Archives for : PTSD

Is it time to drop the diagnosis of PTSD?

Is it time to drop the diagnosis of PTSD?

CAUTION!  The material in this post was rejected by the “Proceedings of the Listening to Trauma Conference: Insights & Actions.” The reason: “Its tone is too contentious for a collection with positive studies of the physiological underpinnings for trauma and meaningful emerging clinical treatments.”  Proceed at your own risk.

In many respects post traumatic stress disorder (PTSD) has been an extraordinarily fruitful diagnosis.  It connected the politics of the Vietnam War with the suffering of hundreds of thousands of veterans (Alford, pp 9-13).  As the authors of The Empire of Trauma, Didier Fassin and Richard Rechtman, put it, trauma today is not a clinical but a moral judgment. Its advantage is that it has given us “this unprecedented ability to talk about—and hence experience—the violence of the world.” (p 276)  In addition, trauma has given us a new perspective on contemporary history, up close and from the ground up.  History written from the perspective of trauma is history written from the perspective of the victims.

Reliability versus validity

And yet I think PTSD has come to an intellectual dead-end for all the reasons discussed in this blog over the last two years.  

Continue Reading >>

Share

Are PTSD and C-PTSD dissociative disorders? Does it matter?

art-1699977_1920Are PTSD and C-PTSD dissociative disorders?  Yes, but it’s more important to remember that they are first of all about terror.

It appears that PTSD and C-PTSD may be grouped under the dissociative disorders in the next edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders).  As Matthew Friedman points out, the new DSM-5 category of trauma and stress related disorders was intentionally placed next to the dissociative disorders in order to suggest their similarity (p. 549).  Whether this is a good direction to be heading is another question. 

A quick definition: dissociation is the division of parts of the self.  Dissociation occurs when the parts of the self that know and feel traumatic experience no longer communicate with the rest of the self.  Dissociation is generally seen on a continuum, more or less.   

What’s dissociative about PTSD and C-PTSD?  

I’ll get to C-PTSD (complex PTSD) in a minute. 

It’s easy enough to interpret the leading symptoms of PTSD in terms of dissociation.  The flashback is a dissociative symptom, a failure to prevent intrusion of unwanted and painful experience.

PTSD criteria read like a short laundry list of dissociative isolative and exclusionary processes (intrusion, numbing, and avoidance). (Chefetz, p. 28)

The dissociation associated with PTSD is characterized by an alteration between hyperarousal and numbing or constriction.  The dialectic of trauma moves between intrusion and numbing.   

Judith Herman (pp. 47-49) and others have argued that the experience of trauma generally moves from early hyperarousal to later numbing and constriction.  Others, such as Richard Chefetz see no progression, just the dominance of one position or another. 

Some people with PTSD present with flooding, and others are so emotionally shutdown that they present as emotionally flat, detached, with active dissociative process.  (p. 80)

Continue Reading >>

Share

It’s time to stop letting the stressor define PTSD

cry-1675277_1920

It’s time to stop letting the stressor define PTSD.  Not doing so makes the new categories of C-PTSD and DESNOS largely irrelevant.

I’ve been posting on this blog for about eighteen months now, a total of fifty-two posts.  Though I’ve written a couple of books on trauma (my latest is Trauma, Culture, and PTSD),  I still feel like a newcomer to the field.  In this post I want to talk about what still puzzles me about trauma theory.  The experience of writing this blog has led to more questions than answers.

I’ve been able to reconstruct to my own satisfaction the origins of PTSD in the Vietnam War  The new diagnostic category served political ends, pointing out what war does to the people who fight it.  The introduction of the disorder called PTSD was progressive politics.  It was also a humane diagnosis, helping to explain to those who suffered from it what was happening to them, giving both soldiers and their families a vocabulary for their pain. 

PTSD in DSM-5

At almost the same time as DSM-5 was being released, the National Institutes of Mental Health was refusing to fund any more research based on the DSM.

National Institute of Mental Health (NIMH) announcement
By Thomas Insel on April 29, 2013

Patients with mental disorders deserve better. . . . That is why NIMH will be re-orienting its research away from DSM categories . . . . The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

If the DSM were the model for physical medicine, then a heart attack would be defined as “chest pain disorder,” a symptom without a cause.

