Friday, April 26, 2013

A Child Psychiatrist's Thoughts on DSM-5: PTSD

One of my favorite books about children who have been traumatized is The Boy Who Was Raised As A Dog, by Dr. Bruce Perry and Maia Szalavitz, which highlights Dr. Perry's experiences working with children who have survived all sorts of horrors, usually perpetrated by the adults that the children trusted most. It is one of the most saddening yet hopeful books that I have ever read; I believe everyone should read it.

Trauma during childhood has been found to greatly increase the risk of an individual later having poor health, both mental (depression, psychosis, suicidality) and physical (obesity, chronic inflammation, and heart disease). Thus, recognizing and treating children who have been traumatized can have a very positive impact. Dr. Perry's book shows how much of a difference a nurturing environment and loving caregivers can have, even for the boy who spent months locked up in a cage with dogs.

Historically, children have been under-diagnosed with post-traumatic stress disorder (PTSD) for a multitude of reasons, highlighted in this review article from 2009. For example, children typically would not tell you that they are experiencing disturbing memories or flashbacks, and they often act out in seemingly inexplicable ways. In my own experience working with children in the foster system, I have seen manifestations ranging from extreme tantrums in response to loud noises to hiding feces in closets. Overmedication of such children is a rampant problem.

Academics who specialize in childhood PTSD have already modified the DSM-IV criteria for diagnosing PTSD to make them more appropriate for children. From the review article:
The alternative algorithm for PTSD in young children (PTSD-AA) includes modifications in wording for several items to make them more developmentally sensitive to young children. For example, the DSM-IV item for irritability and outbursts of anger was modified to include extreme temper tantrums. However, the major change is a modification to lower the requirement for the C criterion (numbing and avoidance items) from three out of seven items to just one out of seven items because many of the C criterion items are highly internalized phenomena that appear to be either developmentally impossible in young children (eg, sense of a foreshortened future) or extremely difficult to detect even if they were present (eg, avoidance of thoughts or feelings related to the traumatic event, and inability to recall an important aspect of the event).
The DSM-5 changes the diagnosis of PTSD in several ways. An individual no longer has to have a subjective fear response during the trauma. In addition to the previous symptoms domains of hyperarousal, re-experiencing, and avoidance, there is now a fourth symptom domain of alterations in mood and cognition. In children age 6 and under, there is a lower threshold for making the diagnosis: 2 arousal symptoms are required, along with 1 symptom of re-experiencing the trauma and 1 symptom of either avoidance or negative alteration in mood/cognition. I'm not sure what the implications are for adults with PTSD, but I do think the changes are for the better when it comes to accurately diagnosing PTSD in children.

Of course, many adults, even when properly diagnosed with PTSD, are still treated with multiple antipsychotics and mood stabilizers. But I believe the tide is starting to turn, and even the military is implementing many non-medication interventions for trauma. Even for young children with PTSD, there are effective treatments such as child-parent psychotherapy (CPP) and trauma-focused cognitive-behavioral therapy (TF-CBT). I hope that making the diagnosis of PTSD more widely accepted in abused children will lead to greater availability and use of such therapies.