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.
We may feel less regretful about this when we understand that the psychiatrists who wrote the DSM III, which started it all, understood that they were not saying anything about the world. They were trying to find a reliable way to communicate among themselves. Psychiatrists know that certain symptoms tend to cluster together, and psychiatrists could reliably identify these patients. But, even (or especially) Robert Spitzer, chair of the American Psychiatric Association task force that drew up the DSM III, acknowledged that the book did not solve the validity problem. It wasn’t supposed to. The APA originally hired him, says Spitzer, to
achieve only the smallest of bureaucratic goals—to bring the DSM into harmony with the World Health Organization’s International Classification of Diseases, known as the ICD. (Greenberg, p. 41)
The validity problem is the problem of whether the DSM is characterizing any real entity in the world. Reliability, getting a bunch of psychiatrists to agree that certain symptoms tend to accompany each other in ways that can be called disorders, is much simpler. Even so, the reliability of most DSM-5 diagnoses is modest between .40 and .60, expressed as a Cohen’s kappa coefficient, a statistic that measures inter-rater agreement. eliminating the possibility that this agreement might be by chance. (Greenberg, pp. 225-228).
Understanding that the DSM never claimed to be making a claim about the real world, unlike physical medicine, which can point to a causal connection between coronary artery disease and heart attack (events in the physical world), may make it easier to let DSM go. The DSM equivalent to heart attack would be chest pain disorder, a comparison the National Institute of Mental Health was not hesitant to emphasize in withdrawing funding from research based on DSM categories.
Some might respond that recent discoveries in neuroscience have transformed the study of PTSD into a proper scientific field, much like any other branch of medical research. I believe that this claim is much exaggerated, a point also discussed in several blog posts.
PTSD serves a political purpose now; that’s fine
Nevertheless, if Fassin and Rechtman are correct then it is in many ways irrelevant that PTSD has come to an intellectual dead-end. PTSD continues to serve a political purpose. Several times it has been proposed to do away with the diagnosis. Interestingly, it is those suffering from what is called PTSD who are often its staunchest defenders, believing that it gives their suffering a dignity and an objective reality. It is also useful for coding and billing purposes, as well as reimbursement from the VA.
So keep the diagnosis, but recognize that one is no longer operating in the scientific realm.
Actually, the term “scientific realm” is bothersome. It’s a useful way of saying that PTSD is a political diagnosis (including the politics of professional associations, like the American Psychiatric Association versus NIMH), but PTSD is really about the varieties of human suffering. In saying that it no longer belongs in the “scientific realm,” I would not want to be interpreted as endorsing the NIMH approach to trauma, which as Greenberg (2013, p. 344) puts it is about electricity and meat, both of which can be measured. Something can be non-scientific and profoundly real. PTSD creates the trauma it discovers, but it does not create trauma.
How to treat suffering
Provide opportunities for people to talk about their suffering with others. Groups of others, therapists, whatever. Try to love or at least care about the people who are suffering. This requires a caring environment, not an assembly line providing drugs or “evidence based therapies.” Provide shelter or asylum when necessary.
Recognize that human suffering is a vast largely underground network. We usually don’t see it unless it’s dramatic, but it affects so many, including the suffering of trauma. Millions suffer trauma in the US alone.
Trauma is real, and the suffering it inflicts is terrible. To my way of thinking PTSD is no longer a useful way to think about it, but if it remains politically useful or even legitimating, then it has its place. We should just not imagine that we are somehow how closing in on the entity called trauma. Our categories are more confused and muddled than ever before.
Perhaps the best thing to do is remember that people’s psychological symptoms generally have meaning, and that talking about our suffering is often the best thing we can do. Talking is the way people elucidate the meaning of their symptoms to themselves and others. Suffering comes in many guises, and there is no need to label every one. “Tell me what ails you, and let’s see if we can’t make some sense out of it together. And if your suffering gets too bad, certain drugs might help, at least for a little while.” Is this an impossibly naïve way to begin?
References
C. Fred Alford, Trauma, Culture, and PTSD. New York: Palgrave Macmillan, 2016
Didier Fassin and Richard Rechtman, The Empire of Trauma: An Inquiry into the Condition of Victimhood, trans. Rachel Gomme. Princeton University Press, 2009.
Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry. New York: Penguin, 2013.
