Resistance to the Diagnostic Construct of Posttraumatic Stress Disorder
Publication: American Journal of Psychiatry Residents' Journal
Today, the concept of psychological trauma is widely accepted. Posttraumatic stress disorder (PTSD) is one of the most empirically substantiated psychiatric disorders and one of the most widely discussed in popular culture. There is nonetheless significant debate within the psychiatric community concerning its validity. Since few quantitative tests are available to differentiate between and diagnose psychiatric conditions, psychiatry categorizes illnesses based on theory, clinical observations, and epidemiological findings, resulting in variable and potentially divisive diagnostic definitions.
Modern History of Traumatology
Until the latter half of the 1800s, "trauma" referred exclusively to physical injury. The concept of psychological trauma emerged in the 1860s. During the American Civil War, combatants suffered from "soldier's heart," involving unexplained chest symptoms (1). Soldiers in the 1870–1871 Franco-Prussian War experienced "traumatic neurosis," including chest pain, fatigue, dizziness, headache, fainting, and nightmares (2). War was considered a trigger for these symptoms in individuals with an inherited predisposition to neurosis.
Freud's early work suggested that childhood sexual abuse could produce "hysteria," characterized by unexplained neurological and behavioral symptoms. In response to societal pressures and his own shifting frameworks, Freud replaced this conclusion with the concept of repressed desires, creating false memories of sexual experiences (3). Hysteria was thereafter considered a result of innate vulnerabilities, with a limited role for instigating events; treatment involved drawing out the patient's repressed emotions and desires, sidestepping external events entirely.
With World War I came "shell shock," originally conceived as a neurological injury from combat (1). After it became clear that the syndrome was psychological, the term was revised to "war neurosis," and some British soldiers were subjected to punishment in accordance with the belief that their suffering was due to weakness of moral character and lack of patriotism (2–4).
In 1952, the Diagnostic and Statistical Manual of Mental Disorders-I (DSM-I) included "gross stress reaction," a time-limited response of normal individuals subjected to stressors including war and natural disasters. Although the terminology was updated, the DSM-II continued this understanding, classifying trauma reactions as a transient adjustment disorder with an emphasis on individual vulnerability rather than inciting events, and an expectation that the syndrome would quickly resolve (5).
In the 1970s, mental health professionals opposing the Vietnam War mobilized their experiences to demonstrate the negative effects of war on soldiers (3). Originally called "post-Vietnam syndrome," PTSD was included in the DSM-III in 1980. The feminist movement then used PTSD as a platform to draw attention to sexual violence, with some thinkers specifically disputing the Freudian position that childhood sexual trauma is a result of Oedipal fantasies rather than true experiences (3). This context brought forth the modern understanding of psychological trauma.
The definition of PTSD has shifted in each version of the DSM, moving from classification as an anxiety disorder to its own separate section. The "A criterion," or inciting traumatic event, has been altered, and symptom categorization has shifted. Current research is focused on biological correlates, specifically alterations to the hypothalamic-pituitary-adrenal axis, decreased hippocampal volume, and autonomic dysregulation (6).
Criticisms of PTSD as a Construct
Medicalization of Social Phenomena
One criticism of PTSD as a diagnosis posits that distress after trauma is expected, and that the term "disorder" medicalizes a normal response to stress, transforming an individual's natural reaction into an illness to be "cured" (7, 8). This reinterpretation of trauma from a life event occurring in a specific context to a medical event occurring only within the biology and psyche of an individual may prevent examination of the event's root causes in a broader social context.
For example, "mental illness" has been used as a catch-all explanation for violence. After mass shootings, American media frequently invoke mental illness as a cause of gun violence, although most individuals with serious mental illness are not violent and access to firearms is a much stronger predictive factor (9). This medicalizes and individualizes these events, recasting them from manifestations of larger social issues requiring collective attention into the deeds of a single individual who can be "fixed" with medical treatment.
Overlap
There is a significant overlap between PTSD and other psychiatric disorders. Many patients with major depressive disorder (MDD) experience symptoms associated with PTSD without any reported history of a traumatic event (10). Although the symptom profile of PTSD successfully separates patients with PTSD from individuals without a mental disorder, half of individuals with various anxiety disorders report symptoms sufficient for a diagnosis of PTSD, leading to the possibility of a high false-positive rate (11).
