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EDUCATION AND DEBATE: Derek Summerfield The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category BMJ 2001; 322: 95-98 [Full text]

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Rapid Responses published:

Victim status:a legal life line

Frank Doyle   (13 January 2001)

from the danger of psychiatry to the danger of ideology

Francesco Del Zotti   (13 January 2001)

sufferers of PTSD deserve to be taken seriously

Ellen Goudsmit   (13 January 2001)

PTSD - a personal response

Phillip Garner   (14 January 2001)

Medicalization of health

Christopher Buttery   (14 January 2001)

A rose by any other name. . .

Gary N Fox   (14 January 2001)

Personnal View

Will Johnstone   (14 January 2001)

Socio-Clinical Blinders Apparent

Lawrence Parlett   (15 January 2001)

At last

Samia El-Sayed Bushra   (15 January 2001)

The dismissal of PTSD raises more questions.

Peter Parry   (15 January 2001)

Maybe PTSD actually was there long before Vietnam?

Rick Zabrodski   (15 January 2001)

"There's more in heaven and earth, Horatio, than are dreamt of in our philosophies . . . "

Stacy M Rios   (15 January 2001)

Thinking about the social usefulness of any diagnosis.

Andrea Litva   (15 January 2001)

What your mind does not know, eyes do not see

Abhijit Chaudhuri   (15 January 2001)

PTSD ( Vietnam )

A A W Amarasinghe   (16 January 2001)

The Convenience of Debating Unexperienced Pain

Gourete Broderick   (16 January 2001)

PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Survivor'.

Lofthouse   (16 January 2001)

A disorder that takes away human dignity and character

Arieh Y Shalev   (16 January 2001)

Thinking again about the post-traumatic stress disorder diagnosis

Salvador Vale   (16 January 2001)

Well intentioned yet factually wrong.

Grant J Devilly   (16 January 2001)

The validity of a diagnosis is not determined by its cause

Tom Clark   (16 January 2001)

Frighteningly educational

Robert King   (17 January 2001)

The validity of PTSD

Arthur Rifkin   (17 January 2001)

Myth of homogeneity

Peter Jezukaitis   (18 January 2001)

Epistemology and Ontology of PTSD

Casimiro Cabrera-Abreu   (18 January 2001)

Post-traumatic stress disorder

M D Beary   (18 January 2001)

Victims' suffering is real

Juliet Cohen   (19 January 2001)

Denial exacerbates psychiatric injury

Tim Field   (19 January 2001)

Politcially correct and incorrect diagnoses

Trevor Stammers   (19 January 2001)

PTSD response to Summerfield

Malcolm Weller   (19 January 2001)

The Parameters of Pain

Judith Hollands   (19 January 2001)

Flawed logic in denial of post-traumatic stress disorder

Simon J Ellis   (21 January 2001)

Social construction of PTSD but one of many contemporary issues

Richard Gist   (21 January 2001)

Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome?

Philip Wynn, Craig Jackson   (23 January 2001)

There are many pragmatically correct ways to describe distress

Susan Hansen, Renata Kokanovic   (24 January 2001)

PTSD is only a disease if you´re employee

Regina Stroebele   (25 January 2001)

Lions led by donkeys

John Hopkins   (26 January 2001)

Re: The Convenience of Debating Unexperienced Pain

Grace Heckenberg   (29 January 2001)

appreciation from a survivor

Grace Heckenberg   (29 January 2001)

Human Misery

Frank Hoffmann   (2 February 2001)

Post-traumatic stress disorder: a convenient diagnosis for patients and doctors

Antonio L Teixeira, Henrique Alvarenga-Silva   (4 February 2001)

Re: Post-traumatic stress disorder: a convenient diagnosis for patients and doctors

Ellen Goudsmit   (6 February 2001)

The role of ‘traumatic memories’ in the psychopathology of PTSD.

Richard Meiser-Stedman   (6 February 2001)

Sticks and stones

Patrick Meade   (7 February 2001)

Psychiatrists are also a construction

Jim Hardy   (9 February 2001)

PTSD or not PTSD? Is that the question?

Ian P Palmer   (14 February 2001)

Utility for whom?

Grace Heckenberg   (14 February 2001)

Re: PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Surviv

Grace Heckenberg   (17 February 2001)

Déjà vu

Anthony Stadlen   (20 February 2001)

Understanding Individual Reactions To Traumatic Events Is Important.

Suzanne Mason, Jim Wardrope   (20 February 2001)

Misappropriation & misuse of PTSD

David Bolton, Kate Gillespie, Michael Duffy, Clive Burges   (20 February 2001)

Re: Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome?

Charline Griffith   (20 February 2001)

PTSD: Origins and Function

Jerry Lembcke   (20 February 2001)

Summerfield's reality vs. medical research

Dinaz Irani   (5 March 2001)

Letter re Derek Summerfield article on PTSD

Yvonne McEwen   (15 March 2001)

PTSD diagnosis can help people 'move on'

Rosie Fenwick   (15 March 2001)

Pathologising War-Affected Societies

Vanessa Pupavac   (25 April 2001)

Physical Correlates of PTSD

Fiona Eaton   (25 April 2001)

If DSM-IV doesn't work, let's try something different

David Brown   (9 July 2001)

Where are the thoughts of Bosnian physicians

Mickey Rostoker   (26 January 2003)

Negotiating with PTSD

Yolande Lucire, Australia   (30 August 2003)

Re: Negotiating with PTSD

Ellen Goudsmit   (1 September 2003)

Re: Re: Negotiating with PTSD

Glenn G. Hakanson MD FAPA   (3 September 2003)

competing interest of PTSD-believers

Grace L Heckenberg   (3 September 2003)

History is not conspiracy heory

Yolande Lucire   (8 September 2003)

Re: History is not conspiracy heory

Ellen Goudsmit   (8 September 2003)

Re: Re: History is not conspiracy heory

Glenn G. Hakanson MD FAPA   (10 September 2003)

Democratic Psychiatry

James A Rodger   (7 May 2008)

