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.  

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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)

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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. 

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Testimony creates the trauma it discovers

zen-178992_1920Testimony can create the trauma it discovers.

Trauma theory and testimony grew up together, beginning in about 1980.  By this I mean that trauma theory and Holocaust testimony emerged as socially and historically significant at about the same time.  It’s worthwhile thinking about their relationship.  If we take the limits of testimony seriously, then much of current trauma theory, especially Cathy Caruth’s account of the “missing moment,” is mistaken. 

It is, of course, not literally true that trauma theory emerged in 1980.  Freud built much of psychoanalysis on his reinterpretation of his patients’ trauma almost a hundred years earlier.  Shell shock, as PTSD was then known, emerged with the First World War.  What happened beginning in the early 1980’s was the inclusion of PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) for the first time.  The introduction of PTSD coincided with the “narrative turn” in the humanities and social sciences.  At about the same time, the Fortunoff Archive for Holocaust Testimony was established at Yale University. 

I have come to believe that Holocaust testimony leads to a misunderstanding of trauma, especially if one does not understand testimony’s limits.  I have published three books on trauma that draw on Holocaust testimonies in the Fortunoff Archive.  I think I understand the limits of testimony better now.  My instructor, so to speak, is Henry Greenspan, author of On Listening to Holocaust Survivors.  I also draw on some more recent papers of his.  In place of testimony, Greenspan has engaged in extended conversations with survivors.  Some of these conversations have lasted decades.  Out of these conversations comes a different way of thinking about testimony and trauma. 

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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.

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Moral injury in civilian life: a new category of trauma

DSC00286To live in the United States today is to be constantly exposed to moral injury. Moral injury is not, however, equally distributed. Some people are vastly more injured than others, and some are not injured at all. Some people inflict moral injury on others. Lots of people are morally injured, and it is not always obvious.

One might argue that such a grand category, applying to so many, must result in pathologizing a normal experience. Moral injury may be normal, but it’s not good. The lives of the morally injured manifest in chronic sadness and despair, overlaying a rage that occasionally becomes dramatic.

From military trauma to everyday moral injury

Moral injury has become something of a hot topic among those who write about the trauma experienced by soldiers at war. So far, I can find nothing written about moral injury that applies to the experiences of civilians in everyday life. Yet, there is no reason it shouldn’t, particularly if it is interpreted properly.  Moral injury is the result of the use of  political power to deny the experiences of others. There is no more pernicious political power than this.

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Cognitive behavioral therapy is a terrible way to treat trauma. And it’s government approved.

IMG_0525_editedblack-1_edited-1The Department of Veterans Affairs may today deliver the worst trauma treatment known to man or woman.

The diagnosis of PTSD is an outgrowth of the protests over the Vietnam War. Distraught and disillusioned Vietnam veterans, together with psychiatrists such as Robert Jay Lifton and Chaim Shatan, developed the “rap groups” that provided psychological support in a community of other vets who had undergone similar experiences. Rap groups worked because they provided a place to share common experiences, including terror and remorse. Rap groups provided community and social support.

The effectiveness of rap groups eventually convinced the American Psychiatric Association to include Post Traumatic Stress Disorder in the third edition of its Diagnostic and Statistical Manual, though this is a long and convoluted story (see http://www.traumatheory.com/whats-going-on-with-dsm-5/ for more details). For some time, rap groups were employed by the VA, often with reluctance, for their members were not always easily managed (Sonnenberg, Blank, Talbott).

No more. David Morris’ recent account of his experience with cognitive behavioral therapy at the San Diego VA tells of a sign on the wall of a waiting room for a small group of vets who were about to enter therapy (p. 195).

PLEASE REFRAIN FROM TELLING WAR STORIES. YOUR STORY COULD BE A “TRIGGER” FOR SOMEONE ELSE.

If the traumatized cannot talk with each other, but only through a therapist, even in a group, then therapy is no longer about creating a community of support for those who suffer. It’s about isolating those who suffer from each other, so they can be processed individually, their trauma chopped into bits.

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What is trauma? How does therapy cure?

Trauma is knowledge of the unbearably real. Trauma is a breaking of faith with all that one held sacred. Trauma is too much too soon. Trauma is “knowledge as disaster,” as Maurice Blanchot put it. The survivor of an environmental disaster captures the meaning of unbearable knowledge when she says

While it could be argued that it’s not a bad thing to become more knowledgeable, it is, I think, certainly a bad thing to become knowledgeable in the way that we’ve become knowledgeable. It’s like a person who’s an agoraphobic. If you’re terrified to go out of the house, you don’t live a very good life. (Erikson 1995, 197)

If trauma is knowledge, then what exactly is it knowledge of? That everyday life is a conspiracy to make the world seem safe enough to live in. Trauma is the result of an experience that makes it impossible for the traumatized to use social conventions the way most of us do in order to relieve anxiety, even dread. An example of such as convention is the statement “just you wait, everything is going to turn out ok.” Well, sometimes it doesn’t. Robinson Crusoe put the lie this way.

How infinitely good . . . providence is, which has provided in its government of mankind such narrow bounds to his sight and knowledge of things; and though he walks in the midst of so many thousand dangers, the sight of which, if discovered to him, would distract his mind and sink his spirits, he is kept serene and calm, by having the events of things hid from his eyes, and knowing nothing of the dangers which surround him. (Defoe, p. 163)

 

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What I learned about trauma from Holocaust survivors: not to idealize integration

Between 2007 and 2014, I viewed over 250 Holocaust testimonies at the Fortunoff Video Archive for Holocaust Testimony at Yale University (Alford, 2009, 2013). Many date from the late 1970’s, and were given before Holocaust testimony became its own genre, with its own norms. Many were talking about their experiences for the first time. Many had not spoken about their lives in the ghettos and concentration camps even with their families. It wasn’t until at least a decade later that talking about the Holocaust became widely accepted, even within the Jewish community.

One of the founders of the Archive was a psychoanalyst and child survivor, Dori Laub. He established an unstructured interviewing format that is still followed. Survivors would frequently talk for a half-hour without interruption. Most interviews lasted about two hours. A number lasted four. There was no time limit. In all this they are quite different from the interviews undertaken for Steven Spielberg’s Shoah Foundation (sfi.usc.edu).

What I learned

Extreme trauma lasts forever. People don’t get over it. They learn to live with it, alongside of it. Those who testified were, for the most part, “successful survivors.” They married or remarried (a number lost their entire families to the Holocaust), built businesses, raised families, had children and grandchildren. They survived surviving by living alongside their trauma, beside their Auschwitz self as one called it.

There are no constants among survivor testimonies, no universal themes. The two that come closest, are “no one can understand who wasn’t there,” and “even today I live a double existence.” Kraft (p. 2) argues that doubling is the near universal theme.

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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.

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