My good friend Willa Goodfellow (Prozac Monologues) has written an extremely thought-provoking
blog piece on PTSD. She summarizes a 2004 article by neuropsychiatrist Nancy Andreasen of the University of Iowa. How we view the condition can be largely attributed to Dr Andreasen.
The phenomenon has been around since the beginning of time, but our understanding remains limited. During World War I, soldiers who experienced "shell shock" were shot as cowards. In World War II, soldiers who suffered "battle fatigue" were given "therapy" to return them to combat in one week. (The therapy, such as exposure to recorded artillery fire sounds, typically exacerbated their distress.) General Patton infamously slapped a bed-ridden soldier.
The postwar DSM-I of 1952 recognized "gross stress disorder," but this was removed from the DSM-II of 1968. The post-Vietnam War era set the scene for its comeback in the DSM-III of 1980. Dr Andreasen was charged with the task of looking into "post-Vietnam syndrome." As Willa describes it:
Given her experience with burn victims, Andreasen pressed for a more inclusive description of the illness. Post Traumatic Stress Disorder entered the new edition, described as a stress reaction to a catastrophic stressor that is outside the range of usual human experience.
Unlike all other mental illnesses, the first criterion for a PTSD diagnosis is an event rather than a symptom. Another way of putting this is that the DSM mandates a valid reason for an individual's response. The DSM-IV of 1994 and this year's draft DSM-5 (due out in 2013) simply play around with the scope of the valid reason. The 1994 version widened the criterion to include events not necessarily outside the range of human experience (such as surviving an auto accident) while the DSM-5 would narrow it again.
Compare this to depression. Psychiatry does not require a valid reason for us to rate a diagnosis. To the contrary, a valid reason - such as bereavement - would rule out a diagnosis (unless the depression were to persist). In this context, depression would be a normal response to an abnormal situation. We are supposed to feel depressed when we lose someone close to us.
We often get clinically depressed for seemingly no reason at all. Since there is no logic to the depression, the thinking goes, we must be thinking and behaving irrationally. And if this significantly interferes with our daily life, we are presumed to have a mental illness. We elicit sympathy or opprobrium, as the case may be.
The same applies across the anxiety spectrum (with the notable exception of PTSD). We don't need a valid reason - such as an intruder entering through the window - to justify a panic attack. Being frightened of your own shadow will do just fine.
So, I'm wondering. What happens to the poor individual who suffers severe trauma for a stupid reason? Not from combat. Not from being exposed to an act of God or an unspeakable outrage. Something stupid, really stupid. Such as perhaps a close encounter with a circus clown. The trauma may be irrational, but then again so is all the rest of mental illness.
Is that person's distress any less?
Suppose two people rupture their ACL. Does the person who ruptured his ACL while playing basketball get treated while the other individual who ruptured hers playing with her dog get sent home? Isn't it the condition - rather than the precipitating event - we're supposed to be treating?
There are no easy answers here. But the questions, the questions ...
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