I must admit that I never used to wait on pins and needles for previous revisions to the Big Book of Maladies (aka Diagnostic and Statistical Manual of Mental Disorders) the way I have been anxiously waiting for this one. Perhaps it’s because I’m writing an abnormal psychology textbook and the prooooooooooo-traaaaaaaaaaac-teeeeeeeeeeeed release of the DSM-5 has added at least a headache per week to that process.
The buildup to the DSM-5’s release has been met with every kind of reaction, from political protests to editorial warfare to a variety of unprecedented statements by major professional and governmental agencies that, somehow, they’re going to ignore whatever the DSM-5 says. The eventual level of acceptance of the DSM-5 seems pretty up in the air. I have my own thoughts on the major alternative to the DSM, the International Classification of Diseases, but I’ll save those for later. And I don’t know what efforts to fund, say, depression treatment research will look like without referring to DSM criteria. From time to time, though, I’m going to weigh in with my thoughts on the changes that have been made from the previous version to this new one.
Much attention has been paid to changes to criteria for personality disorders, autism spectrum disorders, and a childhood precursor to psychotic disorders. However, I think that one change that will be more consequential than any of those has been almost completely neglected.
There were a couple of changes to Posttraumatic Stress Disorder (PTSD). The first change is mainly organizational. PTSD is now included among a new category of Trama- and Stressor-Related Disorders. It has been moved from the Anxiety Disorders chapter into a new one, where it joins its cousins Acute Stress Disorder and Adjustment Disorder, along with Reactive Attachment Disorder and Disinhibited Social Engagement Disorder (both of which focus on the damage that trauma and neglect can do to a child’s ability to form secure attachments).
The second change is a bigger deal, in my opinion. The definition of a trauma has been changed to–for the first time–include sexual victimization. Previously, the DSM defined trauma as an event in which a person experienced, witnessed, or was confronted with actual or threatened death, serious injury, or a threat to the physical integrity of the self or others. Whatever that means. The revised criteria define a trauma to include exposure to actual or threatened death, serious injury, or sexual violence.
Seems like little thing but I think it has at least two implications that could affect all of us. First, it recognizes the vile and toxic nature of sexual violence and reduces the need for a sexual violence survivor to try to demonstrate that she or he thought death or serious injury were imminent. The perpetration of sexual violence is enough! This could assist witnesses in sexual crime prosecution, and could also make it easier to conceptualize some of the problems faced by those targeted with childhood sexual victimization.
Second, it has direct implications for our military. Two disturbing stories come to mind. There have been numerous reports that military management has sought to reduce costs by putting pressure on Veterans Affairs clinicians to underdiagnose PTSD (for example, this story). Also, there have been awful reports about the nauseatingly high rates of sexual victimization of female soldiers in the military and the further victimization of these soldiers by the military brass (for example, this story). I think that the implications of redefining trauma to include sexual violence will–and should–put the spotlight on rape in our military and enable greater levels of diagnosis, recognition, service connection, and ultimately prevention. That benefits all of us, including those who fight and serve in our name.