![]() Subjective symptoms and financial benefit suggest that secondary gain plays a role in PTSD diagnoses. ![]() In 1988, the National Vietnam Veterans Readjustment Study found that 30.9% of Vietnam veterans had full-blown PTSD-but only 15% of these vets had been assigned to combat units.9 Analyses using narrower diagnostic criteria and verified reports of trauma exposure reported rates from 2.9% to 15.5%.10 Gold and coworkers8 showed that college students without a traumatic experience were more likely to meet the other diagnostic criteria of PTSD. Bodkin and colleagues7 showed that among those for whom pharmacological treatment of major depression was considered, patients with and without a trauma history met the diagnostic criteria for PTSD at identical rates (78%). There is a more fundamental problem: PTSD symptoms may not be linked to trauma. That the PTSD cluster incorporates many nonspecific indicators of psychiatric distress found in other common psychiatric conditions calls into question the validity of the diagnostic category. A 1995 survey reported that 88% of men and 79% of women with a diagnosis of PTSD had at least 1 comorbid diagnosis.6 Major depression, the most common comorbidity, was diagnosed in almost 50% of patients with PTSD. The PTSD symptom profile overlaps with those of common mental conditions, such as mood disorders, anxiety disorders, and substance abuse. APA researchers responded to criticism of the way PTSD was formulated by making changes: 11 in the 1987 revision of DSM-III-R, and 15 in the 1994 DSM-IV edition.5 Today there are almost 200 combinations of symptoms through which PTSD can be diagnosed. The DSM-IV sourcebook contains the empirical evidence used to create categories of disorders.4 The decision-making process is complex, and human judgment is required to create diagnoses. The American Psychiatric Association (APA) started by using the military’s diagnostic criteria. A second assumption was that those treated would become chronically disabled. This perspective focused on the aftereffects of war rather than the psychodynamics of individual patients.3 It was assumed that an organic brain change had occurred secondary to the psychological arousal of stress. The 1980 edition of DSM (DSM-III) included PTSD after lobbying by antiwar psychiatrists, Vietnam veterans’ organizations, social workers, and psychologists.1 According to Scott,2 these advocates argued that traumatic memories of war were reemerging in more virulent form as PTSD. We seek only to reexamine research evidence, to clarify the impact of culture on diagnosis, to reevaluate the consequences of trauma, and to ensure optimal allocation of resources. We do not minimize the suffering of those who experience trauma or the need for comfort and restitution. But research calls into question the very existence of the “PTSD” syndrome, and its diagnostic formulation remains invalid. The VA treats 200,000 veterans with this diagnosis annually at a cost of $4 billion. Currently the Veterans Administration (VA) is the world’s largest recipient of per patient funding for PTSD.
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