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“PTSD”: Psychopathology vs. Average Trauma Reaction

Feb 08

Thank God, Buddha, Krishna, et al. for our foreign readers! Many of them live in countries where the North American obsession with “PTSD” doesn’t exist (now that is interesting in itself, as they are also police personnel….. hmmmm cultural issue, political issue, selection issue?). Once again the lines have been buzzing with their questions about the state of the art regarding “PTSD”. In the absence of your presence, I thought they posed some very interesting questions. I have asked permission to answer them in a general fashion on-line so that you all may benefit as well. I received the “green light” from them all and will attempt to put their queries into several paragraphs that you may enjoy. As is the custom with the “blogosphere” I will not provide a complete Reference section but will instead cite particular authors in my text that you may dig for if you are so inclined. This piece has all the potential of being a bit lengthy, you best grab your favourite beverage……..I’ll wait. (Oh yeah, the expected caveat, I am not your therapist and these remarks are not to be considered as part of your therapy! I’m just that little voice that won’t stop buzzing in your ear, like your newly discovered uncomfortable underwear.)

OK, all set, here we go? SHIT HAPPENS, and not just to you!! Unfortunately, you have not cornered the market on ugliness. Please don’t forget the homeless, gays, lesbians, transsexuals, women, Aboriginals, Jews, the elderly, people of colour, the mentally and physically challenged to name only a few. To do so discredits both you and them. Many of them experience more shit in a day than you do in a lifetime. World wide (epidemiological) data suggests that MOST people experience at least one and more often several potentially traumatic events during their lives (Breslau, et al. 2000; Copeland, et al. 2007; Kessler, et al. 1995). However, as we have seen not everyone reacts to these events in the same way. They roll off some peoples backs without much fuss, some experience only temporary disruptions of their lives, others wrestle with them for months and then gradually improve, and finally some are chronically crippled by them. It seems expected that humans would respond differently to these traumatic events. It has only been recently however, that the big name researchers and theorists have paid much attention to the full range of reactions that we may have to these traumatic events (Bonanno, 2004).

When that “shit” does happen, it often hurts. Some of us need psychological intervention. That intervention, provided by the mental health community, can be the diagnosis and treatment of psychopathology; or it can simply be a concern with tracking the average response to traumatic events as a way of understanding and addressing the broad societal impact.

“Loosey-goosey” folk theories regarding trauma have been around forever (Daly, 1983; Shay, 1991). It wasn’t until the 1800’s that scholars began to connect violent and/or life threatening events with psychological/physiological dysfunction in the form of theories. Most of the 1900’s was tied up in definitional controversy largely due to the potential for malingering in the war-related context (Lamprecht, et al. 2002; Shepard, 2001). Initial opinions clustered around the notion that war trauma resulted from personal weakness, and was designated “traumatic neurosis” (Kardiner, 1941).

This attention eventually resulted in “PTSD” becoming a recognized diagnostic category in the 1980 edition of the DSM. The formalizing of this diagnosis has come at a cost however; it has tended to fuel the fires of definitional controversies. As I have noted previously, following the DSM III (1980) the expanded criteria (posed to address the subjective experience) lowered the threshold and made the diagnosis less valid (McNally, 2003). In addition you have heard me “rail on” about how studies looking at the latent structure of “PTSD” through a “you have it or you don’t” type of analysis have actually contributed to more of a dimensional (“we all, to some degree, got it”) structure (Broman-Fulks, et al., 2006; Ruscio, et al., 2002). This data contributes to a compelling case for “PTSD” being a continuous dimension ranging from mild to severe rather than a discrete clinical category.

I say what follows with the greatest of respect for all those uninformed (law enforcement?) speakers, advocates, counsellors, media darlings and bloggers; the intense obsession with “PTSD” in both lay and professional writing has done little more than cloud the wide range of responses we can experience following a potentially traumatic event. The most blatant example involves depression. How and why these co-morbid (exist together) indicators might co-vary (interact) over time is not well understood; and there isn’t really enough good data to stick your neck out and assert anything. Some researchers have shown that depression and “PTSD” can originate from the same source; whereas, others have suggested that “PTSD” may originate as a result of the failure to recover (Breslau, et al. 2000; Gilboa-Schechtman, et al., 2001). That is, it may be that people get “bummed out” due to continually struggling with a traumatic exposure, and in some cases contribute to the development of “PTSD” (Bryant et al., 2007).

