Requiring both avoidance and emotional numbing in DSM-V PTSD: Will it help?

doi:10.1016/j.jad.2010.10.032

Journal of Affective Disorders

Volume 130, Issue 3, May 2011, Pages 483-486

https://doi.org/10.1016/j.jad.2010.10.032 Get rights and content

Abstract

Objective

The proposed DSM-V criteria for posttraumatic stress disorder (PTSD) specifically require both active avoidance and emotional numbing symptoms for a diagnosis. In DSM-IV, since both are included in the same cluster, active avoidance is not essential. Numbing symptoms overlap with depression, which may result in spurious comorbidity or overdiagnosis of PTSD. This paper investigated the impact of requiring both active avoidance and emotional numbing on the rates of PTSD diagnosis and comorbidity with depression.

Method

We investigated PTSD and depression in 835 traumatic injury survivors at 3 and 12 months post-injury. We used the DSM-IV criteria but explored the potential impact of DSM-IV and DSM-V approaches to avoidance and numbing using comparison of proportion analyses.

Results

The DSM-V requirement of both active avoidance and emotional numbing resulted in significant reductions in PTSD caseness compared with DSM-IV of 22% and 26% respectively at 3 and 12 months posttrauma. By 12 months, the rates of comorbid PTSD in those with depression were significantly lower (44% vs. 34%) using the new criteria, primarily due to the lack of avoidance symptoms.

Conclusion

These preliminary data suggest that requiring both active avoidance and numbing as separate clusters offers a useful refinement of the PTSD diagnosis. Requiring active avoidance may help to define the unique aspects of PTSD and reduce spurious diagnoses of PTSD in those with depression.

Introduction

The proposed DSM-V revision to the criteria for posttraumatic stress disorder (PTSD) includes several modifications (www.dsm5.org). In addition to some new criteria, separating the current DSM-IV active avoidance (C1–C2) and emotional numbing cluster (C3–C7) into two separate clusters is proposed. These clusters have been renamed C (persistent avoidance of stimuli associated with the trauma; one or more symptom required from three) and D (negative alterations in cognitions and mood; two or more symptoms required from seven). In DSM-IV, three symptoms from the combined cluster (C1 to C7) were required for a diagnosis. Thus, whereas it was possible under DSM-IV to meet the criteria by endorsing only numbing symptoms, both are mandated for a diagnosis in the proposed revision. This is consistent with factor analytic studies indicating that these two groups of symptoms are structurally distinct, arise from separate mechanisms, and vary in their clinical associations with other mental phenomena (King et al., 1998, Naifeh et al., 2008, Palmieri et al., 2007, Simms et al., 2002). The numbing symptoms also overlap with the features of depression, which may result in spurious comorbidity or misdiagnoses of PTSD in cases better conceptualised as depressive (Spitzer et al., 2007, Watson, 2005). Research examining the impact of this change on PTSD prevalence and comorbidity with depression, and its implications for diagnostic assessment in clinical practice, is therefore essential in contributing to considerations for DSM-V. Given existing research suggesting the convergence of PTSD and depression by 12 months posttrauma (O'Donnell et al., 2004), it is also important to examine the impact of these proposed changes on diagnosis and comorbidity with depression over time. We investigated PTSD using both approaches to avoidance and numbing, as well as depression, in traumatic injury survivors assessed at 3 and 12 months post-injury.

Section snippets

Method

Participants comprised 835 traumatic injury survivors interviewed 3 and 12 months following admission to specialized trauma services in four hospitals in Australia. Patients were included in the study if they had experienced an injury severe enough to require admission of at least 24 h to a level 1 trauma centre, had either no brain injury or a mild traumatic brain injury (MTBI) (American Congress of Rehabilitational Medicine, 1993), were aged between 16 and 70 years of age, and displayed

Results

For the 835 persons examined for this study, the prevalence of a DSM-IV PTSD diagnosis at 3 months was 9% (78 cases) and 10% (80 cases) at 12 months.

These rates reduced significantly to 7% at both 3 months [58 cases: z = 2.30, p < 02] and 12 months [62 cases: z = 1.67, p < 0.05], respectively, using the proposed DSM-V criteria that explicitly require both avoidance and numbing. This change represents 26% and 22% of PTSD cases respectively under DSM-IV no longer meeting the criteria using this DSM-V

Discussion

These findings indicate that mandating both active avoidance and emotional numbing symptoms for a PTSD diagnosis would result in approximately 25% fewer cases being identified. At three months these 25% of cases report lower symptoms across all four symptom clusters. By 12 months, the reduction in those meeting the criteria for a DSM-V diagnosis who qualified under DSM-IV is primarily due to failure to meet the active avoidance criteria. Given research indicating convergence of PTSD and

Role of funding source

This study was supported by a National Health and Medical Research Council Program Grant (300304).

Conflict of interest

The Australian Centre for Posttraumatic Mental Health is partially funded by the Australian Government Department of Veterans' Affairs.

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Brief reportRequiring both avoidance and emotional numbing in DSM-V PTSD: Will it help?

Abstract

Objective

Method

Results

Conclusion

Introduction

Section snippets

Method

Results

Discussion

Role of funding source

Conflict of interest

J. Anxiety Disord.

J. Anxiety Disord.

Definition of mild traumatic brain injury

J. Head Trauma Rehabil.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale: evidence for the dimensionality of posttraumatic stress disorder

Psychol. Assess.

Posttraumatic stress disorder and depression following trauma: understanding comorbidity

Am. J. Psychiatry

Brief report
Requiring both avoidance and emotional numbing in DSM-V PTSD: Will it help?