Diagnostic Musings on Tribulations of the COVID-19 Pandemic: “TPSD” and PTSD

Abstract

A made-up diagnosis of “TPSD,” or “toilet paper stress disorder,” illustrates inherent features of current definitions of trauma and stress for the diagnosis of posttraumatic stress disorder (PTSD) in current American diagnostic criteria for psychiatric disorders. Special emphasis is given to application of these concepts to the 2019 coronavirus (COVID-19) pandemic. This article emphasizes the differentiation of trauma from other stress in the diagnostic criteria for PTSD. It further explains that the current criteria do not include naturally-occurring non-emergency medical illness as trauma, which would exclude naturally occurring viral infections, whether occurring sporadically or as part of a situation formally declared to be a major disaster, such as the COVID-19 pandemic. “Product champions” for the PTSD diagnosis, enthusiastic proponents of unrestrained use of the PTSD label for anyone experiencing adversity or psychiatric symptoms and needing psychiatric treatment, have pushed for the expansion of the diagnostic criteria and for more widespread application of the diagnosis of PTSD, an occurrence also known as “bracket creep.” Research needed to validate the diagnostic criteria for PTSD and categorize syndromes following stressors not currently defined as traumatic is outlined in this article with specific methodological recommendations to inform decisions about changes to diagnostic criteria.

Introduction

The 2019 coronavirus (COVID-19) pandemic was highly stressful for entire populations, especially for the most severely affected subsets including frontline healthcare providers, patients infected with the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2) pathogen, and their loved ones and close contacts. Many challenging stressors emanated from the COVID-19 pandemic. A list of stressful consequences of the pandemic, although by no means exhaustive, includes fear of being infected by or infecting others, oppressive workloads for healthcare workers, inadequate resources such as personal protective equipment and medical equipment for patient care, social isolation from enforced quarantine and physical distancing practices to minimize infection, and loss of businesses and employment and other financial damages during extended societal shutdowns.^1,2 Additional COVID-19-related difficulties were shortages of household staples in stores that emerged during the pandemic. Such hardships, however, are not defined as trauma in existing PTSD criteria, even when they occur as part of conditions created by disasters. Consideration of these hardships will serve to illustrate fundamental understanding of the definitional distinctions between trauma and other stressors through a hypothetical diagnosis of “toilet paper stress disorder” (TPSD), an acronym that refers to a specific example in this category related to toilet paper shortages in stores that many people found distressing.

COVID-19 Application of Stress and Trauma Nosology

A stressor for the public during the pandemic was created by critical shortages of essential supplies for daily life such as toilet paper, baby formula, and gasoline for automobiles, resulting partly from interrupted supply chains and runs on products by panicked shoppers. The situation became so serious that people considered resorting to practices used to address the lack of essential supplies in crises of decades past. ³ Although quite stressful, shortages of essential supplies for daily life cannot formally be construed to represent trauma according to the formal American criteria for posttraumatic stress disorder (PTSD) in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5^th edition, text revision (DSM-5-TR). ⁴

Trauma is specifically defined in the criteria for PTSD as an immediate threat to life or limb, ie, a physical danger that causes bodily injury or harm to those in its path. ⁵ According to these criteria, naturally-occurring medical illness—no matter how medically serious or even potentially fatal, such as heart failure or cancer—does not necessarily qualify as a traumatic event in the most recent DSM-5-TR criteria for PTSD (with named exceptions involving “medical emergencies” and “catastrophic” medical events such as awakening during surgery, anaphylactic shock, and acute heart attacks ⁴ (see text accompanying the criteria, p. 305). Naturally-occurring viral illness, even severe infection running its course during a pandemic that is considered to constitute a major disaster, would therefore not fit the trauma definition. SARS-CoV-2 infection in the COVID-19 epidemic fits the broader category of stressors but does not qualify within the more specific subset of traumatic stressors. ⁶ Technically, therefore, a DSM-5-TR diagnosis of PTSD cannot be applied to SARS-CoV-2 infection, whether through direct, witnessed, or indirect exposure, because the symptoms do not arise from a qualifying trauma exposure. ⁵

