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Arieh Shalev, chair of psychiatry at Hadassah Medical School in Jerusalem, has seen his share of day-to-day trauma. When he visited us this past June, he noted what a remarkable year this has been for all of us involved in treating traumatized individuals. Unlike most citizens who are forced to stand by helplessly in the aftermath of terrorism, many of us had an opportunity to apply the skills we have accumulated during our professional lives and participate actively in recovery efforts after the September 11 attacks. This also has given us a fresh opportunity to test our most cherished assumptions. In my mind, one of these is the relevance of our diagnostic construct: PTSD, on which we have hitched so much of our professional identity.

Clinical and research teams at the Trauma Center in Boston have been deeply involved in intervention projects surrounding the attacks on the World Trade Center, and we are once again struck by the degree to which trauma reaches the total organism of those who are most affected-the irritability, the insomnia, the loss of concentration, the inability to experience pleasure, the multiple physical complaints.

It is as if the totality of the organism has been reconfigured. PTSD as a diagnosis was constructed around the idea that people are haunted by the memory of a specific event. However, in the people we follow, their memories are not what plagues them the most. Their core seems to be gone-they no longer can trust themselves and feel at home in their bodies; their relationship with their surroundings have become profoundly disturbed.

I understand these clinical phenomena as clinical correlates of the neurobiological abnormalities that have been found in PTSD-for example, increased activation of the amygdala, changes in brain stem sympathetic and parasympathetic activation, decreased thalamic functioning, decreased activity of the anterior cingulate and dorsolateral prefrontal cortex, abnormal arousal modulation, and so forth. These basic deficits in self-regulation are in line with what we found in the DSM IV Field Trial: For most treatment-seeking people, it was not intrusive recollections, but outbursts of anger, irritability, depression, self-destructive behavior, and feelings of shame and alienation that distinguished them from non-treatment seeking community controls with PTSD.

In contrast to a grant rejection I received in 1982, in which the opening line read: "It has never been shown that PTSD is relevant to the mission of the Veterans Administration," the relevance of PTSD as a diagnosis has become unquestioned over the past 20 years. For example, my colleague Robert Macy looked at the records of 384,000 Medicaid recipients in Massachusetts and found that PTSD and depression are diagnosed nearly equally.

However, patients who meet the criteria for PTSD spend 10 times as much time in the hospital than patients with the diagnosis of depression alone. Almost all of these PTSD patients seem to have histories of multiple traumas and severe disturbances in their early caregiving relationships. Relatively few patients seen in clinical practice seek help after having suffered a one-time traumatic incident, such as one rape, a terrorist attack, or a single motor vehicle accident.

Currently, the long-term psychiatric sequelae of chronic, multiple traumas are classified under the same rubric (PTSD) as those of a one-time incident. Whatever does not fit within the narrow confines of the PTSD construct is relegated to apparently unrelated "comorbid conditions."

As a result, we have no good way of describing how consistently convoluted the psychiatric presentations of chronically traumatized patients are, and how complex their treatment is. Clearly, the maturity of the central nervous system at the time of the trauma, the relationship of victim to perpetrator, culture and many other factors all have an enormous impact on the clinical manifestation of the disorder. One size does not fit all. An attempt was made to address this dilemma by introducing the diagnostic entity of Disorders of Extreme Stress (DESNOS) into the DSM IV, but, for now, this has been placed obscurely in the Associated Features of PTSD in the DSM.

Over the past two decades, a great deal has been learned about the treatment of acute trauma, but the most severely traumatized individuals are excluded from our studies because of their multiple comorbidities. One extreme example is patients diagnosed with dissociative identity disorder (DID). Between 1997 and 1998, about 1,200 patients officially carried that diagnosis in Massachusetts (almost invariably associated with severe and prolonged interpersonal childhood trauma or multiple medical procedures); most of them also met diagnostic criteria for PTSD.

In Massachusetts, patients with DID have the highest utilization rate of any psychiatric diagnosis. Yet, to my knowledge, there currently is not a single funded research program in the United States studying the phenomenology and treatment of this common, costly and extremely disabling disorder.

The majority of traumatized treatment seeking individuals have histories of exposure to interpersonal violence, usually by intimates, often starting early in the life cycle. Our field has yet to begin to systematically address the interface between the effects of particular traumas and those of disrupted attachment systems.

A vast body of research has shown that early disruptions of attachment interfere with children's ability to modulate physiological arousal, negotiate satisfactory interpersonal relationships and distinguish between relevant and irrelevant information. Clearly, while the study of war neuroses, motor vehicle accidents, terrorist attacks and hurricanes has shed much light on how the human organism responds to trauma and can be helped to recover, investigating that darkest side of human nature-our capacity to horribly abuse and neglect our own offspring and intimates-continues to be clouded with controversy and denial.

Because so little systematic research has been done on patients with these histories, the question of how best to approach their legacy of trauma remains a wide-open question that urgently needs our attention.