Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case-control study

Aim

To determine the presence of disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans who suffer from combat-related posttraumatic stress disorder (PTSD).

Methods

The research included 247 veterans of the 1991-1995 war in Croatia who suffered from PTSD and were psychiatrically examined at four clinical centers in Croatia during a month in 2008. It was based on the following self-assessment instruments: The Harvard Trauma Questionnaire (HTQ): Croatian Version, the Structured Interview for Disorder of Extreme Stress (SIDES-SR), and the Mini International Neuropsychiatric Interview (MINI)

Results

Based on the SIDES-SR results, we formed two groups of participants: the group with PTSD (N = 140) and the group with both PTSD and DESNOS (N = 107). Forty three percent of participants met the criteria for DESNOS. There was a significant difference in the intensity of posttraumatic symptoms between the group with both PTSD and DESNOS and the group with PTSD only (U = 3733.5, P = 0.001). Respondents who suffered from both PTSD and DESNOS also reported a significantly larger number of comorbid mental disorders (U = 1123.5, P = 0.049) and twice more frequently reported comorbid depression with melancholic features (OR = 2.109, P = 0.043), social phobia (OR = 2.137, P = 0.036), or panic disorder (OR = 2.208, P = 0.015).

Conclusion

Our results demonstrate that PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria. A greater intensity of symptoms and a more frequent comorbidity with other psychiatric disorders, especially depression, panic disorder, and social phobia require additional therapy interventions in the treatment processes.Posttraumatic stress disorder (PTSD) is a common, but not the only disorder that develops as an effect of a traumatic experience. The prevalence of PTSD in general population is 1 to 14% (1-4). In case of war veterans, the rate ranges from 15 to 57% (3,5,6). As much as 79% of persons suffering from PTSD suffer from another mental disorder and 44% suffer from three or more mental disorders. This means that in case of a large number of traumatized persons, PTSD diagnosis covers only a few mental disturbances (7-11).Chronic or complex PTSD and DES or DESNOS (disorder of extreme stress not otherwise specified) have been investigated since the 1990s (12-15). DESNOS is defined and viewed as a group of symptoms within associated features of PTSD, and as such it may be included in future classifications (2,9). On the other hand, the ICD-10 introduced a diagnostic category of Enduring Personality Change After Catastrophic Events (F62.0), which includes features such as hostility and mistrustful attitude toward the world, social isolation, a feeling of emptiness and hopelessness, irritability, and estrangement. The diagnosis can be given only after two years of the illness duration and it excludes the diagnosis of concurrent PTSD because the enduring change is seen only as an adverse outcome of a long-lasting PTSD, not as a separate entity that can exist in comorbidity with PTSD (1). After its full development, enduring personality change cannot be treated that easily. The ICD-10 classification does not allow diagnosing the comorbidity of PTSD and Enduring Personality Change After Catastrophic Experience or DESNOS as a corresponding diagnostic category proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification (2).The correlation of DESNOS and PTSD is still not completely clear. It is not specified whether DESNOS is a separate clinical entity or a complication of PTSD. Potential factors are severity of traumatic experience, correlation with the severity of PTSD, comorbidity in Axes I and II of the DSM-IV classification system, and a range of personal and social factors that add to the development of the disorder (9,16,17). In spite of clinical experience and results speaking in favor of the presence of the entity that can be developed as an effect of trauma independently of PTSD or in comorbidity with PTSD, the DSM IV classification has not included this category (2,16-19).However, over the past 15 years a number of studies have discussed the possible inclusion of DESNOS in the DSM-V classification (16-19), many criteria have been defined, and even a specific questionnaire, Structured Interview for Disorder of Extreme Stress (SIDES), has been formed (9). Six clusters of symptoms have been proposed for establishing the DESNOS diagnosis: 1) alterations in regulation of affect and impulses (eg, extreme and unmodulated emotional states); 2) alterations in attention or consciousness (eg, dissociation); 3) alterations in self-perception (eg, image of self as fundamentally damaged); 4) alterations in interpersonal relations (eg, impaired relational boundaries); 5) alterations in biological self-regulation (eg, somatization), and 6) alterations in sustaining beliefs (eg, spiritual alienation) (18).[REMOVED HYPERLINK FIELD]DESNOS mostly occurs as a separate disorder, but also in comorbidity with PTSD. The prevalence of DESNOS is 1% in female student population (19), 2% in civil population exposed to war (18), and up to 57% in war veterans, 31% in comorbidity with PTSD and 26% as a separate diagnostic category (16). Furthermore, the prevalence of PTSD is the same in the general population and treatment-seeking population (17). Nearly a half of the treatment-seeking population meets the criteria for DESNOS, which suggests that symptoms of DESNOS, more likely than symptoms of PTSD, are the ones prompting patients to seek help (17).Clinical experience in working with war veterans in Croatia shows that there are patients suffering from chronic PTSD who report a range of symptoms meeting the criteria proposed for DESNOS (9). However, possible comorbidity of DESNOS and PTSD has not been assessed, probably to conform to the existing ICD classification (1). It may be assumed that DESNOS affects patients with severe clinical features of PTSD and that it also occurs in cases of Axis I comorbidity. These assumptions were the subject of our investigation.