Neurologic studies also fail to differentiate between PTSD and other conditions. Hypocortisolemia and diminished hippocampal volume, often cited as signs of PTSD, are also present in MDD and anxiety disorders. The pharmacological benefits of selective serotonin reuptake inhibitors across all three categories also obscures any distinctions among them (8).
Overuse
Another criticism of the PTSD diagnosis is its potential for overuse. When a patient presents after a traumatic experience, PTSD may be instantly assumed, potentially leading to the dismissal of other explanations and treatments for the patient's symptoms. PTSD is not an inevitable response to trauma; although the vast majority of individuals experience at least one traumatic event, as defined by DSM-5, within their lifetime (89.7% of respondents to the National Stressful Events Survey, 2011), the prevalence of PTSD in the general population has been estimated to be less than 10% (12). This, combined with the high rates of comorbidity with other psychiatric disorders, suggests the risk of mislabeling, resulting in overdiagnosis at the expense of accurately identifying the true source of a patient's distress.
Difficulty in Definition
The definition of PTSD has fluctuated, with conflicts over the A criterion, the timing of symptom onset, whether symptoms must be thematically related to the inciting traumatic event, and the interactions with other psychiatric disorders in the same individual (13).
The A criterion especially has undergone repeated changes. What is trauma? Is the event itself the most important factor in generating posttraumatic symptoms? Social or community responses? Patient vulnerabilities? Perhaps a combination of these factors? This uncertainty is incompatible with expectations of absolute determination within the medical model and may lead to some patients being dismissed because their experiences were not deemed traumatic "enough" by clinicians operating on a narrow view of trauma.
Complex PTSD: A Modern Corollary
One recent development in traumatology is the emerging diagnosis of complex PTSD (C-PTSD). First described by Judith Herman in 1992 (3), C-PTSD is the result of prolonged interpersonal trauma. It is associated with childhood abuse or neglect, intimate partner violence, kidnapping and hostage situations, human trafficking, and more. These situations result in prolonged feelings of terror, worthlessness, and hopelessness and a deformation of one's identity and sense of self (14).
Although DSM has not adopted the diagnosis, it is included in ICD-11. It resembles but is distinct from PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder. Initial studies have shown that PTSD and C-PTSD are distinguishable, particularly based on symptoms involving altered sense of and disorganization of self, which are present in C-PTSD but not PTSD (15, 16). Furthermore, despite concerns that C-PTSD may be redundant with borderline personality disorder, the diagnoses can be differentiated even when comorbid (17, 18).
Supporters have posited that the introduction of C-PTSD could reduce diagnostic comorbidity, as C-PTSD encompasses symptoms leading to diagnoses of MDD, dysthymia, social phobia, or borderline personality disorder alongside PTSD (16). The organization of these individuals' experiences under C-PTSD could facilitate more integrated therapeutic approaches (19).
Although it remains to be seen how C-PTSD will be incorporated into widespread psychiatric practice, the diagnosis merits further consideration and could help to increase nuance in the psychiatric community's understanding of trauma.
Conclusions
The primary duty of a clinician is toward the patient, but practice sometimes outpaces understanding. Treatments and medications are prescribed because they appear to improve patients' daily functioning and health outcomes, even though we are not yet sure why or how they achieve these effects.
Whether or not PTSD uniquely "exists" when stripped of context is less meaningful than the fact that patients experience distress after traumatic events, and psychiatrists have tools to ameliorate this distress. Future work in the field of traumatology should focus on improving the diagnostic categories used to describe patients' symptoms and to develop effective treatments.
As the history of traumatology demonstrates, caution is warranted when incorporating new concepts into diagnostic paradigms. Our increasing yet limited understanding of the brain precludes the use of biological evidence as theoretical underpinning. However, the consideration of C-PTSD and other classifications may move the field toward a more nuanced view of trauma and expand appropriate frameworks from which mental health professionals can respond to achieve optimal clinical outcomes.
References
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American Journal of Psychiatry Residents' Journal
Pages: 5 - 7
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Published online: 6 December 2021
Published in print: December 6, 2021
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