יום רביעי, 23 במרץ 2011

PTSD, borderline personality disorder, sexual assault, and 30 years of research.

What do we mean when we say PTSD? 
What don't we mean?

According to Paula Schnurr's (2010) "journal of traumatic stress" editorial review of 30 years of publications since the first inclusion of PTSD in American diagnostic manual, the number of publications grew over nine-fold between 1980–1984 and 1995–1999, from a mere 930 to 8,606, giving rise to new journals dedicated to the field, growing with every disaster and war, and though the growth trend has curbed down since then in the US, now, European, Australian and Japanese researchers continue to contribute a growing part of the publications. Schnurr, who is currently the Deputy Executive Director of the Veterans Affairs National Center of PTSD (National Center of PTSD, 2010), does not refer to the research of PTSD as a result of sexual assault.

In their critical essay, Gross and Graham-Berman (2006) claim that PTSD's emergence in 1980's DSM-III was a result of the Vietnam War and the acknowledgement of veteran rights, and that the diagnosis criteria were also constructed for white, middle-class, combat veteran men. They claim that the very diagnosis criteria and scales that were later used in civilian context were lightly adapted from their original purpose to diagnose combat veterans' PTSD, and women who suffered from trauma and did not fit the combat veteran diagnosis would have been diagnosed as dissociative or borderline personality disorders (BPD). 

DSM-IV's (APA, 2000) symptom checklist for BPD overlap greatly with PTSD, but DSM-IV's definition of PTSD does not consider neglect, family violence or sexual abuse in childhood as traumatic. In their study of a general population sample, Pagura et al. showed that PTSD and BPD are similarly prevalent, 6.6% and 5.9% respectively, mutually predictive, as 24% of people diagnosed with PTSD also had BPD and 30.2% of people with BPD also had PTSD, and also referring to research on neuro-physiological similarities between the two disorders. A possible re-constuction of the differentiation could remain on a severity scale only.

DSM-V's personality disorders work group (2010) chose to keep BPD mostly as a personality type, referring to the national medical burden of BPD, they might mean that this is a way to allow people with BPD to retain their insurance benefits. This along with the declared acknowledgement of sexual abuse as trauma and emotions such as anger and shame as symptoms under the diagnosis of PTSD in DSM-V, mean insurance benefits will now also be granted to sexual assault and abuse victims as suffering from a clinical disorder and not only a personality type. So it seems in the future a lot of BPD will be PTSD.

Accepting the inherent neglect in the very definition of PTSD for the past 30 years, it seems there is less research on PTSD as a result of sexual assault when one searches APA's PsycNet. For example, in their meta-analysis of literature from 1998-2010, Yufik and Simms (2010) indeed refer to the same number of articles about combat or terror related PTSD and about interpersonal violence related PTSD (only partly referring to sexual assault victims) research publications, but their cumulative sample size is 8977 for the former and 3020 for the latter, statistical power that implies where research and development funding has been provided, and where it had not been so ample.

Seems like DSM-V reconstruction of PTSD and its neighboring BPD, requires new research and new requirements for construct validity.

References

APA. (2000). DSM IV TR online - borderline personality disorder. Retrieved February 18, 2011, from AllPsych: http://allpsych.com/disorders/personality/borderline.html

APA. (2010). Rational of revisions to personality disorders. Retrieved February 18, 2011, from DSM-V proposed revisions: http://www.dsm5.org/ProposedRevisions/Pages/RationaleforProposingFiveSpecificPersonalityDisorderTypes.aspx
Gross, M; Graham-Berman, S A. (2006). Gender, Categories, and Science-as-Usual: A Critical Reading of Gender and PTSD. Violence Against Women , Vol 12 (4) pp. 393-406.
National Center of PTSD. (2010, September 15). Retrieved February 17, 2011, from US governement Department of Veteran Affairs: http://www.ptsd.va.gov/professional/ptsd101/presenters/paula-p-schnurr-phd.asp
Schnurr, P. (2010). PTSD 30 Years On. Journal of Traumatic Stress , Vol. 23 (1), pp. 1–2.
Yufik, T & Simms, L J. (2010). A Meta-Analytic Investigation of the Structure of Posttraumatic Stress. Journal of Abnormal Psychology , Vol. 119, No. 4, 764–776.





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