What the PTSD Diagnosis Leaves Out

Broadening Our Understanding of Trauma

Mary Sykes Wylie

Back in the late 1970s, a motley crew of Vietnam War vets, sympathetic psychiatrists, antiwar activists, and church groups undertook a crusade to have a hastily-assembled new diagnosis almost completely innocent of scientific research included in the DSM-III.

Driven by a sense of mission and responsibility to the huge population of Vietnam vets and buoyed by the accumulating everyday clinical evidence that their war experience had profoundly disrupted the lives of thousands and thousands of young men, this unlikely coalition prevailed.

Once established as a distinct disorder in the official manual of psychiatric diagnoses, the otherwise unaccountable behavior of badass vets—their hair-trigger tempers, violence toward wives and girlfriends, drinking and drugging, difficulty getting and keeping jobs, social alienation—suddenly made sense. There was a reason for it and the reason had a name and that name was Post-Traumatic Stress Disorder (PTSD).

A PTSD diagnosis is quite straightforward. A person is exposed to a traumatic event or events “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” and followed, down the line, by variations on intrusive re-experiencing of the event, persistent and crippling avoidance, and increased arousal patterns.

Clear, brief, intuitively sensible, the definition of PTSD diagnosis implies a kind of satisfyingly simple, dramatic, and implicitly moral story line: Individuals are innocently minding their own business when—wham!—they’re slammed by a frightful, shattering, life-threatening happenstance, and are never the same again. The trauma may have “ended,” but not in the perpetually recycling memories and disrupted nervous systems of the victims.

Yet no sooner had the PTSD diagnosis been signed, sealed, and delivered, that many clinicians began to realize that the new diagnosis by no means encompassed the experience of all traumatized clients.

Soon after the publication of DSM-III, Boston psychiatrist and trauma expert Bessel van der Kolk recalls that a woman came to see him after she’d beaten up her boyfriend. “She said, ‘I have PTSD,” he says, “but after I’d spent some time with her, I told her, ‘No, actually you don’t have PTSD, you have something else. You cut yourself, you space out a lot and don’t remember things, you shift personality, you feel lots of shame and self-blame, you get extremely upset by very small things—that’s not PTSD.’”

Even though she did show signs that aligned with a PTSD diagnosis, her symptoms seemed to take off from there into unexplored territory—a psychological terrain very different from that of traumatized vets.

The patients van der Kolk was seeing, almost entirely women, had multiple, often severe, and apparently global problems affecting their sense of identity and self-perception, their relationships, their ability to moderate emotion, even their physical health. They also shared one other feature: They all reported histories of childhood incest.

In the popular ferment generated by the feminist movement of the ‘70s, women were beginning to tell stories previously never mentioned in public, revealing the appalling ordinariness of rape, wife-battering, child abuse, and incest. Therapists willing to take seriously what their female patients were telling them began learning about an unsuspected and nasty underside of American domestic life and the effects of child abuse.

These therapists soon discovered that the PTSD diagnosis was simply too narrow to encompass the extent and the messiness of what needed to be described. But then, neither did any other diagnosis.

“As long as we live in a world in which there are no definitions and no language for what’s wrong with people, we can’t do anything about it,” observed van der Kolk. “When a diagnosis ignores the reality of what people suffer from, we’re living in psychiatric la-la land.”

Topic: Trauma

Tags: child abuse | cut yourself | DSM | dsm-iii | post traumatic stress disorder | psychiatrist | PTSD | PTSD diagnosis | stress disorder | therapist | therapists | traumatic | traumatic stress | traumatic stress disorder | traumatized