Victim status:a legal life line 13 January 2001
Frank Doyle, general practitioner principal Melbourne Australia. Send response to journal: Re: Victim status:a legal life line	There are some individuals who see an opportunity to regain their self respect in adverse situations.I am thinking of trivial work related conditions that end up years later with a court settlement that justifies and ensures the "client" will never work again.So often it was the Repetitive Strain Injury (which seems to have run it's course) which never got better.Funnily enough severe fractures did much better.The problem with our human condition is that we deal much better with anger than grief.It always struck me as odd that if 90% of your problems were at home and 10% at work then it followed that therefore 100% was due to work.It is not to say that we are hard hearted but truth is too unpalatable and fantasy believable.Finally ,anyone who has been sent to war is an admission of society's failure and of their citizen's betrayal.
from the danger of psychiatry to the danger of ideology 13 January 2001
Francesco Del Zotti General practitioner - Verona _ Italia Send response to journal: Re: from the danger of psychiatry to the danger of ideology	I think that your paper is dangerous : you are fighting the power of psychiatry with the help of an ideological and political negation : the refusal of the objective reality of strong external stressor Francesco Del Zotti - Verona - Italy
sufferers of PTSD deserve to be taken seriously 13 January 2001
Ellen Goudsmit, Medical archivist London Send response to journal: Re: sufferers of PTSD deserve to be taken seriously	Sir, I found Summerfield’s paper on post-traumatic stress disorder (PTSD) both lacking in understanding and unhelpful(1). 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 aftermath of Auschwitz and Omagh, Vietnam and Cambodia, King’s Cross and Hatfield. You do not get PTSD after tripping over a paving stone. And in most cases, you have to wait an awful long time for compensation. Organisations like the Dutch Auschwitz Committee fought a long battle to get minimal financial help for the survivors of the Holocaust who were too damaged to work(2). Summerfield links the awareness of PTSD with financial factors and the advantages of victimhood. If you read anything on the experiences of Holocaust survivors, you will know that most did not chose either survivorhood or victimhood. In Holland, it has been estimated that only 20% of those who came through the war managed to function normally and cope reasonably well. For the eighty per cent who didn’t, there was little recognition of their distress, and a distinct shortage of help. However, the Jews fared better than the other victims of the Nazis, including the Sinti and Roma population (formerly known as gypsies). Their suffering was effectively denied for fifty years(3). Human beings learn slowly. It took a lot of media attention (and the odd Spielberg movie) to show the rest of us what these individuals went through. And even then, you still come across ‘ learned’ members of our society who write about events like this in terms of an “unpleasant but scarcely extraordinary experience”. In Britain, most of us can live our lives knowing that we are unlikely to end up in concentration camps, that we will probably not have to kill another human being, or see our loved ones being blown up or hacked to pieces. Most of us will not witness a major fire nor be involved in a serious train crash. However, we should show some respect for those who have been through such experiences and who have not been able to deal with the memories. We don’t have to trivialise their distress or cast aspersions about their ‘motives’. PTSD is not a disease. It’s a psychiatric disorder. Recognition is not the same as medicalisation. Do we go back to the old ways and ignore these people’s symptoms? Do we tell them that it’s perfectly normal and natural, ‘we all have our problems’ so like the rest of us, they should ‘pull themselves together’ and stop being so silly? Are we going to tell soldiers who cannot cope with the dirty side of conflicts that we’ll offer them a few weeks rest and if that doesn’t work, we’ll shoot them? So there’s a link between prior psychiatric illness and PTSD? Of course there is. If you are a more sensitive soul, you are more likely to succumb, in certain circumstances, to both. Having said that, the more traumatic the event, the more likely people will eventually develop post- traumatic type of problems. We’ve seen that in Holland, where an expert in the subject was still working in his eighties because of the number of new cases forty years after the end of the war. I know of a member of the Dutch resistance who was captured and tortured for a short time by the Germans. He had no symptoms until his retirement, when his youth came back to haunt him in the middle of the night. In short, properly diagnosed PTSD is more than a few unpleasant recollections or normal distress. We recognise it now, to enable us to compare research and improve patient care. It’s in DSM-IV-TR because of what we know and what we can offer. Admittedly, it is a psychiatric construct. So what? It exists independently of the gaze of psychiatrists and its recognition reflects increased knowledge and compassion. It’s not about choosing victimhood, and it’s not clinically meaningless. 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’ spent their free time in the pub or were hooked on tranquillisers. Yours Ellen Goudsmit Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322: 95-98. 2. Bijl M. Nooit meer Auschwitz. Het Nederlands Auschwitz Comite, 1956-1996. Bussum: Thoth. 1997. 3. Boom, J. Heimwee naar de horizon. Eindelijk erkenning voor Sinti en Roma. Reprinted in Auschwitz Bulletin 2000; 44: 12-15.
PTSD - a personal response 14 January 2001
Phillip Garner, retired (due to ill health) Send response to journal: Re: PTSD - a personal response	Dear Editor/ Mr Summerfield As a gulf veteran with a diagnosis of PTSD (one of several diagnoses of multiple conditions)and a retired Staff Nurse, I found your article both inaccurate and insulting. I did not ask to suffer from intrusive thoughts, flashbacks, nightmares,and all the other myriad of symptoms connected with PTSD (I expect none of the other conflict veterans did either), nor do I expect any victim of a violent crime or witness to a traumatic event wanted the after effects of being such a witness. The diagnosis MAY be given to some people inaccurately - but who are you to assume that you can tell how another person may react to any news? As with conflict a sight, sound, or experience may leave a person with PTSD, yet another person may encounter the same sight, sound, or experience and not be affected from the symptoms of PTSD. The same would go for any individual you care to mention (including medical staff - how many Doctors and Nurses have faced violent assaults and not been able to return to work after such an event.) Your article does not give your qualifications - only Honourary senior lecturer - Sir - I put it to you that You need to re-assess your views on this subject and show a bit more compassion for the suffering of others.
Medicalization of health 14 January 2001
Christopher Buttery, Professor of Public Health Virginia Commonwealth University - Rcihmond. VA USA Send response to journal: Re: Medicalization of health	Thank 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 delivery medical services is increased again!
A rose by any other name. . . 14 January 2001
Gary N Fox, Medical College of Ohio Mercy Health Partners Family Practice Residency Program, Toledo, OH Send response to journal: Re: A rose by any other name. . .	The terminology that physicians use changes regularly. Dermatoses are named, renamed, and renamed again. Same with bacteria. Psychiatry is no different. The author states, "The diagnosis is a legacy of the American war in Vietnam and is a product of the post-war fortunes of the conscripted men who served there. They came home to find that they were being blamed for the war." I recently attended a conference where it was stated that PSTD may be relatively new under that name, but was well described in the US Civil War era (1860s) as "Soldier's heart" and in World War I as "battle fatigue." Gary N. Fox, MD
Personnal View 14 January 2001
Will Johnstone, Self Employed DAUB Send response to journal: Re: Personnal View	I was diagnosed as suffering from PTSD in 1997. I agree with some of your views, and personally think that a diagnoses of PTSD is used when nothing else will fit, I don;t know if I do suffer from PTSD or not, I only know I "lost" 3 years of my life, I withdrew from the world, was physically sick if I ventured outdoors, was afraid of the world, and had overwhelming guilt feelings. I am now "better", I have my own business, and am back as a social being, but did have 3 years of absolute hell, but was it PTSD? I don't know, but I'm sure this condition does exist.
Socio-Clinical Blinders Apparent 15 January 2001
Lawrence Parlett, Capt. USAFR, MSC S.C.L.I.W.C. Send response to journal: Re: Socio-Clinical Blinders Apparent	The obviously theoretical premise presented in this article reminds me of mistakes made when combining minimal experience with narrowly focused literary research. Sociology and medicine generally don't combine well in articles. This is a prime example. Better luck next time.
At last 15 January 2001
Samia El-Sayed Bushra, SHO Oldchurch Hospital NHS Send response to journal: Re: At last	At last this confusing topic is tackled. I suggest putting this forward in simple terms for the lay-man perhaps in one of the leading daily newspapers.
The dismissal of PTSD raises more questions. 15 January 2001
Peter Parry, Child & Adolescent Psychiatrist Medical Unit Head, Boylan Inpatient Service, Women's & Children's Hosp, Nth Adelaide, Sth Australia Send response to journal: Re: The dismissal of PTSD raises more questions.	In an unreferenced "rapid electronic response" (which is an excellent innovation by the BMJ) I'd just like to add to Dr Goudsmit's response with which I essentialy agree. Dr Summerfield highlight's the undoubtedly real problems of "victimhood", the side effects of compensation seeking behaviour and a medicolegal industry that can skew the victim/survivor's self-concept and behaviour. However to deny PTSD is to run the opposite risks of hidden and untreated suffering and a medicolegal industry that colludes in a culture of denial (such as in the Soviet Union as Dr Summerfield points out). To that extent I also think Dr Summerfield's paper is potentially dangerous. PTSD predates the Vietnam War, though DSM and ICD have only had their heyday post Vietnam, and Dr Summerfield perhaps confuses these issues. "DaCosta's syndrome" and "Shell Shock" were well described and very common entities in the American Civil War and First World War respectively - as I was reminded in the best selling novel I just finished over the festive season: "Birdsong" by Sebastian Faulks. The novel appeared well researched and finished by noting that most of the veterans who survived WWI died young and in ill health. Dr Summerfield notes that up to 99% of the residents of Freetown can be diagnosed with PTSD. He implies this confuses normality with pathology. But the residents of Freetown are to be compared not amongst themselves - but with the human population as a whole. If their streets are awash with blood and adults and children with missing hands, and there's been anarchy and no stable authority for years...then perhaps widespread psychopathology is to be normal. That does not mean that the skills of survival, the defences that allow one to cope with horror, a positve, hopeful and humane attitude cannot coexist with PTSD, as such virtues undoubtedly do. If the trees in a section of the Murray River here in Australia are all stunted or dying from salinification..that implies a cause toxic enough to affect the whole population of trees. It is normal for those trees to be sick. I believe that the work of Prof Bessel Van der Kolk amongst others highlights the neuroimaging and biochemical aspects of PTSD pathology. In the same way a botanist could show the effects of salinity on trees. To say that PTSD is purely a sociopolitical construct no longer is sufficient. Nonetheless Dr Summerfield correctly highlights the need to focus on recovery and resilience, and highlights the problems in doing this inherent in the compensation process. One could dismiss the diagnosis of PTSD..but it'd have to be replaced with "Anxiety Disorder with Bad Memories". That may be preferable in some circumstances for the reasons stated by Dr Summerfield, but I'm not sure if much would be gained and I worry about what would be lost.
Maybe PTSD actually was there long before Vietnam? 15 January 2001
Rick Zabrodski, Clinical Assistant Professor University of Calgary Send response to journal: Re: Maybe PTSD actually was there long before Vietnam?	I wonder if the author has ever been in combat and had close friends die while very nearly losing his own life? I recall that two of my uncles, both in active action in WWII had symptoms of PFTSD even though it did not yet exist. One was a sniper (almost got caught - they killed you slowly if they did get you.) The other was the only surviving member of a mine detecting squad. Both got better with time. My father, who survived two direct hits on two different occasions to his tank (colleagues mortally wounded both times) amongst other near misses over 4 years has NEVER, EVER wanted to "visit" Europe.
"There's more in heaven and earth, Horatio, than are dreamt of in our philosophies . . . " 15 January 2001
Stacy M Rios, Attorney at Law Rios Law Office Send response to journal: Re: "There's more in heaven and earth, Horatio, than are dreamt of in our philosophies . . . "	Derek Summerfield's article about post-traumatic syndrome reveals how short-sighted and elitist some medical professionals can be when faced with a condition or disorder which cannot yet be fully explained in completely physiologic terms. Summerfield's premise, that an actual psychiatric disease or disorder must have existed throughout time indeterminate, is a factually inept concept. Neolithic humaniods may have not suffered from Parkinson's disease, or Alsheimer's, or may have not known prostate cancer, only because they did not live long enough to acquire such diseases. Did they even live long enough to contract cancer? Does this mean that cancer is not actually a diagnosis because preternatural humans did not live long enough to suffer this disease? What Summerfield has recognized is that there is a lack of complete understanding when it comes to psychiatric diagnosis and the electro- chemical reactions in our brains. Psychiatry has not kept abreast with the developments in neurology, and as such, the breach between the two areas of science creates a schism in our complete understanding of how the human brain learns, develops, grows, and directs our behavior. It is sad that Summerfield chooses to deride the existence of a disorder, rather than to explain why the disorder should fall under other psychiatric definitions, such as clinical depression, or bi-polar disorders. Simply put: it is much easier to deconstruct existing theories and deride the significance of new theories without positing an explanation or hypothesis in the alternative. Telling the reader that PTSD is merely a socio-cultural invention leaves many questions unanswered and is a sorry replacement for an actual scientific hyphothesis regarding alternative defects or possible diagnosis.
Thinking about the social usefulness of any diagnosis. 15 January 2001
Andrea Litva, Lecturer in Medical Sociology Dept. of Primary Care Send response to journal: Re: Thinking about the social usefulness of any diagnosis.	Dear Editor I was intrigued to see published in this weeks BMJ, an article around the social construction of post-traumatic stress disorder. Let me begin by stating that I do not feel that Summerfield's argument is 'dangerous'. He is simply applying the social constructionist model to PSTD and this 'ideology' is no more threatening or destructive than the biomedical model. The social construction of illness and disease is well recognised in the medical sociology literature and this article simply adds to an existing debate. The socially constructed nature of (almost?) all illness/disease/disorder is well recognised amongst medical sociologist and psychologists. Illness and disease cannot exist or emerge separate from society. What is perhaps downplayed in the article, and seems to have aroused much angst amongst respondents, is a recognition of the importance of diagnosis - any diagnosis - for patients suffering from a collection of symptoms. Talcott Parson first recognised the importance of going to the doctor and being diagnosed in his description of the sick role. Regardless of the socio/political/medical contexts from which illness/diseases/disorders emerge (although fascinating), in western society when people are diagnosed by clinicians they are generally no longer regarded as personally responsible for causing their illness behaviour. Arguably this removes them from being regarded as 'deviants' or at least morally questionable people and places them firmly into the legitimating hands of medicine. I think for those suffering from PTSD, a diagnosis can provide them with much needed legitimacy thus allowing them to retain their place within society without diminishing what they are experiencing. It may well be the 'medicalisation of everyday life' but as long as the biomedical approache dominates the way western society approaches their problems, it is a very necessary evil. Perhaps we need to start thinking beyond clinical outcomes and start thinking what the 'real' role of medicine is in western society.
What your mind does not know, eyes do not see 15 January 2001
Abhijit Chaudhuri, Senior Lecturer in Neurology University of Glasgow Send response to journal: Re: What your mind does not know, eyes do not see	In his article, Summerfield argues that post-traumatic stress disorder(PTSD) is an example of "medicalization of health"(1). The phrase, "medicalization of health", is, like the article itself, an abstract concept divorced from medicine and borrowed from the literary world, as shown by the comment of Buttery(2). Lest we all forget, let me remind the author that medicine was developed as the youngest branch of science to answer the honest and genuine health symptoms experienced by people in the community.By author's own logic, we should not attempt to use analgesia to ease obstetric pain because we are medicalizing the human experience of normal labour and indeed, we seldom use analgesia during the birth of animals. Likewise, we should take the examples of Summerfield and Buttery and tell our junior doctors to ignore the unfortunate woman in the clinic with PTSD since she was physically violated because she is only attempting to medicalize her single unfortunate physical encounter! We should probably also have asked the visiting Balkan lady to shut up and behave normally even though she has classical PTSD from her experience of witnessing her entire family wiped out in front of her eyes in minutes! Why did Hippocrates ever write "Where the love of man is, there, also, is love of the art of medicine"? He must be surely wrong in the current standards of medical practice! The major scientific problem with Sommerfield's article is that it fails to recognise the neurobiology of severe physical and emotional stress that has been extremely well researched in the past decade (3-5). Stress, which may be defined as the cumulative biological reaction mounted by an organism in response to acute or chronic noxious stimuli, is known to produce many effects in the central nervous system, including breakdown of the blood-brain barrier(3), changes in neuronal function with altered gene expression and abnormal neurotransmitter production (4).There is also speculation that chronic stress may affect memory due to the effect of glucocorticoids on the hippocampal neurons(5). While we may not yet know the precise pathogenesis of PTSD, the suggestion that PTSD is an Amercian pseudodiagnosis invented in the post-Vietnam war era is historically inaccurate and naive. Rubbishing PTSD(1), chronic fatigue syndrome(2)or Gulf War syndrome has become a favourite pastime of some physicians. May be these physicians no longer need a stethoscope, but everytime I look at mine,I hear Rene Laennec whispering: "Listen to your patients. They are giving you the diagnosis". References 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322:95-8 2. Buttery B. Medicalization of health.www.bmj.com (accessed on 15.01.01) 3. Friedman A, Kaufer D, Shemer J, et al. Pyridostigmine brain penetration under stress enhances neuronal excitability and induces early immediate transcriptional response. Nature Med 1996; 2: 1382-5 4. Kaufer D, Friedman A, Seidman A, Soreq H. Acute stress facilitates long lasting changes in cholinergic gene expression. Nature 1998; 393:373-77 5.McEwen B. Protective and damaging effects of stress mediators. N Engl J Med 1998; 338:171-9
PTSD ( Vietnam ) 16 January 2001
A A W Amarasinghe, Private Psychiatric Consultant Augusta, Georgia. USA Send response to journal: Re: PTSD ( Vietnam )	The diagnosis of PTSD among the United States veterans of the Vietnam War has already devoured a colossal amount of dollars from Uncle Sam. It goes on and on. Whether PTSD is fact or fantasy or just another fraud neeeds to be addressed.
The Convenience of Debating Unexperienced Pain 16 January 2001
Gourete Broderick, Advertising Send response to journal: Re: The Convenience of Debating Unexperienced Pain	I read, with interest, Mr. Summerfield's article on the invention of PTSD. It often amazes me how people who have not experienced such traumatic pain feel that they are therefore qualified to speak on a subject for which they are not personally aquainted - other than through study. How familiar are they with people who have PTSD? Have they spent an hour, a day, a week, a month with someone who has PTSD? Walk with us for a while and study this "invention" from both sides of the equation. Late last summer, I was on short term leave. While on a theraputic walk my mind was taken over by traumatic experiences that occured to me and I did not realize that I had walked right out into coming traffic. When my mind allowed me to perceive my present situation I walked away from the driver who, through no fault of his own, would have run me over with his car. I wept the rest of the way home not because he almost ran me over but because he did not. I have no doubt that had you been with me at that precise momemt Mr. Summerfield that you, too, would have no doubt about whether or not PTSD is real or invented. I would like to go on record as stating that sadly, PTSD is all too real. Regards, Gourete Broderick
PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Survivor'. 16 January 2001
Lofthouse , Advocate Send response to journal: Re: PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Survivor'.	For many, a re-diagnosis of PTSD is the only 'compensation' they receive for their status as 'Victims'. Prior to 1980 when this condition was recognised as a Diagnostic category, thousands of patients presenting with symptoms of prolonged distress were diagnosed as 'Schizophrenic', subjected to often brutal, often ludicrous 'experimental' treatments without informed consent, forcibly medicated, then returned to the conditions that had caused them to manifest the original symptoms. The long-term harassment and racially-motivated assaults suffered by first generation immigrants to this country correlates well with the incidence of 'Schizophrenia' amongst the Afro-Caribbean and Asian population prior to 1980. It led directly to the rather spurious notion that their symptoms had 'genetic' causation, an unsubstantiated myth still prevalent amongst a generation of General Practitioners. There is still no Legal right to a re-diagnosis, and, as an Advocate who often meets with Fund- Holding GP's reluctant to 'waste money' on a re-diagnosis, I record Dr. Summerfields' article as doing nothing more than adding insult to what is for many, a very, very real injury.
