Introduction
The course of psychotraumatology probably changed forever in 1980 when the term “posttraumatic stress disorder” (PTSD) was first coined in DSM III. The diagnosis arose out of the difficulties being experienced by Vietnam veterans on their return to the United States. The diagnostic criteria have been refined in DSM III R and DSM IV. The biggest change has taken place with regard to Criterion A while criteria B, C and D have remained largely unchanged, albeit with some relatively minor modifications. There are, in my opinion as a clinician in civilian practice, several problems associated with the diagnosis of PTSD and it is, perhaps, time for a radical review of the concept.
Diagnostic Criteria
Criterion A changed from referring to an event that would affect almost anyone through an event outside the range of normal human experience to a situation where one of the important features is now the individual’s perception of the event rather than how most people would view the event. This clearly is a very fundamental change from the concepts, which initially led to the formulation of the condition. Criterion A incidents can now include the most catastrophic of events, serious physical illness, childbirth, dog bites and more minor events such as rear-end shunts if the individual, perhaps because of pre-existing vulnerabilities, perceives himself/herself to be at risk. Clinically, there is an enormous difference between the presentation of the war veteran, or of an individual who has experienced a very major trauma, and the individual subjected to a much more minor trauma even though each may present with similar symptomatology and functional disability. Clearly, the treatment process will be very different. While the same could be said of other psychiatric conditions, e.g., depression, those conditions are based on symptomatology and do not require a cause to be identified for the condition.
As has been previously described in the literature, there is a difference in the temporal development, clinical significance and, perhaps, underlying mechanisms of the criterion C symptoms, the emotional numbing symptoms suggesting more serious pathology. Diagnostic approaches concentrate on the presence or absence of the Criterion C symptoms while reporting of therapeutic studies tends to describe whether the symptoms have been successfully treated or not without commenting upon this difference.
Neurosis Divisible/Co-Morbidity
It is clear that posttraumatic stress disorder is not a homogeneous condition in the same way as schizophrenia or depression are not single entities. However, most research seems to assume that all individuals with PTSD, although dissimilar in many characteristics, should be grouped together. Although progress has undoubtedly been made, this perhaps helps explain why, to date, attempts at finding biochemical and anatomical markers for PTSD have had only limited success. The same reasoning also may be applied to the modest size of treatment effects in therapeutic trials, both psychotherapeutic and pharmacotherapeutic. With regard to the latter, some consideration does appear to have been given to more detailed analysis which has shown, for example, that those who have been victim of single rather than multiple trauma do better and that females tend to respond better to SSRIs.
PTSD without a cormorbid condition is the exception rather than the rule. Most treatment trials, while not outruling comorbidity, tend to insist that the post traumatic stress disorder must be the primary diagnosis with the comorbid condition secondary. In everyday clinical practice, such an artificial distinction is often very difficult to make and of little or no clinical value. In my opinion, the comorbidity of these conditions reflects the continuum of neurotic illness as noted above. The understandable attempts to categorize PTSD and other neurotic conditions are not particularly helpful clinically.
PTSD is not the only psychological illness which occurs following trauma. Indeed, it is probably not the most common. However, if one were to look at the literature, one would not think this to be the case. In the Journal of Traumatic Stress over the past number of years, the great majority of papers refer to posttraumatic stress disorder. Relatively few refer to posttraumatic depression. Yet, in my clinical experience, individuals who develop depression post trauma, with or without comorbid PTSD, are more seriously ill and tend to have a worse prognosis than those who are not depressed.
Many individuals who are traumatized also suffer loss. Such loss can include bereavement, loss of physical health, loss of functioning or material loss. Clearly, in such circumstances, there will be considerable overlap between PTSD and traumatic grief (presuming both conditions are present). The tendency to focus upon the PTSD may mean that the traumatic grief is not given the attention it requires and, on many occasions, it may well be the more significant condition.
All psychiatric illness has a multifactorial etiology. This is now being increasingly recognized with regard to posttraumatic stress disorder whereas previously little consideration was given to preexisting vulnerability factors. Unlike other psychiatric conditions, however, post traumatic stress disorder, by including criterion A, tends to ignore this reality. Clinically, it seems nonsensical to separate out the actual trauma that occurs within an abusive relationship from the many other, sometimes subtle, effects of living within such an abusive relationship.
