A Crosswalk Study of DSM-IV and DSM-5 Criteria for PTSD from the DSM-5 Field Trials.

Objective: Posttraumatic stress disorder (PTSD) is prevalent and sometimes severely disabling. Providing effective treatment for PTSD and addressing its social consequences require accurate diagnosis. PTSD criteria have changed in all editions of the American Diagnostic Criteria since introduction of the diagnosis in DSM-III in 1980. The DSM-5 Field Trials demonstrated very good inter-rater reliability for PTSD, but a crosswalk study comparing DSM-IV and DSM-5 criteria has potential to identify diagnostic differences generated by changed criteria. Methods: A DSM-IV to DSM-5 PTSD crosswalk study was conducted in real-world adult clinical treatment settings in two DSM-5 Field Trials sites, the Dallas (N = 93) and Houston (N = 48) Veterans Affairs medical centers. The crosswalk assessment was conducted by trained clinicians who interviewed the patients and rated both sets of criteria on a combined checklist. Results: PTSD prevalence differed insubstantially between criteria sets (42% vs. 45% and 55% vs. 52% in the Dallas and Houston sites, respectively), with moderate to excellent diagnostic agreement (reliability indicated, respectively, by κ = .53 and .93); however, substantial proportions of individuals diagnosed in one criteria set did not meet criteria in the other. Differences in cross-criteria diagnostic reliability were largely a function of differing definitions of criterion A trauma. Conclusions: Reliability across the two criteria sets was generally good to excellent, and diagnostic discrepancy predominantly reflected the elimination of criterion A2 in DSM-5 with a smaller contribution from changes to the avoidance and numbing criteria.

A Nosological Exploration of PTSD and Trauma in Disaster Mental Health and Implications for the COVID-19 Pandemic.

The coronavirus disease of 2019 (COVID-19) pandemic rapidly spread around the world, resulting in massive medical morbidity and mortality and substantial mental health consequences. Post-traumatic stress disorder (PTSD) is an important psychiatric disorder associated with disasters, and many published scientific articles have reported post-traumatic stress syndromes in populations studied for COVID-19 mental health outcomes. American diagnostic criteria for PTSD have evolved across editions of the manual, and the current definition excludes naturally occurring medical illness (such as viral illness) as a qualifying trauma, ruling out this viral pandemic as the basis for a diagnosis of PTSD. This article provides an in-depth nosological consideration of the diagnosis of PTSD and critically examines three essential elements (trauma, exposure, and symptomatic response) of this diagnosis, specifically applying these concepts to the mental health outcomes of the COVID-19 pandemic. The current criteria for PTSD are unsatisfying for guiding the response to mental health consequences associated with this pandemic, and suggestions are made for addressing the conceptual diagnostic problems and designing research to resolve diagnostic uncertainties empirically. Options might be to revise the diagnostic criteria or consider categorization of COVID-19-related psychiatric syndromes as non-traumatic stressor-related syndromes or other psychiatric disorders.

Association of PTSD symptom groups with functional impairment and distress in trauma-exposed disaster survivors.

BACKGROUND: In the nearly a quarter of a century since the addition of the clinically significant distress/impairment criterion to the definition of PTSD in DSM-IV, little research has been done to examine the association of this criterion with symptom group criteria and with the numbing subgroup specifically. This study was conducted to examine these relationships in a large database of disaster survivors consistently studied across 12 different incidents of the full range of disaster typology. METHODS: Analysis was conducted on a merged database representing 1187 trauma-exposed survivors of 12 different disasters studied systematically. DSM-IV-TR criteria for disaster-related PTSD were assessed with the Diagnostic Interview Schedule. RESULTS: PTSD Group C (avoidance/numbing) and numbing specifically were less common and more associated than other symptom groups with criterion F (distress/impairment). Consistently in multivariable models, group C and numbing were independently associated with criterion F. Group D (hyperarousal) was less strongly associated with criterion F. Neither group B (intrusion) nor avoidance were associated with criterion F. CONCLUSIONS: In this and other studies, group C and numbing specifically have been shown to be associated with criterion F, which is consistent with the demonstration that group C and the numbing component specifically are central to the psychopathology of PTSD. The addition of the distress/impairment requirement broadly across the psychiatric diagnoses in DSM-IV added little value to PTSD symptom criteria. Future revisions of diagnostic criteria may benefit by carefully considering these findings to possibly re-include a prominent numbing symptom section.

