PTSD: A problematic diagnostic category

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Abstract

Since the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, posttraumatic stress disorder (PTSD) has become a remarkably dominant theme in mental health discourse and diagnostic practice. This development has been encouraged by the diagnosis being officially presumed to exist in acute, chronic, delayed, complex, subdromal, and even “masked” forms. Here, we present an historical and clinical review that indicates how, since 1980, the term PTSD (along with its dubious embellishments) replaced established views on mental responses to trauma to the detriment of patient care and psychiatric investigation. From this historical perspective, we review and evaluate the natural course of emotional and behavioral reactions to traumatic experiences, and as well their assessment, formulation, and therapeutic management in both civilian and military situations. From this we conclude that the concept of PTSD has moved the mental health field away from, rather than towards a better understanding of the natural psychological responses to trauma. A return to prior standards of diagnostic practice and therapeutic planning would greatly benefit patient care, rehabilitative services to veterans, and epidemiologic research.

Section snippets

What was known

Long before the term PTSD was coined, mental health professionals had seen how frightening events that threaten or produce bodily injuries can evoke a fairly stereotyped distressful psychological state in people. They identified this state as a natural psychological reaction, and in that way similar to the grief reactions produced by personal losses. Their opinions rested on the study of victims of violence and trauma – industrial, natural, political, and military – during the first three

Birth and development of PTSD

PTSD, as we know it today, was born in just such changing circumstances. As the 1960s brought unrest with authority and growing discontent over American military involvement in Vietnam, a group of psychiatrists and Vietnam War veterans combined to propose a new approach to the psychological consequences of exposure to warfare and other forms of trauma.

Most of the psychiatric advocates for the new approach had strong antiwar opinions, especially about this particular conflict. They saw, as

Conclusions

What do we conclude now at the end of this long experience in “Traumatology”? PTSD, as presently diagnosed, described, and treated, has failed to improve on what had been standard teaching. It has redefined and overextended the reach of a long-recognized natural human reaction of fear, anxiety, and conditioned emotional reactions to shocks and traumas. It has been a seedbed for outlandish ideas about mental life. Social and political reasons, more than medical and psychiatric ones, gave it

Acknowledgements

We thank our student Kareem Ghalib M.D. for his help in developing data from Medline on PTSD. We also are conscious of a deep debt of gratitude to Richard J. McNally and Simon Wessely who, on hearing of this manuscript in an earlier form, helped resuscitate it from oblivion and generously offered many important suggestions from their own work and that of others to improve and bring it up to date.

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