Letters

RAPID RESPONSES FROM BMJ.COM

The paper by Summerfield provoked a spirited debate on bmj.com. As of February 13, 45 e-letters had been posted on bmj.com in response to the paper, a few of which are published below (in whole or in part).Editor

Medicalization of health

Sufferers of PTSD deserve to be taken seriously

Some efforts to help cause harm

Two personal views

Medicalization of health

This article originally appeared in BMJ USA

EDITORThank you for reiterating the problem of medicalization of health. This issue first came to my attention when I read Ivan Illich's book Medical Nemesis in the late 1960s. This book should be part of every physician's bookshelf. This is an issue I discuss with my graduate students regularly, as the media keep inventing new diseases and epidemiologists are asked whether there really is such a disease. (Another good example is "chronic fatigue syndrome.") Then, legislators try to decide whether such "diseases" should be covered by insurance. Then, the "complementary medicine" adherents come up with a new way of ripping off the elderly and poorly educated by suggesting a new expensive herbal remedy to treat the "problem." And, the cost of delivering med-ical services is increased again.

Christopher Buttery, professor of public health. 
Virginia Commonwealth University, Richmond, Virginia, USA kimro{at}crosslink.net

Sufferers of PTSD deserve to be taken seriously

EDITORI found Summerfield's paper on post-traumatic stress disorder (PTSD) both lacking in understanding and unhelpful. The latest incarnation of DSM-IV reminds us that this category refers to people who have experienced or witnessed events "that involved actual or threatened death or serious injury, or a threat to the physical integrity of self and others." It therefore refers to the survivors of Auschwitz and Omagh, of Vietnam and Cambodia. You do not get PTSD after tripping over a paving stone. And in most cases, you have to wait an awfully long time for compensation. Organizations like the Dutch Auschwitz Committee fought for more than 20 years to get minimal financial help for the survivors of the Holocaust who were too disabled to work.

Summerfield links awareness of PTSD with financial factors and the advantages of victimhood. However, if you read anything about the experiences of Holocaust survivors, you learn that most did not choose either "survivorhood" or "victimhood." In Holland, it has been estimated that only 20% of the survivors managed to function normally after the war. For the 80% who didn't, there was little recognition of their distress, and a distinct shortage of help. Still, the Jews fared (comparatively) better than some of the other victims of the Nazis, including the Sinti and Roma population (formerly known as gypsies). Their suffering was effectively denied for 50 years.

PTSD is not a disease. It's a psychiatric disorder. Recognition is not the same as medicalization. It enables us to compare research and thus improve patient care. Personally, I find discussions of disorders like these as "pseudoconditions" highly offensive. To me it reflects ignorance and a certain amount of denial. I don't want to go back to the old days of stiff upper lips and pulling yourself together. Let's remain realistic, stop exaggerating the apparent advantages of a medical label, and remember that many of those who "kept a stiff upper lip" often spent their free time in the pub or became hooked on tranquilizers.

Ellen Goudsmit, medical archivist. 
London, UK ellengoudsmit{at}hotmail.com

Citations omitted here are available at www.bmj.com/cgi/eletters/322/7278/95.

Some efforts to help cause harm

EDITORIn our recent treatment of the psychosocial response to disaster,¹ the following passage appeared in our introductory chapter:

"Perhaps the most salient cause for concern in all the interventionist zeal is captured in Gilbert and Silvera's concept of overhelping. They demonstrated that immediate and highly visible attempts to `help' a target individual with processes that the target would, in fact, have successfully executed without aid served to defeat perceptions of self-efficacy central both to personal and interpersonal assessments of mastery on the part of the target. These assessments of self-efficacy, however, may be crucial to successful adjustment. Accordingly, given the consistent finding that most individuals confronted with disaster resolve its impacts with or without intervention, the very essence of our current trend toward rapid, highly promoted, highly visible intervention may be, at its most essential foundational level, counterproductive for those we most intend to aid."

No one, to my knowledgenot Summerfield, and certainly not I or my colleaguesis questioning the suffering of those who struggle with the aftermath of truly traumatic life events. How we ascribe labels to that experience, however, strongly shapes attributions, expectancies, actions, and interventions. The cardinal imperative for the scientist-practitioner has always demanded that we critically question even those axioms we hold most dear. Not all help proves helpful; some efforts to help, no matter how compassionately and fervently intended, ultimately render individual and/or social harm. Whether in construction of theory or in clinical consultation, the most basic of our caveats must never stray far from the dictum Primum non nocere (First, do no harm).

Richard Gist, PhD associate professor of psychiatry. 
University of Missouri-Kansas City, USA Richard_Gist{at}kcmo.org

Additional citations in the response by Gist, omitted here, are available at www.bmj.com/cgi/eletters/ 322/7278/95.

Two personal views

EDITORI was diagnosed as suffering from PTSD in 1997. I agree with some of Summerfield's views, and personally I think that a diagnosis of PTSD is used when nothing else will fit. I don't know if I do suffer from PTSD; I only know that I "lost" three years of my life, I withdrew from the world, I was physically sick if I ventured outdoors, I was afraid of the world, and I had overwhelming guilt feelings. Now I am "better," I have my own business, and I am back as a social being, but I did have three years of absolute hell. Was it PTSD? I don't know, but I'm sure this condition exists.

EDITORAs a survivor of years of traumatic child abuse, I have lots of experience with most of the "symptoms" of PTSD. In light of that, I find it puzzling that any person who has survived serious trauma would wish to have his/her responses to such dire experiences degraded as symptoms of a disorder.

After being cast into a subhuman role by perpetrators and sometimes also those who witnessed the abuse without taking steps to rescue the victims, why would victims of abuse seek more dehumanization through psychiatric judgments requiring that self-respect be completely stripped away?

What I needed most was not to be free of the nightmares, constant and pervasive fearfulness, and so on, but rather to trust my perceptions and reactions, and to feel resilient, competent, independent, and self-sufficient.

Will Johnstone, self-employed. 
Preston, UK shankly{at}ic24.net

Grace Heckenberg. 
Portland, Oregon, USA grace{at}pcez.com