DSM-V PTSD Change Excludes Some Soldiers From Diagnosis

Many Mental Health Providers Ill Prepared for Treating Veterans
Many Mental Health Providers Ill Prepared for Treating Veterans
Some soldiers who would have met diagnosis under DSM-IV criteria are now diagnosed with adjustment disorder, which may impact their care.

TORONTO — A change in the definition of post-traumatic stress disorder (PTSD) in the DSM-5 is causing problems for some military veterans who are considered “subthrehold cases” as they don’t fully meet the new diagnostic criteria. As a result, they are instead being diagnosed with adjustment disorder, which can lead to a loss of benefits.

This is posing problems for Veterans Administration (VA) clinicians as soldiers who would have been diagnosed and coded in the military’s electronic medical record system as having PTSD based on the DSM-IV criteria no longer are, which can affect their treatment, according to Charles Hoge, MD, of the Center for Psychiatry and Neuroscience at Walter Reed Army Institute of Research in Silver Spring, Md.

Hoge, who spoke with Psychiatry Advisor about his presentation at the American Psychiatry Association Annual Meeting on the clinical implications of the changes prior to delivering it, said that adjustment disorder — defined as a short-term condition that occurs when a person has great difficulty coping with, or adjusting to, stressful situations  — is not an optimal diagnosis for subthreshold PTSD.

“The problem with adjustment disorder is it’s a diagnosis of exclusion,” he said. “There is no set of specific symptoms to meet or not meet the definition.”

Hoge added that when it is coded into the medical record system, adjustment disorder has more “pejorative terms” associated with it than PTSD in the military.

Making matters worse, an adjustment disorder diagnosis can lead to administrative separation from military service, and a potential loss of benefits.

In the DSM-5, diagnosis of PTSD shifted from anxiety disorders to trauma and stress disorders. In addition, it increased the number of symptoms from 17 to 20, but also reworded eight of the original 17 symptoms.

In a Lancet Psychiatry article published in August, Hoge reported that based on an assessment of more than 1,800 veterans, about 30% of soldiers who screened positive for PTSD under DSM-IV would not have done so under DSM-V.

One of the changes in the new criteria for PTSD is that solders must demonstrate active avoidance. However, Hoge said that in his experience, many soldiers learn to override the avoidance process. “I see a lot of soldiers who meet the old definition but because often they don’t have active avoidance, they don’t, technically, meet the new definition.”

Hoge said that he has recommended that clinicians use an anxiety disorder diagnosis in lieu of adjustment disorder for subthreshold PTSD cases.

“And if clinicians find soldiers meet the old definition [of PTSD] in DSM-IV, they should go ahead with that,” he added.


Hoge CW. Comparing the DSM-IV & DSM-5 PTSD Criteria in Soldiers Exposed to Combat: Problems with the New Definition and Clinical Implications. Presentation at: APA 2015. May 16-20, 2015; Toronto, Canada.