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Letters to the Editor   |    
“A Rose Is a Rose Is a Rose”?
Peter Barglow, M.D.
Am J Psychiatry 2013;170:680-680. doi:10.1176/appi.ajp.2013.13010087
View Author and Article Information

The author reports no financial relationships with commercial interests.

From the Department of Psychiatry and Medicine, University of California Davis Medical School, Sacramento, Calif.

Copyright © 2013 by the American Psychiatric Association

Accepted March , 2013.

To the Editor: I challenge the assertion in the January editorial by Freedman et al. (1) on DSM-5 reliability statistics that posttraumatic stress disorder (PTSD) “is another historic accomplishment, with a kappa of 0.67.” Since the majority of the 960 adult PTSD patients who were sampled for DSM-5 were interviewed at Veterans Affairs facilities, high rater concordance is not surprising (2). The notoriety and secondary gain associated with this disorder at these treatment locations probably concretized patients’ diagnostic self-identifications, which were most likely communicated to and adopted by the research interviewers.

The editorial quotes the statement by Robins and Guze that reliability is the “first test of validity for diagnosis” (3). But “first” refers to time sequence only, not to the word “foremost.” Validity, estimating the truth or falsity of scientific propositions, requires meeting three additional criteria. First, distinct boundaries must separate a disorder from other disorders. But the comorbidity of PTSD with generalized anxiety disorder, depression, and substance dependence (4) fails this requirement. Second, genetic aggregation should characterize family members of individuals diagnosed. Genetic association studies of PTSD have identified promising candidates such as the serotonin transporter gene (SLC6A4) (5). But robust confirmation requires extensive research efforts devoted to this gene and other suspects, requiring sample sizes possibly in the thousands. And third, the diagnosis must be substantiated by quantitative evidence (i.e., biological assays, brain imaging, or psychological tests). But pervasive contradictions and conflicting claims bedevil PTSD studies examining the morphology of the hippocampus and measures of substances such as catecholamines, cortisol, or glutamates.

Kendler (6) proposed a fifth widely accepted validity criterion: a diagnosis must generate relevant treatment benefits. But the 2008 Institute of Medicine evaluation of 53 medication interventions and 37 psychotherapy studies concluded that there was insufficient evidence of beneficial long-term treatment effects from any PTSD intervention with the exception of prolonged exposure therapy (7). Little has changed since then.

Applying the above five criteria for the validity of a psychiatric diagnosis to PTSD gives it a weak position in DSM-5 nosology.

Freedman  R;  Lewis  DA;  Michels  R;  Pine  DS;  Schultz  SK;  Tamminga  CA;  Gabbard  GO;  Gau  SS;  Javitt  DC;  Oquendo  MA;  Shrout  PE;  Vieta  E;  Yager  J:  The initial field trials of DSM-5: new blooms and old thorns.  Am J Psychiatry 2013; 170:1–5
[CrossRef] | [PubMed]
 
Clarke  DE;  Narrow  WE;  Regier  DA;  Kuramoto  SJ;  Kupfer  DJ;  Kuhl  EA;  Greiner  L:  DSM-5 field trials in the United States and Canada, part I: study design, sampling strategy, implementation, and analytic approaches.  Am J Psychiatry 2013; 170:43–58
[CrossRef] | [PubMed]
 
Robins  E;  Guze  SB:  Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia.  Am J Psychiatry 1970; 126:983–987
[PubMed]
 
Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Cornelis  MC;  Nugent  NR;  Amstadter  AB;  Koenen  KC:  Genetics of post-traumatic stress disorder: review and recommendations for genome-wide association studies.  Curr Psychiatry Rep 2010; 12:313–326
[CrossRef] | [PubMed]
 
Kendler  KS:  Toward a scientific nosology: strengths and limitations.  Arch Gen Psychiatry 1990; 47:969–973
[CrossRef] | [PubMed]
 
Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine:  Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence .  Washington, DC,  National Academies Press, 2008
 
References Container
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References

Freedman  R;  Lewis  DA;  Michels  R;  Pine  DS;  Schultz  SK;  Tamminga  CA;  Gabbard  GO;  Gau  SS;  Javitt  DC;  Oquendo  MA;  Shrout  PE;  Vieta  E;  Yager  J:  The initial field trials of DSM-5: new blooms and old thorns.  Am J Psychiatry 2013; 170:1–5
[CrossRef] | [PubMed]
 
Clarke  DE;  Narrow  WE;  Regier  DA;  Kuramoto  SJ;  Kupfer  DJ;  Kuhl  EA;  Greiner  L:  DSM-5 field trials in the United States and Canada, part I: study design, sampling strategy, implementation, and analytic approaches.  Am J Psychiatry 2013; 170:43–58
[CrossRef] | [PubMed]
 
Robins  E;  Guze  SB:  Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia.  Am J Psychiatry 1970; 126:983–987
[PubMed]
 
Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Cornelis  MC;  Nugent  NR;  Amstadter  AB;  Koenen  KC:  Genetics of post-traumatic stress disorder: review and recommendations for genome-wide association studies.  Curr Psychiatry Rep 2010; 12:313–326
[CrossRef] | [PubMed]
 
Kendler  KS:  Toward a scientific nosology: strengths and limitations.  Arch Gen Psychiatry 1990; 47:969–973
[CrossRef] | [PubMed]
 
Committee on Treatment of Posttraumatic Stress Disorder, Institute of Medicine:  Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence .  Washington, DC,  National Academies Press, 2008
 
References Container
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