The decision to exclude most naturally-occurring medical disorders from the definition of trauma in DSM-5, ⁷ with the consequence of disallowing a diagnosis of PTSD for these instances, has not been well supported by empirical data. Regardless, this decision was retained in the subsequent text revision. ⁴ Further studies with research designs and methods for purposes of informing changes in the criteria are needed to determine whether this decision will hold up under empirically-informed scrutiny. Specifically, research efforts have been recommended to establish whether psychiatric symptoms and long-term outcomes of COVID-19 exposures are dissimilar or equivalent to those from classically-defined traumatic events such as physical attacks or accidents with injuries. ⁸ Necessary research designs would involve the collection of data about the symptoms and other accompanying characteristics of the syndrome and comparing them across types of stressors or traumas and over time. If they are identical to characteristics of classically-defined trauma, this suggests that they may be the same disorders, but if they are distinct, this suggests that they may be different syndromes. Such data represent a starting point to inform the definitional categorization of COVID-19 exposure as a potential source of PTSD.

Additional research will then be needed ⁵ to further advance the validity of PTSD related to COVID-19 by following Robins and Guze’s classic 5-phase procedure for validation of diagnosis. This 5-phase process of investigation requires: (1) description of consistent illness characteristics (“clinical description”), (2) differentiation of the syndrome from other known disorders (“delimitation from other disorders”), (3) observation of familial associations (“family study”), (4) observation of consistency over time (“follow-up study”), and (5) identification of biological correlates (“laboratory studies”) ⁹ (pp. 107-108). By this process, if syndromes following traditional trauma defined by DSM-5-TR PTSD criteria have consistent characteristics distinct from those following broader stressors, appear distinct from 1 another and from other known disorders, transmit through families with distinct patterns, have different courses over time, and can be found to be biologically distinct, then such findings provide compelling evidence that they are different disorders. However, findings that are similar across all these processes provide evidence that the syndromes represent the same entity.

The categorical distinctions between trauma and more broadly defined stressors in American criteria ⁶ do not automatically devalue or discount the importance of the experience of SARS-CoV-2 infection or the pandemic more generally just because the infection is excluded from the circumscribed definition of trauma. Many stressors may elicit more severe psychological responses than trauma, for example the agonies of undergoing a messy divorce or failing a critical professional exam may have more psychological impact than some traumatic events such as sustaining a simple wrist fracture in a fall. It is paramount to recognize that it is not the personal psychological response that defines the trauma but the physical damage it causes, and just because 1 incident evokes greater psychological distress than another does not define it as trauma, or as “more traumatic,” by the established criteria. To think clearly about the nosology of PTSD, it is critical to separate the personal psychological response (eg, the symptoms) from the nature of the precipitating event, ie, the trauma itself.^5,6 A seemingly minor yet far-reaching change in the PTSD criteria in DSM-5 (in addition to the exclusion of naturally-occurring illness from the definition of trauma), the trauma criterion A2 requirement of a personal reaction of “intense fear, helplessness, or horror” that had been added in the preceding version of the manual was removed (p. 428 ¹⁰ ). This latter revision in DSM-5 wisely helped to separate personal reactions from the definition of trauma, improving clarity of the understanding of trauma.

Circling back to the definition of COVID-19 pandemic-related stressors, shortages of essential supplies would not be classified as a traumatic event in DSM-5-TR. Thus, no one can be considered to have PTSD as a result of essential shortages alone, no matter how distressing it was and even if it occurred during a declared disaster, because it did not inflict physical injury or a threat thereof. Because the scarcity in stores of essential supplies on which people depend daily can be considered an undeniable stressor, a related diagnosis could possibly be created in the diagnostic section of trauma- and stressor-related disorders under the name “toilet paper stress disorder” (“TPSD”). The COVID-19 pandemic shortage of essential supplies highlights historical controversies related to diagnostic criteria for trauma and PTSD and even more comprehensively for psychiatric diagnosis in general. The name for the TPSD diagnosis within the DSM-5-TR section on trauma- and stressor-related disorders would not violate the definition of trauma as it purposely conforms with a stress-related and not specifically a trauma-related syndrome. To illustrate the definitions of trauma and other stressors for psychiatric disorders, a previous article by this research team followed this logic to the absurd by describing stress syndromes that would presumably be associated with exposure to a non-trauma stressor or to even no stressor at all,. ¹¹ The TPSD concept proposed herein fits with this line of reasoning.

