PTSD and the DSM

May 16, 2013

PTSD and the DSM     Recently it has become fashionable to criticize the Diagnostic and Statistical Manual (DSM) as psychiatry is about to switch over from DSM-4 to DSM-5.  Certainly the DSM has its limitations, but these are the limitations of psychiatry.  Mental illness is difficult to define with numbers, which makes it different from hypertension, diabetes, or hypothyroidism.

    The DSM serves a major function for psychiatric clinicians.  It provides useful clinical guidelines for defining each type of mental illness.  When I am trying to decide whether someone has panic disorder, bipolar disorder, or posttraumatic stress disorder (PTSD), it is helpful to sit down with them and go over the DSM criteria for each illness.  Usually, within a few minutes we can come to a pretty secure answer.  This was not the case before we had the DSM.  PTSD was first defined in 1980 as part of the DSM-3.  Prior to 1980 the diagnosis of PTSD was not recognized.  It was called “shell shock”, “combat fatigue”, “war neurosis”, “soldier’s heart”, and a variety of other names, none of which were well defined.  Many veterans with what we now call PTSD were going untreated.  They were living in cabins or shelters in the woods, in single rooms of their houses, or lying homeless on the streets.

    Over the years since 1980, PTSD was redefined once in the DSM-4, and is being redefined again for the DSM-5.  As the definition becomes further and further refined, our understanding of the condition improves.

    PTSD is a many-faceted condition.  It requires exposure to an event or events that involve death or serious injury or the threat of such things.  Symptoms include intrusive recollections (memories, dreams, flashbacks), avoidance (of thoughts, activities, or memories; reduced interest, attachment, emotion, future planning); hyperarousal (insomnia, anger, vigilance, startle, trouble concentrating).

    As we learn more about treating PTSD, it has become increasingly apparent that nightmares and flashbacks are a central feature of the disorder, more central than other features.  Furthermore, nightmares and flashbacks tend to go together, daytime flashbacks leading to nightmares, nightmares leading to daytime flashbacks.

    My own preference in treating PTSD is to go after the nightmares, making every possible effort to get rid of them.  Currently, there are two methods for eliminating PTSD nightmares.  One method involves psychotherapy, a particular type of therapy I call “dream revision”, also called “imagery rehearsal therapy” (IRT).  The other method involves a particular anti-hypertensive medication known as “prazosin”, an alpha-1 adrenergic blocking agent.  The adrenergic receptors are sensitive to norepinephrine (nor-adrenaline), an activating transmitter in the body and the brain.  Overactivation of norepinephrine receptors can cause elevated blood pressure (hypertension).  Some antihypertensive agents block beta receptors (beta blockers); others, like parazosin, block alpha receptors (alpha blockers).

    Prazosin’s effect in blocking nightmares may be due to its action on the amygdala in the brain, which has many alpha-1 adrenergic receptors.  The amygdala is known to be overactive in PTSD.

    Dream revision involves changing the text of the nightmare to give it a happier outcome.  As a type of cognitive therapy, dream revision probably works on the anterior cingulate cortex (ACC), which helps regulate the amygdala.  The ACC is known to be underactive in PTSD.  The goal of psychotherapy in PTSD is to strengthen the ACC and restore its regulating function over the amygdala.  Severe trauma appears to create a condition of “learned helplessness”.  Effective psychotherapy helps the PTSD sufferer regain control of their life.  An important first step is to take control of their nightmares.

    It is important to note that dreams cannot as yet be studied scientifically, using current research tools.  The only way to know what a subject is dreaming is to wake them up and ask them.  Perhaps future research will develop methods for decoding brain waves, thereby providing objective information about dream content.  There is not as yet a “neuroscience” of dreaming.

    It is also important to note that psychoanalysis, as formulated by Freud and Jung, was designed to interpret and understand dreams, not eliminate them.  In this sense, dream revision is the opposite of psychoanalysis.

    Once nightmares (and flashbacks) are eliminated, the next step in PTSD treatment is to work at changing bad habits that may have formed over the years.  Charles Duhigg’s bestselling book, The Power of Habit (2012), is a useful guide in this task.  In future blogs I hope to review some of the details of how to change bad habits that develop as part of PTSD.