The introduction of posttraumatic stress disorder (PTSD) into psychiatric nosology has brought new insights as well as controversy. It has deepened our understanding of how severe traumas that exceed ordinary coping mechanisms affect the human mind; however, complex clinical manifestations of PTSD have created serious confusion in diagnostic and therapeutic practice.
The majority of psychiatric disorders are diagnosed according to symptoms, signs and traits. Posttraumatic stress disorder is unique in that etiology is a primary diagnostic factor; and, in patients with PTSD, etiology and symptoms are not always in harmony. Both DSM-IV and ICD-10 are often impractical in regard to PTSD because many patients exhibit multiple symptoms concomitantly or at different times. In addition, the current categorization of PTSD under the umbrella of anxiety disorders is inadequate and misleading, as the PTSD symptom complex overlaps with psychoses, affective disorders, dissociative disorders, personality disorders and numerous other psychiatric disorders.
According to trauma theory, which seems to have been tailor-made for PTSD, acutely painful memories are often buried deeply in the thickets of repression. The strain of trauma invariably seeps through to the surface of consciousness, however, and various seemingly unrelated emotions and behaviors begin to emerge. Trauma may lead to not only PTSD, in the narrowest sense, but to the development of other serious psychiatric disorders.
Therefore, it is impossible to discuss any reclassification of PTSD without discussing trauma, dissociation and coping mechanisms. The nature of the trauma, pre-existing psychiatric disorders, available support systems, age at the time of the traumatic experience and other factors predispose patients to a variety of psychiatric responses (Gladstone et al., 1999; Jung, 2001; Silva et al., 2000).
For instance, it has been my clinical experience that violent, repeated sexual trauma in early life almost invariably leads to severe psychotic features, while nonviolent sexual abuse later in life tends to bring about less severe disorders in psychosexual development, including personality disorders.
In the complex interaction between the nature and severity of trauma and the varying vulnerability of the victim, a spectrum of psychiatric symptoms emerges: acute psychotic, panic, dissociative, depressive features on one extreme, symptoms of narcissistic personality and antisocial personality on the other, and symptoms of multiple personality and borderline personality in between. These multiple clinical features support the idea that PTSD would more accurately be an acronym for posttraumatic spectrum disorder, as opposed to posttraumatic stress disorder.
Theoretical BasisGiven the mounting evidence for the spectrum concept of posttraumatic disorders, a radical revision of PTSD classification is warranted. To address the shortcomings of the current classification system, we must first identify the traumas that precipitate the marked aberration of biopsychosocial functions that are characteristic of PTSD. Second, the vastly different clinical features need to be categorized into a limited number of psychiatric disorders in order to be useful.
The rationale for classifying the different posttraumatic symptoms, signs and traits into one major Axis I diagnostic category has four theoretical cornerstones.
1. Because the psychiatric symptoms that follow trauma frequently coexist and intermingle with one another, it is sensible to make diagnostic distinctions based on one or more predominant clinical manifestations (Jung, 2001; Kolb, 1989).
2. The method of classification of the PTSD spectrum should be based on the current classification system. Psychoses, affective disorders, dissociative disorders, personality disorders, along with other specific psychiatric disorders, should be adopted to represent the complex emotional, cognitive and behavioral manifestations of posttraumatic spectrum disorders.
3. These disorders must be distinguished diagnostically and therapeutically from other psychiatric disorders with similar symptoms, signs and traits unrelated to trauma.
4. Theoretical support must be developed to integrate the etiology, psychopathogenesis, psychopathology and psychotherapeutic relevance of the seemingly unrelated complex of psychiatric disorders.
The classification posttraumatic stress disorder should be replaced with posttraumatic spectrum disorder, using the following subclassifications:
- PTSD with psychotic features;
- PTSD with depressive features;
- PTSD with anxiety and panic features;
- PTSD with dissociative features;
- PTSD with borderline features; and
- PTSD with other clinical features.
