It’s time to stop letting the stressor define PTSD

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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. 

Why has it been so hard to include these three disorders under the category of PTSD:

  • Developmental Trauma Disorder (DTD)
  • Complex PTSD (C-PTSD)
  • Disorders of Extreme Stress Not Otherwise Specified (DESNOS)?

You might respond that they are already there.  DSM-5 implicitly recognizes C-PTSD with its new subtype of dissociative PTSD.  Similarly, DSM-5 implicitly recognizes DTD with its new subtype of pre-school PTSD.  One professional has concluded that PTSD in DSM-5 has become more “DESNOS-ish.”  Perhaps the key piece of evidence for this is that PTSD is no longer considered an anxiety disorder, but a trauma and stress related disorder, in which experiences of dissociation are often present.  But there is a problem in the way these subtypes are included in PTSD.

The problem is shared by the International Classification of Diseases (ICD-11), which serves as the DSM for the rest of the world.  ICD-11 will include C-PTSD.  Like DSM-5 with its dissociative and pre-school subtypes of PTSD, ICD-11 makes the presence of PTSD a gateway requirement for C-PTSD. The DSM-5 puts it this way.

The dissociative subtype is applicable to individuals who meet the criteria for PTSD and experience additional  depersonalization and derealization symptoms.

About carving up the world with our categories, Plato reminds us that we must be careful to cut where the joints are (Phaedrus, 265e).  What reason is there to require that all the criteria for PTSD be met before someone can be diagnosed with C-PTSD?  Certainly C-PTSD is related to PTSD, but the relationship is one of similarity, not subtype. 

People with C-PTSD are generally pretty similar to people with borderline personality disorder.  Rather than recognizing the squishiness of the category of PTSD, Judith Herman  holds that most C-PTSD is being misdiagnosed as borderline personality disorder, defining C-PTSD in terms of “a history of subjection to totalitarian control over a prolonged period.” (p. 121)  Herman has taken a category that expands our understanding of PTSD and contracted it to a single cause. 

The stressor as gateway

Originally the definition of PTSD in terms of the stressor (criterion A) was emancipatory, linking the suffering of soldiers to their service in Vietnam.  Today the retention of the stressor as a “gateway” requirement only renders PTSD and its subtypes less subtle.  In the case of  CBT the result is to focus trauma treatment on singular events, the stressor.  Or rather, CBT only makes sense if the stressor is defined narrowly, an event, not a way of life.  Is the treatment driving the concept of trauma itself? 

Wouldn’t it make more sense to focus on treating the symptoms, not worrying about where they come from except as this is part of the sufferer’s story, which is likely to be more complex than any diagnosis?  Talking with a therapist, talking with fellow sufferers, body therapy, such as massage or yoga, drugs when necessary, community, and love—this is how PTSD is best treated, and it is from its treatment we can define trauma as seems best.  Originally PTSD made trauma and the pain it inflicts political and public. Today it should not be allowed to render our understanding of trauma one-dimensional.

Why does the stressor remain so central?

One reason is because the very concept of post-traumatic stress disorder seems to require it.  But, in almost every life there are enough stressful events to qualify.  Trouble is, if we go down this route then anyone can qualify for a diagnosis of PTSD.  The result is that PTSD would have as much to do with the vulnerability of the person to trauma as it would the trauma itself. 

I think that’s fine, but it conflicts with two agendas.  One is represented by

academic and clinical psychologists who are still concerned about defining and defending the border between the traumatic and the non-traumatic; in fact, negotiating and maintaining that border is one of the raisons d’être of the discipline. (p. 215)

In support of this claim, Kansteiner cites Richard McNally (2003), who is so worried about “bracket creep” that he would limit PTSD to events such as the Bataan Death March, his favorite example (p. 280).

For a somewhat different reason, Judith Herman insists on the dose-response curve: the severity of your PTSD depends almost entirely on how long and to what kind of trauma you were exposed.  “Individual personality characteristics count for little in the face of overwhelming events.” (p. 57) 

McNally doesn’t want people who are vulnerable to trauma to receive the diagnosis, for then the symptoms of PTSD can afflict anybody, and the diagnosis loses its validity.  Herman insists on the dose-response curve because she wants PTSD to be an indictment of society, not a marker of individual vulnerability.

I don’t care.  It’s not the job of a diagnosis to say whether a person suffered enough to deserve it.  And it’s not the job of a diagnosis to serve as social criticism, though it may.  PTSD provides a language through which people can talk about their suffering.  There may be better languages, but PTSD is the lingua franca of millions of sufferers, and there is no reason to abandon it.  In any case, the available alternative is not the language of literature and poetry, but the language of the brain, which is even further removed from experience. 

References 

Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry.  Penguin, 2013.

Judith Herman, Trauma and Recovery.  Basic Books, 1997.

Wulf Kansteiner, “Genealogy of a Category Mistake: A Critical Intellectual History of the Cultural Trauma Metaphor.” Rethinking History, vol. 8, no. 2 (2004), pp. 193-221.

Richard McNally, Remembering Trauma.  Harvard University Press, 2005

Allan Tasman et al.  Psychiatry, 4th edition, 2 volumes.  Wiley, 2015. 

 

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Comments (7)

  1. “Is the treatment driving the concept of trauma itself?”

    Yes, yes it is — and for a reason, that of the ongoing dehumanization and objectification of human beings in our technocratic world.

    • calford@umd.edu

      Yes, Emma. I agree that the objectification of humans is the great driver of this process. What can be measured and fixed in a limited period of time with limited resources tends to become part of the diagnosis itself. The odd thing is that some very smart people get caught up in this.

