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Friday, 02 January 2009 09:40

The Limits of Talk - Page 4

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A Diagnosis Non Grata

While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.

Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-I ) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968--the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSM-III (see sidebar page 37).

So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions--probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress"--this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."

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