A disorder that takes away human dignity and character 16 January 2001
Arieh Y Shalev, Professor and Chair Department of Psychiatry, Hadassah University Hospital, Jerusalem Send response to journal: Re: A disorder that takes away human dignity and character	Encouraged by Dr. Summerfield's revelations (BMJ 2001:322.95-8) I imagined myself going to my clinic, tomorrow, and, at last, telling my PTSD patients that their disorder is but a social invention. I also thought that I would apologize; openly admitting that psychiatry was wrong in choosing to diagnose their problem (let alone treat it) and that I myself erroneously 'medicalized' their condition instead of seeing it as normal human suffering. Given that suffering is normal, as says Dr. Summerfield, I was also preparing myself to encourage each of my patients to bless his or her sort for having survived adversity and to never mention the word victim again - not even when the trauma was a group rape. It's a matter of dignity and honor. Better be normal and suffer than have a mental disorder treated. My daydreaming continued, however, and I saw myself meeting an anorectic patient, for whom I care very much, and telling her that, from now on, given the roots of her disease in social ideals of feminine thinness, she should simply start eating. To my very sick schizophrenic patient, still overwhelmed by a recent and demonic exacerbation, I was prepared to show evidence that schizophrenia is but a scientific delusion1. So far for social constructivism. If anything, PTSD exemplifies how good it is that despite orthodoxy and arrogance, the medical profession is sometimes forced to listen and respond to people's pain. In my younger age severe personality disorders were doomed as 'not suitable for psychotherapy.' Diseased combat veterans had 'problems of character,' or were simply called 'degenerates2. I am very glad not to be there any more. Not that PTSD is built in stone. But neither are depression, psychosis, mental retardation, delirium etc...Meanings change over time, and one hopes that this will continue. Yet, what is fascinating about PTSD is that despite its tentative beginnings, this diagnosis has generated more replicable biological findings than most traditional disorders3. This embattled syndrome has, in fact, been able to identify groups of people with very common physiology, endocrinology, responsivity to chemical challenge and functional brain imaging findings. Moreover, the development of PTSD, de novo, in newly traumatized individuals offers one of the best opportunities to study the ways in which mentally stressful events become neuronal events and irreversibly transform the central nervous system's responsivity and functioning4. The marriage between PTSD and the neurosciences is, unfortunately, more productive than the acceptance of the disorder in many medical circles. One wonders, in fact, what is so shocking in admitting that extreme events must affect brain (be it in ways of etching memories) and that such changes may turn wrong, in some individuals. Finally, one wishes to protest, once again, against the reluctance to identify a mental disorder in those who suffer, just because this might become a 'psychiatric diagnosis.' One would have thoughts that these days are over, that is, that human dignity is not lost when one also suffers from a mental disorder. Doctors should encourage their patients to disclose distress and seek help, when such help can be offered. They should also be able to differentiate normal sorrow from major depression, reasonable doubt from obsessive rumination, idiosyncrasy from schizophrenia, and transient responses to extreme events from prolonged and devastating PTSD. They should not be confused, however, by claims that the pervasive and interminable personal disaster that is PTSD is not a disorder. Arieh Y. Shalev, M.D. Professor of Psychiatry Head, Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel 1. Boyle M. Schizphrenia A scientific delusion. 1990, Routelage, London. 2. Witztum E, Levy A, Solomon Z. Lessons denied: a history of therapeutic response to combat stress reaction during Israel's War of Independence (1948), the Sinai Campaign (1956) and the Six Day War (1967) Israe; Journal of Psychiatry and Related Sciences, 1996; 33, 79-88 3. Pitman RK, Shalev AY, Orr SP. Post-traumatic stress disorder: emotion, conditioning, and memory, in The Cognitive Neurosciences, 2nd ed. Edited by Gazzaniga MS. Cambridge, MA, MIT Press, 2000. Pp. 1133-1148 4. Shalev AY, Pitman RK, Orr SP, Peri T, Brandes D. Auditory Startle in Trauma Survivors with PTSD
Thinking again about the post-traumatic stress disorder diagnosis 16 January 2001
Salvador Vale, Direccion de Posgrado Facultad de Medicina, Universidad Autonoma de Campeche, Mexico Send response to journal: Re: Thinking again about the post-traumatic stress disorder diagnosis	The published viewpoint about “post-traumatic stress disorder” in January 13, 2001 (1) is confusing to me. The author contends the validity of several matters and as a result of this mixed reasoning he concludes that the diagnosis of PTSD is just some type of suffering that patients exhibit as a “certificate of psychological impairment ” I) Accepting there is nowadays promotion of personal rights, which support a sense of individual injury and grievance, is not indicative that people with PTSD symptoms are not diseased. What is it to be “diseased”? Summerfield says that a disease should have an objective existence in the world. The gold standard to accept the presence of a disease is to find some biological difference that distinguishes this precise entity from other biological states. In this sense, the increased levels of corticotropin-releasing hormone (CRH) in nervous tissues (2) (3), the hypocortisolism (a condition that may increase the CRH synthesis and release) (4), and the consequently increased activation in peripheral blood lymphocytes (5), all of them are biological distinctive events consistent with the “disease status” of PTSD. The corollary of this deregulated stress-response system, hippocampus atrophy, debilitates further the PTSD patients. Consequently, PTSD assembles characteristics of a true disease. II) A different matter is the erroneous use of a medical diagnosis (PTSD) within the trauma industry (like a kind of social movement trading on the authority of medical pronouncements). Here, we must accept that some type of social engineering should be done to limit these manoeuvres, but it does not include abandon a medical diagnosis. III) An old discourse within some intellectual circles contends that the mental health disturbances are just social constructs and that they do not represent biological entities. This statement was frequent during the 70’s when existed abuse of “diagnosing psychosis ” to label people activities represented political dissidence in some countries. Unfortunately, with the elaboration of the Diagnostic and Statistical Manuals in psychiatry, although it solved the communication problem that occurred without them, criticisms were developed because the diagnostic categories can be viewed as “democratic elaborations”. Summerfield correctly suggests: ” the entire cannon of diagnostic categories in DSM-IV is phenomenological and descriptive …” . But this circumstance is not at odds with the PTSD diagnosis. It makes clear our lack of knowledge about biological markers for many diseases, like occurs in other areas of psychiatry and medicine (think for example, in major depression or chronic fatigue syndrome respectively) IV) Summerfield makes statements without evidence-based data, about the value of stoicism (the stiff upper lip) and of fortitude as possible healthier “style of living”. There is tension, he says, between this older, time-honored construction, which center on resilience and composure, and what is emerging today. However, nobody walks now thousands of kilometers like the ancient Greeks against the Persian army during warfare of Alexander. Recently appeared need of social support for human beings, if is used with correctness, can improve the quality of our lives. Finally, in PTSD the "traumatic memory" is not the basic pathology of the disorder. It is the most easily communicated symptom (like cough during a pneumonic process) but the pathophysiologyical basis of this disease can be found in the deregulated stress-response system within the hypothalamic-pituitary-adrenal axis, a disturbance that only a proportion of persons that suffer traumatic events will exhibit. We should avoid to label as a disease any clinical distress, like Summerfield proposes. However, if we, psychiatrists, are now doing these errors, it is probably not due to the intrinsic weakness of the PTSD diagnosis. It is the consequence of our poor clinical performance. We must try to make better diagnoses, but not eluding clinical entities without good reasons. 1.- Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2000; 322: 95 – 98 2.- Backer DG, West SA, Nicholson WE et al. Serial CSF corticotropin -releasing hormone levels and adrenocortical activity in combat veterans with post-traumatic stress disorder. Am J Psychiatry 1999; 156: 585 – 8 3.- Kellner M, Wiedemann K, Yassouridis A et al. Behavioural and endocrine response to cholecistokinin tetrapeptide in patients with post- traumatic stress disorder. Biol Psychiatry 2000; 47: 107 – 111 4.- Heim C, Ehlert U, Hellhammer DH. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology 2000; 25: 1 – 35 5.- Wilson SN, van der Kolk B, Burbridge J et al. Phenotype of blood lymphocytes in PTSD suggests chronic immune activation. Psychosomatics 1999; 40: 222 . 225
Well intentioned yet factually wrong. 16 January 2001
Grant J Devilly, Senior Lecturer Department of Criminology / Psychology, University of Melbourne Send response to journal: Re: Well intentioned yet factually wrong.	This article (1) has indeed brought zealous feedback for the author from far and wide, yet I see this article as ‘good intention, poor method, bad outcome'. There are some good arguments within this article which have been jaded by their method of use. Ideology and the latest fad from post- modernism (or is post-structuralism still the flavour of the month?) is not the same as reasoned evidence. Let us consider... PTSD is not solely a "legacy of the American war in Vietnam". As others here have written in response to this article, there is a long legacy to the problems which people present with and the term "PTSD" was designed to encapsulate. In fact, one of the earlier documented reports of a returned serviceman with such problems is that reported by the Greeks in 400 B.C. and written by Herodotus (2) (see Gersons and Carlier (3) for a discussion of the modern historical and political evolution of PTSD). However, the kernel of truth (if one excuses the pun) which Summerfield's argument relies upon is that the Vietnam War (for the record there were other countries involved as well as America and Vietnam) led to a ready number of returned servicemen displaying and reporting similar problems. This lead to research aimed at rectifying the problems and returning the servicemen back to their former capacity. However, research relies on the assumption that we are comparing apples with apples. For this to occur a set of criteria are described which a committee of experts agree describes the common presentation of those reporting the problem and from scientific observation and investigation. This description which, to the chagrin of the post-modernists, we shall call a "diagnosis" helps make research studies comparable across settings. A description of what has become known as PTSD has been around since 400 BC, yet it became known as PTSD in 1980. However, this was also partly due to the similarity of symptoms between Vietnam veterans and sexual assault and rape victims. This is why it is Post-Traumatic Stress Disorder and not War Neurosis, Soldiers Heart, Combat Fatigue, Shell Shock, etc etc. The argument of medicalising an issue is again not the whole truth. Following a disaster it has unwittingly become popular to "debrief" people. Such a process of iatrogenically presenting, priming and prepping medicalised information appears now to be a very poor response(4). In fact Summerfield rightly wrote warning of this as far back as 1995 in this journal (5). However, people presenting with a cluster of signs (dare I use the word "symptoms" again?) does not equate to the "medicalisation" of a problem. In fact it appears to be a disenfranchisement of the patient (erhmmm, I mean person). If this is a socially constructed phenomena - why do we get similar presentation rates and symptoms around the world and similar success rates when treated? In fact, when we don't arrive at similar treatment success rates this alerts us to a possible problem with either the sample or the intervention (6). Of course an argument referring to the circular nature of naming and presentation leads to a circular, non -profitable argument which Wittgenstein ended with the phrase "whereof we cannot speak, thereof we must remain silent". Summerfield also appears to be suggesting an argument against the current form of trauma tourism being practiced by so many debriefing companies and "Humanitarian Assistance Programmes", if the phrase isn't a tautology. This is a most laudable and worthwhile argument in my opinion, one based upon a growing body of empirical support. However, this argument is different to suggesting that all diagnoses are a western concept and harmful. The PTSD array of symptoms are very adaptive if one is in an ongoing trauma. Hyperarousal, avoidance and numbing all have a very valued function during trauma - just ask a veteran / rape victim / earthquake survivor etc. So referring to 99% of the inhabitants of war-torn Sierra Leone as meeting the criteria for PTSD, is again misleading. What is being talked about is acute (sometimes chronic) current stress, not PTSD - there is no POST but still CURRENT. Wait 4 weeks after the terror has stopped (and the person really is objectively safe) and measure again, then wait 3 months down the track and measure again. This is why therapists will not treat a person who is still being traumatised. They may well recover down the track and the current symptoms are of benefit. Deciding who is presenting with a genuine case and who is attempting a cash payout to spend the rest of their days drinking Martinis in Bali is again an issue of which all therapists and forensic assessors are aware. To dismiss all cases of PTSD, as Summerfield suggests, as evidence that the claimant / patient is suffering a serious lack of firmness to their upper lip is obviously risible. However, the need for accountable methods of validation is well taken. I could go on but then this letter would be nearly as long as the article. However, in summary, Summerfield's paper appears to spring from the well of good intentions, yet appears a somewhat confused, and at times inaccurate, article. I question whether he believes the presented argument himself, but rather is playing Devil's Advocate for the sake of debate - going for 10 when he only want 5. 1. Summerfield, D. (2000). The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 322, 95-98. 2. Herodotus. (1972). The Histories. Harmondsworth, Penguin Books. 3. Gersons, B.P. and Carlier, I.V. (1992). Post-traumatic stress disorder: The history of a recent concept. British Journal of Psychiatry, 161, 742-748. 4. Kenardy, J. (2000). The current status of psychological debriefing: It may do more harm than good. British Medical Journal, 321, 1032-1033. 5. Summerfield, D. (1995). Debriefing after psychological trauma. Inappropriate exporting of western culture may cause additional harm. British Medical Journal, 19, 509. 6. Devilly, G.J., and Foa, E.B.(In Press). The investigation of exposure and cognitive therapy: Comments on Tarrier et al (1999). Journal of Consulting and Clinical Psychology.
The validity of a diagnosis is not determined by its cause 16 January 2001
Tom Clark, Clinical Research Fellow in Psychiatry University of Birmingham Send response to journal: Re: The validity of a diagnosis is not determined by its cause	Summerfield (1) gave an interesting discussion of the validity of the diagnosis of post traumatic stress disorder (PTSD). It is unfortunate that in doing so he overstated his case and diluted the impact of his argument by confusing two fundamentally distinct issues. The concept of illness and the validity of medical and, in particular, psychiatric diagnoses do not necessarily impinge upon a consideration of the potential misuse of such diagnoses. There is little doubt that PTSD is over- diagnosed, that it exists beyond the medical sphere, diagnosed by psychologists, nurses and other health professionals, lawyers and the media. It is clear that in modern society, the influence of prevailing individualistic and self-centred values and the need for a universal term for suffering which may justify the actions of “victims”, litigants and their advocates has lead to this over expansion of the concept of PTSD. However this does not invalidate a diagnosis when it is used appropriately. Acquired Immune Deficiency Syndrome is an obvious example (of many) that denies Summerfield’s assertion that in order for an illness to be “real”, neolithic people must also have suffered from that particular diagnosis. The influence of socio-political factors in the genesis of psychological symptoms that may form a diagnostic category similarly does not deny the diagnosis. Psychological, social and other extrinsic factors are of importance in the pathogenesis of all illnesses, physical as well as psychiatric. Such factors may give rise to illness just as legitimately as genetic aberrations, infection, diet and lifestyle. Consequently illnesses may indeed come and go through time and across cultures. Summerfield’s questions “where were they before?” and “where did they go?” remain valid but they do not imply a lack of objective reality. Psychiatry relies entirely on a syndromal classification of disease. This inevitably introduces subjectivity to diagnosis, which makes psychiatric diagnoses more vulnerable to misuse than those of other medical specialties. It is not a problem unique to psychiatry however. The problems described by Summerfield may also operate with regard to diagnoses of whiplash injuries, post-concussional syndrome, back injuries, chronic fatigue syndrome and many others. The baby (post-traumatic stress disorder) should not be thrown out with the bath water (spurious eponymous “diagnoses”). Rather, psychiatry should strive to classify psychological reactions to stress more accurately, pursue the holy grail of biological markers to inform and aid appropriate and objective diagnosis and embrace the task of educating the public and the media in the correct use, significance and interpretation of current diagnostic labels. References 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322:95-8
Frighteningly educational 17 January 2001
Robert King Private Practice Send response to journal: Re: Frighteningly educational	Most interesting responses, and where do we start, where do we go from here. While I read through each response, I see older men, who believe they were there. I see younger men who were there, and I see women, young and old who see yet another story. It's not simply a battle, it's not a horrific accident, it may not even be an "attack". It is something we as a society may do to each other. It may be vicious, perhaps it was war, personal invasion of home or soul, or the loss of a pet. It's not a new clincial finding, your simply looking at a name. PTSD is relevant to the insurance industry and that is why it is in the DSM. "PTSD" is relevant to the patient, the patient takes "it" seriously, and all of us who are doctors, nurses, therapists, psychologists need to focus on what we can do to assist our patient's to rally above this personal conflict. I think the statement that the condition is "non- specific and imprecise" is silly and shallow. Your engineering background appears to be blinding your wisdom to heal. We need to treat the patient, they are in need.
The validity of PTSD 17 January 2001
Arthur Rifkin, attending psychiatrist Hillside Hospital Send response to journal: Re: The validity of PTSD	I believe the author overstates his case. He says PTSD arose from the ridicule American veterans of the Vietnam War received. I don't believe he can cite evidence that such ridicule occurred to any substantial extent, and more relevantly, that those veterans diagnosed with PTSD suffered such ridicule. The larger point concerns distinguishing illness from bad behavior. In the absence of a known etiology or pathophysiology, we assign the sick role with some reluctance. Yet, we do it without significant opposition in conditions such as schizophrenia, depression, mania, OCD, phobias, and some other conditions. For other conditions, such as the paraphilias, personality disorders, and addictions, we have uncertain convictions. Even if we feel comfortable defining an illness, does that exculpate the person with that illness from moral obloquy for all his behavior? I see no theoretical or practical means of clearly dividing the behavior arising from sickness or from freely-chosen bad motives. We may postulate that illness comes from a disordered mind or brain, but we have no foolproof way of determing whether the mind or the brain are disturbed. We say the self-centered, over-emotional person has borderline personality disorder, at least some do use this diagnosis, but we say the mean bigot does not have a disorder. His meanness and bigotry arise, we say, from poor learning, but his mind and brain function normally. I don't see sufficient evidence to sustain differences such as these. I suggest that the way out of this muddle is to give-up the attempt to define illness and keep our attention focused on whether the person has symptoms that distress him, or others, and for which we have treatments that ameliorate these symptoms. Let the criminal justice system decide how they want to deal with these people who commit crimes, and let psychiatrists try to help people in a nonjudgmental way. This doesn't imply we condone misbehavior, but if we have means to correct such behavior, we should offer it. If we consider diagnosis merely a short-hand way of saying something useful in predicting important information about the patient, and don't consider diagnosis some naturally-occurring thing like a chemical compound, we may spare ourselves much grief. Arthur Rifkin, MD
Myth of homogeneity 18 January 2001
Peter Jezukaitis, Occupational Physician Private Practice, Adelaide Australia Send response to journal: Re: Myth of homogeneity	A myth of homogeneity is often promolgated when inferences are made from sampling a phenomenon at its extremes. In the case of PTSD using generalisations from the experience of veterans or from "trips on footpaths" does little to understand all that we see. Australia experienced an epidemic of RSI in the 1970's occuring in a population not well predicted by ergomonic risk. The reasons for the rise and dramatic fall are not well understood. A research opportunity was missed. Its reduction is unlikely to have been influenced by a biomedical paradigm. An endemic however continues in relation to cumulative trauma that always existed and continues to be evident. Questions addressing impairment, sufferring, disability and causation will have multidemsional answers.
Epistemology and Ontology of PTSD 18 January 2001
