about to follow another conceptual basis for grouping and understanding mental illness, this will be a sea change for psychiatry in America, and pretty much everywhere else.
What happens to the concept of PTSD once it is deconstructed into its Research Domains? Is there room for understanding the personal meaning of the traumatic event: for grief, guilt, shame, moral injury, intergenerational history or any other dimension of human experience which clinical experience and abundant research demonstrate to have significant importance in understanding and treating PTSD? And what has become of the patient in this debate?
Where Does This Leave Psychiatry at the Beginning of the 21st Century? Pretty much where it was at the end of the 19th Century!
For late-19th-Century psychiatrists, the study of mental health and illness was synonymous with the study of the brain. New technologies led to a cascade of neuroscientific discoveries which promised to reveal the nature of mental phenomenon and offer new treatments for debilitating disorders. New diagnostic systems reclassified mental illness. It was a time much like our own.
Still, for all the many breakthroughs in late-19th-Century psychiatry, perhaps the most revolutionary was Joseph Breuer and Sigmund Freud’s 1895 declaration in their Studies on Hysteria that “…psychical trauma — or more precisely the memory of the trauma — acts like a foreign body which long after its entry must continue to be regarded as an agent that is still at work…” Thus Breuer and Freud identified traumatic memories as discrete agents of pathology in mental illness, much like a splinter under the skin, or a germ within its host. The idea that a memory could, in itself, be pathogenic, was a critical step beyond the then predominant brain degeneracy theory of hysteria and marked the beginning of modern psychiatry. Yet, although Breuer and Freud agreed that psychological trauma was provoked by overwhelming events, they differed decisively on how memories became pathogenic.
Biological Bias Then and Now
In early-21st Century psychiatry, many continue to think of psychological trauma as a pathogen (like a germ) inducing discrete changes in biological structures and processes that interact with genetic vulnerabilities to produce specific mental disorders. Following the disease model, modern psychiatry seeks the “antibiotic” which will eradicate the pathogenic memory. This underlying assumption is in operation whether we offer a drug meant to alter the activity of the amygdala, reset a receptor, or counter a gene in the aftermath of psychological trauma. It also applies in “body therapies” or EMDR, Eye Movement Desensitization and Reprocessing, therapy.
Freud, whose life ambition had been as a biological researcher and who had already made significant neuroscientific discoveries (including defining the neurological phenomenon, agnosia, and being the first to recommend the use of cocaine as a local anesthetic) had to leave neuroscience behind for the same reason that APA and NIMH now disagree on how to frame DSM V: science has yet to supply the missing links between the biology of the brain and the disorders of the mind. Lacking available neuroscientific tools but still needing to understand and treat his patients, Freud proceeded to work with mental disorders including posttraumatic disorders at the level of human experience (and with success).
Who Would Want a Microscope with Just One Lens?
Neuroscience and clinical science, while not interchangeable, are each necessary lenses for psychiatrists. To choose to use only one lens or the other is to descend into what Leon Eisenberg described as a futile oscillation between brainlessness and mindlessness in psychiatry. Despite the enduring cry for “the re-medicalization of psychiatry” and long after the “Decade of the Brain” we cannot, as physicians, forget physician and master teacher Francis Peabody’s advice in his landmark 1927 article, The Care of the Patient:
Disease in man is never exactly the same as disease in an experimental animal, for in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment… for the secret of the care of the patient is in caring for the patient.
These Considerations lead to a Modern Psychiatric Manifesto as Follows:
The essence of science is to accurately describe nature
The essence of psychiatry is to accurately describe human nature in its full complexity in order to alleviate mental illness and promote health
Since our focus is human nature, we need to balance our enthusiasm for neuroscience, genomics and other biological studies with a dedication to understanding and treating our patients as people.
Our primary goal as psychiatrists can never be accomplished through reductionism or abstraction of any kind: biological, psychological or social
What Then is PTSD?
Clearly, PTSD exists simultaneously at neurobiological and human levels. It can and should be studied, understood and, whenever possible, treated at both levels but, by the same token, there are aspects of psychological trauma and PTSD which are, at least for now, most pragmatically addressed at the level of human experience. In fact, to do less than consider the personal component of psychological trauma is to be truly unscientific.
Who is PTSD For?
As Samuel Shem reminds us in his novel, The House of God, “The patient is the one with the disease.” The definition of PTSD, like all clinical concepts, is meant to serve our patients by enabling us as physicians to better understand and treat them. If PTSD is the patient’s problem and if our duty as psychiatrists is to care about the patient, shouldn’t the language of DSM and its very structure prioritize our patients’ needs? It is time to find out if patients are better served by the term PTSD or PTSI.
What are We as Psychiatrists?
Freud was fond of quoting his teacher, the neurologist Jean-Martin Charcot, in saying that “theory is a lovely thing but it does not prevent the facts from existing.”
If we fail to research our treatments, what are we as mental health professionals?
But if we abandon our focus on the patient (even for a highly sophisticated or a highly fundable theory), what are we as psychiatrists?
Dr. Harold Kudler is associate director of the Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, and an associate professor of psychiatry and behavioral sciences at Duke University.