David Dobbs has a really excellent and thought-provoking article on the diagnosis (and perhaps over-diagnosis) of post-traumatic stress disorder over at Sciam. The essential point is that it’s extremely hard to define a normal psychological response to traumatic events. Are nightmares normal? Is it normal to experience bouts of anxiety or depression? Dobbs profiles several big name psychiatrists who think that PTSD has become too vague for its own good, and is creating a generation of patients who are trapped in a self-fulfilling vision, in which the diagnosis actually makes it harder for them to get over the trauma:
Over the past five years or so, a long-simmering academic debate over PTSD’s conceptual basis and incidence has begun to boil over. It is now splitting the practice of trauma psychology and roiling military culture. Critiques originally raised by military historians and a few psychologists are now advanced by a broad array of experts indeed, giants of psychology, psychiatry and epidemiology. They include Columbia University’s Robert L. Spitzer and Michael B. First, who oversaw the last two editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, former chair of Johns Hopkins University’s psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard J. McNally, a leading authority in the dynamics of memory and trauma and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they assert, represent a faulty, outdated construct that has been badly overstretched so that it routinely mistakes depression, anxiety or even normal adjustment for a unique and especially stubborn ailment.
I thought this study was particularly interesting, as it illustrates how a psychiatric diagnosis can quickly get cemented into self-identity. The end result is a rewriting of our personal narrative, so that it becomes even more traumatic:
A 1990s study at the New Haven, Conn., VA hospital asked 59 Gulf War veterans about their experiences a month after their return and again two years later. The researchers asked about 19 specific types of potentially traumatic events, such as witnessing deaths, losing friends and seeing people disfigured. Two years out, 70 percent of the veterans reported at least one traumatic event they had not mentioned a month after returning, and 24 percent reported at least three such events for the first time. And the veterans recounting the most “new memories” also reported the most PTSD symptoms.
To McNally, such results suggest that some veterans experiencing “late-onset” PTSD may be attributing symptoms of depression, anxiety or other subtle disorders to a memory that has been elaborated and given new significance or even unconsciously fabricated.
“This has nothing to do with gaming or working the system or consciously looking for sympathy,” McNally says. “We all do this: we cast our lives in terms of narratives that help us understand them. A vet who’s having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense.”
Needless to say, this is a very controversial, delicate subject. On the one hand, it’s essential that the stigma of PTSD is removed, so that soldiers and patients don’t deny a real, medical condition. And yet, it’s also crucial that PTSD doesn’t become a catch-all condition, which leads to the neglect of other mental illnesses, such as depression or anxiety disorders. Over at his blog, David features links to many of his sources. And see Vaughan for even more.