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The Devolution of a Diagnosis: PTSD, Part Deux

We don’t seem ready to acknowledge that the largest danger to our women and children isn’t Al-Qaeda, but the people who are supposed to love and take care of them.
Bessel van der Kolk, MD

NOTE: This is a continuation of the story started in Part One of this series about a diagnosis called Developmental Trauma Disorder (DTD) that would apply to many children who are or were abused. We resume our story just as the people who decide what gets into the DSM-5® (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) receive an unprecedented amount of research data and information in order to make their wise decision.

Shall we find out what happens?

Before we get to that, however, please note that “frontline mental health troops—overwhelmed and underpaid social workers and therapists serving in poor communities—seem(ed) to respond with a collective ‘At last!’ when they hear(d) about the new diagnosis.”* Speaking as a “whelmed” (not over- or under-) and well-paid-enough therapist, I joined my sisters and brothers in rejoicing. However, here is what happened.

The DSM-5® subcommittee overseeing “Posttraumatic” diagnoses, having done a thorough review of the evidence, came back with this: “The range of symptoms covered in the proposed criteria is too broad, . . . it would supersede not only PTSD, but it would also supersede all internalizing and externalizing disorders that appeared following interpersonal trauma and poor rearing. Nearly any problem that followed childhood mistreatment would have to receive this new diagnosis.”* So, there you have it!

Actually, this statement lends weight to a theory I’ve had for a long time. This theory states that the entire DSM could be boiled down to four diagnoses: Inherited Neurological Disorder, Brain Injury Disorder, One-Time Trauma Disorder, and Ongoing Trauma Disorder. The first two are “nature” and the last two are “nurture.” The rest of the book, say about 900 or so pages of it, could be tossed in favor of a handy, pocket-sized booklet. But, that would not work for the entities invested in all the other diagnoses, such as the pharmaceutical industry, the legal system, and, dare I say, the American Psychiatric Association (publishers of the DSM®).

Anyway, back to our story.

The DSM® folks further argued that although they were presented with a literal mountain of evidence in favor of the new diagnosis’ validity, “correlation does not imply causation.” This is a standard mantra in science (which psychiatry and psychology pretend to be), used to argue something with which they evidently can’t be bothered.

On the side of fairness, however, consider the “proposition” process here in California, where I live. This process, like in several other states, allows the actual voting public to decide whether to enact certain laws through voting for propositions. Many times propositions that sound perfectly reasonable get shot down due to the fact that, as written, they don’t fulfill exactly what the public or the political process wants. I see both sides of this particular story and wonder whether this happened with DTD. Like, “it’s a good start, but it needs refinement.” I hope so.

In the meantime, let’s look at other possibilities as to why the DSM® committee handed down their decision. First, we’ll focus on this as a “classic case of the old division in science and philosophy between lumpers and splitters (lumpers focus on commonalities between different phenomena, splitters on the distinctions between them). The DTD diagnosis is the very embodiment of the lumper spirit, while the DSM is essentially defined by its splitter ethos.”*

In addition to this difference, note that the people who came up with DTD consisted in large part of clinicians who actually work with the population they describe. On the other hand, “the most influential shapers of the DSM® are overwhelmingly epidemiologists and other researchers, whose databases rest on responses to prepackaged rating scales, rather than on clinical encounters.”*

One of the people leading the charge for DTD, Bessel van der Kolk, MD, theorizes about “the most likely explanation (for turning DTD down): academic laboratories are funded to study particular disorders. If you say that your disorder is part of a larger picture, which includes elements from several other diagnoses, then you’d have to rearrange your lab, your concepts, your funding, and your rating scales—and you also have to confront the fact that if children are terrified and abandoned by caregivers, this will affect their brains, minds, and behavior. That seems to be too much to ask.”

Dr. van der Kolk further states that “there are 10 times as many kids getting abused in America than there are soldiers fighting in Afghanistan and Iraq, and their maltreatment is strongly correlated with our huge jail population, high crime rates, poverty, and school dropouts, not to mention suicide, depression, obesity, and a host of other issues. But none of this is in people’s purview—the connection between these vast social problems and the way we raise our kids isn’t being made.”

So this brings us back full circle to my question in Part One of this series: “Wouldn’t (a ‘war’ against child abuse or a ‘love-in’ for children) pretty much take care of all those other wars, over time?” Well, in the meantime, Dr. van der Kolk and company continue to fight the good fight and prepare for their next go-round with the DSM® committee.

As the last word (as if) on this topic (at least in this article), I feel glad that someone continues to champion the cause of child abuse. In addition, I feel the need to speak for the adults (my clients) who once were children and were abused. There is no diagnosis in the works for these people, only for actual children. Oh, well. Maybe next decade.

DSM, DSM-5, and Diagnostic and Statistical Manual of Mental Disorders are registered trademarks of the American Psychiatric Association.

Copyright 2014 Daniel J. Metevier

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