Is PTSD Over-Diagnosed?

Thanks to NAADAC Government Relations Intern Mara Gray for guest-blogging this post!

What exactly is PTSD? The DSM-IV-TR defines Post Traumatic Stress Disorder as an anxiety disorder following a traumatic event, in which the person frequently re-experiences the event, shows avoidance or numbing of general responsiveness, and has an increased arousal level (such as not being able to sleep or overall irritability). These symptoms have to be present at least one month.

Now when we think of PTSD, what comes to mind? Soldiers from Vietnam or those returning from Iraq. Substance abuse. Homelessness. But have these images led us to misunderstand what PTSD really is? Richard J. McNally, a psychologist at Harvard University, argues that might be the case in a recent article called “Soldiers' Stress: What Doctors Get Wrong about PTSD” published in the April edition of Scientific American Magazine.

Photo taken by Sgt. Timothy Kingston and accessed from Army.mil's Photostream. It is used with a Creative Commons license.

McNally says that readjustment issues are bound to occur after the traumatic events that war imposes on our servicemembers. However, are clinicians too quick to offer a diagnosis of PTSD when, some of the responses returning veterans exhibit are part of the natural healing process? For example, Maj. Matt Stevens, even two years after returning from duty, has dreams about his experience in war. He’s quoted as saying, “One night I dreamt I was bird-watching with my wife. When we saw a bird, she would lift her binoculars, and I would lift my rifle and watch the bird through the scope. No thought of shooting it. Just how I looked at birds.” Should a dream such as this be dealt with as a disorder, or is it a “healthy” attempt to by Stevens to understand his past and integrate it into his everyday life?

The article argues further that PTSD has often been over-diagnosed. For example, a study in 1990 reported that 31% of veterans experienced PTSD at some point in their lives. A follow-up study found that “clinically significant impairment,” the level required for diagnosis, was found in only 11% of those veterans. In 2006, a different study found that of 12,000 troops, only 4.3% of soldiers developed symptoms calling for a diagnosis. However, many advocates and clinicians still cite the 31% number as the standard rate of PTSD in veterans.

Why does this matter? Whether people are facing readjustment issues, depression, or PTSD, they would all likely benefit from some kind of counseling. So what difference does their diagnosis make? According to McNally, the fact that “treatment flows from diagnosis” means that treatment cannot be properly tailored for the client if there isn’t an accurate diagnosis. For example, Cognitive Based Therapy for those suffering from PTSD focuses on shaping responses to a traumatic event by repeatedly exposing the patient to these events in a controlled manner, as to eventually create a health response. Cognitive Based Therapy for depression, by contrast, focuses on reshaping dysfunctional thoughts and emotions in order to form healthy responses to current, everyday events. If someone with depression is incorrectly diagnosed with PTSD, the problem may be missed all together. Instead of learning to reshape current thought patterns, patients are busy recalling old memories.

PTSD undoubtedly affects many American soldiers. However, McNally’s warning that we should not use PTSD as a catch-all diagnosis is well-taken. Some need counseling for PTSD; some need counseling for depression or substance abuse. Many need it for all three diagnoses (and there might be others). However, one thing is for sure: both the VA and the community need to do all they can to address every servicemember’s individual needs.