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6 Comments

Friday, August 1, 2014 3:45:26 PM | posted by Catherine Dunn
As a practitioner who has worked with both WWII vets and Vietnam vets, the diagnosis of PTSD, has indeed, the majority of criteria required to meet the distinction of the diagnosis, in the presenting histories of these groups.
With respect to childhood incest and the differential diagnosis if FMS, in my experience, has been in some very real manner, un-related to the patient who presents with inscrutable memories that must not be irresponsibly misdiagnosed, or come under scrutiny of healthcare practitioners who have difficulty believing the patient. It is imperative that we begin treatment respectfully believing the presenting history of the patient, and to do the work with her/him, as a process to differentiate what is necessary for us to accept, and reach the confirmation, or disconfirm with the readiness of the patient to realize what is accurate, or what has been misunderstood. To disregard the patient's history without a respectful dialouge into the patient's perspective, leaves open the very harmful experience of the patient feeling too many reprehensible, harmful feelings that only serve to re-injure the individual sense of self actualization. This is an extremely complex issue, requiring the therapist to be willing to listen and explore the patient's beliefs. So many of the cases, are actually true rather than not.
Diagnosis of PTSD, in all cases of incest or childhood physical or sexual abuse requires the therapist to be an expert diagnostician. This comes with both professional knowledge and experience.

Saturday, June 7, 2014 12:02:05 AM | posted by daisy swadesh
(author of above comment--daisys)

Friday, June 6, 2014 11:59:05 PM | posted by daisys
1. Thank you, MSW, for your as always pithy, bulls-eye comments. The difference is trauma in adulthood vs trauma during the developmental years.
2. Abram Kardiner seems to have laid the groundwork for PTSD 40 years before in his 1941 book--the Traumatic Neuroses of War--in which he spoke of a "physio-neurosis" (Bvd Kolk cites Kardiner's groundbreaking work in Traumatic Stress).
3. Would you briefly revisit the Oedipus complex and put it, at last, to rest?
In 1958 I was dealing with the incest in my family when I heard of it. I DIDN'T get molested the night when I was 12 because my response was extreme fear to my father's invitation to my sister and me. And eventually I could ask--"how can pre-pubescent children accurately "fantasize" adult sexual behavior unless they have experienced it?" I also realized it was a perfect cover-up for a molester/pedophile if the fantasy and the desire was the child's.
3. A recent re-reading of the O.c. brings out that the gods were punishing O's father because he violated a trust and raped the son of a king he was mentoring. In contrast, Oedipus fled from his adoptive parents when he heard of the prophecy he would kill his father and rape his mother. (How could that outrageous misinterpretation have survived for so many decades? And why is NAMBLA still insisting sex is normal for children--who aren't socially, emotionally or physiologically ready for sex?)

Thursday, May 15, 2014 7:05:21 PM | posted by Serena Patterson
I keep up on all the PTSD research, especially that of Vander Kolk and Brier. But I also keep going back to Judith Butler's classic book on Truama, from the late 1980's. She defined trauma as that which robs us of the (often unconcious) assumptions upon which we have built our lives. Assumptions like, "if I do right by people, they will do right by me," and "My country is good." In this view, a keystone of understanding trauma is understanding the impact of disillusionment. This is really important to my work with Vets--probably more so because I'm a civilian and therefore see the Vets who don't want to talk to the military psychologist.

So, for me, the DSM definition misses this: the Disillusionment factor.

There is also a second problem with the DSM definition, which Butler also identified. It doesn't take into account the impact--often identical in presentation to "classic" PTSD--of highly stressful circumstances that are inescapable and unjust. This would include being a child in an abusive home, being a spouse in an emotionally abusive marriage, being a kid who is subjected to daily humiliation and torment in school, being exposed on a daily basis to racism, homophobia and/or the steady stream of humiliations that our society doles out to the very poor, the very fat, the very different-looking. In other words, we need a terminology for the psychiatric impact of Oppression. I believe it was Butler who proposed "Oppression Artifact Disorder".

Thursday, May 15, 2014 5:21:45 PM | posted by Serena Patterson
False Memories have not been validated as a distinct "Syndrome", although they may occur on their own, they are very distressing, and they may be symptomatic of somthing else. or is rape in the family a diagnosis on its own; having experienced a traumatic event does not automatically mean one has a psychiatric disorder. So PTSD vs. FMS when child abuse is alledged is not clear thinking; the process of unravelling a complex truth that may be buried in layers of smokescreen begins!

Thursday, May 15, 2014 4:05:11 PM | posted by judithr2
Two comments!
1) Just after WWII and when DSM and DSM 2 didn't yet have the Diagnosis of PTSD, we did diagnose Holocaust Syndrome.
2) When finding rape and other abuse within the family, one must consider False Memory Syndrome in the differential diagnosis.