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income. Objective: To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment. Design, Setting, and Participants: The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed. Interventions: Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community. Main Outcomes and Measures: A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period. Results: A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004). Conclusions and Relevance: This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD. Trial Registration: clinicaltrials.gov Identifier: NCT01817712.

Exercise for PTSD in Women Veterans: A Proof-of-Concept Study.

INTRODUCTION: The safety, feasibility, and efficacy of a 12-week structured exercise program targeting post-traumatic stress disorder (PTSD) in women Veterans of childbearing age was tested in a pilot study. MATERIALS AND METHODS: Thirty-one women Veterans of childbearing age were enrolled in the study, 22 remained eligible after the baseline assessment, and 16 completed the exercise protocol. The exercise program consisted of moderate intensity aerobic exercise (brisk walking), 4 times a week, for 12 weeks. Data were collected on duration, intensity, and side effects. The Clinician Administered PTSD Scale was administered at baseline and at the end of 12 weeks. Weekly assessments provided data on PTSD and depression symptoms, pain, and quality of life. RESULTS: Both post-traumatic and depressive symptoms improved significantly by the end of study. There were no adverse events related to exercise. A small focus group provided subjective experiences supporting positive effects of exercise on emotion and physical health. CONCLUSION: The preliminary results of this study suggests that 12 weeks of moderate intensity aerobic exercise may be a promising intervention for PTSD in women Veterans of childbearing potential. Further controlled studies are warranted to determine efficacy of moderate intensity exercise as a treatment modality for this population.

Advances in Psychiatric Diagnosis: Past, Present, and Future.

This editorial examines controversies identified by the articles in this special issue, which explore psychopathology in the broad history of the classification of selected psychiatric disorders and syndromes over time through current American criteria. Psychiatric diagnosis has a long history of scientific investigation and application, with periods of rapid change, instability, and heated controversy associated with it. The articles in this issue examine the history of psychiatric nomenclature and explore current and future directions in psychiatric diagnosis through the various versions of accepted diagnostic criteria and accompanying research literature addressing the criteria. The articles seek to guide readers in appreciating the complexities of psychiatric diagnosis as the field of psychiatry pushes forward toward future advancements in diagnosis. Despite efforts of many scientists to advance a diagnostic classification system that incorporates neuroscience and genetics, it has been argued that it may be premature to attempt to move to a biologically-based classification system, because psychiatric disorders cannot yet be fully distinguished by any specific biological markers. For now, the symptom-based criteria that the field has been using continue to serve many essential purposes, including selection of the most effective treatment, communication about disease with colleagues, education about psychiatric illness, and support for ongoing research.

Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations.

The criteria for posttraumatic stress disorder PTSD have changed considerably with the newest edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Changes to the diagnostic criteria from the DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a new diagnostic category named "Trauma and Stressor-related Disorders", the elimination of the subjective component to the definition of trauma, the explication and tightening of the definitions of trauma and exposure to it, the increase and rearrangement of the symptoms criteria, and changes in additional criteria and specifiers. This article will explore the nosology of the current diagnosis of PTSD by reviewing the changes made to the diagnostic criteria for PTSD in the DSM-5 and discuss how these changes influence the conceptualization of PTSD.

The evolution of PTSD criteria across editions of DSM.

BACKGROUND: The diagnosis of posttraumatic stress disorder (PTSD) has remained controversial from the time of its first inclusion in DSM-III. No reviews have fully documented the shifting PTSD definitions across editions of the criteria. This article chronicles the evolution of PTSD across editions of the DSM. METHODS: Diagnostic precursors to PTSD in DSM-I and DSM-II were briefly described, followed by systematic review of PTSD in subsequent editions of the DSM. Sections of the criteria and accompanying text were sorted into tables permitting visual comparisons across the editions. Research findings related to specific changes in the editions were provided from available research literature identified through specific PubMed searches using keywords relevant to each specific change. RESULTS: Fundamental topics of debate identified in this review are validity of the diagnosis, the trauma criterion, the role of symptoms in defining its psychopathology, differentiation from other disorders, and specifiers such as delayed onset. CONCLUSIONS: DSM-5 has corrected several major ambiguities and errors of the former editions that are fundamental to the construct of PTSD as a disorder that is defined conditionally in relation to exposure to trauma, but problems remain in DSM-5 trauma criteria, especially inconsistencies between exposure criteria and the definition of trauma. Discerning the critical distinctions required to understand PTSD depends on underlying clarity in terminology and precision in application of the diagnosis by academicians and clinicians. Trauma must be differentiated from other kinds of stressful events and conceptualized as an incident defined by physical injury rather than by emotional response.