Casimiro Cabrera-Abreu, Consultant Psychiatrist Mental Health Clinic, Regina, Saskatchewan, Canada. Send response to journal: Re: Epistemology and Ontology of PTSD	Sir, Summerfield's paper was long overdue. As a psychiatrist working in Canada, and proud of having been trained in Great Britain, I have been overwhelmed by the arbitrariness and the superficiality of the construct "Post-traumatic stress disorder" which I encounter almost everyday tagged to some of my patients in an irresponsible fashion. It is precisely from two Canadian scholars, one philosopher and the other a historian of psychiatry, that we can get some further insight into Summerfield's incisive critique of this "condition". The philosopher, Ian Hacking, in a recent book borrows (1) from John Searle (another philosopher) two interesting concepts, which can be applied to Summerfield's analysis. In discussing the "social construction" of mental illness, Hacking mentions the fact that young women with Anorexia Nervosa die from their condition. In this sense their condition is epistemologically objective but ontologically subjective. Post-traumatic stress disorder is also epistemologically objective (i.e. people suffer) but it displays ontological subjectivity (it is the result of an elaborate historical process mired in the intricate tapestry of the construction of DSM - III and its sequels). The second Canadian scholar is Edward Shorter who in his book "From Paralysis to Fatigue" (2) impinges upon the subtle and interactive process between physicians, patients and cultural mores. Spinal irritation, reflex theory, gynecological surgery to cure nervous mental illness and hysterical fits were the result of this ongoing process. According to Shorter "when the doctor's idea of a 'legitimate' disease changes, the patients' idea changes as well. When the doctors shifted their paradigm from reflex neurosis emphasizing motor hysteria to the central nervous paradigm of sensory symptoms, the patients shifted accordingly." I believe that Summerfield's paper elevates the tone of the debate around the unwarranted medicalization of human suffering rather than confusing it. It also poses interesting questions concerning the current status of psychiatric classification systems. Casimiro Cabrera-Abreu MRCPsych Consultant Psychiatrist Regina, Saskatchewan, Canada. casimiro@sk.sympatico.ca 1.Hacking I. The Social Construction of What? Harvard University Press. Cambridge, Massachusetts; 1999. 2.Shorter E. From Paralysis to Fatigue. A History of Psychosomatic Illness in the Modern Era. The Free Press. New York; 1992.
Post-traumatic stress disorder 18 January 2001
M D Beary Send response to journal: Re: Post-traumatic stress disorder	Editor - Summerfield in his review of the diagnosis of post- traumatic stress disorder notes the inherent problem of including both cause and effect in the operational definition of an illness. DSM IV not only includes the symptomatology but also the types of traumatic experiences essential to make the diagnosis. It would be ludicrous to state that a rib could only be fractured by certain types of blows in certain circumstances. The same must apply to psychiatric injury. Surely the same rigour must be taken to distinquish in the symptomatology between psychiatric injury and the mind's healing mechanisms. In PTSD there would seem to be an initial neurophysiolgical injury to the the startle mechanism which remains grossly over-reactive coupled with traumatic memories that act as noxious foreign bodies in the mind. added to this are the healthy and unhealthy responses which may be normal distress or abnormal distress such as a major depressive disorder. Summerfield seems to combine all these elements as normal distress. It is refreshing that he points out that in high-lighting this ancient disorder american psychiatrists were able to improve the lot of the defeated Vietnam army veterans by making their psychiatric injury compensatable. They seem to have acted in the same way as did socially conscious gps at the inception of the NHS when they prescribed huge qunatities of cottonwool to their very poor and cold patients each winter. In contrast with the planned changes to the Mental Health Act psychiatrists in the UK may find themselves under social pressure to act in ways which may not be in the patient's best interest unlike the americans who "invented" PTSD. 1. Summerfield. D BMJ 2001;322:95-8 MD Beary Consultant Psychiatrist The Priory Hospital North London, London N14 6RA
Victims' suffering is real 19 January 2001
Juliet Cohen Send response to journal: Re: Victims' suffering is real	Editor - In his views on the sociological origins and implications of post traumatic stress disorder Summerfield seems to overlook the clinical basis for this complaint. There are real patients out there who complain of a group of symptoms best described by the diagnostic criteria of DSM IV and that is why these criteria are used. Not all seek compensation, many have no name for their condition, but they do often seek help. Of course there is a gradation of severity from those who have been in a minor road traffic accident to those who have survived horrendous atrocity, just as there is a gradation from sadness to full-blown depression. That does not make it less of a clinical entity and it does not make it less of a challenge to treat. Dismissing the suffering of a patient with PTSD as a sociological problem is the same as telling a depressed patient to pull themselves together. Some can do it and some cannot. Some patients can bear great pain without it ruining their life but others find the pain impinges on their ability to carry out a normal life. When their symptoms are disabling we should not tell patients to pull themselves together but try and offer various forms of therapy. Summerfield quotes with apparent approval a remark in the American Journal of Psychiatry to the effect that if anyone liked a psychiatric diagnosis they were given it would be PTSD. Has he ever really listened to a patient describe the hell of their nightmares and flashbacks? Has he looked at their pallor, their red-rimmed eyes, their bitten fingernails and thought that this was merely a construct of media hype and compensation neurosis? Perhaps he has been lucky enough never to suffer an accident or witness any horror in his medical training that had the power to linger in the memory and reappear in dreams? It is hard otherwise to explain such an outlook. Much is made in his article of the lack of specificity of the diagnosis. This feature is hardly unique in medicine. Arthritis is a condition far harder to diagnose specifically and with an enormous range of symptoms and severity but this does not make the term itself without use both to doctors and patients. Summerfield also comments on PTSD's dependence on external events to define its onset and the recency of this idea as pathological in the context of the long history of man's traumatic memories. Most orthopaedic diagnoses are entirely dependent on external traumatic events for their causation but we do not find surgeons agonising over whether to nail the broken pieces of bone back together just because in days gone by they were left to heal as best they could. Finally Summerfield cites a recent survey of adults in war-torn Freetown, Sierra Leone. He comments that the finding of 99% incidence of post traumatic stress disorder is clinically meaningless, presumably simply because the incidence is so high. What he seems unable to see is the possibility that the incidence is high because terrible events have occurred and the people are suffering. It may be possible to define war as a 'sociological construct' but its effects on human beings are as real as the people who experience them. Victims' suffering is real to them and it is up to doctors to try and relieve this, not debate its existence. Juliet Cohen General Practitioner Donnington Health Centre, 1 Henley Avenue, Oxford, OX4 4DH 1.Summerfield D The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001 322:95-98 Summerfield worries that the overuse of the PTSD label will have terrible consequences but I have greater faith in the intelligence of the average man.
Denial exacerbates psychiatric injury 19 January 2001
Tim Field, Author - Speaker Oxfordshire Send response to journal: Re: Denial exacerbates psychiatric injury	Dr Summerfield's controversial views on PTSD seem to stem from prejudice rather than from experience. Having experienced PTSD I can vouch for its existence. Having since supported thousands of people with similar symptoms (and causes) I can also vouch for the damage that subsequent denial can wreak. Iatrogenic denial (in which invention and the use of jargon play a central role) is a significant factor in the prevention of healing and recovery which may constitute negligence and even malpractice. Another form of denial is to confuse psychiatric injury with mental illness, with which there is some superficial similarity - but many core differences. In a compensation culture there will always be the occasional frivolous claim. However this should not be suborned as a specious justification for denying the existence of a type of injury which some professionals have difficulty differentiating. Instead we should identify the reasons why frivolous cases succeed whilst genuine cases fail. The reasons, it turns out, have to do with the inability of some mental health professionals to recognise, diagnose and treat psychiatric injury, including Post Traumatic Stress Disorder. Defendants will often commission a specific psychiatric viewpoint (and a specific psychiatrist), regardless of the injured individual's circumstances or causal events, for the express purpose of abdicating responsibility, evading accountability, and avoiding financial penalty. Collusion in such practices brings the psychiatric profession into disrepute. Schopenhauer wrote, "All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third is it regarded as being self-evident". For self-evident experience-based information on PTSD (and one of its poorly-recognised causes) I refer you to www.successunlimited.co.uk/PTSD/index.htm
Politcially correct and incorrect diagnoses 19 January 2001
Trevor Stammers, Tutor in General Practice, St. George's Hospital Medical School Send response to journal: Re: Politcially correct and incorrect diagnoses	Summerfield (1) gives a timely warning that "the psychiatric category is the instrument by which moral change is fashioned into a medico-legal one" . He argues that "psychiatric diagnosis is primarily a way of seeing", since disorders come and go in each new edition of the Diagnostic and Statistical Manual of Mental Disorders . Around 1974, one of the disorders that went was homosexuality. Just as Summerfield identifies the medicalisation of post-traumatic stress disorder in relocating distress from the social to the clinical arena, Satinover (2) similarly traces the demedicalisation of homosexuality in relocating sexual orientation from the clinical to the social arena. In a fascinating counterpoint to Summerfield's observations on the increase in diagnosis of PTSD, Satinover points out that between 1966 and 1974, Medline listed 1 021 articles on the treatment of homosexuality. Between 1992 and 1994 there were only two such articles listed, despite the fact that there were more than twice the number of journals by then. Reading the Summerfield and Satinover accounts together has been a highly illuminating exercise, which has challenged my conceptual framework of how psychiatric diagnoses operate. I commend it to other BMJ readers. Trevor Stammers 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category BMJ 2001; 322 95-98 2. Satinover J. Homosexuality and the politics of truth. Baker 1996. Michigan. (ISBN 0-8010-5625 X)
PTSD response to Summerfield 19 January 2001
Malcolm Weller, Hon Research Prof Middlesex Univ 30 arkwright road, london NW3 6BH Send response to journal: Re: PTSD response to Summerfield	EDITOR - There are errors in the article, The invention of post- traumatic stress disorder and the social usefulness of a psychiatric category by Derek Summerfield, BMJ 2001;322:95-98 ( 13 January ), and Dr. Summerfield's points are sometimes unclear. Taking these points in the order in which they appear. In the United Kingdom awards for psychological damages based on the diagnosis (of PTSD) can be several times higher than, say, the #30,000- #40,000 limit that the Criminal Injuries Compensation Authority applies for the traumatic loss of a leg. Response. This is not so for pain and suffering, perhaps Dr. Summerfield is considering loss of earnings. I am unclear whether this is what he means and if he does mean this in some cases whether he considers that this is inappropriate. The entire canon of diagnostic categories in DSM-IV is phenomenological and descriptive, bar post-traumatic stress disorder. Aetiology is not included in definitions because it is invariably multifactorial. Only post-traumatic stress disorder supposes a single cause. Response. It is my understanding that a single cause is also proposed in the definitions of post puerperal depression and psychosis, and shared psychotic disorder (that used to be called folie a deux). What is distinctive about an adverse experience for a survivor would come through in the active conceptualising and meaning making of that experience, a process which the survivor undertakes. However, no psychiatric model captures this. Response. I find this somewhat opaque. It seems to be part of the critique of the PTSD but it is my understand that the way that all psychiatric conditions are conceptualised is an interaction between an individual's genetic make up, his or her personality, personal history, social environment and the significance of the event or events for them within these contexts. The diagnosis is claimed to represent a distinct category of psychopathology, but it is largely grounded in phenomena that are common to many other psychiatric diagnoses, such as mood, anxiety, sleep patterns, etc. Response. There is a limited repertoire of physiological responses to stress and limited facets of emotional life. Accordingly, there are overlapping features in most psychiatric diagnoses but each diagnosis has a unique grouping of these phenomena. The way that Dr. Summerfield's argument is constructed, one has the impression that this point is uniquely problematic in PTSD. Above all, the diagnosis of post-traumatic stress disorder lacks specificity: it is imprecise in distinguishing between the physiology of normal distress and the physiology of pathological distress. Response. Clinical studies have found that PTSD is associated with changes in hypothalamic/pituitary/adrenal (HPA) axis function (for a review, see Bremner et al 1999 (1)) and that patients with PTSD differ from those with depression with respect to cortisol response. It was also known that stress exposure may have long- term effects on the corticotropin-releasing factor/HPA axis (1). This is consistent with epidemiological studies that show that PTSD is often chronic and enduring, and therefore likely to affect future employment prospects. Malcolm Weller Hon. Research Professor, Middlesex University, 30 Arkwright Road, London NW3 6BH malcolmweller@hotmail.com 1. Bremner JD, Southwick SM, Charney DS (1999): The neurobiology of posttraumatic stress disorder: An integration of animal and human research. In: Saigh PA, Bremenr JD, editors. Posttraumatic Stress Disorder: A Comprehensive Text. Needham Heights, MA: Allyn & Bacon, 103/143.
The Parameters of Pain 19 January 2001
Judith Hollands, Author and Professor of English Onondaga Community College Send response to journal: Re: The Parameters of Pain	I agree that Dr. Summerfield appears to have sound intent in his article regarding PTSD; however,mis-labeling takes prime focus. Certainly an inaccurate diagnosis raises problems for patients and liability suits. However, as a trained advocate for targets of trauma and abuse,the issue here is pain, not its accurate label. No one would invent the kind of suffering trauma engenders: damaged intimacy and trust,fears for situations (although innocuous in the present)which trigger abusive memories, inability to function as before,coping with the misunderstanding and suspicions of others,and shame and guilt (where none is due). Statistics reveal only 2% of reported abuse, particularly endured from supposedly trusted partners,proved without basis. Yet we, as a society, tend to leap upon small statistics with "A-HAH!" fervor, as if so much more is served if we disprove the legitimacy of suffering. The expression of pain, tightly checked, is learned. Indeed, the conditioned suppression of feelings goes back a long way as the route for turning out"real" men. In particular, grief and crying are discouraged.If there is a social construct of doubtful value,it is this,labeling, judging,and making gender-specific certain emotions when, in truth, we all arrive with the same array,and infant boys display more emotionality at birth, not less (1) That we presume to disallow the appropriate response to odious emotional input, circumventing biology,is, to me, most suspect. Recent findings here in the US on the impact of circumcision, most of them performed up to 1999, without anesthesia, have recorded,in some highly sensitive infants, changes in brain structure and in nervous system relay that reflect,most probably, permanent alterations. In one instance, one infant cried so passionately, he ruptured a major blood vessel in his stomach. This has moved some doctors to call the procedure, particularly without anesthesia, "barbaric." and The APA (American Pediatric Association) to issue a recommendation that all infants undergoing the procedure be given pain-relieving medication. Prior to the mid-l980's, "infant pain was denied by the medical community "(2), and it was generally held no harm was done. So much for expertise. What I think this issue begs is the genesis of "normalcy" where pain and its response patterns are concerned. If in conditioning standards, their root is arbitrary and questionable. The locus of impact and its degree of tolerance, are, indeed subjective, as designed by Creation. Exterior endorsement as the arbitrer of reality has severe limitations, ones research, gladly, is beginning to recognize. l. Pollack William, PhD. (1998) REAL BOYS Henry Holt&Co. New York USA p>2. Circumcision Resource Center Boston Mass. Infant Responses During and Following Circumcision" 1/09/01 http://www.circumcision.org/response.htm
Flawed logic in denial of post-traumatic stress disorder 21 January 2001
Simon J Ellis, Consultant Neurologist North Staffordshire Royal Infirmary Send response to journal: Re: Flawed logic in denial of post-traumatic stress disorder	Editor - The paper on post-traumatic stress disorder (PTSD) by Summerfield (1) starts with flawed logic and ends in denial. By starting from an assumption that a psychiatric diagnosis has an objective existence independent of the observer he sets psychiatry in a world of its own. All other diagnoses are observer dependent. In fact all reality is observer dependent. As a neurologist migraine exists as an illness and may be related to changes if serotonin. It is irrelevant whether Neolithic people suffered with what we would call migraine. The concept of migraine is useful in my clinical practice. Its existence is dependent on its utility. Homosexuality was once considered a disease. In today's society such a view is laughable. The concept of homosexuality as a disease has lost its utility and so no longer exists. Summerfield believes that PTSD is a recent social construct, despite citing evidence that some thing similar (shell shock) was recognised during the First World War. He doubts that Neolithic people had PTSD and therefore denies its existence. I doubt Neolithic people had much in the way of squamous cell lung cancer, but I doubt not the utility of such a diagnosis today. Summerfield thinks that the idea that of a traumatic memory being a pathological entity is a recent construct. This concept goes back at least as far as Freud (2). It seems not unreasonable that memories of bad events might produce psychological harm. To believe otherwise would mean having to reject the notion that sexual abuse in childhood can result in psychological damage and social dysfunctioning in adulthood. If you believe in relativity then although here may be societal norms of what constitutes a traumatic event, the crucial issue is, how an event is interpreted by the individual. Summerfield feels that PTSD confabulates normality and pathology and devalues "true" illness. The DSM IV criteria for PTSD (4) are not a description of normality. Part of the criteria is "the disturbance causes clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning." Patients I have seen are disabled, unable to return to their occupation, unable to do normal daily activities such as driving and unable to visit certain places as a result of the psychological trauma they have received. Summerfield contributes to the myth that there is an army of professionals supporting unjust claims for damages. The reality is that litigation for personal injury is difficult, slow and the financial compensation is generally much less than the financial loss. I am yet to meet a claimant who would have rather have the money they finally receive than the injury they sustained. He criticises "sympathetic" psychiatrists for assisting claimants. Far better some sympathetic psychiatrists assisting the courts in determining as accurately as possible the true disabilities of claimants than unsympathetic psychiatrists deny suffering and disability on the grounds that they do not think Neanderthal man had similar problems. We are not talking about trivial sadness, but serious disabling pathology. If a school of psychiatry wishes to distance itself from such patients so be it, but other caring professionals will wish to understand their patients problems and advise to the best of their abilities. References 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001;322:95-8. 2. Breuer J, Freud S. Studies on Hysteria. Originally published 1895, 2000, Basic Books. 3. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision) 4th edition (15 June, 2000) American Psychiatric Association. Potential Conflict of Interest Derives income from medicolegal practice.
Social construction of PTSD but one of many contemporary issues 21 January 2001