Henceforth, the NIMH research goal is to fill in the “Draft Research Domain Criteria Matrix,” which links 5 basic natural formations, such as “systems for social processes,” including attachment and fear, with eight columns of units of analysis, such as genes, molecules, and cells.

The goal is to move from mind to brain, so that there will no longer be any need to talk about mind at all. It’s all about electricity and meat, as Gary Greenberg puts it.  And electricity and meat can be measured.  Not, however, in the language of human suffering. 

American psychiatry and psychology have been cut off from the official world of science, but not from VA funding (over 100 million dollars since 2012 for PTSD).   This has consequences.  One, I believe, is the failure of more trauma specialists to object to the VA’s endorsement of cognitive behavioral therapy (CBT), including exposure therapy, as the treatment of choice, the only “evidence based treatments.”

These treatments are short-term, can be learned from a manual, and administered by lesser trained persons.  CBT is quick and cheap compared to long term therapy by well trained persons.  But consider CBT’s difference not only from traditional talk therapy, but also from the rap groups that sprang up in the Vietnam War era, in which veterans could exchange experiences.  CBT discourages “cross talk,” as people talking with each other is called (Tasman et al., p. 1928).  The potential of PTSD to help sufferers explain to each other the varieties of torment and relief has been lost. 

This does not mean we should abandon the diagnosis of PTSD.  Indeed, when this is proposed it is often sufferers who object most strenuously, for the diagnosis has helped many people make sense of their disrupted lives.  It does mean that we should rethink the category. 

Continue Reading >>

Share

Epigenetic transmission of trauma: gene or meme?

mice-800875_1920There’s lots of talk these days about the transgenerational transmission of trauma (TTT).  Some of it focuses on epigenetic changes in the chemical environment of the genes that make people more or less susceptible to trauma.  I find this topic incredibly complicated and difficult to understand.  I’ll try to explain it the best I can, but the reader should be clear that as far as PTSD is concerned, the epigenetic transmission of trauma is still up in the air, a hypothesis with no established empirical (scientific) basis.  As two of the leading researchers put it in the Journal of Traumatic Stress,

There have been no empirical demonstrations of epigenetic modifications per se in association with PTSD or PTSD risk. (Yehuda and Bierer, p. 430)

This reality has done little to dampen speculation, including that of Yehuda and Bierer, as we shall see.  I’m not sure if this is bad or good.  Mostly I think it’s irrelevant.

Continue Reading >>

Share

Trauma as Attachment

aurora-1197753_640My main idea in this post: one reason the symptoms of trauma persist is because people become attached to their traumas. Symptoms serve as a locus of attachment in a world in which each and every attachment can vanish in a moment. It’s kind of like a small child clinging to an abusive parent.

Tom, a Vietnam veteran, went to see Bessel van der Kolk about his PTSD. Among his most disturbing symptoms were nightmares. Van der Kolk prescribed a drug that had been shown to be effective in reducing the incidence and severity of nightmares. Returning two weeks later, Tom said the medicine didn’t work because he wasn’t taking it. Why?

I realized that if I take the pills and the nightmares go away . . . I will have abandoned my friends, and their deaths will have been in vain. I need to be a living memorial to my friends who died in Vietnam. (p. 10)

Van der Kolk writes that Tom’s answer led him to realize he would probably be spending the rest of his life trying to learn the answers to the mysteries of trauma. I’m not sure van der Kolk learned the right lesson.

For van der Kolk, trauma is a disorder in the brain that is expressed in and through the body. Thus, the title of his recent book, The Body Keeps the Score. However, if we take Tom’s answer seriously, it seems as if it is the meaning of the story that is important. It is the meaning of Tom’s trauma that keeps him locked in the past.

Trauma is attachment to our traumas

If we think about Tom’s trauma in this way, then his nightmares and other traumatic symptoms keep him attached to the only place that really counts in his life. The past is the most meaningful place he knows, as it is for many traumatized soldiers who fail to distinguish their attachment to their buddies from attachment to their trauma. If this were so, it would help to explain why traumatized people get stuck in the past. Considering the alternatives, it’s where they most want to be, or at least where they most need to be.

