PTSD

Giving all due respect to James Randolph Hillard, MD, I cannot agree with his posttraumatic stress disorder (PTSD) diagnosis, given the information he provided in “Workplace mobbing: Are they really out to get your patient?” (Current Psychiatry). He does not make a case for DSM-IV-TR Criterion A (the person has been exposed to a traumatic event in which both of the following were present: the event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others [A1] and the person’s response involved intense fear, helplessness, or horror [A2]),¹ despite what other “stress” symptoms the patient experienced.

If data exist that correspond with Criterion A, let us know. Criterion A exists for a purpose, and unless it’s changed in DSM-V clinicians should stick to what’s defined and not make up their own diagnosis.

Melvyn Nizny, MD, DLF
Cincinnati, OH

Reference

1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

Dr. Hillard responds

Dr. Nizny makes a very interesting point. DSM-IV-TR requires that a patient must meet 6 sets of criteria for a PTSD diagnosis. The patient described in my article convincingly met Criterion A2 and Criteria B, C, D, E, and F. In terms of Criterion A1, DSM-IV-TR states: “Traumatic events that are experienced directly include, but are not limited to, military combat, violent physical assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarcerations as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.”

I think I can make the case that the patient described in my article meets the “letter” of Criterion A1 by arguing that he experienced threat of “serious injury.” He faced loss of livelihood, loss of much of his core identity, and loss of nearly his whole social network, which consisted mostly of people at his place of employment.

I am fairly sure, however, that such an argument does not follow the spirit of Criterion A1, which seems to imply that PTSD should be diagnosed only if there has been a physical threat. On the other hand, I do not have much sympathy with that concept. Why should threats of physical harm be more likely to produce symptoms than other types of threats? Recent empirical studies¹ do not support the existence of a posttraumatic stress syndrome uniquely associated with physical threats, as opposed to all other threats.

Dr. Nizny notes that Criterion A exists for a purpose, but for what purpose? Michael First, MD, co-chair and editor of DSM-IV-TR, was quoted as giving a partial answer: “The litigation about PTSD when we were working on DSM-IV was going crazy, so we thought it would be wise to limit it to high-magnitude events…there was a huge debate over how broad versus how narrow Criterion A should be.”² In the same article, Dr. First is quoted as stating that the definition “should change with the next revision of the Diagnostic and Statistical Manual.” The committee that designed the criteria for PTSD in DSM-IV in 1994 would probably have preferred to have seen this patient diagnosed as “adjustment disorder with mixed anxiety and depressed mood,” probably to make it less likely that he could successfully sue for damages.

I am convinced that workplace mobbing can present a pathogenic stress to victims that is as severe as that caused by physical injuries or threats. Furthermore, I am convinced that mobbing victims are entitled to have their day in court, as are victims of physical injuries in the workplace. Finally, I am convinced that when psychiatrists underestimate the severity of stress involved in workplace mobbing, they are at risk of failing to treat their patients appropriately. For these reasons, I have not chosen to use a “strict constructionist” approach to diagnosis in this case.

James Randolph Hillard, MD
Associate provost for human health affairs
Michigan State University
East Lansing, MI

Giving all due respect to James Randolph Hillard, MD, I cannot agree with his posttraumatic stress disorder (PTSD) diagnosis, given the information he provided in “Workplace mobbing: Are they really out to get your patient?” (Current Psychiatry). He does not make a case for DSM-IV-TR Criterion A (the person has been exposed to a traumatic event in which both of the following were present: the event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others [A1] and the person’s response involved intense fear, helplessness, or horror [A2]),¹ despite what other “stress” symptoms the patient experienced.

If data exist that correspond with Criterion A, let us know. Criterion A exists for a purpose, and unless it’s changed in DSM-V clinicians should stick to what’s defined and not make up their own diagnosis.

Melvyn Nizny, MD, DLF
Cincinnati, OH

Reference

1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

Dr. Hillard responds

Dr. Nizny makes a very interesting point. DSM-IV-TR requires that a patient must meet 6 sets of criteria for a PTSD diagnosis. The patient described in my article convincingly met Criterion A2 and Criteria B, C, D, E, and F. In terms of Criterion A1, DSM-IV-TR states: “Traumatic events that are experienced directly include, but are not limited to, military combat, violent physical assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarcerations as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.”

I think I can make the case that the patient described in my article meets the “letter” of Criterion A1 by arguing that he experienced threat of “serious injury.” He faced loss of livelihood, loss of much of his core identity, and loss of nearly his whole social network, which consisted mostly of people at his place of employment.