Richard Gist, Principal Assistant to the Director Kansas City, Missouri Fire Department Send response to journal: Re: Social construction of PTSD but one of many contemporary issues	Summerfield's incisive, if sometimes overstated, position regarding the social construction of PTSD (1) is only underscored by the nature (and often the tenor) of the responses it has engendered here. His assertions, whether directly made or merely inferred by the respondents, are variously credited, questioned, attacked, or decried--many times from a foundation of emotion and rhetoric as much as from one of academic argument and discourse. In our recent edited treatment of psychosocial response to disaster (2)--itself a social phenomenon that has grown in such prolific proportions as to warrant serious critical examination--we ended our introductory chapter with the following passage: "Perhaps the most salient cause for concern in all the interventionist zeal is captured in Gilbert and Silvera's (3) 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 (4). Accordingly, given the consistent finding that most individuals confronted with disaster resolve its impacts with or without intervention (5,6,7,8,9), 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. "It becomes clear in this context where the weak links lie. The 'symptoms' which have been collectively defined as indicative of PTSD have, if we are to be objectively truthful, no necessary link to traumata, either generally or specifically, nor does trauma hold any particularly sufficient linkage to the symptoms catalogued. The correlative connections, no matter how heretical to so suggest, may not represent much more than numerical commentary on the variability one's grandma knew so well in the reactions of her peers and acquaintances to the severe schematic disequilibrium wrought of life's most unfortunate experiences. "She knew well that those of 'weaker constitutions' were often overwhelmed by events, but that others showed remarkable and truly humbling resilience in the face of even the most ghastly misadventures. She likely knew also that the nature and functioning of support systems, belief structures, and community had profound effects on whether these trials became, when later seen in retrospect, landmarks or land mines. But when she spoke of these experiences, her vernacular likely considered 'misfortune' rather than 'malady'; when she spoke of accommodation, it was probably couched in concepts more like 'growth' and 'grace' than like 'treatment' or 'recovery.' "Iatrogenesis through conceptual imperialism is a dangerous and insidious specter that lurks close to the heart of all socially constructed nosologies. The struggles and challenges of the human condition are not in most cases essential maladies, no matter how profound the disequilibrium accompanying them--unless and until we assign them that convention. Tough questions about progressive weakening of the stressor criterion, contamination through exacerbation of or interaction with premorbid conditions, or other such aspects of the assignment of labels bearing some pretty hefty implications all their own do not equate to denial of individual discomfort, much less to denial of validity, dignity, or individual worth. These are, however, signs of a conservative and probably well reasoned resistance to pernicious assignation of labels that inch ever so insidiously toward the dangerous and distorted postmodern position that all discomfort is pathognomonic and all disequilibrium symptomatic. It is hard to see that as a healthy or a helpful direction. "Every classical theory of development has held--whether implicitly or explicitly stated; whether intuitively or empirically derived--that challenge and disequilibrium are inescapable harbingers of growth, and that arrested development is the basis for much that we label as dysfunction. But this is not, we would contend, basis for conceiving the impact of life events through any implied model of pathological process instituted by traumatic insult. It is rather cause to consider a wide continuum of adaptations to the essential and inescapable confrontations of life and living, and a challenge to bring the best of our foundations to bear on understanding and enhancing those systems of commonwealth and support that lend us the strength to persevere." (10) Staab, Fullerton, and Ursano (11) proposed in that text the rudiments of an alternative construction of the PTSD concept, derived of psychological and social process considerations and couched in the vernacular of systems theory rather than as any extension of a reified metaphor to physical disease. But the broader questions involve not just widely ranging misapplications of the nosological entry, but even more the astounding range of proprietarily marketed "patent remedies" imported to virtually any affected community by swarms of "trauma tourists." Unfortunately--though probably not surprisingly--many of these intervention products are of questionable value and derivation; more disturbingly, though, even some derived of long-accepted postulates regarding early intervention and prophylaxis (e.g., "psychological debriefing") have proven on sound evalustion to be inert at their best and reliably iatrogenic to some (see Kenardy's recent BMJ editorial(12)or the updated Cochrane Review on debriefing (13) for succinct, if somewhat limited, overviews). Poorly grounded constructs yield poorly specified theory; this, in its turn, yields poorly bounded practice. The ultimate result is a social and clinical landscape fecund for misadventure on many levels (see Gist, Woodall, & Magenheimer (14) for more detailed discussion). No one, to my knowledge--not Summerfield, and certainly not I or my colleagues--is 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 (15). The cardinal imperative for the scientist- practitioner has always demanded that we critically question even thos axioms we hold most dear. Not all help proves helpful; some efforts to help, do matter how compassionately and feverently intended, ultimately render individual and/or social harm. Whether in construction of theory or in clinical consultation, the ost basic of our caveats must never stray far from primacy: "Primum non nocre" (First, do no harm). Richard Gist, Ph.D. Principal Assistant to the Director Kansas City, Missouri Fire Department Associate Professor of Psychology University of Missouri-Kansas City References: (1) Summerfield, D. (2001). The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 32, 95-98. (2) Gist, R., & Lubin, B. (Eds.). (1999). Response to disaster: Psychosocial, community, and ecological approaches. Philadelphia: Brunner/Mazel. (3) Gilbert, D. T., & Silvera, D. H. (1996). Overhelping. Journal of Personality and Social Psychology, 70, 678-690. (4) Major, B., Cozzarelli, C., Sciacchitano, A. M., Cooper, L., & Testa, M. (1990). Perceived social support, self-efficacy, and adjustment to abortion. Journal of Personality and Social Psychology, 59, 452-463. (5) Cook, J. D., & Bickman, L. (1990). Social support and psychological symptomatology following a natural disaster. Journal of Traumatic Stress, 3, 541-556. (6) Helzer, J. E., Robins, L. N., & McEvoy, L. (1987). Post- traumatic stress disorder in the general population: Findings of the Epidemiologic Catchment Area Survey. New England Journal of Medicine, 317, 1630-1634. (7) McFarlane, A. C. (1988). The longitudinal course of posttraumatic morbidity: The range of outcomes and their predictors. Journal of Nervous and Mental Disease, 176, 30-39. (8) Redburn, B. G., Gensheimer, L. K., & Gist, R. (1993, June). Disaster aftermath: Social support among resilient rescue workers. Paper presented at Fourth Biennial Conference on Community Research and Action, Society for Community Research and Action (Division 27, American Psychological Association), Williamsburg, VA. (9) Rubonis, A. V., & Bickman, L. (1991). Psychological impairment in the wake of disaster: The disaster-psychopathology relationship. Psychological Bulletin, 109, 384-399. (10) Gist, R., Lubin, B., & Redburn, B. G. (1999). Psyhosocial, ecological, and community perspectives on disaster response. In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 1-23). Philadelphia: Brunner/Mazel. (11) Staab, J. P., Fullerton, C. S., & Ursano, R. (1999). A critical look at PTSD: Constructs, concepts, epidemiology, and implications. In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 101-128). Philadelphia: Brunner/Mazel. (12) Kenardy, J. A. (2000). The current status of psychological debriefing: It may do more harm than good. British Medical Journal, 321, 1032-1033. (13) Wessley, S., Rose, S., & Bisson, I. J. (2000). Brief psychological interventions ("debriefing")for trauma-related symptoms and the prevention of post-traumatic stress disorder (Cochrane Review). The Cochrane Library, Issue 2. Oxford, UK: Update Software. (14) Gist, R., Woodall, S. J., & Magenheimer, L. K. (1999). And then you do the Hokey-Pokey and you turn yourself around . . . In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 269-290). Philadelphia: Brunner/Mazel. (15) Yates, S., Axsom, D, & Tiedeman, K. (1999). The help- seeking process for distress after disasters. In R. Gist & B. Lubin (Eds.), Response to disaster: Psychosocial, community, and ecological approaches (pp. 133-165). Philadelphia: Brunner/Mazel.
Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome? 23 January 2001
Philip Wynn, Lecturer in Occupational Medicine* Occupational Psychologist** Institute of occupational health, Craig Jackson Send response to journal: Re: Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome?	In his article concerning the ‘invention’ of post traumatic stress disorder (PTSD) and the social usefulness of a psychiatric category that "removes any blame" from the individual and places it elsewhere, we suspect that Derek Summerfield1 has taken a brave step. Sympathy and understanding for individuals involved in traumatic incidents is fully deserved, and is not questioned here. However from an occupational health perspective, diagnoses of PTSD may become an endemic problem. Any attempt at a definitive distinction between stress that employees can be expected to face, and stress which they should not, would be ethically, legally and procedurally impossible. Suffering from undue stress in the workplace has often carried implicit assumptions that individual coping styles and psychosocial modifications of stress were determinants of outcome. This is seemingly not so with PTSD, yet the individual must surely play a role since not all individuals exposed to horrific events develop such problems2. Summerfield confines his observations to PTSD although there are analogies with ill defined but disabling syndromes in occupational and insurance medicine, such as chronic whiplash following accidents, occupationally related chronic simple low back pain, and ‘repetitive strain injury’3. Aetiological factors are poorly understood for each although an increasing body of research into these modern epidemics emphasizes the prognostic importance of psychological and non-medical factors. The chronicity of these conditions may in part be due to over medicalisation in the explanation of the cause or significance of symptoms by clinicians. In addition the last 50 years has seen the relationship between patient and doctor complicated by an increasing emphasis on the doctor as gatekeeper to compensation, sickness absence benefits and ill health early retirement pensions. This potentially distorts the information provided by patients in whom these issues are of relevance and places pressure on the clinician to label common non-specific symptoms as diagnostic entities4. Consequently, Summerfield’s quote regarding PTSD as a ‘good’ psychiatric label to be given is not without precedence in medicine as a whole, as some of these other disorders give access to secondary gain whilst ‘blame’ for the condition lies firmly outside the patient themselves. Perhaps in future, clinicians will use a more flexible multidimensional model to understand much of what is now labeled as PTSD, ‘stress’, anxiety and depression, and the functional somatic disorders, as expressions of human distress5. Such an approach may prove more rewarding in the development of therapeutic options for sufferers of such conditions. 1. Summerfield, D. The invention of Post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322: 95-8. 2. Firth-Cozens J, Midgley SJ, Burges C. Questionnaire survey of post -traumatic stress disorder in doctors involved in the Omagh bombing. BMJ 1999; 319:1609. 3. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130(11):910-21. 4. Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000 Apr 20; 342(16):1179-86. 5. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999 Sep 11;354 (9182): 936-9.
There are many pragmatically correct ways to describe distress 24 January 2001
Susan Hansen , Renata Kokanovic Send response to journal: Re: There are many pragmatically correct ways to describe distress	If you put it in terms of simply 'stress', and it's the way a person deals with a very stressful event, rather than some sort of madness that is in them, you change the whole way they approach it … and it makes it easier for them to deal with. Because it is a huge hurdle for a lot of these people to overcome… It's the initial hurdle of "I need help. I need some assistance with my problem."1 This comment, by a torture and trauma counsellor, illustrates neatly a number of the issues at stake in the vigorous debate sparked by Summerfield2 on the veracity and pragmatics of the psychiatric category of 'Post Traumatic Stress Disorder' (PTSD). This counsellor's observation is drawn from a recent study1 of the varied understandings of 'mental illness', and of psychological and psychiatric 'services', held by people from culturally and linguistically diverse (CALD) backgrounds. Although Summerfield touches on the social implications of psychiatric diagnosis, and Litvia3 (Brief Response, 15/1/01) draws out some of the repercussions of the 'sick role'4 for persons diagnosed with PTSD, the discussion thus far (implicitly or otherwise) has been centred on the understandings 'Western clinicians' have of the lived experience of 'Western patients' in distress. In an increasingly culturally diverse environment, and with the issues of torture and trauma being at least equally applicable to people from CALD backgrounds, it seems reasonable to consider the impact of a psychiatric diagnosis of PTSD on clients with divergent 'health beliefs'. In our study, we were explicitly concerned with the issue of the stigma that is often attached to 'mental illness'. From the data obtained via focus groups conducted with CALD people, and from semi-structured interviews with mental health practitioners, the inappropriateness of western diagnostic taxonomies for many CALD communities became apparent. Stigma in CALD communities can lead to the social isolation and ostracism of not only the affected person, but their immediate family - it is thus vital that clinicians are aware of the very real ramifications that a diagnosis of 'mental illness' can have for persons so described. Notably, the stigma attached to 'being in psychological distress', and 'being diagnosed with a mental illness' appeared to be mitigated by whether or not there was an obvious 'external cause' for the disorder - as was the case for diagnoses of PTSD in torture and trauma survivors. However, there was still a level of stigma attached to such diagnoses. Dr Shalev5 (Brief Response 16/1/01) wonders how s/he could possibly "tell her PTSD patients that their disorder is but a social invention?" Surely, however, no one could seriously argue that Summerfield's intent is for clinicians to callously dismiss the 'calls for assistance' of people in distress? Indeed, this central and defining issue is covered in Summerfield's initial 'Summary Points', where he states that " distress or suffering is not psychopathology" (p. 95). That is, it is unnecessary to recategorize distress and suffering as anything but distress and suffering in order to be of assistance. Clinicians alerted to the possibility of having to differentiate 'genuine' cases of PTSD from 'less serious' presentations might consider Sacks'6 gentle reminder that there are a multitude of pragmatically correct ways of describing human conduct.7 How, then, might we otherwise describe PTSD? Alternatives to describing psychological distress and suffering as "PTSD" can be found in the everyday language of everyday persons. However, there are likely to be cultural variations in the ways in which people prefer to talk about their 'suffering and distress'. Further, the very notion of 'psychotherapy' is not universally accepted as a 'sensible' way to approach 'mental health problems'. Nonetheless, the observations of the torture and trauma counsellor cited above suggest an alternate means by which distress can be 'acknowledged', and 'normalised', in order that clinicians are able to 'offer assistance'. 'Refusing diagnosis' does not necessarily engender a callous dismissal of the reality of the suffering of clients. Indeed, finding alternative - non-stigmatising - ways of talking about distress may offer people another 'way out' - and one that need not necessarily involve "the medicalisation of everyday life as a necessary evil" (Litvia, 15/01/01) REFERENCES 1 Kokanovic, R. Petersen, A., Mitchell, V. & Hansen, S. (2001) Caring for 'the mentally ill' in culturally and linguistically diverse communities. Perth, Australia: Eastern Perth Public and Community Health Unit. Available (from March): http://www.rph.wa.gov.au/hpnetwork/eppchu.html 2 Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a diagnostic category. British Medical Journal, 322; 95-8 3 Litvia, A. (2001) Thinking about the social usefulness of any diagnosis. BMJ Electronic Letters, 15 January. 4 Parson, T. (1964) Social Structure and Personality. New York: The Free Press. 5 Shalev, A. (2001) A disorder that takes away human dignity and character. BMJ Electronic Letters, 16 January. 6 Sacks, H. (1995) Lectures on Conversation (Vols. 1 & 2). Edited by G. Jefferson and with an Introduction by E.M. Schegloff. Oxford: Basil Blackwell. 7 McHoul, A. & Rapley, M. (2000) Sacks and clinical psychology. Clinical Psychology Forum, 142, 5-12
PTSD is only a disease if you´re employee 25 January 2001
Regina Stroebele, self employed "GP" in Germany D- 81675 Munich Send response to journal: Re: PTSD is only a disease if you´re employee	If you lose your husband, your employment, get no money by any public institution, have to run for your life persecuted by a crazy driver, have to move 2 times within 2 years and with 2 children under 14, again lose your work and have to pay for the health insurance of yourself and 2 children although you`re a mentally sane physician with a Specialist`s qualification and a Doctor`s degree, you `re not allowed be ill by yourself, because then you will die from starvation. Any of my employed and PHS - insured patients would be classified as "mentally sick" or "at risk of suicide" even by me, if they weren`t able to cope with such a situation. For me, there was no other possibility than to continue walking/going on. Now, I`ve got my own practice in addition to my website, and I again have no time for such diseases. By the way: in the meantime, we`ve got a new Minister for Health Affairs, at Berlin. http://www.reginadoctor.de
Lions led by donkeys 26 January 2001
John Hopkins, GP Darlington Send response to journal: Re: Lions led by donkeys	Dear Dr Smith, My grandfather was a soldier in the First World War. Years after the war, he described conditions in the trenches. Before going over the top the men would get blind drunk. A machine gun would be aimed along the trench for those who lost their nerve. Some tried to escape the front by opening a flesh wound, putting a penny in, and waiting for sepsis. To this day, Victoria Railway Station in Manchester maintains the door that my grandfather and thousands of others walked through on the way to France. His brother, Arthur, was one of those who did not come back. During the Battle of the Somme, troops on both sides were said to have imagined they saw the Angel of Death riding over the battlefield. Twenty-five years later, the same apparition might have seen above the camps in Europe where millions were turned to ash; Dachau, Buchenwald and Auschwitz. Those who survived the camps, like the men who came back from the trenches, were broken. My grandfather was one of many soldiers who spent long periods in psychiatric hospitals. His son became a chemist whose greatest fear was madness. The most famous witness of the camps was also a chemist, Primo Levi. He took his own life after years of treatment for depression. Shortly before his death he described the illness as worse than his experience of the camp because, by then in his sixties, he lacked the resilience of youth. Since 1945 there have been many wars. There have been countless tragedies falling short of war only for those who were not engaged. The human spirit survives, it may flourish for a while, but it bears the scars. Yours sincerely, Dr John Hopkins
Re: The Convenience of Debating Unexperienced Pain 29 January 2001
Grace Heckenberg City of Portland, Oregon Send response to journal: Re: Re: The Convenience of Debating Unexperienced Pain	Summerfield's article did not deny that overwhelmingly frightening and painful experiences can and do cause prolonged suffering and difficulties, some of which is described in the criteria for PTSD. He did not write that none of us suffer as the result of overwhelming experience or try to portray that suffering as trivial or minor. Instead Summerfield questioned the point of describing that suffering as an illness.
appreciation from a survivor 29 January 2001
Grace Heckenberg City of Portland, Oregon Send response to journal: Re: appreciation from a survivor	As 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 natural responses to such dire experiences degraded as symptoms of sickness. After being cast into a subhuman role by perpetrators and sometimes also those who witnessed the abuse without taking steps to rescue the victim, why would victims of abuse seek more dehumanization through psychiatric judgments which require that self respect be completely stripped away? My personal experience was that what I needed most was not to be free of the nightmares, constant and pervasive fearfulness, etc. but rather to trust my perceptions and reactions, to feel resilant, competent, independent and self-sufficient. It was difficult enough dealing with the effects of serious violent abuse without adding the burden and stigma of so-called mental illness. I had enough problems without therapists undermining my self respect by authoritatively proclaiming my responses sick, me incapable of dealing with anything on my own and in need of suffering even more (e.g. 'do the work') to achieve some state of wellness that would essentially consist of denial of the horrors and impact of the horrors that I experienced. At least several responses to Summerfield's article declared such pathologization of natural reactions as necessary to collect compensation. Certainly that's a sad state of affairs, that victims of highly traumatic experience submit to more brutality in the form of psychiatric belittlement in order to receieve compensation. That's no justification for retaining and using the insulting diagnosis of PTSD but rather an indication that justice systems that require such designations are in need of modification. (Victims of some of the most serious abuse, e.g. child abuse, are never eligible for compensation anyhow. Perpetrators tend to belong to power groups that are able to define away the abuse and harm in the eyes of others. For example, in my USA state, child beating & whipping are still legal exceptions to the statutes that make beating & whipping adults serious crimes punishable by years in prison with the adult victims of such experiences deemed entitled to compensation. It is politically convenient to recognize only certain sorts of child abuse as harmful and to deal conveniently with the adult survivors of horrible childhoods as "criminals" and "mentally ill" instead of victims of abuse as well as gross social injustice.) While reading responses to Summerfield's article, I marveled at how unable to think about life without the definitions of the 'mental health' industry many psy-practitioners and psy-consumers have become. Certainly some suffering people uncritically welcome PTSD diagnosis/treatment because it seems less onerous than other types of psy-diagnosis/treatment. The false promise of making everything OK again must also seduce many victims to abandon their better judgment and cling to false hopes that treatment will provide respect and caring they crave. And perhaps those who do the diagnosing and treating enjoy the benefits of comforting Just World thinking behind victim-bashing (as psy-dx/treatment obviously is) and claiming the wisdom & authority to judge others' lives and experiences too much to look critically at their beliefs and practices. Who wants to be 'well' in the standards of the society that allowed the abuse! Who wants to be cozily reprocessed into a born again believer in self-serving human myths such as altruism, morality, and free will? There's no going back once one has seen the truth about human nature. The only difference between human beings and chickens who peck wounded members of their flocks to death is that former are smart enough to disguise what they are up to and accomplish it with a minimum of unslightly blood and gore. The PTSD nonsense, like all psychiatric diagnosis and treatment, is just a method of containing, suppressing, and beating down hurt individuals while allowing the pretense that we are somehow civilized and better than other animal species. Trauma opened my eyes, and I'm certainly not going to shut them again no matter how awful the view.
Human Misery 2 February 2001
Frank Hoffmann, GP Balmoral Surgery, Deal Send response to journal: Re: Human Misery	Dear Editor Derek Summerton has to be congratulated for taking us to a different viewpoint of the montain of human misery, nowadays called postraumatic stress syndrome. May I ask for maps of other peaks such as depression, ADHD or even cardiovascular disease? The only cloudy issue in his article seems to me his assumption that a medical disease, as part of the definition, has to be independent from culture. Coronary heart disease is well accepted as a medical term. Is it reasonable two assume that CHD was a condition affecting cave men and women? It can make sense to have a medical label for some conditions other than postraumatic stress disorder, even when prevailing living circumstances are causative. This does not imply that medical treatments are necessarily the best remedy.
