A recent VA rules change and the traumatic event requirement in PTSD.
A recent VA rules change and the traumatic event requirement in PTSD.
复制标题
DOI：
10.1001/jama.2010.1739
复制
发表时间：
2010-12
期刊：
影响因子：
--
通讯作者：
R. Pitman
中科院分区：
文献类型：
--
作者：
R. Pitman
退伍军人事务部 (VA) 最近放宽了在裁决因创伤后应激障碍 (PTSD) 导致的服役相关残疾索赔时记录创伤事件的要求。这一行动被广泛解读为意味着 PTSD 服务连接不再需要发生实际的创伤事件。例如，《纽约时报》7 月 7 日的一篇文章指出，退伍军人管理局的“新规定还将允许对有充分理由害怕创伤性事件（称为压力源）的军人进行赔偿，即使他们实际上并未经历过这些事件。” 7 月 17 日，一位著名精神病学评论员在《华尔街日报》上发表文章指出，“退伍军人管理局的新规定允许退伍军人获得创伤后应激障碍 (PTSD) 伤残福利，前提是作为非战斗人员，他们有充分理由担心敌对活动，例如交火或爆炸。换句话说，退伍军人现在可以因他们没有实际经历过的事件而受到创伤，提出福利索赔。” 1980年，PTSD成为美国精神病学协会精神障碍诊断和统计手册（第三版）（DSM-III）的正式实体。此后不久，退伍军人管理局也效仿，将创伤后应激障碍 (PTSD) 列为可补偿疾病。此外，由于 DSM-III 规定 PTSD 可能会延迟发作，因此 VA 对其通常要求在服兵役期间或服兵役后一年内承认该疾病的要求做出了明显的例外。在这些行动中，退伍军人事务部表现出了对现有专业标准的值得称赞的忠诚。退伍军人事务部具有里程碑意义的行动的实施有时会因申请人证明 PTSD 诊断所依据的创伤事件确实发生的行政要求而受到阻碍。这通常意味着依赖军事记录。然而，这些记录有时会丢失，甚至不存在，这并不是退伍军人的过错。当一家军事公司不堪重负时，记录保存并不是重中之重。 VA 现在已采取行动解决这个问题。当前 DSM-IV-TR 治疗 PTSD 的必要条件是“经历、目睹或遭遇过涉及实际或威胁死亡或严重伤害的事件，或对自我或他人的身体完整性构成威胁的事件”。在没有明确暴露于此类事件的情况下，无论症状如何，都无法做出 PTSD 的诊断。需要立即且严重的威胁；对未来的恐惧，例如在战区服役期间常见的恐惧，是不够的。这些是该行业明确的标准。有报道称，退伍军人管理局现在计划向那些害怕创伤事件但实际上没有经历过创伤事件的军人提供创伤后应激障碍（PTSD）补偿，这令人不安。如果属实，这将背离公认的医疗标准，这将为退伍军人管理局精神科医生进行创伤后应激障碍补偿评估带来巨大的困境。管理者可能会修改医学疾病的诊断标准的建议引起了医生的潜在关注。然而，很难想象退伍军人管理局官员会像尝试修改类风湿性关节炎的标准一样自行重新定义创伤后应激障碍。事实上，仔细阅读 7 月 13 日在《联邦公报》上发布但提前几个月征求意见的新规则表明，退伍军人事务部并没有这样的意图。退伍军人事务部的裁决自始至终明确表示，其目的只是修改所报告的战时事件的记录要求。当声称的压力源与退伍军人对敌对军事或恐怖活动的恐惧有关时，退伍军人的报告足以确定压力源的发生；无需进一步证实。规则变更附带的补充信息澄清，VA 仍然认可当前的精神病学标准，以确定所声称的压力源（无论是否有记录）是否构成合格的压力源。
THE DEPARTMENT OF VETERANS AFFAIRS (VA) recently eased requirements for documentation of traumatic events in the adjudication of claims for service-connected disability for posttraumatic stress disorder (PTSD). This action has widely been interpreted as meaning that the occurrence of an actual traumatic event is no longer required for PTSD service connection. For example, a New York Times article indicated on July 7 that the VA’s “new rule would also allow compensation for service members who had good reason to fear traumatic events, known as stressors, even if they did not actually experience them.” A July 17 Wall Street Journal article by a prominent psychiatric commentator noted that the “new VA rule allow[s] veterans to receive disability benefits for PTSD if, as non-combatants, they had good reason to fear hostile activity, such as firefights or explosions. In other words, veterans can now file a benefits claim for being traumatized by events they did not actually experience.” In 1980, PTSD became an official entity in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (Third Edition) (DSM-III). Shortly thereafter, the VA followed suit by making PTSD a compensable disorder. Moreover, because the DSM-III provided that PTSD could have a delayed onset, the VA made a conspicuous exception to its usual requirement that the disorder be recognized during or within 1 year following military service. In these actions, the VA demonstrated a laudable fidelity to existing professional standards. Implementation of the VA’s landmark action has at times been thwarted by the administrative requirement that the applicant prove that the traumatic event underlying the PTSD diagnosis really occurred. This usually means relying on military records. However, such records are sometimes lost or even nonexistent through no fault of the veteran. When a military company is being overrun, record keeping is not a high priority. The VA has now acted to redress this problem. The current DSM-IV-TR sine qua non for PTSD is having “experienced, witnessed, or [been] confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” In the absence of unequivocal exposure to such an event, a diagnosis of PTSD cannot be made regardless of symptoms. Immediate and serious threats are required; fear of future ones, such as commonly experienced during service in a war zone, is insufficient. These are the clear-cut standards of the profession. The reports that the VA now plans to allow PTSD compensation for service members who feared traumatic events but did not actually experience them are troubling. If true, this would represent a departure from accepted medical standards that would create a formidable dilemma for VA psychiatrists performing PTSD compensation evaluations. The suggestion that administrators could revise the diagnostic criteria for a medical disorder is of potential concern to physicians. However, it is difficult to imagine that VA officials would take it on themselves to redefine PTSD any more than they would attempt to revise the criteria for rheumatoid arthritis. In fact, a careful reading of the new rules published in the Federal Register on July 13 but circulated for comment months in advance indicates that the VA has no such intent. The VA ruling makes it clear throughout that its intent is to revise only the requirements for documentation of a reported wartime event. When a claimed stressor is related to the veteran’s fear of hostile military or terrorist activity, the veteran’s report is sufficient to establish the stressor’s occurrence; no further corroboration is required. Supplementary information accompanying the rules change clarifies that the VA still endorses current psychiatric standards for whether a claimed stressor, documented or not, constitutes a qualifying