I am fairly sure, however, that such an argument does not follow the spirit of Criterion A1, which seems to imply that PTSD should be diagnosed only if there has been a physical threat. On the other hand, I do not have much sympathy with that concept. Why should threats of physical harm be more likely to produce symptoms than other types of threats? Recent empirical studies¹ do not support the existence of a posttraumatic stress syndrome uniquely associated with physical threats, as opposed to all other threats.

Dr. Nizny notes that Criterion A exists for a purpose, but for what purpose? Michael First, MD, co-chair and editor of DSM-IV-TR, was quoted as giving a partial answer: “The litigation about PTSD when we were working on DSM-IV was going crazy, so we thought it would be wise to limit it to high-magnitude events…there was a huge debate over how broad versus how narrow Criterion A should be.”² In the same article, Dr. First is quoted as stating that the definition “should change with the next revision of the Diagnostic and Statistical Manual.” The committee that designed the criteria for PTSD in DSM-IV in 1994 would probably have preferred to have seen this patient diagnosed as “adjustment disorder with mixed anxiety and depressed mood,” probably to make it less likely that he could successfully sue for damages.

I am convinced that workplace mobbing can present a pathogenic stress to victims that is as severe as that caused by physical injuries or threats. Furthermore, I am convinced that mobbing victims are entitled to have their day in court, as are victims of physical injuries in the workplace. Finally, I am convinced that when psychiatrists underestimate the severity of stress involved in workplace mobbing, they are at risk of failing to treat their patients appropriately. For these reasons, I have not chosen to use a “strict constructionist” approach to diagnosis in this case.

James Randolph Hillard, MD
Associate provost for human health affairs
Michigan State University
East Lansing, MI

Giving all due respect to James Randolph Hillard, MD, I cannot agree with his posttraumatic stress disorder (PTSD) diagnosis, given the information he provided in “Workplace mobbing: Are they really out to get your patient?” (Current Psychiatry). He does not make a case for DSM-IV-TR Criterion A (the person has been exposed to a traumatic event in which both of the following were present: the event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others [A1] and the person’s response involved intense fear, helplessness, or horror [A2]),¹ despite what other “stress” symptoms the patient experienced.

If data exist that correspond with Criterion A, let us know. Criterion A exists for a purpose, and unless it’s changed in DSM-V clinicians should stick to what’s defined and not make up their own diagnosis.

Melvyn Nizny, MD, DLF
Cincinnati, OH

Reference

1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

Dr. Hillard responds

Dr. Nizny makes a very interesting point. DSM-IV-TR requires that a patient must meet 6 sets of criteria for a PTSD diagnosis. The patient described in my article convincingly met Criterion A2 and Criteria B, C, D, E, and F. In terms of Criterion A1, DSM-IV-TR states: “Traumatic events that are experienced directly include, but are not limited to, military combat, violent physical assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarcerations as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.”

I think I can make the case that the patient described in my article meets the “letter” of Criterion A1 by arguing that he experienced threat of “serious injury.” He faced loss of livelihood, loss of much of his core identity, and loss of nearly his whole social network, which consisted mostly of people at his place of employment.

I am fairly sure, however, that such an argument does not follow the spirit of Criterion A1, which seems to imply that PTSD should be diagnosed only if there has been a physical threat. On the other hand, I do not have much sympathy with that concept. Why should threats of physical harm be more likely to produce symptoms than other types of threats? Recent empirical studies¹ do not support the existence of a posttraumatic stress syndrome uniquely associated with physical threats, as opposed to all other threats.

Dr. Nizny notes that Criterion A exists for a purpose, but for what purpose? Michael First, MD, co-chair and editor of DSM-IV-TR, was quoted as giving a partial answer: “The litigation about PTSD when we were working on DSM-IV was going crazy, so we thought it would be wise to limit it to high-magnitude events…there was a huge debate over how broad versus how narrow Criterion A should be.”² In the same article, Dr. First is quoted as stating that the definition “should change with the next revision of the Diagnostic and Statistical Manual.” The committee that designed the criteria for PTSD in DSM-IV in 1994 would probably have preferred to have seen this patient diagnosed as “adjustment disorder with mixed anxiety and depressed mood,” probably to make it less likely that he could successfully sue for damages.

I am convinced that workplace mobbing can present a pathogenic stress to victims that is as severe as that caused by physical injuries or threats. Furthermore, I am convinced that mobbing victims are entitled to have their day in court, as are victims of physical injuries in the workplace. Finally, I am convinced that when psychiatrists underestimate the severity of stress involved in workplace mobbing, they are at risk of failing to treat their patients appropriately. For these reasons, I have not chosen to use a “strict constructionist” approach to diagnosis in this case.

James Randolph Hillard, MD
Associate provost for human health affairs
Michigan State University
East Lansing, MI