Post-traumatic stress disorder: a convenient diagnosis for patients and doctors 4 February 2001
Antonio L Teixeira, Private Psychiatric Consultants Belo Horizonte, Brazil, Henrique Alvarenga-Silva Send response to journal: Re: Post-traumatic stress disorder: a convenient diagnosis for patients and doctors	Distress is not always pathological. However the anguish of distress compels the sufferer to give it a name and a meaning (1). They are conveniently supplied by many medical diagnosis. Medical diagnosis also allows the person to assume a "sick role" and may offer financial benefits (2). That seems to be the case with some patients with post-traumatic stress disorder (PTSD). Despite being a psychiatric diagnosis, PTSD is accepted by patients and has come to be largely employed by physicians, even in relatively ordinary events as appointed by Summerfield (3). Many patients not only refuse psychiatric diagnosis but are hostile to it because it implies fault, weakness, and even malingering (1) .Nevertheless, PTSD "has become the means by which people seek victim status" (3) and being victim is a major attitude toward distressing situations in present days (4). It is time to rethink some psychiatric categories not to consider disease human feelings. References: 1. Ross SE. "Memes" as infectious agents in psychosomatic illness. Ann Intern Med 1999; 131: 867-871. 2. Sharpe M. Doctors' diagnoses and patients' perceptions. Lessons from chronic fatigue syndrome. Gen Hosp Psychiatry 1998; 20: 335-338. 3. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322: 95-98. 4. Roudinesco E. Pourquoi la psychanalyse? Paris, Librairie Arthème Fayard, 1999.
Re: Post-traumatic stress disorder: a convenient diagnosis for patients and doctors 6 February 2001
Ellen Goudsmit, Medical Archivist London Send response to journal: Re: Re: Post-traumatic stress disorder: a convenient diagnosis for patients and doctors	I note that many contributors to the discussion of the Summerfield paper seem to have a rather confused view of what PTSD is and who actually suffers from it. For instance, this disorder should only be diagnosed in certain circumstances where people have been confronted with death or potential injury to themselves or a significant other (cf. DSM-IV-TR). In practice, it has been applied to people with particular symptoms following such events as the holocaust, fires, train, plane and car crashes, hearing a child has terminal cancer etc. I personally do not regard these is any old 'ordinary' events. (Incidentally, I'm aware that colleagues have also used the term in relation to symptoms reported by doctors treating people after Omagh. It's a moot point whther that was the most appropriate diagnosis in this case and the follow-up was rather short. Perhaps acute stress might have been more accurate?). Lastly, a response from Dr. Stroebele suggested that only employees can afford to develop PTSD, and that as a busy GP, she did not have time to succumb to such disorders. I don't think that Holocaust survivors had the time either and I'm not sure this is a helpful and sympathetic contribution to the debate. I know of a GP who survived a Japanese camp and who developed PTSD a few years ago. He was forced to give up his practice and the work he loved. He was self-employed and busy too! The fact that a few individuals fight for and receive compensation does not mean that the illness is just a convenient label for those requiring an excuse to adopt the sick role, or that those who admit to the condition are seeking victim status. Recognition of the disorder has nothing to do with people wanting to pathologize distress for dubious reasons, nor is it related to any political agenda which I'm aware of. Let's stick with the definition we have and try to limit the speculation and the victim-blaming. Regards to all,
The role of ‘traumatic memories’ in the psychopathology of PTSD. 6 February 2001
Richard Meiser-Stedman, PhD student Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, SE5 8AF Send response to journal: Re: The role of ‘traumatic memories’ in the psychopathology of PTSD.	Summerfield’s description of the PTSD ‘phenomenon’ makes for interesting reading, and highlights the importance of understanding the social history and impact of psychiatric diagnoses. He makes both valid medico-legal and clinical points, acknowledging the importance of resisting the temptation to label a person ‘in sympathy’ such that they may receive compensation, and warning against encouraging a potentially maladaptive ‘victim’ mentality. However, Summerfield does not adequately address the all-important issue of the psychopathology of PTSD. I believe that, in attempting to get to the heart of the matter, Summerfield correctly directs his criticism at the concept of ‘traumatic memories’, but that his criticism is based on an ignorance of the research into this particular phenomenon. Summerfield’s rejection of the idea of ‘traumatic memories’ is most powerfully refuted by Brewin et al.’s1 suggestion that ‘neuroanatomical research has located a variety of pathways that might permit sensory data associated with an emotionally significant event to be stored in memory without being subjected to cortical processing [p.676]’. The ‘dual representation’ model proposed by these authors suggests that ‘traumatic memories’, that result from a lack of cortical processing, are poorly processed, fragmented, involuntarily elicited, sensory based memories unlike ‘normal’, deliberately retrieved memories. This is perhaps the best explanation of the highly emotion- laden, vivid, physiologically arousing, and even dissociative re- experiencing experiences that are the cardinal feature of PTSD. In addition to offering a highly coherent account of many of the symptoms of PTSD, Brewin and his colleagues succeeded in relating cognitive phenomena to neural circuitry, that presumably would meet Summerfield’s definition of a ‘natural entity’. As a researcher in this area, I wish to have no part in ‘medicalising’ all distress that entails from unfortunate events. I am keen to further understand what promotes and inhibits the processing of ‘traumatic memories’, and the sequelae that they have for the traumatised individual. ‘Traumatic memories’ can form the basis of highly debilitating, chronic and distressing condition, that is worthy of discussion, research, and I believe, treatment, guided by a detailed and scientific conceptualisation. 1 Brewin CR, Dalgleish T, Joseph, S. A dual representation theory of posttraumatic stress disorder. Psychol Rev 1996;103:670-86. Note: The author of this response is supported by a MRC studentship.
Sticks and stones 7 February 2001
Patrick Meade, Happy PTSD survivor New York City Send response to journal: Re: Sticks and stones	This is a bad article in so many ways - bad science, bad data (none), bad logic, bad writing - that it diminishes the BMJ for lending it credibility by publishing it. If the article had even spent a quarter of its allotted space on identifying new or alternative solutions to the non-trivial problems of PTSD patients as it has in dismissing their problems out of hand in favour of the hoary old "stiff upper lip" approach, then it might have provided a modicum of value. As it is, the author merely trails his hand along the ground, grabs a fistful of old stones and hoists them skywards through the greenhouse generously provided by the BMJ. Sure, the stones may splatter and gain attention, but at what expense? Next time, the author could try providing a credible alternative, well-structured logic in his arguments, and a more appropriate publication - given his preference for debunking, might I suggest "Marxism Today"?
Psychiatrists are also a construction 9 February 2001
Jim Hardy, General practitioner Bethnal Green Health Centre, Florida Street, London E2 6LL Send response to journal: Re: Psychiatrists are also a construction	Editor, I agree with Summerfield (1) that " ....the diagnosis of post-traumatic stress disorder (PTSD) has become almost totemic." It is clear that as a diagnostic category it attracts great pecunary interest from a variety of quarters. Pecunary interests have also attached themselves to mainstream psychiatry in recent years. An interest that invests considerable research money in the development and promotion of newer and better drugs for the treatment of depression and psychosis. The result is a dominant biochemical model that is intolerant of qualitative concerns. Summerfield argues that PTSD is a construction of our time and that it would not have existing in neolithic (or any other)times. He is right that it would not have been called PTSD, but madness, badness, anxiety and unhappiness are present and have been present in all societies and they have been constructed and continue to be constructed in many different ways. He is wrong to assume that psychiatrists have a monopoly on diagnostic categories and that DSM 4 is immutable. His statement that "To conflate normality and pathology devalues the currency of true illness, promotes abnormal illness behaviour and incurs unnecessary public costs," is confused. Is he really in a position to decide? Is emotional pain, for instance, not a "true illness"? And if so, how does he know? When is an illness not an illness? When is an illness a disease? The real issue with PTSD is that is inhabits the borderlands of mental ill -health. Psychiatrists increasingly are distancing themselves from these areas of practice. One suspects it is because they are uneasy in a climate that promotes neurotransmitters at the expense of good old fashioned caring. Unfortunately the available structures do not support the latter. Luckily, as with everything else, primary care is ideally placed to deal with these problems, but it is a scandal that community mental health teams in many parts of the country will only accept a psychiatric diagnosis if a patient is to gain access to the service. Jim Hardy. General practitioner. Bethnal green Health Centre, Florida Street, London E2 6LL. jameshardy@doctors.net.uk Competing interests; none
PTSD or not PTSD? Is that the question? 14 February 2001
Ian P Palmer, Tri-service Professor of Defence Psychiatry Royal Defence Medical College, Fort Blockhouse, Gosport, Hampshire PO122AB Send response to journal: Re: PTSD or not PTSD? Is that the question?	PTSD, or not PTSD, is that the question? What is a normal psychological reaction to trauma? “Medical disorders create complex problems, ones that have extended beyond questions of medical diagnosis and therapy to issues of social attitudes and policy” (1) How emotive and sad that Derek Summerfield has been so violently savaged in the Post Traumatic Stress Disorder (PTSD) debate (2). It would appear that to a few respondents the expression of social or cultural aspects of a disorder mean that either the author cares less or the individual is being blamed for their suffering. Anyone who knows the work of Derek Summerfield will know he is far from uncaring. What intrigues me is the absence of a forum to discus this matter rationally and without rancour. The sequelae of traumatic events is too important to be left to doctors alone. The focus on the economic sequelae of such reactions has naturally led to the explosion of blame and legal cases which in my humble experience are seldom of benefit to the individual caught up in the proceedings. I wonder if we are all suffering from a collective blindness. Why can exposure to trauma not consistently predict who gets PTSD? Why has PTSD become synonymous with any psychological reaction to stress? Have we forgotten the multifactorial genesis of ‘neurotic’ disorders and limitations of categorical classifications (3). A moment’s introspection will reveal that the symptoms of PTSD are ubiquitous and may be considered in dimensional rather than categorical terms. Following the break-up of an important emotional relationship such as a love affair, we all experience unbidden thoughts and images of our ex -partner which may be triggered by events, people or places and lead to efforts (of varying success) to avoid these triggers as they upset us. We will feel emotionally aroused and labile, on edge, unable to settle or sleep properly. This is often associated with behaviours such as drinking too much, becoming irascible, irritable and angry, acting impulsively (and at times inappropriately). I would propose we call them the Post Traumatic Stress Reaction (PTSR). Such symptoms and associated behaviours are seen in ‘real’ PTSD, differing only in degree, duration and context. How does PTSR or PTSD develop? Surely they result from the complex interaction between the event; the individual and their strengths and vulnerabilities; the environment during and after the exposure and the culture from which they hail and return. There is also bound to be a neuro-physiological reaction, but it strikes me that the meaning of the event is at the core of the individual’s psychological reaction and how it is managed. My military practice has informed me that whilst psychological reactions to trauma are similar to grief reactions. Both trauma and grief change us and offer us a chance to mature as humans. Such change is inevitable and irrevocable, but need not be negative. The emotional distress associated with loss may be great, but with time assimilated memories will be recollected without pain and the positive aspects within the loss understood and accepted. Like grief, the PTSR is a human reaction to loss. Losses may include bereavement, but more often pertinent is the helplessness engendered at the loss of control caused by the trauma. Loss of innocence at witnessing gruesome events, of ‘invulnerability’ or omnipotence, loss of faith in the ‘predictability’ of life or of Faith itself. Deep rooted anxieties such as the randomness of life and existence itself are questioned, and answers required. In addition the spiritual dimension of traumatic events should not be ignored. Like grief, PTSR settles for most without any interventions from professionals. Help and support are rightly sought from family and friends and those who shared the experience. Psychological defence mechanisms whilst beneficial initially, may become malignant preventing acceptance of change and interfering with resolution of the experience. In grief, dysfunctional relationships with the deceased, the manner of the deceased’s death, current psycho-social support and environment after the death all interact to produce ‘difficult’ or ‘easy’ grief. Whatever happens there will be grief. There will be a grieving process and any unwarranted intrusion into this grieving process holds the potential to interfere with it, which may be an explanation as to the possibly deleterious effects of Psychological Debriefing or Critical Incident Stress Debriefing (CISD). Society knows and understands mourning and would, I hope, be mortified if the neurologists put it all down to neuro-structural or pharmacological damage! I suggest that society needs to accept that after trauma a similar process occurs. The question of when a psychological reaction becomes a psychiatric disorder is important. Quite where this boundary lies is ‘negotiated’ by society in conjunction with medicine; psychology; the law; philosophy; religion; ethics; anthropology; sociology and political science, in much the same way ’Shellshock’ was from 1915 (4). Another problem in the debate relates to PTSD as a ‘not my fault’ or ‘attractive’ psychiatric label, much like Shellshock in WWI. Arguments about compensation and suspicions about malingering have changed little over the years and only fuel the emotional tenor of the debate. On the other hand we must be aware of the tendency for some (including survivors themselves) to blame survivors (the ‘deserving’ victim) thereby excluding them from the help they may need. Psychological reactions to trauma challenge our core beliefs and identities, as does grief. I believe Grief offers as good a simile as any when trying to understand what has happened to a patient and how to help them following exposure to traumatic events. Whilst the omission of context and meaning in the diagnostic process, and the disproportionate focus on the traumatic event alone, makes sense nosologically, it may not help our patients. A full assessment requires information about pre-morbid personality; life history; psycho-social support; the environment before, during and after an event; the context in which the event occurred, and at what stage in the individual’s life cycle it was experienced and the culture in which the survivor lives. I believe our blindness to the ubiquity of the PTSR leads to the over -diagnosis of PTSD. The labelling of reactions as disorders compounds the tendency for victims, and society, to search for someone, or something, to blame which is hardly therapeutic. Is it because context and meaning are so hard to quantify and measure that psychiatry has such difficulty with their part in the genesis of PTSD and PTSR? Have we let our patients down by our obsession for measurement and quantitative rather than qualitative research? Have we colluded with the voyeurism of Society by focusing on the traumatic event alone? (5). My fears are encapsulated in the following quote: “..the medical literature on PTSD still struggles with the issues of responsibility played out in debates over individual predisposition, social environment and neuro-psychology. Meanwhile the recent extension of the PTSD concept to cover victims of child abuse, rape and other violent acts also speaks clearly to the dilemmas of approaching human tragedy with reductive medical models. For while PTSD provides a language with which to acknowledge and describe the impact of horrible events on people’s lives, it also groups so many diverse experiences together in the name of medical science that it strips them of their specific human meaning and consequence. And this may ultimately prove to be not only reductively dehumanising, but also intellectually and therapeutically stifling.” (1) 1. Feudtner, C. (1993) Shellshock and the Ecology of Disease Systems. History of Science. Vol. 31 (4) 377-420 2. Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal. 322: 95-98 3. Goldberg, DP. (1996) A Dimensional Model for Common Mental Disorders. British Journal of Psychiatry. 168 (suppl.30), 44-49 4. Ritchie, RD. (1968) One History of Shellshock. PhD Dissertation, Univ. of California San Diego
Utility for whom? 14 February 2001
Grace Heckenberg Send response to journal: Re: Utility for whom?	Several responses have defended the PTSD diagnosis on the basis of utility. Utility for whom? For mental health professionals? YES. It allows them to call natural emotional reactions to overwhelming events a disorder, thereby allowing them to justify treating that disorder and to be paid by medical insurers for such treatment. For society in general? YES. The judgment of the natural responses of victims of emotionally overwhelming experiences allows them to essentially ignore and politically disenfranchise such people. It allows those who do not want to pay for measures to create a safer socity to pretend that there are ways of 'curing' the natural result of violence and abuse. The special knowledge of those who have had significant traumatic experience can be dismissed as 'sickness' and not heeded as significant and valid. For relatives and friends of people diagnosed with PTSD? YES. It allows them to believe that they are not responsible for or capable of helping friends and relatives of who are victims of overwhelmingly terrifying experiences. They can defer responsibility and understanding to professionals without guilt. For the small percentage of people who have experienced traumatic overwhelm and are able to get compensation through the courts? YES. For traumatized people who don't want to be disabled, who want to get on with life and be functioning and respected members of society in spite of their experiences of traumatic stress? NO. For the last group the judgment of their natural reactions to such overwhelming experience as pathological is an insidiously invalidating punishment that strips them of a political voice, robs them of dignity, and tends to push them into treatment situations in which their self respect and strength are regarded as barriers to 'recovery.' Rather than having the changes that traumatic stress can produce regarded as precious knowledge for which such victims have paid dearly, that knowledge is dismissed as symptom. And for that, everyone loses.
Re: PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Surviv 17 February 2001
Grace Heckenberg, survivor City of Portland, Oregon Send response to journal: Re: Re: PTSD sufferers mis-diagnosed as Schizophrenic deserve the status of 'Victim' rather than 'Surviv	Dr. Lofthouse wrote: "For many, a re-diagnosis of PTSD is the only 'compensation' they receive for their status as 'Victims'. Prior to 1980 when this condition was recognised as a Diagnostic category, thousands of patients presenting with symptoms of prolonged distress were diagnosed as 'Schizophrenic', subjected to often brutal, often ludicrous 'experimental' treatments without informed consent, forcibly medicated, then returned to the conditions that had caused them to manifest the original symptoms. […] I record Dr. Summerfields' article as doing nothing more than adding insult to what is for many, a very, very real injury." Please do not speak for the many psychiatric survivors who don't want any diagnosis, including one of PTSD. I'm a psychiatric survivor. Your description of pre-1980s practices was approximately what I experienced: Severe abuse in my family resulted in what some demean as PTSD, problems resulted in a diagnosis of paranoid schizophrenia, complete loss of credibility, forced treatment including with depressive drugs and electroshock, imprisonment on psy-wards where it was predicted that I would spend the rest of my life suffering from a presumed brain disorder. The effect of the combined experiences nearly killed me, and I was 30 years old before I could quite believe it happened and wasn't just a nightmare too horrible to be true. Like a lot of other psychiatric survivors, many years later I sought what I thought would be exoneration by re-diagnosis with PTSD. And like most survivors who have tried that, I was very disappointed. PTSD is a diagnosis given out to those deemed worthy of sympathy and victimhood. The psy-gods are very reluctant to give such kind diagnosis to psychiatric survivors who quite naturally tend to be very angry and defiant in diagnosis/treatment settings. Instead they tend to replace the old schizophrenia diagnoses with personality disorder diagnoses or more supposedly neurobiological diagnoses such as "depression." And even if they deign to acknowledge that we were traumatized, they largely refuse to acknowledge the horror of our psychiatric experiences. Psy-gods choose how they want to see us and if that isn't in keeping with how we see ourselves, they proclaim our view part of our presumed sickness. Eventually most psychiatric survivors I've known have realized that it is stupid to care about the arbitrary judgments of those who don't even what to acknowledge what we went through. And there is no point in diagnosis for what cannot and really should not be fixed because it is simply a natural response. To seek re-diagnosis is to perpetuate the power of those who hurt us. One of the defining qualities I've noticed among psychiatric survivors is an intense sort of self respect that proclaims that no matter how difficult or painful our feelings, they are ours, natural to our lives, and we will not agree with condemning them as pathological. That self respect is what allowed us to survive intense victimization (usually in our families) followed by official re-victimization through psychiatry. Accepting the notion that our suffering is sickness would be inconsistent with and undermine that hard won self respect. Being a hardy, independent survivor is preferable to being a "sick" and dependent victim. Psychological "illness" is no more helpful or respectful a judgment than that of neurobiological disorder.
Déjà vu 20 February 2001