The COVID-19 pandemic has evolved to endemic status as declared by the Centers for Disease Control (CDC), although the World Health Organization (WHO) still calls COVID-19 a pandemic but without its prior public health emergency. ¹² Fewer COVID-19 cases and fewer medically severe cases and fatalities are occurring as time passes since the pandemic. During this time, a COVID-fatigued public has developed a more casual approach to COVID-19. Recommendations for measures such as isolation and mask use for infection have declined, and vaccination is less appealing to the public. According to the CDC, future vaccination recommendations for COVID-19 will likely involve longstanding periodic boosters, possibly even annual vaccinations such as for influenza. Regardless, the psychosocial aftereffects of COVID-19 stressors and “long COVID” syndromes have not disappeared.

History has demonstrated that pandemics come and go, and future pandemics will certainly occur; thus, vigilance will be needed. In the absence of changes in the criteria defining trauma for PTSD and delineating trauma specifically from stressors more generally, the present rules and conventions will still apply. Diagnostic issues surrounding trauma and distress in the scenario of an infectious pandemic represents more than just a mental exercise in itself. Psychiatric diagnosis has historically had far-reaching consequences for afflicted populations.

Prevailing Attitudes Toward Mental Illness

There has been a longstanding and unfortunate history of negativity and stigma against individuals with psychiatric illness. ¹³ The formally established term for these disorders is “mental disorders” ¹⁴ as specified by all versions—I through 5—of the American Psychiatric Association’s main diagnostic manuals entitled Diagnostic and Statistical Manual of Mental Disorders (bolded emphasis added). However, degradation of the terminology used for these illnesses in recent literature has been acknowledged as a further contributor to the stigma problem. ¹⁴ Harmful consequences involving “virtually all life domains” ¹⁵ (p. 202) have befallen those afflicted with mental disorders as a result of stigma against those with mental illness, including punishment and torture, brutal executions, sexual sterilization, lifelong institutionalization, imprisonment, ridicule and ostracism, outcast from society, and social disadvantage, among other assorted afflictions. ¹⁶

Psychiatric illness itself, however, has come to be viewed more sympathetically, especially in recent decades, as reflected in many recent books and movies portraying mental illness compassionately. This trend has been accompanied by movements for mental illness to confer conferring social benefits, ¹⁷ such as income subsidies, housing assistance, public healthcare provisions, and general disability benefits.

Introduction and Evolution of PTSD in the Official Classification of Mental Illnesses

PTSD is a psychiatric diagnosis that has historically been a source of major controversy. The diagnosis was established in official criteria in 1980 with DSM-III ¹⁸ in the context of public enthusiasm. In the 1970s, the syndrome had a public groundswell of support for inclusion as a diagnosis in American psychiatric nomenclature, especially among veterans of the Vietnam War.^19,20 Validity of the proposed diagnosis, however, was argued to be contaminated by compensation-seeking issues among military veterans. ²¹ Nevertheless, formal adaptation of the diagnosis of PTSD allowed not only military veterans but also victims of other types of trauma to qualify for a psychiatric diagnosis based on having experienced trauma. ⁶ The establishment of the diagnosis of PTSD has provided a source of disability and other compensation for military veterans and civilians alike. However, the evolution of the definition of trauma for the diagnosis of PTSD over subsequent versions of the diagnostic criteria has prompted important changes in the definition of trauma, a critical element of the diagnosis of PTSD. ⁶ This evolution has hampered efforts to compare trauma research findings across different historical eras and made it even more difficult to apply diagnostic criteria for PTSD across time. The politics surrounding PTSD can only become more complicated given the past and likely future instability of the diagnostic criteria.