It is certainly a strong possibility that your view of this mess has been influenced by the existing literature’s tendency to look at the problem as “binary” (i.e. pathology vs. absence of pathology……..I know, I know, I have a tendency to do this…..please forgive me, I get over stimulated). This view tells us little about normative responses to trauma, and moreover it has limited the collection of data on the broader issue of adjustment. Consequently we know little about the kind of distribution of “PTSD” across time or whether no response to trauma should be viewed as an aberration or as a form of “extreme health” (Bonanno, 2004).

Some of my colleagues (much more astute than I) have suggested that an alternative approach to getting an idiosyncratic handle on trauma is to compare group differences looking at an average response on a continuous measure of adjustment. Granted this approach doesn’t tell us much about individuals but it is parsimonious and avoids some of the conceptual and statistical limitations of the “PTSD” phenomenon.

One of the attractive features of this statistical approach (using averaged scores on a continuous measure) is that we can get a sense of the duration of the posttraumatic impact. And it seems that the prevalence of subjects meeting the diagnostic criteria for “PTSD” seems to decline steeply during the first year following the potentially traumatic event and then continues to diminish to a minority of subjects who continue to experience chronically elevated symptoms (Breslau, 2001). OK, put the beverage down for this…..when continuous measures are applied to “PTSD” symptoms and “PTSD” related symptoms we also see a tapering pattern; and the greater variability in continuous data allows us to make a more detailed predictive analysis over time. For example, a study of those Italian earthquake survivors from a decade or so ago, found the subjects who incurred physical damage or had been evacuated with more posttraumatic symptomology than those who did not experience this kind of exposure (Bland et al., 2005). Don’t get me wrong, using averages also has its’ problems. In the absence of individual data on the distribution of posttraumatic symptoms in the population, the meaning of “having symptoms of PTSD” is open to debate. Several symptoms listed in the DSM are not clearly associated with the stimulus event (e.g. “difficulty sleeping”) and open to a general response by the subject (i.e. we all have difficulty sleeping from time to time). Therefore the observation that one group has some “symptoms” of “PTSD” lacks clear clinical information (Bonnano et al., 2006). (Are you getting the picture here? Do you see why these well meaning but not well informed people who burst forth on these blogs, newscasts, banquets, and even newly formed counselling services, with their hearts on their sleeves might be guilty of oversimplifying matters?)

Are you beginning to see that when we look at a wide range of trauma adjustment across several points in time a more complex picture emerges? This exercise might even suggest that the term “traumatic” is not well applied. It might even emphasize how the term “traumatic” is a misnomer; it may be that “potentially traumatic event” (PTE) is a more accurate descriptor (Bonnano, 2004; Norris, 1992) as most people who are exposed to PTE’s cope remarkably well (Bonnano, 2004; Bonnano et al., 2008). The science is clear; some do incur long lasting difficulties however the vast majority of people who encounter extreme adversity are going to recover much of their normal functioning within several months to years post-event and most show nothing more than transient disruptions in their ability to function.

It seems that everyday thinking on trauma (as offered by not well informed emergency personnel advocates) has failed to capture the full range of adjustment following a traumatic exposure; and this is likely the result of misconceptions regarding the nature of underlying variability in change across time. The traditional approaches to trauma including the “you got it or you don’t” distinction are based upon the notion that horrific life events result in a homogenous distribution of change over time (Duncan,et al., 2006; Muthen, 2004).

Good news!!!!!! At least in the scientific community (in contrast with those involved in the “PTSD” frenzy) the picture has begun to change. Those who are steeped in this research (e.g. Bonnano, Breslau, Mancini, Curran, Jung, Muthen) are clearly finding a natural heterogeneity of the human response to stress. Their work has clearly illustrated multiple, unique trajectories of human stress responding. Moreover their research has identified multiple and unique paths of adjustment to potentially traumatic events.

Well respected research using the basic trajectory approach suggests that most of the variability can be caught in four typical trajectories; a relatively stable path of healthy functioning or resilience, a delayed reaction, gradual recovery, and last and least, chronic dysfunction (Bonnano, 2004).

I hope this brief overview has enlightened and possibly encouraged you. In addition, I hope I have managed to address all the questions posed by your foreign brothers and sisters; who have expressed a sincere interest in your working conditions and general well being. Anyone like to send them a brief message on the blog? And please remember……….

“YOUR GREATEST GLORY DOESN’T COME IN NEVER FALLING, BUT IN RISING EACH TIME YOU DO!”

Dr. Mike Webster
Registered Psychologist
#0655

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