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|The Long Shadow of Trauma - Page 8|
Commenting on his group's rejection of the task force's proposal, Matthew Friedman, the chair of the DSM trauma work group insists that, "I encouraged them to submit their diagnosis to DSM. Their proposal was reviewed by many people from different work groups who generally felt the evidence was not compelling. Their research was almost entirely retrospective, collected from different places, under a variety of conditions, using different kinds of measurements. They need to identify in advance, not retrospectively, what the criteria should be, develop the diagnostic instruments to assess them, then go into the field and rigorously apply it to see whether the criteria they propose are accurate, whether they hold together diagnostically and constitute a diagnosis that is sufficiently differentiated from others."
According to Charles Zeanah, psychiatry professor and executive director of the Institute of Infant and Early Childhood Mental Health at Tulane University and a critic of DTD, the whole debate is a classic case of the old division in science and philosophy between lumpers and splitters (lumpers focus on commonalities between different phenomena, splitters on the distinctions between them). The DTD diagnosis is the very embodiment of the lumper spirit, while the DSM is essentially defined by its splitter ethos. "Some people [the DTD camp] look at traumatized kids and say, Ôwait a minute! These kids have way too many symptoms other than PTSD caused by trauma, so we need a bigger tent,'" says Zeanah. "Maybe, but the concern is that the diagnosis becomes so big, so inclusive of everything that it just turns into Ôpsychopathology, with no further specifications.' You could take two kids with the same disorder who bear almost no resemblance to each other and they might both be assigned the same diagnosis—maybe that tent is a little too big. One risk factor can have a multiplicity of outcomes, but that doesn't mean you have to call all of those outcomes by the same name." The ACE study is a case in point, he argues, a relatively narrow set of circumstances early on apparently resulting in a host of physical and psychological disorders later in life—suicide, alcohol abuse, drug addiction, depression, among many others. "But we don't call them all the same thing, says Zeanah. "We don't lump them altogether under the name ÔACE disorder.'"
Another source of mutual hard feelings between DSM members and the non-DSM world of clinical practice is the issue of who actually takes care of these patients. The most influential shapers of the DSM are overwhelmingly epidemiologists and other researchers, whose databases rest on responses to prepackaged rating scales, rather than on clinical encounters. Even DSM-IV chair Allen Frances, in one broadside on the "psychiatric civil war" now being fought, wrote to the The Psychiatric Times last summer that "almost everyone responsible for revising the DSM-V has spent a career working in the atypical setting of university psychiatry," their clinical experience "restricted to highly select patients who are often treated in a research context." The gist of Frances's remarks was that scientific work coming from this rarified environment—including the DSM itself—didn't generalize well for the typical clinician-in the-street, so to speak.
It seems likely that most DSM members disagree with and resent the imputation that they don't get or even care about multiply troubled people beyond their own pristine research samples. "I really bristle when people make the distinction between researchers and clinicians," says Friedman with some passion. "I'm a doctor, I treat patients, and I want to have the best diagnosis I can. Most of us in this business are also clinicians, who have been seeing patients for a long time. The researcher-clinician dichotomy is false. What all of us working on DSM-V want to do is take the best scientific evidence we have and synthesize it into a diagnostic classification scheme that makes it easier for people to identify clinically significant constellations of symptoms, resulting in better diagnosis and better treatment. It has to be useful to the clinician in the trenches."
Nevertheless, at the heart of the rejection of his task force's proposal, van der Kolk sees not the weighing of different kinds of evidence and the disinterested workings of science, but the more elemental forces of professional politics. "The most likely explanation: academic laboratories are funded to study particular disorders," he says. "If you say that your disorder is part of a larger picture, which includes elements from several other diagnoses, then you'd have to rearrange your lab, your concepts, your funding, and your rating scales—and you also have to confront the fact that if children are terrified and abandoned by caregivers, this will affect their brains, minds, and behavior. That seems to be too much to ask."
Though temporarily stymied, the NCTSN task force is by no means defeated. Enlisting the support of the foundations that fund the treatment of traumatized children, who don't want to see their investment wasted on inadequate treatments for inadequate diagnoses, they've been able to raise the money for a DTD field trial and enlisted the sites that are able to carry out the required research. In addition, there are murmurings that, since so many maltreated children are also poor, DTD sympathizers in Congress would like to enable Medicaid to bypass DSM entirely and pay for treatment geared to some kind of complex trauma diagnosis for children. "We're still going ahead full throttle," says van der Kolk. "I feel very optimistic."