Regardless, application of the diagnosis of PTSD has proliferated since it was first included in the diagnostic criteria. ²⁰ A potential psychological advantage of the diagnosis of PTSD to patients is that, by definition, it allows individuals to assign external attributions to their psychological difficulties, ²² shifting the accountability for their problems from within themselves to an external source, ie, the trauma to which they were unfortunately exposed through no apparent fault of their own. It is not surprising, then, that many patients, treatment providers, and other stakeholders have developed a favorable view of PTSD. Major treatment approaches have been developed and promoted for this disorder,^23,24 providing extensive opportunities for mental health professionals to practice their PTSD expertise, given that 8% of the general population has been identified to have PTSD, ²⁵ representing potentially millions of individuals needing mental health care. ²⁰ Enthusiastic proponents of unrestrained use of the label of PTSD for anyone experiencing adversity or psychiatric symptoms and need for its treatment may be construed as “product champions” of the diagnosis. The “product champion” phenomenon has been ascribed to passionate supporters of certain practices and innovations more broadly,^26-28 but this concept could well be invoked for enthusiasm for PTSD specifically.

Given this history, it should not be surprising that diagnostic “bracket creep” (p. 115) ²⁹ has ensued with increasing popularity of the diagnosis of PTSD. The most likely source of this problem is in the variability in the application of criterion A, the “trauma criterion” for PTSD, ⁶ because symptoms that could be attributed to the disorder are so prevalent^30,31 that they alone do not define the disorder. The trauma criterion requires not only the occurrence of a qualifying traumatic event, but a requisite exposure by the individual, of 3 potential types: (1) direct exposure (physical endangerment or injury), (2) witnessed exposure of others being endangered or injured, or (3) indirect exposure through learning about a qualifying trauma exposure of a close associate. ⁵

Exposure through contact with media portrayals of strangers exposed to trauma, even of extensive news broadcasts of national- and international-level disasters, has been specifically excluded from current PTSD criteria as a valid trauma exposure type, except for occupationally-related exposures to gruesome images. ⁵ Otherwise, virtually everyone could potentially be a trauma victim and develop PTSD after highly newsworthy disasters. ⁵ Such a broad paradigm is not useful for psychiatric categorization and treatment for individuals within populations, such as with the invocation of psychiatric labels for millions of Americans after the 9/11 attacks. ³²

Some people might conclude that these concepts of trauma exposure are derived from “old data” not accounting for more modern developments in media providing instant, graphic, and highly-disseminated reports of catastrophic events through social media. Older research is not necessarily invalid simply because of its age, ³³ and the principles under consideration may hold constant despite technological changes over time. Research is needed to test the previously-established psychological effects by specifically studying current technologies of media dissemination of news about mass casualty incidents to determine if the effects are similar or distinct, to further inform potential changes to the diagnostic criteria.

Conclusions

The limitation of the definition of trauma for the diagnosis of PTSD in DSM-5-TR that excludes most naturally-occurring medical illness including viral illness such as SARS-CoV-2 has been unsatisfying for those whose COVID-19 experience was severely distressing or even disabling, especially patients with severe illness and their loved ones and their healthcare providers. More empirical support for the decision in DSM-5 to exclude naturally-occurring medical illness from the definition of trauma is needed. Evidence is lacking to demonstrate definitively whether psychiatric syndromes related to experience of the COVID-19 pandemic have the same characteristics and outcomes and longitudinal courses as psychiatric syndromes related to conventionally-defined traumas such as physical assaults and serious accidents.

If COVID-19-related psychiatric syndromes are found to differ from those following conventional trauma, they may fall under stress-related disorders such as adjustment disorder. Some COVID-19-related syndromes could readily be classified into already-established disorders such as major depressive disorder. These last 2 possibilities involve utilization of entities already in existing criteria rather than requiring additions to the diagnoses already provided. Alternatively, a new stress-related disorder could be defined for COVID-19-related syndromes, although the wisdom of developing new psychiatric diagnosis specifically for COVID-19 is not yet empirically supported. Symptoms of these problems could well be considered to be distress not arising to diagnostic considerations.

Because people seem to care so much about medical labels for their experience relating to trauma and diagnosis of PTSD (driven in part psychologically and in part by eligibility for compensation such as medical benefits and legal awards), research to validate COVID-19-related syndromes is much needed. For now, “product champions” of trauma-related syndromes must await scientific advances toward diagnostic validation.