in Thinking about psychiatry

Post traumatic Stress Disorder – two views

Orthodox view:

In the ICD-10 PTSD is listed under ICD-10 as F43.1; here find a summary of the PTSD information available on the Royal College of Psychiatrists website:

In our everyday lives, any of us can have an experience that is overwhelming, frightening, and beyond our control. We could find ourselves in a car crash, the victim of an assault, or see an accident. Police, fire brigade or ambulance workers are more likely to have such experiences – they often have to deal with horrifying scenes. Soldiers may be shot or blown up, and see friends killed or injured.
Most people, in time, get over experiences like this without needing help. In some people though, traumatic experiences set off a reaction that can last for many months or years. This is called Post-Traumatic Stress Disorder (PTSD).

PTSD can start after any traumatic event. A traumatic event is one where we can see that we are in danger, our life is threatened, or where we see other people dying or being injured. Some typical traumatic events would be military combat or a serious road accident or being taken hostage or being diagnosed with a life threatening illness.  Even hearing about the unexpected injury or violent death of a family member or close friend* can start PTSD.

The symptoms of PTSD can start after a delay of weeks, or even months. They usually appear within 6 months of a traumatic event.  Many people feel grief-stricken, depressed, anxious, guilty and angry. As well as these understandable emotional reactions, there are three main types of symptoms produced by such an experience:

  • Flashbacks & Nightmares – where people find themselves reliving an event again and again.  Ordinary things can trigger ‘flashbacks’.
  • Avoidance & Numbing – where sufferers avoid places and people that remind you of the trauma, and try not to talk about it.  Numbing is where people deal with the pain of their feelings by trying to feel nothing at all.
  • Hypervigilance – this is like being “on guard” all the time.

These symptoms can be accompanied by: muscle aches and pains, diarrhoea, irregular heartbeats, headaches, feelings of panic and fear, depression, drinking too much alcohol and using drugs.
Traumatic events are so shocking as they undermine our sense that life is fair, reasonably safe, and that we are secure. The symptoms of PTSD are part of a normal reaction to narrowly avoided death.  However not everyone will get PTSD after a traumatic experience.  Over a few weeks, most people slowly come to terms with what has happened, and their stress symptoms start to disappear.  However about 1 in 3 people will find that their symptoms just carry on and that they can’t come to terms with what has happened.  The more disturbing the experience, the more likely you are to develop PTSD.

Possible explanations for why PTSD occurs:
The first of these is psychological.  When we are frightened, we remember things very clearly. Although it can be distressing to remember these things, it can help us to understand what happened and, in the long run, help us to survive.  The flashbacks, or replays, force us to think about what has happened; we can decide what to do if it happens again. After a while, we learn to think about it without becoming upset.  Being ‘on guard’ means that we can react quickly if another crisis happens.
In terms of the body and its mechanisms, adrenaline is a hormone our bodies produce when we are under stress. It ‘pumps up’ the body to prepare it for action.  When the stress disappears, the level of adrenaline should go back to normal.  In PTSD, it may be that the vivid memories of the trauma keep the levels of adrenaline high.  This will make a person tense, irritable, and unable to relax or sleep well.

The hippocampus is a part of the brain that processes memories. High levels of stress hormones, like adrenaline, can stop it from working properly – like ‘blowing a fuse’. This means that flashbacks and nightmares continue because the memories of the trauma can’t be processed. If the stress goes away and the adrenaline levels get back to normal, the brain is able to repair the damage itself, like other natural healing processes in the body. The disturbing memories can then be processed and the flashbacks and nightmares will slowly disappear.

PTSD Critical view:

Rather than being something with an objective existence, whether identified by psychiatrists or not, the origins of PTSD are actually grounded in the political and social, emerging as it did during the fallout from the Vietnam War.  At this time returning American soldiers found themselves pilloried and marginalised.  The new diagnosis of PTSD shifted the emphasis from the brutal actions of soldiers towards the essentially traumatic experience of war.  The diagnosis bestowed victimhood and thereby moral exculpation.  Originally envisaged as being appropriate for application to only extreme and unlikely experiences, the diagnosis has come to encompass relatively common, albeit unfortunate, events (see * above).  Vulnerability, rather than resilience is now considered to be the norm.

Modern western culture has taken a direction whereby a nation is judged as an economy rather than as a society and where great disparities of wealth are tolerated and even argued necessary.  ‘Psychological thinking’, individualism and personal rights are increasingly prominent.  Grievances for life’s injustices under such circumstances are common and individuals largely tailor their behaviour to fit expectations.   In this way PTSD allows compensation to be granted in a socially acceptable way.
PTSD is also weak as a diagnostic category.  A psychiatric disorder is not necessarily a disease, but rather a way of seeing; throughout history people have had disturbing recollections and despair, but the idea of traumatic memory as a fixed, circumscribed, pathological entity separate from other varieties of psychological distress is recent.  Rather than representing, as one might expect from its separate categorisation , a entirely independent disease process, PTSD is grounded in phenomena which are shared by other psychiatric disorders.  It also lacks specificity as it fails to distinguish what is ‘pathological’ from ordinary distress.  Furthermore, its conception that the condition’s aetiology involves a single traumatic event from which all else follows is dubious given the influence that other factors must have over the development of the disorder, for example coping styles and previous psychiatric history.

PTSD is made rather than discovered, but once invented, it is hard to uninvent; each time a diagnosis of PTSD is made its existence is further solidified.


Further reading:

The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category BMJ 2001;322:95-98

PTSD: a critical appraisal

Article on Dr Pat Bracken and his book Trauma: Culture, meaning and philosophy

On the concept of trauma BMJ2009;339:B4577 – access restricted

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