Blame, PTSD and DSM-5: an urgent need for clarification

ABSTRACT DSM-5 substantially revised the PTSD criteria relating to exposure, redrawing symptom clusters and introducing additional symptom criteria, among them a newly defined criterion of persistent distorted blame of self or others. This commentary argues that there are fundamental problems with the current DSM-5 formulation of the blame criterion for PTSD. Most critically, there is conflation of self-blame and other-blame, which are two distinct phenomena, and there is heterogeneity in the research findings regarding the association between both kinds of blame and PTSD. Secondly, distortion of blame may be complex to determine. Finally, standard assessment tools fail to accurately represent the criteria as currently formulated. Despite the conceptual ambiguity in the diagnostic criteria and the lack of clarity regarding the assessment of this item in commonly-used measures, there is also evidence that blame is associated with other PTSD symptoms, is clinically relevant and may be an important intervention target in therapy. It is crucial, therefore, to clarify the blame criterion, differentiating aspects of self-blame and other-blame and, even more importantly, delineating the boundaries between normal and pathological blame.

• Clarification of PTSD diagnostic criteria is urgently needed.
The revisions to the PTSD construct in DSM-5 include the addition of a symptom in the newly-defined negative alterations in mood and cognitions (NACM) cluster of 'persistent distorted blame of self or others about the cause or consequences of the traumatic event(s)' (criteria D3). Blame of self or others is a common reaction to traumatic events and, in some cases, may be normative, justified, appropriate and possibly helpful (Gray, Nash, & Litz, 2017). Yet, blame has been found to be associated with higher levels of PTSD in various studies (Cox, Resnick, & Kilpatrick, 2014).
This new 'distorted blame' criterion has not yet been well-studied, other than as part of a general exploration of the underlying dimensional structure of PTSD. Studies indicate that the D3 blame criteria loads well onto the new NACM cluster (Contractor et al., 2014;Elhai et al., 2012;Miller et al., 2013), while other studies suggest that blame may be part of a more narrow negative affect cluster which is differentiated from anhedonia symptoms (Armour et al., 2015;Liu et al., 2014). These studies do not address fundamental problems with the blame criterion as currently formulated.
The first critical issue is the conflation of two different phenomenaself-blame and other-blame each of which has different associations and implications. Self-blame is a cognitive appraisal in which there is an internal attribution of responsibility for a negative event. This may be related to feelings of worthlessness and psychological distress (Zahn et al., 2015). Blame of others, conversely, reflects an external attribution of responsibility for the event, which could serve a self-protective function, reducing the need to make these negative internal attributions (Zinzow, Seth, Jackson, Niehaus, & Fitzgerald, 2010).
Research has indicated heterogeneous findings in the associations between both kinds of blame and PTSD. While some studies found self-blame to be associated with greater levels of PTSD (Cantón-Cortés, Cantón, & Cortés, 2012;Hassija & Gray, 2012;Moor & Farchi, 2011), others found that self-blame was associated with lower PTSD symptoms (Startup, Makgekgenene, & Webster, 2007) or was not associated with PTSD (DePrince, Chu, & Pineda, 2011). The findings related to other-blame are also mixed; some studies have indicated that other-blame is an effective coping strategy (Larsen & Fitzgerald, 2011), while others found that otherblame was associated with higher PTSD (Nickerson, Aderka, Bryant, & Hofmann, 2013;Zinzow et al., 2010). These inconsistent findings may be because the association between both self-and other-blame and PTSD might depend on the nature of the traumatic event (Reich et al., 2015) and cultural context (Wong & Tsai, 2007).
A second issue refers to the issue of 'distortion' of blame. Traumatic situations are often complex and multi-causal, making it hard for trauma survivors and mental health professionals to judge whether the blame has become 'distorted'. It is also questionable whether the blame even needs to be 'distorted' in order to constitute an element of the PTSD construct; Delahanty et al. (1997), for example, found that when motor vehicle accident (MVA) survivors were indeed responsible for the accident, higher self-blame was associated with more distress.
Finally, there is a lack of consistency between the DSM-5 criteria and their application via standard assessment tools, particularly self-report measures. The PCL-5 (Weathers et al., 2013) formulates this item as: 'blaming yourself or someone else for the stressful experience or what happened after it', omitting the distortion aspect. The PSSI-5 (Foa et al., 2016) clarifies that a person may make comments like 'I should have known'. Yet blame (of self or others) may actually be an understandable and possibly helpful reaction to an event as the survivor attempts to understand and process their experiences, and perhaps take responsibility where appropriate (Gray et al., 2017). Applying the standard assessment tools in their current form, however, may run the risk of reframing this understandable coping response as psychopathology.
Does this mean we should exclude blame from the DSM-5 criteria? There is not yet a clear answer to this question. Despite the conceptual ambiguity in the diagnostic criteria, the heterogeneity in the research findings and the lack of clarity regarding the assessment of this item in commonly-used measures, there is also evidence that blame is associated with other PTSD symptoms, is clinically relevant, might help distinguish PTSD from other disorders, could provide information about the traumatic event itself and may be an important intervention target in therapy (Cox et al., 2014;Friedman et al., 2011;Taylor, 2017).
It is crucial, therefore, to clarify the blame criterion, differentiating aspects of self-blame and otherblame and, even more importantly, delineating the boundaries between normal and pathological blame. Future research could then more sensitively and specifically assess whether blame ought to be part of the PTSD construct, and whether it matters to whom blame is attributed or if the blame attribution is distorted. As diagnostic criteria are formulated and reformulated, and amidst the often-valid criticism regarding DSM-5, there is an urgent need for clarification.