      I think that certain types of training, such as psychoanalysis (broadly defined), can serve as a barrier to this process. But of course there is a reason psychoanalysis is not thriving. Still, I’m glad it’s around. Fred

  2. Your writings on trauma are among most sensitive and thoughtful I have seen, Fred.

    May I ask where your interest in the subject comes from?

    • calford@umd.edu

      Dear Emma, I suppose my interest in trauma comes from personal experience with what is often called C-PTSD.

      But, intellectually (always an easier area to write and talk about), it comes from the work I’ve done on psychoanalytic social theory. If you look at my vita (there’s a link on the about me page of this blog), you’ll see I’ve written a dozen or so book applying psychoanalysis to social theory.

      I think when I got to trauma I realized that here is one dramatic place where the psychological and the social meet. Though I don’t always agree with her, Judith Herman was an inspiration on this point.

      Regards, and thanks for asking. Fred

  3. John

    Yes! Why has it been so difficult for psychiatry and psychology to include all trauma related iterations into a single category of trauma and stress related disorders? Within the realm of illness, psychological trauma is much more complex than most all other cause-and-effect phenomena. Extreme stress effects may be shared and similar among: the little boy who sees his father battering his mother; the Marine who served honorably in combat, becomes textbook symptomatic, is temporarily assigned as a recruiter, doesn’t make his monthly quota and is court-martialed as a malingerer by a commander who has only recruited and has never seen fellow Marines die; the young female Sailor who proudly stands at parade rest on the deck as the ship leaves harbor and parents watch proudly from shore only to be medically evacuated weeks later to her home of record due to being sexually assaulted by the senior leader that told this Sailor’s family that he would look after her; the African-American Soldier who fought honorably and was purposely exposed to mustard gas experiments during World War 2, was told never to disclosed the details for purposes of national security, and was then brutalized by other Americans during the civil rights era and beyond; the Jewish-American Soldier who due to deeply held religious and moral beliefs was ambivalent about killing during World War 2, helped liberate the concentration camps, and has tremendous guilt about surviving and about initially questioning killing the Nazis. The stressor does not always equal the stress disorder.

    The DSM too has never been good on cause, has been inconsistent on effect, and has been silent on cure. The current DSM 5 limits cause to direct exposure, witnessing, learning about life-threatening, or non-fatal but violent events (traumata), or repeated exposure to less severe versions of traumata. Its forebear, the DSM IV, limited cause to direct experience, witness of, or confronted with actual or threatened death or serious injury or threat to physical integrity of self or others and, as result, fear, helplessness or horror was experienced. I am not sure about the causal route listed in the DSM III, but that version was the first diagnostic mention of PTSD and so is also likely to describe cause that is quite different than later versions of the manual.

    The Research Domain Criteria Matrix (RDoC), the Brain Research through Advancing Neuro-technologies (BRAIN) Initiative, and even the DSM 5 (insofar as a professional association’s diagnostic manual also serves as national policy) all of have been insufficient, thus far, at moving towards a comprehensive conceptualization that is subjectively satisfying to the qualitative experience of trauma survivors and that is objectively helpful to mental health professionals. Although patterns of convergence are appearing between administrators focusing exploration guidelines of trauma-related disorders, researchers investigating within those guidelines, and front-line clinicians tracking and the subjective experience of the traumatized and the objective understanding of that experience, we are only slightly better off than we were in 1980.

    Neuroscientists understand that dysregulation of the hypothalamic–pituitary–adrenal axis and adrenergic dysfunction occurs after sexual trauma, can persist for years after the trauma, and may partly explain why survivors with a sexual trauma history have a greater burden of physical illness. Psychodynamic practitioners understand insecure attachment, affect dysregulation, ego depletion, failures at mastery-competence, turning against the self may also result in physical illness. Even cognitive-behavioral theorists and therapists are noticing the limits of therapies like Prolonged Exposure and Cognitive Processing Therapy, and are admitting the critical mechanisms for action of these interventions must involve empathy (to limit treatment drop-out, to foster a sense of safety, and to help the client’s attachment organization form more securely). More integrators of these phenomena, like Allan Schore, are needed.

    Likewise, more advocacy work within consumer-survivor movements is needed. Vietnam vets creation of Vet Centers and the diagnosis of PTSD, domestic violence survivors successful passage of VAWA, Gay activist passage of the Ryan White CARE Act, African-American passage of civil rights legislation and of the BLM movement all have validating and empowering effects. As Shay states, the “communalization of trauma” is a necessary part of the healing. And communalization must involve symbolic expression of the trauma (artistically, politically or both) and unconditional acceptance of the traumatized subjective experience. In some ways, a diagnosis can work at cross-purpose to communalization as it both gives voice to survivors and then limits this voice with categories of “this, not that”.

    • calford@umd.edu

      Dear John, your comprehensive reply leaves me with little to add. I think we agree that the problem is not so much in deciding what’s in and what’s out regarding trauma. If it’s traumatic, it’s trauma. I’m most intrigued by your last remark that the communalization of trauma is necessary.

      I suppose different rituals are appropriate for different traumas (war time trauma vs. developmental trauma, for example), but I think we are so bereft of rituals, it is the traumatized and their advocates who will have to create the time and space for them, as well as the rituals themselves. As you remind me, in Achilles in Vietnam, Shay does an interesting job on how this was done in Athens and today in the military. Ancient Athens seems to have done it better. I haven’t read his more recent book. I think I should.

      Once again, thanks for the thoughtful reply. Fred

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