Managing posttraumatic stress disorder and major depression in women veterans during the perinatal period.

The recent surge in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era women Veterans, most of whom are younger compared to other women Veterans, presenting with mental health issues is expected to pose new clinical challenges. Treatment of mental health conditions in women Veterans is not considered comprehensive without adequate examination of the impact of reproductive events across the life span, such as their menstrual cycle, pregnancy and postpartum period, and menopausal transition. The overarching aim of this article is to discuss emerging clinical issues in managing common psychiatric conditions such as posttraumatic stress disorder and major depression during pregnancy and postpartum period in the VA healthcare system and secondly, to identify steps to advance the knowledge and understanding of these complex issues. Information to be gained in this area has immediate clinical application in the overall management of major psychiatric conditions in women Veterans during pregnancy and postpartum, and implications for policy-making decisions.

Pharmacological blockade of memory reconsolidation in posttraumatic stress disorder: three negative psychophysiological studies.

Posttraumatic stress disorder (PTSD) may involve over-consolidated emotional memories of the traumatic event. Reactivation (RP) can return a memory to an unstable state, from which it must be restabilized (reconsolidated) if it is to persist. Pharmacological agents administered while the memory is unstable have been shown to impair reconsolidation. The N-methyl-d-aspartate (NMDA) partial agonist d-cycloserine (DCS) may promote memory destabilization. In the three studies reported here, we investigated whether the ß-adrenergic blocker propranolol or the glucocorticoid (GR) antagonist mifepristone, given at the time of traumatic memory reactivation, could reduce PTSD symptoms and physiological responding during subsequent traumatic imagery. Individuals with PTSD were randomized as follows: Study One: propranolol with memory reactivation (n=10) or without reactivation (n=8); Study Two: reactivation mifepristone (n=13), non-reactivation (NRP) mifepristone (n=15), or double placebo (PL) (n=15); Study Three: reactivation mifepristone plus d-cycloserine (n=16), or two placebos (n=15). Subjects underwent memory retrieval by describing their traumatic event. A week later they engaged in script-driven traumatic mental imagery, while heart rate (HR), skin conductance (SC), and facial electromyogram (EMG) responses were measured. There were no significant group differences in physiological responsivity or change in PTSD symptoms in any of the studies. These results do not support successful blockade of reconsolidation of traumatic memories in PTSD.

Redesign of a Screening Process for VA Homeless Housing.

Standardizing the screening processes for homeless housing among VA facilities can make programs more accessible to veterans experiencing homelessness and improve provider knowledge of existing and available services.

Unseen battles: the recognition, assessment, and treatment issues of men with military sexual trauma (MST).

While there is increasing attention on sexual violence in the military, the focus has been primarily on women. There is very little information regarding the effects of and treatment for men who experience military sexual trauma (MST). The aim of this article is to consolidate the known information about men with MST including prevalence rates, factors that affect those rates, gender differences, medical and psychiatric sequelae, and finally a review of two experimental studies. Implications for future research, practice, and policy are also discussed.

Rapid HIV testing experience at Veterans Affairs North Texas Health Care System's Homeless Stand Downs.