Anthony Stadlen, Existential psychotherapist in private practice; teacher of psychotherapy. London Centre for Psychotherapy; Regent's College School of Psychotherapy and Counselling, London. Send response to journal: Re: Déjà vu	Dr Summerfield's paper (1) contains some reasonable ideas. The most telling response has been that of Grace Heckenberg, who asks: "After being cast into a subhuman role by perpetrators and sometimes also those who witnessed the abuse without taking steps to rescue the victim, why would victims of abuse seek more dehumanization through psychiatric judgments which require that self respect be completely stripped away?" (2) But it is bizarre, and a disgrace to scholarship; shocking, though not surprising; that neither Dr Summerfield's paper nor any of the responses to it mentions the work of Professor Thomas Szasz. It is Szasz who has revolutionized thinking on so-called 'mental illness'. He published his groundbreaking book, 'The Myth of Mental Illness' (3), more than forty years ago. He referred to so-called PTSD, for instance, in his 1987 book, 'Insanity: The Idea and its Consequences' (4, pp. 205-6). Indeed, he discussed and denounced not only the alleged 'mental illness' PTSD but also another alleged 'mental illness', namely, 'factitious PTSD'. This latter 'illness' was said to cause those whom it struck to claim, falsely, that they were suffering 'symptoms' due to their having been in combat in Vietnam; some had never even been in Vietnam! Szasz quotes the psychiatrists, Edward Lynn and Mark Belza, discussing the "etiologies of the disorder and the underlying pathology and . . . recommendations for diagnosis and treatment" (5). I telephoned Dr Summerfield to ask why he made no acknowledgement of Szasz's seminal work in this field. Dr Summerfield confirmed his awareness of Szasz's writings, such as 'The Manufacture of Madness' (6) and a 1991 paper (7) in 'The Lancet', with the title, 'Diagnoses are not diseases'. I pointed out that Dr Summerfield's own paper contained the 'summary point': 'A psychiatric diagnosis is not necessarily a disease'. I asked whether this was not an almost unchanged, unacknowledged quotation of the title of Szasz's 'Lancet' paper of 1991. Dr Summerfield's reply was: "Well, it's also a quotation from me." Eventually, Dr Summerfield did show some remorse, and said that my rebuke was justified. But he tried to justify the omission of Szasz by arguing that the 'British Medical Journal' was not for experts. However, it is surely above all for non-experts that the leading figures in the field should be indicated; though decency, honesty and scholarship require this in any case. Did this not occur to anyone at the 'British Medical Journal'? What function does the failure to cite Szasz (of which Dr Summerfield's failure is merely the latest instance) serve for medicine and psychiatry? I notice that Dr Summerfield's paper is listed under the heading, 'Imitation is the sincerest flattery', at The Thomas S. Szasz, M.D. Cybercenter for Liberty and Responsibility (8). 1. Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 322: 95-98. 2. Heckenberg, G. (2001) Appreciation from a survivor. BMJ rapid response to Summerfield (1). (29 January 2001). 3. Szasz, T. S. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Paul B. Hoeber. 4. Szasz, T. S. (1987) Insanity: The Idea and its Consequences. New York: John Wiley. 5. Lynn, E. J. and M. Belza (1984) Factitious posttraumatic stress disorder: The veteran who never got to Vietnam. Hospital and Community Psychiatry, 35 (July 1984): 697-701. 6. Szasz, T. S. (1970) The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement. New York: Harper Row. 7. Szasz, T. S. (1991) Diagnoses are not diseases. The Lancet, London, 338 (December 21/28): 1574-1576. 8. http://www.enabling.org/ia/szasz/imitation.html
Understanding Individual Reactions To Traumatic Events Is Important. 20 February 2001
Suzanne Mason, Locum Consultant in Accident and Emergency Medicine Department of Accident and Emergency Medicine, Northern General Hospital, Herries Road, Sheffield,, Jim Wardrope Send response to journal: Re: Understanding Individual Reactions To Traumatic Events Is Important.	EDITOR - Summerfield's paper about Post-Traumatic Stress Disorder (PTSD) is likely to provoke lively debate(1). As he points out, PSTD has come to be associated with relatively commonplace events such as road traffic accidents, assaults and difficult labour. Our own study of injured male Accident and Emergency Department attenders has confirmed that psychological morbidity is common, but that individual reactions and perceptions of these events differ(2). The factors that affect the variation in symptom development seem to involve those related to appraisal of the event itself, coping strategies used following the event and social consequences of the event, such as involvement in litigation. Summerfield uses the example of a survey in Sierra Leone where 99% of adults were diagnosed with PTSD as evidence that the diagnosis is imprecise in distinguishing between normal and pathological distress. Perhaps, however, it is not unusual to expect that, following exposure to such an extreme stressor, PTSD symptoms would be common. These extreme stressors are rare in Western society, but a small proportion of patients attending the Emergency Department will have experienced such severe trauma and may develop significant psychopathology even though they have no risk factors making them vulnerable. However, with less extreme stressors, it is the combination of pre-existing psychological make-up, individual appraisal of an experience and subsequent adjustment to ‘everyday’ events which influence psychological outcome. Similarly, litigation increases vulnerability to such problems probably by interfering with normal internal processes of event resolution(3). There is currently little evidence for the benefits of intervention for PTSD(4). However, this finding should encourage more robust research in order to identify the best approach. Understanding the nature and range of reactions that are experienced should guide interventions which can enable the individual to return to premorbid functioning. Finding the correct label for an individual with post-traumatic psychological symptoms is not important. However, recognition that most undergo different degrees of unhappiness and distress is vital, and incorporating this into clinical training and practice may reduce the promotion of illness behaviour that we are seeing today. References 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal. 2001;322:95-98. 2. Mason S, Wardrope J, Turpin G, Rowlands A. The psychological burden of injury: An eighteen month prospective cohort study. Journal of Accident and Emergency Medicine (submitted) September 2000. 3. Ehlers A, Mayou RA, Bryant B. Psychological Predictors of chronic PTSD after motor vehicle accidents. Journal of Abnormal Psychology. 1998;107(3):508-519. 4. Wessely S, Rose S, Bisson J. Brief psychological interventions (debriefing) for trauma-related symptoms and the prevention of post traumatic stress disorder (Cochrane Review). In: The Cochrane Library. Oxford: Update Software. Issue 2, 2000.
Misappropriation & misuse of PTSD 20 February 2001
David Bolton The Sperrin Lakeland Health & Social Care Trust, Kate Gillespie, Michael Duffy, Clive Burges Send response to journal: Re: Misappropriation & misuse of PTSD	Dear Editor Ref: EDUCATION AND DEBATE The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category Derek Summerfield; BMJ 2001; 322: 95-98 We are a group of staff who have been involved in addressing the consequences of the Omagh bombing which was referred to, in Summerfield’s article in the 13th January edition of BMJ (Education & Debate; Summerfield, Derek; ‘The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category’; BMJ Vol. 322; pp 95- 8). For two and half years we have worked with over 600 people who have been affected by their experiences of the bombing, including children and adults, and those directly involved and those who provided help. The level of severity of reactions to the tragedy has ranged from short-term distress to protracted and deep-seated reactions, sometimes accompanied by suicidal thoughts. Notwithstanding Summerfield’s interesting and challenging analysis, and his conclusions, we firmly believe on the basis of our extensive experience that the concept of trauma related psychological disturbance, including PTSD, is a valid and helpful framework. From the Omagh experience we would suggest that it is particularly helpful in that it enables the therapist with the client, through the use of a common language, to conceptualise or make sense of the overwhelming and distressing reactions and experiences. Beyond that, the framework helps in the determination of an appropriate process through which the client can be helped. By basing our interventions on this concept, we have seen clients making very significant progress and return to previous levels of functioning, or occasionally make significant and very positive life changes. In our experience, through the use of concepts such as PTSD, we have categorised people presenting with severe reactions, but in doing so have, time and time again, provided reassurance that, contrary to their fears, they are not suffering from madness. In terms of responding to the impact of a tragedy on a community, the concept has been of great assistance in helping managers and practitioners to determine the overall and longer term impact on the community, to develop appropriate services, and to enable other key organisations involved in the life of the community to understand the underlying poisoning effect of a major tragedy. We accept that PTSD is a construct that involves the drawing together of different types of reactions to traumatic experiences, and setting thresholds and conditions on the degree to which these reactions are experienced, etc. In that sense it is arbitrary although founded we believe upon considerable reflection, and like many other ideas can be misappropriated and misused. In our view, Summerfield’s critique says more about how the concept has been misappropriated and misused, than about its relevance to the task of addressing the reactions to traumatic experiences. It would be wise to keep open the prospect of the concept being further developed and refined. Social pressures can drive such development and refinement but we believe they should be driven by the relevance of the concept to those who have adverse reactions to traumatic events, and its clinical (as opposed to its social) usefulness. David Bolton, Director of Social Work with the Sperrin Lakeland Health & Social Care Trust, manager of community trauma response to the Omagh bombing; Kate Gillespie, Consultant in Psychiatry and cognitive therapist; Michael Duffy, team leader of the Omagh Trauma Team and cognitive therapist; Clive Burges, Consultant in Occupational Health for the Sperrin Lakeland H&SC Trust THE ERNE HOSPITAL, ENNISKILLEN, CO. FERMANAGH, Northern Ireland, BT74 6AY
Re: Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome? 20 February 2001
Charline Griffith, retired teacher Hawaii Send response to journal: Re: Re: Post Traumatic Stress Disorder (PTSD): Another contemporary occupationally related syndrome?	PTSD can be work related. I know I have sought early retirement because of the debilitating symptoms of this disorder. Ask those of us who have witnessed these senseless killings on school campus, faced the terror in a child's eyes and the gut-wrenching wails of parents who learn their child has been murdered in a wanton act of violence. Those of us drawn to this field are by nature compassionate, caring individuals, perhapsthis leaves us more vulnerable to the onslaught of PTSD. If some one had told me I would one day battle triggers in my life set off by common exposures to everyday events... I would have tossed the idea aside, perhaps even scoffed it. Now I know PTSD is real, that it cripples and alters one's life, one's ability to cope. That PTSD can strike days later - years later with the same raw vengence as a tropical storm on a clear day. I applaude those who question the wisdom in denouncing PTSD, your efforts are deeply appreciated by those of us injured by the trauma we have witnessed, your words encourage us in our efforts to battle the insurance giants who scan medical literature in an effort to support their disclaimer - that we are frauds and not entitled to benefits from workers'compensation.
PTSD: Origins and Function 20 February 2001
Jerry Lembcke, Associate Professor, Sociology Holy Cross College, Worcester, Massachusetts, 01610 Send response to journal: Re: PTSD: Origins and Function	Derek Summerfield is correct that PTSD is a social construction but there is more to say about who constructed it, how, and how the concept functioned in post-Vietnam America. In my book THE SPITTING IMAGE: MYTH, MEMORY, AND THE LEGACY OF VIETNAM (NYU Press, 1998) and the article "The `Right Stuff' Gone Wrong" in CRITICAL SOCIOLOGY (24/1-2, pp. 37-64) I argue that PTSD was as much a mode of political and cultural discourse constructed by the media as anything "found" by mental health professionals. Furthermore, Psychiatrists imported almost all its key elements (e.g. alienation, survivor guilt, and flashbacks) from other contexts. PTSD functioned to help erase the memory of the war as an act of U.S. agression that we lost because the Vietnamese beat us by rewriting it as a war we lost because we defeated ourseselves, i.e. our military was stabbed in the back, our soldiers spat on, etc. The image of the dysfunctional PTSD-stricken victim-veterans displaced the historical reality that the war politicized and empowered a generation of GIs who revolted against the war and joined the movement to stop it.
Summerfield's reality vs. medical research 5 March 2001
Dinaz Irani, Women's Sexual Health Counsellor Toronto, Canada Send response to journal: Re: Summerfield's reality vs. medical research	Editor: This letter is in response to Dr. Summerfield’s article on the invention of Posttraumatic Stress Disorder (PTSD).1 Yes, PTSD did arise as a DSM classification in the wake of the Vietnam War and indeed PTSD is a diagnosis with sociopolitical influences. However Dr. Summerfield cannot assume that Neolithic peoples did not respond with extreme horror, have distressing recollections, intrusive thoughts and avoid associated stimuli associated with being a “victim” or witness to a gruesome attack. Nor can he assume that Neolithic peoples exposed to severe traumas, including rape, did not respond in a way symptomatically which would fulfill DSM criteria for PTSD. The author paints a picture of a society where countless individuals are readily coming forward to claim their “victim status” and subsequent cash payout. In actuality, recent research reveals that this couldn’t be further from the truth. PTSD is in fact under diagnosed in primary care, with patients more likely to focus on somatic complaints and less likely to acknowledge emotional trauma without specific questioning.2 The real financial burden is the high medical utilization of undiagnosed PTSD patients for somatic complaints.3 The stigma of mental illness continues to cause patients to focus on physical complaints so stating that PTSD is a diagnosis that patients like to have is an extreme exaggeration. The goal of psychiatry and society should be to remove the stigmas attached with mental illness. Placing judgment on those with even a small degree of comfort with a PTSD diagnosis is hardly the way to accomplish this. Dr. Summerfield discusses police constables and others with high stress occupations stating that “all are seeking compensation for post-traumatic stress disorder…” Police personnel are in particular very reluctant to admit to PTSD symptomology, despite the fact that the percentage of police officers with PTSD is much higher than in the general population.4 Here again, he chooses to ignore the research. Dr. Summerfield makes no suggestion as to what he would do differently to change the current diagnostic status of PTSD. Perhaps in the future he can make such recommendations and in the meantime examine the scientific research which validates the existence of the distinct disorder. A recent review article written by Tucker and Troutman5 2000 would be the most appropriate place to start. The PTSD diagnosis, like other medical diagnoses such as sciatica, is subject to abuse by a minority seeking compensation. The majority of PTSD patients, perhaps more than any other patient population, need constant reminding that they are not at fault and have no reason to feel guilty during recovery efforts. Questioning the legitimacy of PTSD as a diagnosis without taking the research into consideration is not likely to achieve this, nor is accusing these individuals of seeking “moral high ground.” In my experience with sexual assault survivors, the majority of them are merely seeking to regain a semblance of their former lives. Dr. Summerfield appears to have little understanding of the well-established connection between stressors and physical and mental illness. What is most disturbing is that Dr. Summerfield, as a senior medical school lecturer, is in a position to influence the minds of others. References 1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ 2001; 322: 95- 98. 2. Samson AY, Bensen S, Beck A, Price D, Nimmer C. Posttraumatic stress disorder in primary care. J Fam Pract 1999; 48: 222-227. 3. Stein MB, McQuaid JR, Pedrelli P, Lennox R, McCahill ME. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry 2000; 22(4): 261-9. 4. McCafferty FL, Domingo GD, McCafferty EA. Posttraumatic stress disorder in the police officer: paradigm of occupational stress. South Med J 1990; 83: 543-547. 5. Tucker P, Trautman R. Understanding and treating PTSD: past, present, and future. Bull Menninger Clin 2000; 64(3Suppl A): A37-51.
Letter re Derek Summerfield article on PTSD 15 March 2001
Yvonne McEwen, Researcher - Trauma Outcome Study Send response to journal: Re: Letter re Derek Summerfield article on PTSD	Eleven years ago I produced a paper called PTSD - Fact, Fantasy or Professional Fascination after a controversial study on the psycho-social effects of the Lockerbie Bomb. I contended that PTSD was a professional fascination with little supportive evidence to back up what the devotees of this alleged disorder claimed. The professionals have still not addressed the issues that I referred to then. The correspondence about Dr Summerfield demonstrates that no progress has been made. We have just completed the first study (we think) that examines the health, social, economic, judicial and political needs of major injury (trauma) patients and the results are quite disturbing. Despite the range of services and agencies available to support the patients, they have been depressingly ineffective in fulfilling patients' needs. Despite the major traumas that these patients suffered, not one of them had been diagnosed with PTSD one year to eighteen months post injury. Of the 110 patients were in the study, three were referred for counselling not by their GP but by their legal advisors and only one went. The patient perceptions of their needs were very much at odds with the current perceived wisdom. This 125-page report opens up a very different argument about trauma and its effects. There is a total lack of epidemiological data on PTSD. Where is the epidemiological evidence for this alleged condition? I have requested epidemiological evidence from self-styled experts on PTSD but to-date my in-tray lies empty. Where are the culturally specific studies on PTSD and how culture impacts on coping, perceptions of mental health and victimhood. Not every culture needs, wants, approves or allows for such ideology. The perception that PTSD is a universal concept is quite clearly nonsense, as we have no epidemiological data to support that argument. There appears to be an incredibly high level of ignorance about trauma at a medico-social, medico-historical level. The same examples get trotted out time and time again, (Vietnam, abuse, domestic violence) usually the American experience which is hardly representative of the rest of the world. If you examine the 108 "experts" that make up the committee that defines PTSD in the DSM Manual, 92 are American. There are so many vested interests in this alleged disorder that truth has become the main casualty. The abuse, misconduct and lack of ethics that some of the supporters and researchers of PTSD have engaged in deserves its own study and classification. Yvonne McEwen FRSA Researcher - Trauma Outcome Study
PTSD diagnosis can help people 'move on' 15 March 2001
Rosie Fenwick, student psychologist uni. of Sussex Send response to journal: Re: PTSD diagnosis can help people 'move on'	Whilst many of the points made in this article were interesting it avoids one important point which psychiatry as a whole has a tendancy to forget. Receiving a diagnosis ought not to result in the individual being pathologised for life. Rather diagnosis should be an opportunity for people to work through their problems and find effective ways of coping and positively getting on with their lives. People daignosed with PTSD can receive treatment which is relevant for their condition rather than receiving drugs based on a wrongful diagnosis - often of schizophrenia. Surely as well as looking at society as a whole psychiatrisits must look into themselves and reasses their attitudes to people with DIFFERENT mental illnesses rather than as a lump, for some it may be a case of drugs, others may benfit from a 'label' which puts them in touch with relevant services and gives them the opportunity to 'move on'.
Pathologising War-Affected Societies 25 April 2001
Vanessa Pupavac, Lecturer School of Politics, Faculty of Law and Social Sciences, University of Nottingham, Nottingham NG7 2RD Send response to journal: Re: Pathologising War-Affected Societies	Derek Summerfield's article on the construction of PTSD is to be welcomed for highlighting the historical specificity of the contemporary Western trauma model. Almost invariably, international aid or media reports, refer to refugees as being 'traumatised', 'hopeless,', 'emotionally scarred', 'psychologically damaged' or 'overwhelmed by grief'. The emotional state of refugees has come to the forefront of humanitarian work, even displacing hunger as the most prominent issue in the Western imagination. Whole populations are deemed to be suffering PTSD and in need of trauma counselling. Many of the respondents to Derek Summerfield's article assume that individuals benefit from the diagnosis of PTSD. Certainly one can cite cases where individuals benefit from having a medically recognised condition - particularly, in contemporary Western culture where, as Derek Summerfield point out, PTSD gives individuals moral status. Nevertheless, the diagnosis of PTSD is not universally welcomed or beneficial, and may be experienced as stigmatising and as well as inappropriate. The negative consequences may be seen in the dynamics of the international politics of trauma. It is questionable whether populations as benefit overall from mass diagnosis of PTSD. The notion of whole societies being traumatised does not just raise medical questions about the appropriateness of particular diagnostic categories and forms of treatment, but has social and political implications as well. The international PTSD model goes further than treating PTSD as a universal response to distress. Trauma is not just treated as a consequence of war, but as a cause of war and a multiplicity of social problems. Under this international model, explanations for conflict or poverty are increasingly sought in traumatic memory. As a political scientist, I am concerned how the trauma model is not only problematic as an explanation for war or poverty, but also how the model effectively delegitimises recipient populations as political actors. Whole societies are being deemed dysfunctional because of their traumatic experiences and therefore unfit to govern themselves. As a consequence, more and more societies are coming under de facto international protectorates where economic and social policy is decided for them. This pathologisation of social and political problems does not just therefore entail cultural imperialism, that is, the imposition of a Western therapeutic model on other societies, which have their own coping strategies. The international trauma model echoes earlier colonial psychology and its conceptualisation of the damaged colonial personality. For decades ago, the Algerian psychiatrist Frantz Fanon in the The Wretched of the Earth1 challenged the colonial pathologisation of the non- Western mind, locating pathology in the colonial or neo-colonial relationship itself. Once fashionable in aid circles, Fanon's insights have been forgotten in the imperative to save war-affected societies from themselves. How do societies respond to the therapeutising of their condition? On the one hand international psychosocial programmes creates a local professional sector with a vested interest in the Western model and the identification of trauma. To paraphrase Jane Austin, an international agency in possession of a good income must be in want of a recipient and this truth is well fixed in the minds of the region. It makes sense for a refugee to take up the offer of counselling in circumstances where they may go onto become cleaners, drivers, or indeed therapists, for the international agency in question. International agencies are systematically promoting the development of local therapeutic profession, often recruited from the recipients of programmes. On the other hand, disquiet is expressed by pathologised populations. This disquiet is now becoming the stuff of literature. For example, Zagreb author Dubravka Ugresic satirises her experiences of counselling in United States and is critical of the therapeutic model's denial of the political. Furthermore, her work puts Western society and responses on the couch. She characterises Western responses to wars as providing cathartic rituals for Western societies, describing the war in Bosnia as bringing the West, 'an unexpected collective psychotherapeutic gift'. The popularity of PTSD in the West and the impulse to therapeutise other societies needs further critical examination both within and outside the medical profession. Footnotes 1 Frantz Fanon, Wretched of the Earth, Penguin, London, 1965 2 Dubravka Ugresic, The Culture of Lies, Phoenix House, London, p. 200.
