Rates of posttraumatic stress disorder (PTSD) diagnosis have increased to 7% in the US (26 million cases) and 5% in other high-income countries after the threshold of diagnosis was lowered in 1987 in the Diagnostic and Statistical Manual of Mental Disorders.
Researchers debated whether PTSD is overdiagnosed in an article that was recently published in the British Medical Journal.
The two authors who argued it has been overdiagnosed attributed that in part to “concept creep” — the expansion of the diagnosis to include “a much broader range of phenomena.”
“In our own clinical experience, the argument that PTSD diagnoses are given only after careful assessment does not hold,” the study authors wrote. “Instead, documented ‘PTSD’ often substitutes for a more psychologically sophisticated formulation, which would take into account dynamic psychosocial issues and more static personality factors. The conflation of stress with trauma — and of trauma with PTSD — has become rife.”
Increasing empathy and understanding of trauma in psychiatry and society have led to more flexibility regarding diagnosis and treatment boundaries, which is “problematic at a public health level” since resources are limited. Resource intensive skills specifically developed to treat PTSD, such as eye movement desensitization and reprocessing therapy should be “directed toward the patients who clearly meet the criteria,” they said. Diagnosing a patient with PTSD may also risk overlooking more common conditions such as depression, anxiety, and personality disorders.
“Furthermore, trivialising PTSD by conflating it with normal responses to difficult situations risks the medicalisation of everyday life, devaluing resilience and protective social factors,” and public skepticism may risk increasing stigma for patients who are experiencing PTSD, they said.
They said a diagnosis of PTSD should be reserved for “a profound and severe response to catastrophic events-and not a spectrum of reactions to trauma or everyday life.”
Authors holding the opposing viewpoint said it is likely that PTSD is “much more commonly underdiagnosed” by clinicians.
PTSD “has remained a clearly specified disorder” with core symptoms — re-experiencing a trauma through distressing intrusive memories, avoiding reminders of the trauma, and hyperarousal — that meet particular thresholds of experiences: occurring after a trauma “in combination, for at least several weeks and must substantially impair functioning.”
“Anecdotes that these criteria are applied too loosely to increasingly large numbers of people are simply not supported by valid research,” they said.
They argued that underdiagnosis may occur instead since few seek help from health professionals because of avoidance symptoms and fear of stigma or lack of effective treatment. Clinicians in primary care settings underrecognize PTSD, studies show.
“In our experience PTSD can go undiagnosed in health services for several reasons, such as difficulty in accessing specialist assessments or difficulty in identifying PTSD symptoms that are overshadowed by co-occurring problems,” they said.
PTSD in adults is associated with risk of suicide attempt and completion, studies show, even after correction for comorbid disorders. Studies show that treatment for PTSD are “clinically effective and cost effective” — if PTSD is recognized.
Exposure to life-threatening COVID-19 and a possible increase in domestic violence during the pandemic, which are two traumatic events that carry a risk of PTSD, may make prioritizing the recognition of PTSD and increasing availability of treatment “particularly timely,” they said.
Tully J, Bhugra D, Lewis SJ, Drennan G, Markham S. Is PTSD overdiagnosed? BMJ. Published online May 5, 2021. doi:10.1136/bmj.n787