Continue Reading >>

Share

What I learned about PTSD from the University of Google

childineyeThe Urban Dictionary says that the “University of Google” refers to a major ignoramus who pretends to be an intellectual. Well, I decided to attend the University of Google for a few days to see what I could learn about PTSD. It’s pretty depressing. So-called reputable sites were the worst. There are a couple of interesting exceptions.

I looked at every site listed on the first three pages of my Google search “PTSD.” This was over the days February 18-22, 2016. The top sites changed every day (sometimes every hour), but not by much, and I included sites that paid to be listed first. Since I’ve done a lot of trauma searches with Google on my computer, my rankings were not quite the same as on my wife’s computer, my i-pad, and my school computer, which I rarely use. Google customizes (that is, markets) its information. Nevertheless, the overlap was considerable.

After a while, the sites started to sound the same. There were a couple of exceptions.

Wiki disappoints

Wikipedia’s entry on PTSD was disappointing. “Psychotherapy is the ‘gold standard’ of treatment for PTSD.” A promising start, but under psychotherapy Wiki includes prolonged exposure therapy (PE), cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR). I expected more from Wiki; I’m not sure why.

Rats, mice, ecstasy, and dogs

A surprising number of sites reported on research with mice and rats, and several report the results of delivering electric shocks to people. In one, people with PTSD show heightened brain activity in areas thought to be associated with stress when shown pictures of frightened face when shocked and not shocked (that is, no difference), while people without PTSD show more anxiety when shocked. The significance of this is left unclear.

The same site, The Brain and Behavior Research Foundation, summarizes a study which shows that MDMA — also known as the rave drug Ecstasy — can treat symptoms of post-traumatic stress disorder in mice. At: https://bbrfoundation.org/ptsd?gclid=CIrI-YnshssCFclkhgodKkIKew. Don’t try this at home.

Continue Reading >>

Share

What if Bessel van der Kolk is right about trauma?

B0000757Bessel van der Kolk (vdK) is probably the world’s most well known trauma theorist. I reviewed his recent book, The Body Keeps the Score, in an earlier post. Since then I’ve read more of his work and listened to him speak for hours (he is all over youtube). The best way I’ve figured out to think seriously about his work is to ask what difference it would make if he were right.

What he says

Asked about how he treats the victims of acute trauma, vdK says

Holding them, rocking them, giving them massages, calming their bodies down is a critical issue. I am probably the minority among my colleagues in that I am much more focused on bodily state than on articulating what’s going on. I think that words are not really the core issue here. It is the state of being, of tenseness, of arousal, and of numbing, and that people need to learn again to be safely in their bodies. (http://www.medscape.com/viewarticle/408691)

Think about this for a minute. One might expect a trauma therapist to say something like “I try to create a safe environment in which my patients can put words to unspeakable experiences. I try to help them remember an experience so they don’t have to constantly relive it.” This makes sense, for trauma is a disorder of time, in which the past is never past but is constantly intruding upon the present.

VdK would have no difficulty with the last sentence, and yet his treatment program (or rather programs) has little to do with the past, and everything to do with the present. Trauma is when the past colonizes the present. Its treatment depends on reappropriating the present, and one does that not through understanding the past, but coming to live in the present, and the best way to do this is to bring the body into the present.

Behind vdK’s approach is his view that PTSD and related traumatic disorders, particularly developmental trauma (childhood abuse and neglect), are disorders of the limbic system, one of the oldest parts of the brain, the one we share with all mammals. In the limbic system, threat is experienced as sensation, and the impulse to fight or flee. Threat turns into trauma when we can neither fight nor flee, when we are trapped, and the stress is turned against the self. Trauma is embedded in the body-mind, a single entity.

Continue Reading >>

Share

The Trauma of Rape Can Be Told

B0000782I just finished reading Lucky, by Alice Sebold. It’s an account of her rape when she was a 19 year old freshman at Syracuse University. The book has really caused me to rethink trauma theory, for there is nothing theoretical about Lucky. She describes her rape in horrifying detail. Even more troubling, at least in some respects, is the response of those around her.

