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PTSD: Yesterday, Today and Tomorrow

Jan 03

This is the last piece in a three part series designed to provide information in an area that is replete with myth and misconception. Certain mental health professionals including humanistic, feminist, and other progressive therapists have had a discomfort with the Diagnostic and Statistical Manual of Mental Disorders (DSM), and its categories, since its inception. The only diagnostic category that seemed to have some value was posttraumatic stress disorder (PTSD). This result came about from PTSD’s origins, its focus on a mental injury, its practical value, and the fact that progressive practitioners were stretching its boundaries to include more and more different types of victims. The diagnosis was unlike most others in the DSM as it became accepted due to laypersons rather than psychiatrists requesting it. It is well documented by several authors, that following the Vietnam War, returning American veterans petitioned the American Psychiatric Association (APA, creators of the DSM) to include a category that would capture the chronic psychological damage seen post-combat, and address necessary counselling services. The term used at the time was “catastrophic stress disorder” (CSD). The most important part of CSD was the precipitating event. The APA balked at including causation as no other categories in the DSM did so. A compromise was reached, PTSD was created, and included in DSM-III (1980). The new category required exposure to a stressor that would cause distress in almost anyone; and included a time-frame and a list of “symptoms”. In 1987 the DSM-III-R was published with the requirement that, “the person experienced an event that is outside the range of usual human experience and would be markedly distressing to almost everyone”.

As veterans issues slipped from prominence and other practitioners took centre stage more changes were to occur. The community of feminist therapists viewed the category as appropriate for victims of childhood sexual abuse, battered women, and others traumatized in a patriarchal society. These therapists, like those who had represented mentally injured soldiers, were keen on having their clients experience the benefits of the diagnosis (e.g. litigation, insurance policies, pensions). The feminist therapists approached the APA to alter the definition of PTSD so that more of their clientele would be included under the umbrella. In 2000 the DSM-IV-TR was altered and this version does not require that the traumatizing event be outside the range of usual experience; thus, including the victims of battery, childhood sexual abuse and other forms of traumatisation. Today, in addition to feminist therapists, transgenerational practitioners and a variety of other progressive clinicians continue to press for wider inclusion (e.g. insidious stress).

On the surface this may look like progress. Currently, many accept that everyday violence against women, harassment and bullying in the workplace, and more, fall under the PTSD umbrella. There is a downside to this; and that is, that these legitimately suffering individuals risk being misinformed, invalidated, and subjected to unnecessary (and often long term) psychological intervention. Take the victims of harassment within the RCMP for example, while it may be true that the recent popularization of PTSD has resulted in a greater awareness of the harm that chronic harassment/bullying can do, the diagnosis has turned the aftermath of the harassment into a “disease” and the bullying itself into nothing more than a precipitating event. In other words, the diagnosis has individualized and pathologized an expected human response that occurs in an oppressive social context. It pays no attention to the toxic social conditions that gave rise to the victim’s response and it treats oppressed people as if they are “mentally disordered”. This smacks of the same logic used in the old Communist Bloc countries, where political dissidence was viewed as mental illness; and dissidents were committed to mental hospitals.

One distinct benefit of the PTSD diagnosis is that it has been used for legal and insurance purposes. This may not continue to be the case. Canadian and American lawyers are already well informed as to the difficulties with a diagnosis of PTSD. Two well respected authors in the field have pointed out, “There are 175 combinations of symptoms by which PTSD can be diagnosed” and “it is possible for two people who have no symptoms in common to receive a diagnosis of PTSD”. This is a clinical nightmare; not unlike trying to nail Jello to the wall. The more the requirements for a diagnosis of PTSD are loosened going forward, the more easily the diagnosis will be discredited, and may soon become of no use whatsoever.

In conclusion, sometimes less really is more. The more experiences that are included, the easier it will be for those with no assessed symptoms in common to be assigned the diagnosis of PTSD. (And you understand that in order for a “disorder” to be recognized it must have its own unique set of indicators and those who are diagnosed with it all must have the same indicators). It follows then that the easier it is for those with few or no, symptoms in common to be assigned the diagnosis, the less likely the diagnosis will be accepted by the courts, government departments, or insurance companies. The psychological/psychiatric industry may have just shot itself in the foot. We might just be better off avoiding the labelling of distressed individuals and focusing more of our energy on addressing the abusive and inhumane conditions that give rise to the distress.

Dr. Mike Webster, R.Psych.

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