Have the Lunatics Taken Over the Asylum? Part 2
The second part of my DSM5 article for The 21st Floor.
Part 2: Post-Traumatic Stress… Disorder?
Everyone knows about Post-Traumatic Stress Disorder. Surprisingly for something so widely-known, it’s only been around in the psychiatric manuals since 1980. In a major difference from many other psychiatric disorders, we know precisely its cause – ‘an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ (as the DSM-IV states). The symptoms include recurrent memories or dreams of the event, the feeling that the event is happening again and again, and ‘intense psychological distress’. The question, however, is this: how valid is PTSD as a distinct disorder, aside from anxiety, depression, phobias, and other problems we already know about?
There are several reasons, detailed in this article by Gerald Rosen and colleagues in the British Journal of Psychiatry a couple of years ago, we might think the answer is ‘not so valid’. Unfortunately, it’s all much more complicated than a simple ‘bad event happens, get distressed, get PTSD’ timeline. People who encounter events which, though distressing, are far from the ‘actual or threatened death (etc)’ DSM criteria often experience symptoms of PTSD, and people who have phobias do, too. Does this mean PTSD could just be an umbrella term for other specific disorders we should perhaps pay more attention to? Rosen et al. give the following hypothetical example:
…a boat captain whose fishing vessel is lost at sea, resulting in the death of several crew. Though not physically injured, the captain starts feeling ‘on edge,’ suffers from insomnia and begins to withdraw from usual activities. Most alien to the fisherman’s self-concept, he becomes anxious when considering a return to his usual occupation.Consequently, he turns down offers to work on other vessels, and he becomes isolated from the fishing industry. Without income, this man becomes increasingly anxious and depressed.
Before the invention of PTSD, psychiatrists and psychologists would have said the fisherman had a normal grief reaction to the death of his friends and a phobia of boats caused by the incident, followed by a depressive episode. Giving all these separate problems one name (PTSD) doesn’t seem to do enough justice to the complexity of the fisherman’s problems.
Rosen and colleagues note that the psychology/psychiatry literature on PTSD has gone a little overboard (with apologies to our poor fisherman on the use of that word) recently. Papers abound on such far-fetched topics as children developing PTSD after watching TV, and people getting some form of Pre-Traumatic Stress Disorder after overhearing a rude comment in the workplace. Surely, say Rosen et al., these things are not all the same, distinct disorder, and we’d be better off looking at each instance separately.
Sadly, the DSM5 draft reveals that the criteria for PTSD have changed, but not really in the right direction. The list of events which may cause the disorder has expanded to include sexual abuse, and now it’s accepted that you can get PTSD by hearing that a traumatic event has happened to a friend, or seeing things that remind you of the event (like when people get abuse-flashbacks in movies from finding their old teddy bear). Fair enough, but is this really addressing the issue, known in the jargon as ‘co-morbidity’, of one disorder sharing loads of features with several other disorders, to the point where the lines between them become terribly blurred?
I would suggest not. The idea of PTSD is an attractive one – in a world of hideously distressing and baffling mental disorders which usually appear without rhyme or reason, it’s nice to have one with a concrete cause that one can trace back to one particular event. However, sweeping a pile of varied symptoms under the PTSD rug may simply confound diagnoses, and we mustn’t forget that we should be taking the time to research the kinds of factors (genetic, social, or otherwise) which may predispose people to certain forms of reaction to adverse events.
Coming up in Part 3! We conclude with Coercive Paraphilic Disorder and the medicalisation of rape. Fun for the whole family.
TO BE CONTINUED…
Rosen GM, Spitzer RL, & McHugh PR (2008). Problems with the post-traumatic stress disorder diagnosis and its future in DSM V. The British journal of psychiatry : the journal of mental science, 192 (1), 3-4 PMID: 18174499