As is not surprising, I completely agree with you, Fred. Love what you say at the end. We either widen our appreciation of human experience or we don’t. And to whatever extent. But that means in its variety, complexity, subtlety, and change. There is very little in current “trauma theory” and the use of the PTSD diagnosis that does that. And there is all too much that does the opposite.
Dear Hank, I particularly appreciate your comment knowing about your groundbreaking work listening to Holocaust survivors. I’m glad you found the conclusion of my post useful. I was afraid I was getting too soppy. But, I guess there’s a time and a place for soppy if it means talking about human suffering in human terms. Fred
Hello Prof. Alford,
What would you say to Gabor Mate’s observation that trauma actually changes brain chemistry and structure? I am referring to his ‘In the Real of Hungry Ghosts’.
James, thanks for your comment. What I would say is that everything changes brain chemistry, including my writing this note. Brain chemistry is how we think and feel. About brain structure, I imagine that trauma changes brain structure, as does depression, anxiety, and lots of other things.
If we knew more about brain chemistry and structure, there might be more effective treatments of trauma. This would actually make the diagnosis of PTSD even less relevant, for evidence of external trauma would no longer be diagnostic for the disease.
Your responses always catch me off-guard by their simplicity. Which shouldn’t be surprising at all. If you ever get a chance to do so, would you be willing to share how you ended up in the practice of psychotherapy while remaining a professor of political theory? My life-long dream had been, and probably still is, to be someone like that. There’s something very liberating about listening to people and sharing their lives with them. I think this is part of Axel Honneth’s theory of recognition. Don’t you think?
Dear James, I’m not a psychotherapist, though I am authorized by the A. K Rice Institute to lead small and large group sessions. Doing this has given me some insight into trauma in groups.
I would say my main experience with trauma is having suffered C-PTSD for most of my life. Thankfully I have found therapists to help. It took me a long time to figure out how to work my personal experience into political theory, but that is what I do. Thanks for asking, and yes, I think Axel Honneth’s focus on mutual recognition is fruitful. Winnicott is quite important to his work, which has surprised and pleased me. Fred
Thank you so much, Fred, for sharing this! I think it’s amazing that you are such an accomplished scholar despite C-PTSD, though something tells me it’s more likely that your keen grasp of the human condition is because of your experience with trauma, not IN SPITE OF it. The wounded healer comes to mind immediately.
I was not aware that Winnicott was central to Honneth’s work, though I have read his close reference to psychoanalysis, especially the Object Relations school. I don’t know if you recall that you recommended Axel Honneth during my dissertation proposal defense. In my subsequent research, I have delved into the work of Sandra Harding, Nancy Hartsock, and recently discovered bell hooks. hooks stands out starkly in my mind because of her description of “mutual recognition” in her seminal work ‘Teaching to Transgress: Education as the Practice of Freedom’.
Hartsock, in turn, writes:
“The construction of the self in opposition to another who threatens one’s very being reverberates throughout the construction of both class society and the masculinist world view and results in a deep going and hierarchical dualism. First, the male experience is characterized by the duality of concrete versus abstract. Material reality as experienced by the boy in the family provides no model and is unimportant in the attainment of masculinity. Nothing of value to the boy occurs with the family, and masculinity becomes an abstract ideal to be achieved over the opposition of daily life. Masculinity must be attained by means of opposition to the concrete world of daily life, by escaping from contact with the female world of the household into the masculine world of public life. This experience of two worlds, one valuable, if abstract and deeply unattainable, the other useless and demeaning, if concrete and necessary, lies at the heart of a series of dualisms—abstract/concrete, mind/body, culture/nature, ideal/real, stasis/change. And these dualisms are overlaid by gender: only the first of each pair is associated with the male.”
And Harding:
“…Men in the ruling classes and races reserve for themselves the right to perform only certain kinds of human activity, assigning the balance to women and men in other subjugated groups. What they assign to others they rationalize as merely natural activity—whether this be manual labor, emotional labor, or reproduction and child care—in contrast to what they regard as the distinctively cultural activity that they reserve for themselves. Of course, their ‘ruling’ activities (in our society, management and administration) could not occur unless others were assigned to perform the social labors they disdain.”
Forgive me for rambling too far afield but I have made reference to these authors to try and tie in my hunch that your pedagogic skills owe their origin to your ability to tap into your “true self” a la Winnicott. And forgive me for being presumptuous enough to attempt such an analysis.
James
Corrigendum: the title of Mate’s book is ‘In the Realm of Hungry Ghosts’, not ‘In the Real…’