Sociocultural Issues
Another limitation of our classifications systems is surely a cultural one. As Derek Summerfield has argued eloquently, the biopsychosocial approach adopted by the Western world does not translate to developing countries. In many such countries, political, cultural, spiritual and economic matters are of much greater importance than Western views of health and illness, and it behooves us all to recognize this. Indeed, due to the increasing multicultural nature of Western society, such issues are very significant to many of our patients.
Nancy Andreasen once wrote that PTSD is the one psychiatric illness that people don’t mind admitting to having. There is certainly some truth in this, perhaps glib, remark. Posttraumatic stress disorder used to be described as a normal reaction to an abnormal event, an event that would affect almost anyone. This normalizing phenomenon, an attempt to distinguish PTSD from other psychiatric conditions, has the effect of increasing the stigma associated with other psychiatric illness, the stamp of approval to this being given by mental health professionals.
The term “posttraumatic stress disorder” clearly implies that the individual is in a posttrauma phase. What if the trauma is ongoing, e.g., in parts of Northern Ireland, particularly in the recent past during our 30 years of conflict? What if the basic social supports, family and community, are destroyed? Surely then the “trauma” is ongoing even if the life threat is no longer present? If one considers the terrorist attacks in New York on September 11, 2001, when does the post trauma phase commence? Is it immediately? Is it when the fires are put out? Is it when the rubble is cleared away? Or is it when Americans no longer feel under threat? It may be that Summerfield’s arguments that the biopsychosocial approach is insufficient will have greater resonance with those in the Western world now.
Most of the concepts surrounding posttraumatic stress disorder have arisen from work with the Vietnam veterans. It looks increasingly as if much of this cannot be extrapolated to civilian populations and this difficulty clearly needs to be addressed by appropriate research in such populations.
The Way Forward?
PTSD, as a clinical and research concept, has been the main vehicle for the very considerable advances that have taken place in the field of psychotraumatology in the past 20 or so years. However, there are many limitations associated with the diagnosis as it currently stands. We must be more open in acknowledging these limitations. The diagnostic criteria as currently used seem, in my opinion, to be much more research oriented than clinically oriented. For practicing clinicians, changes need to be made.
There certainly is an argument to be made for disposing altogether with Criterion A and considering “the group of PTSDs” in the same way as one considers depression and schizophrenia, groups of illnesses defined phenomenologically. However, I think this would lose the uniqueness associated with the diagnosis, which has been very valuable. An alternative approach might be to coalesce the different approaches to Criterion A that have been used in the classification systems during the past 20 years. So, for example, Criterion A could be divided into a) a traumatic event outside the usual range of human experience which would have an impact upon almost anyone, b) a minor event which would only traumatize those who are vulnerable for whatever reason with perhaps an intermediate category in between.
As has been done with depressive disorder in ICD 10, the condition could be further classified from the clinical point of view regarding degree of severity, with functionality being given even greater importance than the mere presence or absence of particular symptoms. This could be an overall impression taking into account comorbidity, preexisting vulnerability factors and other perpetuating factors. This would be of much greater value clinically and also with regard to future research, which should be more clinically based. Another issue to consider is whether Criterion C should be subdivided into avoidance and emotional numbing subsections.
In conclusion, the field of psychotraumatology would almost certainly not have expanded as richly during the past 20 years had posttraumatic stress disorder not been formulated. However, there are very real limitations to the condition as it is currently diagnosed. These are particularly evident clinically. More clinically based diagnoses and research should now be considered.
References
Andreasen, N.C., Posttraumatic stress disorder: psychology, biology and the manichae in warfare between false dichotomies. American Journal of Psychiatry, 152, 7, 963-965, 1995.
Andrews, G., Slade, T., Peters, L., Classification in Psychiatry: ICD 10 versus DSM-IV. British Journal of Psychiatry, 174, 3-5, 1999.
Foa, E.B., Riggs, D.S., Gershuny, B.S. Arousal, numbing and intrusion: symptom structure of PTSD following assault. American Journal of Psychiatry, 152, 1, 116-120, 1995.
Summerfield, D.A. The Impact of War and Atrocity on Civilian Populations. Psychological Trauma, a Developmental Approach, Gaskell, London, 1997, 148-155.
Tyrer, P. Neurosis Divisible? The Lancet, 1985, 685-688.
Oscar Daly is a consultant in General and Community Psychiatry in Lisburn, Northern Ireland.