Misdiagnosis of PTSD?

[GCoyote]

Very interesting article in this month's Scientific American about serious problem in the diagnostic criteria for PTSD and many problems that might be creating for our veterans.

Soldiers' Stress: What Doctors Get Wrong about PTSD

[Mountain Man]

Originally Posted by GCoyote

Very interesting article in this month's Scientific American about serious problem in the diagnostic criteria for PTSD and many problems that might be creating for our veterans.

Soldiers' Stress: What Doctors Get Wrong about PTSD

I imagine he's right, but given the amount of money and PR invested in this diagnosis, it's now an unstoppable juggernaut.

[Centrix Vigilis]

exactly....because now... sooner or later even a hangnail gets something. This system like medicare is broke but it's the only one many have...so i am real hesitant to criticize in general...but riding the buck wagon with a non-service connected PTSD pension benefit @ $970..oo a month is going to continue to be expensive.
But as to over diagnostics? that's not surprising... some may be willing to err on the larger side to get a vet help....others far far to many others are merely doing this to perp the system...keep a job and ensure the cob is maintained...iow bureaucrats at work....

[DocCasualty]

Very interesting read, thanks for the link. I wish I had more time to share a few of my thoughts on this now but am at work. Hopefully I can come back to this thread later.

[Centrix Vigilis]

hope so cuz i likeee's them cannons yes i do.

nice to see you here.

best
CV

[Mountain Man]

Originally Posted by Centrix Vigilis

exactly....because now... sooner or later even a hangnail gets something. This system like medicare is broke but it's the only one many have...so i am real hesitant to criticize in general...but riding the buck wagon with a non-service connected PTSD pension benefit @ $970..oo a month is going to continue to be expensive.
But as to over diagnostics? that's not surprising... some may be willing to err on the larger side to get a vet help....others far far to many others are merely doing this to perp the system...keep a job and ensure the cob is maintained...iow bureaucrats at work....

Precisely, CV. And many are remembering the refusal to diagnose Gulf War Syndrome, or radiation -induced cancer from nuclear testing, or to diagnose cancers as being related to agent Orange. VA has a miserable track record.

Practitioners are now very much inclined to "fail safe" on behalf of the patient.

[DocCasualty]

So many issues here, kinda hard to know where to start. I certainly respect Scientific American and believe it to be a peer-reviewed journal in some sense, however, when it comes to medical/psychiatric issues, I doubt that puts it exactly in line with Annals of Psychiatry, NEJM, BMJ, JAMA et al. I do think they put forward a good case for this overdiagnosis of PTSD in combat veterans and utilizing comparable retrospective studies and international studies with similar conclusions goes a long way toward that end. I am always reminded though of a quote which I believe is properly attributed to Benjamin Disraeli, "There are lies, damn lies and statistics". Thus caution is always warranted in interpreting these things and again, true peer-review goes a long way here too.

The article is spot on that PTSD and virtually all psychiatric diagnoses are clinical diagnoses. While I believe that some day we will identify objective markers for many of these, the DSM-IV is the best tool we have at this point in time and at most, it is our best attempt to objectify subjective criteria. If you've ever thumbed through one (or you can find it online; just Google), you're immediately struck by the number of cross-over symptoms in many different disorders. If fact, absent frankly psychotic symptoms, most of us can identify with many of these descriptions, yet have no true mental health disorder. As was alluded to in the article, a hallmark of diagnosis rests on the concept of interference of function in one's life, which again is a fairly subjective matter. So combine a less than perfect diagnostic tool, plagued with debatably broad criteria, then add plenty of room for judgement calls and I think you see that their still remains a lot in the realm of "art" in diagnosis.

The main critic (sorry, I read it hours ago and can't recall his name) made a statement to the effect of "you need a proper diagnosis for proper treatment", which is generally true. However, that statement is not as absolute at you might think. In fact, given how fluid this diagnostic quagmire can be, many psychiatrists firmly state that what is important is devising a treatment plan that works, regardless of what the diagnosis is (within reason). In other words "a rose is a rose by any other name". You must also consider that perhaps the individual carries more than one diagnosis, which is quite common and treatment would be directed at all of these, negating the premise of "missed diagnosis" and "wrong treatment plan".

I tend to agree with those who state there are many built-in facets to the system that would tend to support over-diagnosis in vets. A history of under-diagnosing historically is certainly one, having denied many vets in the past many services they were justly due. I tend to discount "self perpetuation" as much of a motive in any aspect of healthcare. While I'm certain is does happen on some small scale, most healthcare systems have limited resources and virtually endless demands. Although I have never worked for the VA, I'm certain they are in this same boat and the impetus is to move people through and out of the system if anything.

I think the article is very accurate in portraying the negative re-inforcement for remaining ill for many individuals. We see the same thing in Community Mental Health, as people try to obtain a disability claim, most quite legitimately. There are malingerers and scam artists everywhere, but I think they do represent a finite minority. I doubt it's any different in the VA system. Most of these are vets with legitimate issues, with the occassional a-hole trying to ride the gravy train interspersed.

While the DSM-V revisions may end up addressing this particular issue of PTSD in combat vets, internal education of VA personnel to initially think "Adjustment Disorder" and reserve PTSD for those individuals with symptoms that are persisting might go a long way too. I did listen to a piece on NPR a few months ago that the VA has re-examined how they are utilizing cognitive-behavioral therapy (CBT) in vets with PTSD. It sounds like they are coming on board with now generally accepted beneficial therapy of "desensitization", the exact opposite of what they (and many others) had been doing for quite a long time.

I did think the snippet about the Australian approach was interesting, as it does seem to address this issue of achieving wellness, over remaining ill to obtain benefits. Whatever we decide, I hope to God we continue to try to do what's best and proper for our veterans. We owe them all so much more than they generally receive.