In the USA, 21% of the estimated 1.1 million people living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are unaware they are HIV-infected. In 2011, Veterans Health Administration (VHA)'s Office of Public Health in conjunction with VHA's Health Care for Homeless Veterans Program funded grants to support rapid HIV testing at homeless outreach events because homeless populations are more likely to obtain emergent rather than preventive care and have a higher HIV seroprevalence as compared to the general population. Because of a Veterans Affairs North Texas Health Care System (VANTHCS)'s laboratory testing requirement, VANTHCS partnered with community agencies to offer rapid HIV testing for the first time at VANTHCS' 2011 Homeless Stand Downs in Dallas, Fort Worth, and Texoma, Texas. Homeless Stand Downs are outreach events that connect Veterans with services. Veterans who declined testing were asked their reasons for declining. Comparisons by Homeless Stand Down site used Pearson χ², substituting Fisher's Exact tests for expected cell sizes <5. Of the 910 Veterans attending the Homeless Stand Downs, 261 Veterans reported reasons for declining HIV testing, and 133 Veterans were tested, where 92% of the tested Veterans obtained their test results at the events - all tested negative. Veterans' reported reasons for declining HIV testing included previous negative result (n=168), no time to test (n=49), no risk factors (n=36), testing is not a priority (n=11), uninterested in knowing serostatus (n=6), and HIV-infected (n=3). Only "no time to test" differed significantly by Homeless Stand Down site. Nonresponse rate was 54%. Offering rapid HIV testing at Homeless Stand Downs is a promising testing venue since 15% of Veterans attending VANTHCS' Homeless Stand Downs were tested for HIV, and majority obtained their HIV test results at point-of-care while further research is needed to determine how to improve these rates.

Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center.

OBJECTIVE: Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS: Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS: The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate's direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS: Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Novel combination strategy to optimize treatment for PTSD.

Post-traumatic stress disorder (PTSD) is increasingly recognized as a serious and potentially debilitating condition in combat veterans returning from Iraq and Afghanistan. Exposure to a potentially life-threatening event such as military combat may be followed by PTSD. Despite recent advances in pharmacotherapy for PTSD, monotherapy with the currently available medications is only partially effective, as demonstrated in large clinical trials of combat veterans with PTSD. This underscores the need to investigate novel combination strategies to enhance treatment response in PTSD. The α-1 adrenergic receptor (AR) antagonist, prazosin, appears promising in recent studies for its capacity to reduce trauma-related nightmares (a group B night-time intrusion symptom) and insomnia (a group D night-time arousal symptom), while recent evidence supports using the ß-AR antagonist, propranolol, to dampen the emotional content of traumatic memories (daytime intrusion symptoms including flashbacks, intrusive recollections of traumatic event, and heightened physiological reactivity/ responsivity to trauma reminders). In this review, we present data supporting the potential utility of combined drug regimen (prazosin and propranolol) acting through different noradrenergic mechanisms, with the potential to target more than one set of PTSD symptoms to optimize PTSD treatment.

Toward validation of the diagnosis of posttraumatic stress disorder.

Unlike most psychiatric diagnoses, posttraumatic stress disorder (PTSD) is defined in relation to a potentially etiologic event (the traumatic "stressor criterion") that is fundamental to its conceptualization. The diagnosis of PTSD thus inherently depends on two separate but confounded processes: exposure to trauma and development of a specific pattern of symptoms that appear following the trauma. Attempts to define the range of trauma exposure inherent in the diagnosis of PTSD have generated controversy, as reflected in successive revisions of the criterion from DSM-III onward. It is still not established whether or not there are specific types of traumatic events and levels of exposure to them that are associated with a syndrome that is cohesive in clinical characteristics, biological correlates, familial patterns, and longitudinal diagnostic stability. On the other hand, the symptomatic description of PTSD is becoming more clear. Of three categories of symptoms associated with PTSD--intrusive memories, avoidance and numbing, and hyperarousal--avoidance and numbing appear to be the most specific for identification of PTSD. Research is now poised to answer questions about the relevance of traumatic events based on their relationship to symptomatic outcome. The authors recommend that future research begin with existing diagnostic criteria, testing and further refining them in accordance with the classic Robins and Guze strategy for validation of psychiatric diagnoses. In this process, diligent adherence to the criteria under examination is paramount to successful PTSD research, and changes in criteria are driven by empirical data rather than theory. Collaborations among trauma research biologists, epidemiologists, and nosologists to map the correspondence between the clinical and biological indicators of psychopathology are necessary to advance validation and further understanding of PTSD.

Personality changes in women recovering from substance-related dependence.

The present study explored the potential for change in personality in women in recovery. Dimensions of the Temperament and Character Model and the five-factor model of personality were examined at baseline and at follow-up after treatment for addiction. Within both models of personality, the factors which have been found to be the best predictors of the presence of a personality disorder (Self-Directedness within the Temperament and Character Model; Neuroticism within the five-factor model) showed significant change at follow-up which suggests the flexibility of personality and the potential for change of personality disorders within women seeking treatment for addiction.