I was now on the other side of something they could not understand. I didn’t understand it myself. (p. 27)

This isn’t a review of the book, which was published in 1999. It has been often reviewed. It even has its own Wikipedia entry. Sebold subsequently published The Lovely Bones, which was made into a movie. She is a good writer.

This post is about my embarrassment at writing about trauma theory after reading Sebold’s book. Not that there is anything wrong with trauma theory, but there is something so real about Sebold’s account that it makes the theory of trauma seem an overly intellectual exercise. At least for me, at least for a little while.

Nevertheless, it’s not so simple, for trauma theory helped Sebold, who says that she learned that a short passage from her book had been published in Judith Herman’s classic work, Trauma and Recovery. Sebold said she decided not just to keep Herman’s book as a memento, but to actually read it. It may not have changed her life, Sebold did that for herself, but it helped her make sense of her experience.

Continue Reading >>

Share

The Book of Woe, and why NIMH said goodbye to DSM-5

IMG_1078This book review and comment are a little off my beat, for they are about DSM-5 in general, not just its diagnosis of trauma, which I addressed in my post of January 20, 2015, http://www.traumatheory.com/?p=86.

The full title of Gary Greenberg’s book is The Book of Woe: The DSM and the Unmaking of Psychiatry. Greenberg is a psychologist and journalist. Some of the juiciest pieces of this book appeared in The New Yorker between 2010 and 2013 (Google Greenberg + DSM + New Yorker; they are all there).

The book begins with a story about Sandy, one of Greenberg’s patients. When Greenberg first saw him Sandy could barely go out of his house. By the end of therapy Sandy had a job, a girlfriend, and what most of us would call a life. Sandy and Greenberg exchanged emails after Sandy moved half way across the country from Connecticut. Eventually the emails stopped. A couple of years later Greenberg received a call from Sandy in the middle of the night. It ran something like this.

You’ve got to help me. They’ve sucked all the bones out of my body. I’m here in this hotel room and my bones are gone. My mother and my father and James. They’ve done this to me. And I don’t want to die. Please don’t let them kill me. You’re the only one who can help. Good-bye. Good-bye. (p. 9)

Greenberg tried to call Sandy back at the hotel he had called from, but there was no answer. He never heard from Sandy again.

The book turns on what to make of Sandy’s phone call.

Continue Reading >>

Share

Whatever happened to DESNOS?

IMG_0319_edited-2DESNOS stands for Disorders of Extreme Stress Not Otherwise Specified, about as clumsy a diagnosis as one could imagine, and an only slightly better acronym. It owes its existence to the persistence of Judith Herman, who in her classic Trauma and Recovery, argued for a special category of trauma she called complex PTSD (C-PTSD). C-PTSD = DESNOS for all practical purposes.

It has long been recognized that there are different types of trauma, but no one has figured out what to do about it as far as PTSD is concerned. Rape, a serious car accident, most wartime trauma takes place during a specified period of time, and often results in the familiar symptoms of PTSD, such as flashbacks, nightmares, sleeplessness, hypervigilance, and a gradual retreat into a smaller world in which the victim is less likely to encounter situations reminding him or her of the original trauma.

But, some trauma doesn’t fit this pattern, generally because it is prolonged, frequently happens at an early age, and often involves people with whom the victim has an intimate relationship. Child abuse is exemplary, but prolonged captivity and confinement of any type also fits the pattern. This includes emotional and physical abuse in marriage or other relationships.

The about to be released International Classification of Diseases, ICD-11, which serves as the DSM for the rest of the world, includes C-PTSD, but only if the victim first fulfills all the requirements of a diagnosis for PTSD. DSM-5 includes most of the symptoms of C-PTSD, achieved in part by enlarging the number of symptoms to twenty. In addition, it includes a dissociative subtype and a pre-school subtype. As with the ICD-11, the basic requirements of PTSD must first be met. DSM-5 does not officially recognize C-PTSD, but one professional’s comment on PTSD in DSM-5 gets it right, remarking that it has become more “DESNOS-ish.”

