Good afternoon.  I am Sid Weissman M.D., and am pleased to have this opportunity meet with you representing the American Psychiatric Association, the medical specialty organization which represents over 37,000 psychiatrists, their patients and families. My professional experience includes serving as a psychiatric physician for the United States Air Force and six years with the Department of Veterans Affairs.

The American Psychiatric Association (APA) is responsible for the preparation, publication, and maintenance of the Diagnostic and Statistical Manual of Mental Disorders, which is now in its fourth edition (DSM-IV).  Thus, we have a vital interest in the work of this subcommittee, and particularly the interest in “expanding the criteria for psychiatric disabilities, especially for Posttraumatic Stress Disorder (PTSD).”

As you have heard from many experts, there is a long history of examining responses to stress, beginning early in this century, with the notion of “shell shock” in World War I and the analytic concept of “traumatic neurosis.”  During WW II Roy Grinker and John Spiegel published War Neurosis in North Africa and Men under Stress addressing the stresses experienced by Army Aviators. Their work ushered in the era of scientific study of stress which extends to the present. This work has expanded to address all severe psychologically traumatizing life events in addition to those experienced in wartime in combat.  The extensive scientifically informed work over the past 50-plus years has resulted in a professional consensus, based increasingly on a rigorous scientific base, of the explicit clinical characteristics of PTSD, its prevalence, and its responsiveness to appropriate treatment.

We understand that the Committee has an interest in the utilization of the diagnosis of PTSD in active duty and discharged military personnel and the impact of this diagnosis on the determination of health benefits and compensation for service-induced disability. 

Need for a Definition Reference Point

All mental disorders – ranging from mild depression to schizophrenia to PTSD – vary in the disability associated with each particular diagnosis.  Hence, questions of disability and severity are at the heart of compensation assessments for SSDI and SSI in the civilian governmental sector.  Because of the broad use of diagnostic criteria, it is important for all clinical, research, insurance claims management, and governmental use of mental disorder diagnoses to have a common frame of reference for diagnostic assessments.  Without such a common reference point, the potential for the development of idiosyncratic diagnostic systems may lead to a dysfunctional and non-cumulative research base and to misuse of diagnostic approaches for financial or political purposes.

 I hope it will be helpful to the committee to have some additional background information about the development of diagnosis criteria and reporting of mental disorders in the U.S. and internationally.   After the development of the United Nations in the late 1940’s, each signatory to the UN Charter agreed to use the World Health Organization (WHO) International Classification of Diseases (ICD) for all morbidity and mortality recording—to assure comparable international health statistics.  Within the U.S., there has been a Clinical Modification (CM) of the ICD codes since about 1977 when the ninth revision (ICD-9) was issued by the WHO.  Although there was a list of mental disorder definitions included in the ICD-9-CM, the NIMH supported research community began using a much more detailed set of explicit Research Diagnostic Criteria (RDC) to obtain greater homogeneity of research subjects.  In 1980, the APA proposed a third edition of the Diagnostic and Statistical Manual (DSM-III) that was based heavily on the RDC prototype of explicit diagnostic criteria, that could be seen as testable hypotheses for their validity in predicting clinical course, treatment response, and eventual etiological information such as genetics or environmental exposure.

This diagnostic prototype was almost immediately adopted by the international psychiatric community, convened by the WHO Division of Mental Health in a historic 1982 Copenhagen conference.   The WHO then worked jointly with the APA and NIMH over the next decade, using the DSM-III as a common reference point, to develop almost identical diagnostic criteria for ICD-10 and subsequently DSM-IV.   Unfortunately, the U.S. has not yet adopted the ICD-10-CM and continues to use ICD-9-CM diagnostic codes for required Medicare claims submissions by the Centers for Medicare & Medicaid services (CMS) (and by private insurance carriers as well).   However, for the past 26 years, mental health and other health care practitioners have been using an alternative set of “descriptors” for ICD-9-CM codes, provided in successive editions of the DSM by the American Psychiatric Association (APA). 

