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Posted to Traumatic-Stress Forum on 12 July, 1996.
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In my work with veterans, primarily Vietnam War veterans, perhaps the most difficult area I face is in diagnosing what is going on with these patients. Specifically, whether they have PTSD or not.
Our team here at the VA in Des Moines, Iowa, has struggled with this for over three years, and are beginning to come up with some approaches which we think make sense. Further, the way we are coming to look at the diagnosis of PTSD can help to make some sense of a field which is becoming increasingly fragmented, contentious, and confused.
The particular difficulty which we face with our population is that the traumatic events with which we are dealing occurred over 20 years ago. In addition, the question of compensation muddies the waters significantly.
In wrestling with this diagnostic dilemma, we have found ourselves at times making a diagnosis without sufficient evidence; conversely, we have at times determined that a PTSD diagnosis was not supported by credible evidence. Which means that we were, in fact, making judgments as to both credibility of the informant, and severity of the purported stressor.
The upshot has been a significant degree of discomfort with our diagnoses.
Recently, in discussing this, we arrived at the following ideas. These are based on our experience, our interpretation of the literature, considerations of perspicuity. What follows is a suggestion, but one which I think has great merit.
The diagnosis of PTSD is an anomaly in the Diagnostic and Statistical Manuals in that it has as one of its criteria an etiological factor. This is unique among DSM diagnoses (except for Mental Disorders due to a General Medical Condition, what used to be called Organic Brain Disorders). The writers of DSM-III and...