Posttraumatic Stress Disorder: Issues and Controversies

Simon Wessely

director, King’s Centre for Military Health Research, Institute of Psychiatry, King’s College, London s.wessely@iop.kcl.ac.uk

Ed Gerald M Rosen

John Wiley & Sons, £24.95/€37.50, pp 288

ISBN 0 470 86285 8

Rating: ***

It is not hard to make psychiatric diagnoses. Diagnoses are largely descriptions. Ask the questions, elicit the symptoms, open the DSM IV, tick the boxes, and you have it. One set of symptoms means schizophrenia. You don’t need to think about the cause, which is fortunate, as we don’t know it. Another set of symptoms and a different set of tick boxes, and then this is depression. Again, the label says nothing about the cause, which is also fortunate, as it may have been anything (or, more likely, things) from a long list of psychological, social, or physical hazards.

There is one exception. Another set of tick boxes and the label might be post-traumatic stress disorder (PTSD). This time the label does indeed specify the cause: it is trauma. Out go the intricacies of psychiatric formulation—the complex interplay of genes, early environment, education, marriage, life events, physical illness, and so on.

For many years such complexity of aetiology was also the accepted wisdom for psychiatric disorder arising after trauma, until 1980 and the appearance of the new diagnosis of PTSD, itself part of America’s attempts to come to terms with the upheavals of the Vietnam war. Here was something simple. Vietnam veterans were troubled for one reason and one reason alone: they had been to Vietnam. Yet, as the essays assembled here by the psychiatrist Gerald Rosen confirm, this seductive simplicity was deceiving, as even the illness of Vietnam veterans was complex. The experience of war played a part, to be sure, but in a context of personality, upbringing, class, culture, and politics.

Belatedly our modern traumatologists (and a curse on the person who invented that hideous moniker) have come to accept that 1980 and the invention of the disorder did not reverse half a century of knowledge and that the person exposed to the trauma matters just as much as the trauma itself to which they have been exposed. Hence some of the essays in this collection are perhaps not quite so contentious as their authors would have us believe.

However, another controversy that shows no sign of resolution is the PTSD culture wars.

On the one hand, as Rosen expresses it in his pithy foreword, “many, if not most, traumatologists believe that PTSD is a timeless, acultural psychobiological response to overwhelming trauma.” In his recent book (Post-traumatic Stress Disorder: Malady or Myth?, Yale University Press, 2003) Chris Brewin labelled these the “saviours” who have finally broken the centuries old taboo on admitting suffering and forced a reluctant society to wake up to the psychic reality of trauma. On the other hand are the sceptics who, while not disputing the capacity of adversity to cause distress and even disorder, consider such reactions to be mediated by culture rather than “hardwired” in the brain.

Central to the rejection of the “it’s all in the brain” formulation is the question of meaning. If I am struck on the head by an iron bar and sustain brain injury, the neurosurgeon with the job of patching me up does not need to ask about my views on the assault. Yet if I see someone assaulted with an iron bar, my views on the incident will influence whether or not I subsequently develop a psychiatric disorder. It matters if I know the person, if I felt I was in danger myself, or if in contrast I thought that the person deserved to be hit on the head. Likewise, witnessing violent death is invariably considered to be a significant cause of PTSD. If someone has been so unfortunate and then develops psychiatric illness, look no further in the search for causation. But for centuries seeing gruesome public executions was not a cause of psychopathology but a spectator sport for all the family. I take my sons to watch Chelsea play; two centuries ago we might have gone to Tyburn. Would the audience then have enjoyed it as much as we enjoyed the Barcelona game? It would certainly have been cheaper.

Gerald Rosen has assembled a talented group of contributors to address the problems inherent in the concept of PTSD. Many are psychiatrists and psychologists, and they include several who are far from being PTSD sceptics but can still be critical of some naive assumptions. He has also persuaded a historian and an anthropologist of trauma—or, to be more accurate, the historian and the anthropologist of trauma—to provide perhaps the most penetrating essays.

The military historian Ben Shephard delivers the biggest kicking to the traumatologists, not only because of their misreading of history but also because of their “trauma inducing” prose style. Shephard takes them to task for ignoring or, worse, misrepresenting the history of the first and second world wars, preferring instead to set back understanding of the management of trauma for a generation: “Simply to ignore and reject hard-won past experience is perverse. The PTSD generation of doctors carried this process to extraordinary lengths—thanks to a combination of arrogance, ignorance and a wilful baby-boomer Oedipal reaction against conventional wisdom.”

Instead Shephard, in this essay and in his seminal history of military psychiatry A War of Nerves: Soldiers and Psychiatrists, 1914-1994 (BMJ 2001;322:177), articulates the key dilemma. How does society “discourage the mass of the population from developing psychiatric problems while simultaneously behaving fairly and humanely to those who do break down?” How do we avoid rewarding people for not fulfilling their duties as citizens or soldiers while ensuring material comforts and compensations for those who do break down?

Nearly every chapter ends by posing similarly challenging and occasionally unanswerable questions. Why, asks the anthropologist Allan Young, did traumatic neurasthenia (in which the central problem was physical and psychic exhaustion whose consequence was symptoms that included unwanted memories) give way to traumatic stress, in which it was the memories that came first and the symptoms and exhaustion second? Moving to the present, how do we avoid applying psychiatric labels to the normal reactions of distress or dismay that most people feel after tragedies? One answer is not to flood Manhattan with “trained counsellors” in the aftermath of 11 September.

The Australian psychologist Richard Bryant asks why psychological debriefing fails to work and probably even makes you worse. Is “better out than in” not such a good idea after all, especially in moments of crisis? One definite PTSD sceptic, the psychiatrist Derek Summerfield, wonders why we have turned our back on valuing stoicism and reticence in the face of adversity, in favour of emotionalism and disclosure. Why has the expectation of resilience given way to the anticipation of vulnerability? Watching the coverage of the Asian tsunami, I was struck by how several Western experts who descended on the stricken areas professed themselves astonished by the resilience, courage, and even cheerfulness of the survivors. I recall one mental health specialist reporting live on BBC Radio 4’s “PM” programme from a Sri Lankan village and expressing his surprise that the children he encountered seemed more keen to return to school than talk about their experiences. They were, he told the listeners, “clearly in denial,” and “only later will they experience the full emotional horror of what has happened to them.” How he knew this was not stated. The programme’s presenter back in London concluded, “Of course, everybody knows that children are the most vulnerable to trauma such as this.” Actually, no—children can be remarkably adaptable and resilient to trauma; it is older generations or people with pre-existing mental disorders who tend to fare the worst. Summerfield ends by echoing the social critic Frank Furedi’s recent observation that the use of terms such as counselling, trauma, syndrome and stress has increased by more than 10-fold in British newspapers in the last decade. Have our lives really become more dangerous, and has our need for counselling consequently become so much greater?

At the start of the second world war US psychiatrists believed they could identify which conscripts would experience mental breakdowns if exposed to combat and, by excluding them from military service, “save these boys from horror.” Yet even with those young men removed—nearly two million of them—rates of psychiatric breakdown remained as high as they had ever been. It took George Marshall, the chief of staff, to call a halt to the screening programme, because the drain on manpower was costing America the war. Many of those who had been denied service were now re-enlisted, and most of them made satisfactory soldiers. General Marshall had restored sanity, says Shephard, but “how the present confusion will be brought to an end is hard to predict.”