Balzacian PTSD: diagnostic considerations

LETTER TO THE EDITORS

Balzacian PTSD: diagnostic considerations

Rodrigo Grassi de Oliveira

MS, MD, PhD, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. Supervisor, Medical Residence in Psychiatry, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil

Correspondence

Dear Editors,

According to Balzac,¹ "a 30-year-old woman has irresistible attractions. Young women have many illusions, much inexperience. (...) Between them, there is an immeasurable distance from being predicted to unpredicted, from strength to weakness. A 30-year-old woman satisfies everything, and young women, risking not to be it, cannot satisfy anything." Posttraumatic stress disorder (PTSD) is almost 30 years old. It was born amidst troubled discussions of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), by the hands of our colleague Nancy.² During this period, like Balzac's women, its maturation arose from its fragility. PTSD is no longer an intrinsic unit and starts being seen as the product of practice by which it is studied and diagnosed.³ This does not mean that PTSD is not an actual disorder, which generates real suffering, but it is still being built and conceptualized.⁴ This is what represents its strength: the recognition of its diagnostic fragility.

Faced to that, some considerations are needed:

a) Despite an inherent ambiguity to the definition of trauma, it is essential to set a severity threshold for the stressful event to diagnose PTSD. Criterion A (DSM-IV) tries to establish guidelines for that, considering individual response. More conservative judgments of this issue are related to reduction in detection of this disorder, as well as more liberal interpretations are related to its increase.⁵ As a rule, only what is in accordance with criterion A of the DSM-VI-TR is qualified for traumatic event.

b) Even if new models of symptom groupings for PTSD have been proposed,⁶ it is absolutely necessary to have the presence of all three symptom groupings - reexperiencing (criterion B), avoidance (criterion C) and hyperarousal (criterion D) - for at least 30 days (criterion E) for diagnosis. Many professionals are susceptible to the so-called confirmatory bias,⁷ i.e., once the clinician knows that the patient was a victim of trauma and reports any symptom, tendency is to diagnose PTSD without actually completely reviewing all symptom clusters. Thus, for instance, a robbery followed by recurrent nightmares could lead to interruption of a more judicious investigation and to early diagnosis of PTSD.

c) To diagnose PTSD, definition of disorder or suffering is a highly complex, but extremely necessary task. If clinical significance (criterion F) is not considered in assessment, probability of diagnosing PTSD after exposure to a traumatic event is approximately 30% higher than when this is taken into account.⁸

d) PTSD can be described categorically or continuously.^9,10 PTSD diagnosis presupposes that a person belongs or not to that category.

Part of the importance of using categorical diagnoses is improvement in reliability between different raters. Such strategy separates individuals that are highly symptomatic from those that do not have symptoms or have moderate symptoms. However, this does not mean that individuals that have a symptom and do not meet all the criteria required for PTSD diagnosis do not have posttraumatic disorders (subsyndromal). In such cases, assessment using screening and severity scales, such as the Post-Traumatic Stress Disorder Checklist - Civilian Version (PCL-C),¹¹ are more adequate. Studies on diagnostic prevalence should use the previously discussed diagnostic criteria.

e) Finally, another fragility of PTSD diagnosis is the evaluation of high comorbidity rates with other psychiatric disorders, which are often overlapping and cause confusion in diagnoses, especially the interface between PTSD and major depression.

This brief communication was an attempt to show that the apparent fragility of PTSD diagnosis reflects a maturity in its understanding. It is through clinical subtlety and perspicacity, along with robust methodological instruments, that Balzacian PTSD can become solid and satisfying. Opposed to what Balzac said about women, PSTD physiognomy started before 30 years and should be respected.

References

• 1. Balzac H. La femme de trente ans. Paris; 1842.
• 2. Andreasen NC. Acute and delayed posttraumatic stress disorders: a history and some issues. Am J Psychiatry. 2004;161(8):1321-3.
• 3. Solomon Z, Horesh D. Changes in diagnostic criteria of PTSD: implications from two prospective longitudinal studies. Am J Orthopsychiatry. 2007;77(2):182-8.
• 4. Young A. The harmony of illusions: Inventing post-traumatic stress disorder. Princeton, NJ: Princeton University; 1995.
• 5. Weathers FW, Keane TM. The Criterion A problem revisited: controversies and challenges in defining and measuring psychological trauma. J Trauma Stress. 2007;20(2):107-21.
• 6. Asmundson GJ, Frombach I, McQuaid J, Pedrelli P, Lenox R, Stein MB. Dimensionality of posttraumatic stress symptoms: a confirmatory factor analysis of DSM-IV symptom clusters and other symptom models. Behav Res Ther. 2000;38(2):203-14.
• 7. Parmley MC. The effects of the confirmation bias on diagnostic decision making. Philadelphia, PA: Drexel University; 2006.
• 8. Breslau N, Alvarado GF. The clinical significance criterion in DSM-IV post-traumatic stress disorder. Psychol Med. 2007;37(10):1437-44.:1-8.
• 9. Grubaugh AL, Elhai JD, Cusack KJ, Wells C, Frueh BC. Screening for PTSD in public-sector mental health settings: the diagnostic utility of the PTSD checklist. Depress Anxiety. 2007;24(2):124-9.
• 10. Berlim MT, Perizzolo J, Fleck MP. [Posttraumatic stress disorder and major depression]. Rev Bras Psiquiatr. 2003;25 Suppl 1:51-4.
• 11. Berger W, Mendlowicz MV, Souza WF, Figueira I. Equivalência semântica da versão em português da Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C) para rastreamento do Transtorno de Estresse Pós-Traumático. Rev Psiquiatr RS. 2004;26(2):167-75.

Publication Dates

• Publication in this collection
  01 Mar 2008
• Date of issue
  Dec 2007