This alternative classification system for mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, now in its 4th edition (called DSM-IV).  Even though the American Psychiatric Association publishes the DSM-IV, psychologists, social workers, counselors, mental health administrators, and policy planners use it routinely for clinical management, record keeping and communication.   Epidemiological surveys and studies of mental health practice patterns use DSM-IV definitions for ascertainment of appropriate case inclusion.  Practice guidelines for clinicians to improve and standardize patient care are keyed to the DSM definitions.  Virtually all research studies on mental disorders define study populations in terms of the DSM categories.  Students of medicine, law, psychiatry, psychology, social work, and all other mental health professions rely on textbooks that describe mental disorders based on the DSM definitions.  

Furthermore, DSM-IV is the de facto official code set for various federal agencies and for virtually all states.  Indeed, there are over 650 federal and state statutes and regulations that rely on or directly incorporate DSM’s diagnostic criteria.  For example, the Department of Veterans Affairs disability program uses the diagnostic criteria in DSM-IV to assess whether an applicant qualifies for disability on the basis of a mental disorder [38 CFR § 4.125]. In addition, CHAMPUS required that the “mental disorder must be one of those conditions listed in the DSM-III” [32 CFR § 199.2]; and Medicaid beneficiaries who apply for admission to nursing facilities because of a mental disorder must meet diagnostic criteria set out in DSM [42 CFR § 483.102].  In California, Medicaid reimbursement to hospitals is keyed to the DSM-IV [9 CCR §§ 1820.205(a)(1)(B) and 1830.205(b)(1)(B)], while in Tennessee, the mental health qualifications to serve as a police officer incorporate by statute DSM [Tenn. Code Ann. § 38-8-106], as do the driver’s license provisions of Pennsylvania law  [67 Pa. Code § 83.5]. 

APA is in the process of assessing the evidence base for PTSD and all other mental disorders in anticipation of a revision of the DSM scheduled for publication in 2011. In June 2005, APA, with the collaboration of the World Health Organization and grant support from the National Institutes of Health, convened an international research planning conference on stress-induced and fear circuitry disorders, a diagnostic grouping that subsumes PTSD. 

A key product of the APA/WHO/NIH conference was the compilation of specific recommendations for research, based on a critical assessment of the existing science base and our identification of near-, intermediate-, and longer-term opportunities for diverse studies and analyses.  In early March of last year, the APA appointed an official DSM-V Revision Task Force which includes a workgroup on stress-related disorders, including PTSD, which will recommend any modifications to the diagnostic criteria that are supported by the science base.  The chair of the workgroup is Dr. Matthew Friedman. He is a psychiatrist and Executive Director of the U. S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder (PTSD) so he brings a critical perspective to the review of the DSM.  A particular focus of this DSM-V workgroup is the reevaluation of the relationship between mental disorders and disability. Research exploring disability and impairment may benefit from the diagnosis of mental disorders being uncoupled from a requirement for impairment or disability in order to foster a more vigorous research agenda on the etiologies, courses, and treatment of mental disorders as well as disabilities and to avert unintended consequences of delayed diagnosis and treatment.

The APA welcomed the IOM’s intensive review of the VA disability ratings process and how it related to the DSM. Any additional information that is specific to the Veteran’s population from emerging from your review will certainly be most welcome by the DSM-V task force committee.

In closing, we hope that knowledge gained from working with our Veterans population will be incorporated into the U.S. and international diagnostic conventions for mental disorders rather than be used to develop into an idiosyncratic diagnostic system unique to the VA or to the Department of Defense.  Likewise, we would hope that there will be a similar interaction with experts convening to study mental health disorder disability assessment, treatment, management and compensation programs which are supported by the Social Security Administration.  One instructive source for these and other expert groups may be found in the work and decisions of the United Nations Compensation Commission, a subsidiary of the U.N. Security Council.  The Commission was established in 1991 to process claims and pay compensation – including compensation to claimants who suffered personal injury and mental pain and anguish – resulting from Iraq’s invasion and occupation of Kuwait.  A common goal for both civilian and military populations is to structure the most effective strategies for maximizing treatment response and functional capacity in those impacted by disability associated with a mental disorder.

Thank you very much.