Here’s the problem

Continue Reading >>

Share

Bessel van der Kolk’s House of Trauma Has Many Mansions. Review of The Body Keeps the Score (2014)

 

IMG_0646,straitFor a man who was a leading defender of repressed memory syndrome in the early 1990’s, providing expert testimony in a number of high profile cases, Bessel van der Kolk has done remarkably well for himself. No matter that he seems to have lost his lab and his Harvard medical school affiliation as a result (New York Times). Some of the qualities that led him off the deep end of the repressed memory bandwagon have led him to write what an important, but flawed, book on trauma, The Body Keeps the Score (2014).

Van der Kolk (vdK) holds that the real problem with trauma is not in the past. The problem is that trauma keeps the sufferer from feeling alive in the present, and so able to enjoy everyday life. All the desensitization in the world isn’t going to do any good if a person can’t enjoy the everyday pleasures of life. The way to approach trauma is to work from body to mind. If you are traumatized, and talking isn’t helping, and you are picking the scabs on your body as a means of self-stimulation and soothing, go see a massage therapist. And while you do that we will continue to talk (pp. 88-89). This isn’t all he has to say, but it is at the core.

Continue Reading >>

Share

What’s going on with the new PTSD diagnosis in DSM 5?

There seems to be movement, but not much change, in the diagnosis of PTSD in DSM 5. PTSD is no longer a fear or anxiety disorder, but has its own category. In part, this seems to be the result of the popularity of PTSD. The APA justifies this stand-alone category partly in terms of the presence of PTSD “at the center of public as well as professional discussion.” (www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf)

In reality, PTSD was created as a result of popular pressure, and it was expanded for the same reason. That is not necessarily a bad thing.
Intriguing is the movement of PTSD toward the category of a dissociative disorder.

The move has not yet been completed, but as Matthew Friedman points out, locating trauma and stress related disorders next to dissociative disorders in the “DSM metastructure” is no accident. The thinking of many seems to be that in the future they will be more closely related. This may be an attempt to come to terms with Chronic-PTSD, or DESNOS (disorders of extreme stress not otherwise specified), championed by Judith Herman, Bessel van Kolk, and others. As Friedman (2013, p. 524) puts it, “I recall overhearing a comment after my . . . presentation in 2011 on DSM-5, that the PTSD criteria were becoming more “DESNOS-ish.”

I’m going to assume that readers are familiar with the major changes in the diagnostic criteria for PTSD in DSM 5, and write more generally about the problem of thinking about trauma in terms of diagnostic criteria. Many diseases have similar symptoms, such as fever, swollen lymph nodes, low blood count, etc., but very different causes. It would be far better, and not just for PTSD, for the DSM to devote less time and attention to parsing symptoms, and instead looking for causes. But apparently the science is not up to the task. In effect, ever since the introduction of PTSD in DSM III in 1980, PTSD has been defined by the traumatic event that precedes it.

Continue Reading >>

Share

Review of Crazy Like Us. With comments on its relationship to Herman’s Trauma and Recovery, and Empire of Trauma.

Crazy Like Us isn’t a recent book, and it is certainly not an academic one. But maybe that’s good, for Watters makes statements about the state of the global PTSD industry that an academic might hesitate to make, at least in plain English.

Crazy Like Us isn’t just about exporting PTSD. It’s about exporting anorexia nervosa to Hong Kong, and a medicalized diagnosis of depression to Japan. But the chapter on the tsunami that brought PTSD to Sri Lanka is the one I’m interested in here.

Watters isn’t anti-psychiatry (his wife is a psychiatrist), and he isn’t against the diagnosis of PTSD per se. His point is that psychiatric categories are cultural categories, and particularly responsive to social change. As the medical anthropologist Allan Young put it, a diagnosis of PTSD “can be real in a particular place and time, and yet not be true for all places and times.” (101-102).

His most important insight is that PTSD is a diagnosis that fits a modern Western world, in which people see themselves as autonomous individuals first, and members of groups and social networks second. In a so-called traditional culture, the diagnosis just doesn’t make sense. So much the worse for us, Watters seems to be saying, but perhaps it’s not so simple.

Continue Reading >>

Share