Physical Correlates of PTSD 25 April 2001
Fiona Eaton, PhD student/tutor Psychology Department, University of Stirling Send response to journal: Re: Physical Correlates of PTSD	In reference to Summerfield's idea that PTSD is an invented disorder constructed by society we would like to refer to the following findings. Heart rate was found to be higher in 20 out of 86 emergency room patients on admission and 1 week later, in those who were subsequently diagnosed with PTSD at 4 months as oppose to those who did not develop PTSD. The difference in heart rate was not related to physical injury, trauma severity or to the intensity of the initial reaction. (Heart rate did not predict subsequent depression or PTSD at 1 month) (Shalev, Sahar, Freedman et al, 1998). Lower levels of cortisol immediately subsequent to the time of trauma were also found in victims later diagnosed with PTSD compared to those not so diagnosed (Yehuda, McFarlane & Shakev, 1998). Reduced hippocampal volume in individuals diagnosed with PTSD has been replicated in four studies (Bremner, Randall, Scott et al,1995; Bremner, Randall, Vermetten et al, 1997; Stein, Hanna, Koverola et al, 1997; Gurvitz, Shenton, Hokama et al, 1996) with the latter study clearly demonstrating trauma-exposed individuals without PTSD do not have significantly smaller hippocampal volumes compared with normal subjects. These findings suggest that there is a physiological basis for the diagnosis of PTSD independent of subjective account or social demand. Fiona Eaton, PhD Student, Department of Psychology, University of Stirling. Ian Tierney, Chartered Clincial Psychologist, The Keil Centre, Edinburgh Reference List Bremner D., Randall, P., Scott, T. N., & et al. (1995). MRI-based measurements of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry., 152, 973-981. Bremner, D., Randall, P., Vermetten, E., & et al. (1997). MRI-based measurements of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse: a preliminary report. Biological Psychiatry, 41, 23-32. Gurvitz, T. V., Shenton, M. E., & Hokama, H. e. a. (1996). Magnetic resonance imaging study of hippocampal volume in chronic, combat-related posttraumatic stress disorder. Biological Psychiatry, 40, 1091-1099. Shalev, A. Y., Sahar, T., Freedman, S., Peri, T., Glick, N., Brandes, D., Orr, S., & Pitman, R. K. (1998). A Prospective Study of Heart Rate Response Following Trauma and the Subsequent Development of Posttraumatic Stress Disorder. Archives of General Psychiatry. 55(6), 553-559. Stein, M. B., Hanna, C., Koverola, C., Torchia, M., & McClarty, B. (1997). Structural Brain Changes in PTSD. R. Yehuda, & A. C. McFarlane (Eds.), Psychobiology of Posttraumatic Stress Disorder. (pp. 76- 82). New York.: New York Academy of Sciences. Yehuda, R., McFarlane, AC., & Shalev, A. (1998). Predicting the development of Posttraumatic Stress Disorder from the Acute Response to a Traumatic Event. Biological Psychiatry., 44, 1305-1313.
If DSM-IV doesn't work, let's try something different 9 July 2001
David Brown, Clinical Psychologist Airport Health Centre, Mascot, Sydney Australia Send response to journal: Re: If DSM-IV doesn't work, let's try something different	The American psychiatric diagnostic scheme DSM-IV (1994) lists three symptoms that are required for a diagnosis of PTSD, which might mean something like this: ·Avoidance – we don’t want to go back to the place where the event happened. ·Intrusion – thoughts and feelings come unbidden into our minds. ·Vigilance – we’re always on the lookout for the same thing to happen again. The scheme is elegant, and people with problems can recognise themselves in it. But it's not very useful, so I rolled my own: A. Fear and avoidance - learned in the body, this consists of an emotion (fear) usually linked to an action (avoiding or running away). Fear is conditioned and unthinking, its entire purpose is to keep me safe by running me away from the thing that hurt me. If my fear has "generalised", I might also be hypervigilant, because the next threat could come from anywhere. I might also have nightmares. For any of these reactions, treatment is by exposure to the thing or place or event that I fear - and by staying there for an hour or more. Repeat once or twice if necessary. But if the therapist doesn't expose me to that which I fear, if they simply talk to me about it, I am not very likely to get better. You see, I can talk about my problems forever! B. Bruised status and lost values. These are related but not identical, so I'll discuss them one at a time. Bruised status means that I feel that my control over my life has slipped, that I am no longer safe in my personal world (perhaps including my home). Perhaps I feel humiliated, perhaps I feel angry, but at heart it's a status thing. I might constantly relive the event, for one and only one reason - I am trying to make it come out better, trying to make myself win! This reliving could be described as “intrusive memories” or “flashbacks” but that description doesn't add to our understanding, in fact it takes away. Or I might take legal action simply in order to prove that I am a worthwhile person. For most people, bruised status eventually heals. But for some, the wound is deeper, and becomes what I call "lost values". The world no longer makes sense, no longer seems “right” or “fair” or “safe”. “They shouldn’t have done that, it was wrong, nobody should treat anyone else like that”. In its strongest form, “why did God allow this to happen?” Again, what is called an “intrusive memory” or “flashback” could be an attempt to rewrite the past, to make it turn out the way it “should” have been. “If only I had put security bars on the windows, then I wouldn’t have been robbed…” To summarise treatment, fear and avoidance can be treated very effectively with exposure. To get over bruised status, simply grow up. Counselling can help - eg rational emotive therapy or "cognitive restructuring", which confronts adolescent attitudes. When we have grown up (at least to some extent) we can say "Yes, I lost that one" and move on. Of course you can't put it as bluntly to the client as I just did. Lost values are much more difficult - they are the realm of religion, ethics, and morals. They are developmental challenges that only some people manage to grow through. A therapist can help mainly by acknowledging that the issue is real, and simply exploring it with the person without pretending to know the answer. I tell people "stay with the question, don't run away from it" and I try to create a positive atmosphere in which such questions are legitimate. As a closing comment on "flashbacks", I have quite a few. Sudden vivid memories of buttercups filled with morning dew, triggered by the sight of a bead of water. Very embarrassing recollections of things I did as a young man - to be faced, not flinched away from. Wonderful family dinners as a child, triggered by a waft of roast lamb or the smell of asparagus in a pot. We come with the wiring for sudden vivid memories, both pleasant and unpleasant; and we also come with the ability to resolve and move on. Over the past few years Australian veterans of the Vietnam war have been returning to their killing fields, and laying their ghosts to rest. At first they can hardly go there, they are so afraid; but when they finally leave, they say "it's just a beautiful field." Of course, go with a friend or helper - if you let yourself run away, fear gets stronger.
Where are the thoughts of Bosnian physicians 26 January 2003
Mickey Rostoker, Assistant Professor of Family Medicine, University of Saskatchewan SouthEnd Medical Clinic, 4637 Rae Street, Regina, S4S 6K6,Canada Regina, SK Send response to journal: Re: Where are the thoughts of Bosnian physicians	In March, I will be presenting PTSD to Bosnian family physicians as part of an international upgrading program. Professor Summerfield's provocative articles have sparked a flurry of very diverse responses ..... which has certainly made the topic more interesting. It will be difficult to discuss a topic which they probably know more about than I do. However, I am at a loss to find one good article from Bosnian physicians, whether they be from the muslim or serb sectors. Where are the voices of these people? Competing interests:   None declared
Negotiating with PTSD 30 August 2003
Yolande Lucire, Senior Lecturer School of Rural Health Sydney 2025, Australia Send response to journal: Re: Negotiating with PTSD	Each war has spawned its own neurosis, The American Civil War generated of chest pain, da Costa’s syndrome. Shell shock was originally believed to be concussion from exploding shells which damaged the brain and body, even when no direct hit had been taken. By 1916, the link between shell shock and concussion had been broken. About one third of cases had developed symptoms suddenly in close proximity to an explosion. A third were men going to their billets or trenches who heard distant shells. The last third had developed symptoms before they reached the battle field, some before they left England. This questioned causation by traumatic shock. The (first) Gulf War spawned its own syndrome, a fear of being affected by toxins, but it was limited to English speakers. Some soldiers have returned from every war, anxious depressed, depleted, exhausted, obsessing, drinking, drugging, becoming withdrawn or mad. They have always been diagnosed and treated according to the beliefs of the medical profession of the day. That was the case before posttraumatic stress disorder was invented. Now everyone, military and civilian, breaks down in the identical prescribed, way. Freud‘s language, repression, traumatic memory and resistance still permeate the discourse and underpin the remedies. Vietnam and its inhuman conditions disgorged debilitated men, preoccupied with clusters of abortions in their wives and cancers in themselves. These were attributed to Agent Orange, particularly to its contaminant dioxin which had the capacity to poison and cause cancer. This issue was never put to test in science or at law. Monsanto settled one big class action then successfully fought off the admission of further claims to court. This debate never reached closure. Information from the United States government about where Agent Orange had or had not been used, or indeed where the war had or had not been fought, was not trusted. Inquiry into dioxin stalled because of the lack of funding to do proper epidemiological studies on widely scattered individuals. Reports of birth defects, sickness and early death continued to emerge from Vietnam where the population lives with dioxin contamination of their food chain. A Government level joint inquiry between the United States and Viet Nam was announced, is presently inquiring further into the effects on the health of the Vietnamese population exposed to Agent Orange. In 1973, psychiatrist Robert Jay Lifton interviewed a very frightened veteran who had seen, but not participated in, the My Lai massacre. The veteran had been told that he would be killed if he ever told anyone about it. People came to believe that My Lai was a tip of an iceberg of similar rampages. Lifton spearheaded a loose body of veterans and clinicians who lobbied the American Government describing, in turn, post Vietnam syndrome, post combat disorder and later, catastrophic stress disorder. During the Viet Nam war and by the early '70s, drug abuse was rampant. After the soldiers came home, breakdowns began. Researching psychiatrists investigated large numbers of ex servicemen and their symptoms could be accounted for within existing diagnoses. However the range of problems from did not lend itself to distributing compensation. A legitimating category was needed to accommodate an essential element, causation by war service. The veterans lobbied the APA to identify a diagnosis that would do this task.. By 1980, the American Psychiatric Association admitted the first of several versions of posttraumatic stress disorder. The stressor, criterion A, the allegedly causal entity, had to be outside the range of normal human experience. This criterion was loosened then tightened up in later editions. An epidemic followed, and spread to the Civilian world. Enthusiastic vested interests still talk of cases which remain undiagnosed and, so, untreated. APA diagnoses are the products of committees of vested interests. Its major use is to allow mental health professionals to communicate in shorthand with insurers and other third party payers. . The APA makes sixty million dollars a year from selling the Manual so the mode is expansionist. 24% of the general population can be diagnosed as having a current disorder. The handbook represents psychiatry’s grab for power and therapeutic jurisdiction. The medicalization of life’s vicissitudes is good for business. Mental diagnoses are created by questions and are categorised according to the DSM. This is called social construction of illness. The DSM contains warnings to the effect that its contents are not generated by scientific processes, but by committees. The book warns that it is not suitable for legal proceedings. Yet the DSM sits at the right hand of every barrister and judge when their cases involve mental health issues. The inclusion of posttraumatic stress disorder in DSM III was a victory for the veterans as it meant free treatment and compensation. The act of delivering to psychiatry a grab-bag of symptoms, representing the suffering of thousands of men and women (mainly nurses), was more political than medical. In l986 the American government asked a veteran’s hospital to devise a treatment for posttraumatic stress disorder, so it could be taught and standardised. Ultimately, this meant that veterans would pay a price by being subjected to treatment programs ill-suited to their needs. The daily activities of this hospital were observed and recorded by a medical anthropologist Allan Young and written up in a book called ‘The Harmony of Illusions: Inventing Post-traumatic Stress Disorder.’ Briefly, veterans were treated as in or out-patients. They qualified for in-patient treatment if they did not have too many so-called ‘characterological’ problems, these being with alcohol, drugs, criminality or personality disorders. The underlying philosophy of the program was primitive Freudian, namely that uncovering of their traumatic memories, bringing them to the surface, would result in a cure. The veterans were expected to recall their traumas in group and individual sessions; to abstain from illicit drugs. Veterans were paid full pensions while they were in hospital. If they could get their previous diagnoses, alcoholism drug abuse, personality disorder, brain damage and occasionally schizophrenia, reversed and, if they could leave the clinic with a diagnosis of Post-traumatic Stress Disorder, then they could get up to $60,000 in back pay. I stress these men were sick ex servicemen, sick in the same that the non service population were sick. It was highly contested that proportionately, more of them were sick than their matched control group who had stayed at home Most could not recall having been distressed during their tour of duty. Some had spent the war in an alcohol or cannabis haze. Some had never seen a battlefield but knew of others who had been killed. They needed a good rationalization for being sick, preferably one that originated in their service so sickness could be attributed to it. Enter Freud’s discarded concepts of repression and traumatic memory. If the serviceman could not remember the trauma that had caused his symptoms, he was told that it was because he had repressed both the traumatic event and the feelings associated with it. He had to recall those feelings to be compensated and cured. Within days or weeks of this treatment, ‘memories’ of war experiences started to emerge, vivid and clear. As they emerged, the men became more disturbed and needed more attention. Young pointed out two further problems with this treatment program. First, co-patients who suggested that some were fabricating their experiences were silenced. If medical and therapy staff expressed that idea, they were warned, then dismissed. This scepticism was given a Freudian name, ‘resistance’ and it was treated as an attitude that had to be overcome. No one asked for recourse to the Army historians in the face of recurrent allegations that some veterans were just making it all up. The second problem was that the expensive and elaborate treatment was never evaluated. When recovered memory therapy in its various guises did come under scrutiny, it did not make it in into any list of evidence-based remedies. The servicemen did not want to talk about their experiences or their feelings, and they would get angry about what was going on. They did not like stirring up of old wounds. Those who had experienced atrocities wanted to get on with their lives, but they were told that they had to dredge it up. Before this remedy was invented, encouraging individuals to stew in their distress was generally considered detrimental to recovery. Therapies which concentrated on the past did not do much for the individual’s future. When PTSD was first put together, the committee recognised that a disorder with poor validity. Symptoms all of which occur universally for a short time after trauma. A serviceman who had experienced catastrophic trauma had only an 8% chance of experiencing a significant number of the symptoms three months later. In prospective studies, around 20 percent of those exposed to life threatening traumas go on to develop a significant reaction. Symptom lists were soon being circulated by various Veteran Associations. Films about veterans were written by script writers with the Manual beside them. The availability of the DSM made instant experts of anyone who could ask leading questions, including lawyers and other veterans. After the symptoms have been identified in a veterans discussion, or by a report writer in the lead up to a forensic examination, the symptoms list became very familiar to the reporting subject. The diagnosis is written in American psychobabble and its unnatural jargon makes the phenomenon of learnt symptomatology very easy to identify. Soon a massive number of claimants in all jurisdictions were able to attend their medical examiners and recite some or all of the following I have intrusive recollections, I’m hyperalert and I have a startle response. I am detached and alienated. I had a rage and hit my wife because I had a flashback while we were arguing at the kitchen table. I don’t watch television in case something comes on that reminds me of it. Psychic numbing was harder to describe. Those who had learnt the symptoms did not know what they did to put an end to their intrusive recollections, so they nursed them and concentrated on them. Stories abounded about the veterans who were concerned that they had not yet finished making their survivor quilt. One of the circulating lists contained a spelling error for ‘survivor guilt’, one of the smaller criteria. They were doing business with posttraumatic stress disorder Experienced forensic examiners are embarrassed when they are confronted with a royal flush of symptoms presented in words not consistent with the speaker’s culture or education. While some veterans never recovered from the war, others had been discharged in good mental and physical health, had enjoyed a marriage or three and had successful businesses or careers and had brought up a family. The ones I saw had got sick twenty or thirty years later when age, alcoholism, marriage breakdown or disease had caught up with them. They report symptoms of posttraumatic stress disorder, reciting them in the same order as the DSM, a set of symptoms that would occur together, in nature, as infrequently as 12345678 would win lotto. I found myself in a sceptical frame of mind so I often asked for recourse to army historians. I soon pleaded off assessing veterans. I found repatriation to be the most ideologically-driven jurisdiction I had worked in, even worse than NSW workers compensation. I did understand they came to believe that having served was the cause of their latter life problems. American psychiatry texts had told them this was the case. As any layman with common sense will tell you, you feel at your worst in the days, weeks or months after a trauma, a loss or a bereavement, then you get better. You do not suddenly feel awful 20 years later, unless, of course, you learn something you did not know before. This counterfactual information did not deter the American diagnosticians. Rather than abandon their caused by trauma paradigm, they shored it up by inventing the concept of delayed Post-traumatic Stress Disorder. The ability to believe the counter-intuitive view is called the ‘trained incapacity of the expert.’ Cause is a scientific concept, hard to prove. Attribution arises out of politics and preoccupations and masquerades as a medical diagnosis. We are being asked to reason backwards, from effect to cause. There are always a myriad causes for any given effect. As the song says, ‘Fools give you reasons, wise men never try.’ My dilemma was that, unless the veterans learnt the symptoms with which they were forced to ‘do business’, judges claim that they did not meet the necessary criteria for posttraumatic stress disorder and they are not compensated. If they could recite the symptoms, however, it was abundantly clear that they had been coached. Tribunals fail to differentiate reports that had been generated by honest clinical examinations from those generated by check lists and leading questions. They distribute benefits in accordance with how many symptoms claimants are able to recall and have documented for them. Alan Young pointed out, ‘if you want your claim to be understood, you'd better use the language of posttraumatic stress disorder -- or other diagnoses -- coined by the DSM. “ Competing interests:   I am the author of Constructing RSI: Belief and Desire
Re: Negotiating with PTSD 1 September 2003
Ellen Goudsmit, Health Psychologist London TW11 9QX Send response to journal: Re: Re: Negotiating with PTSD	It's been a while since we had a good old conspiracy theory in the eBMJ. And how timely! Another thing we can blame on the Americans. Do we assume that there were no Australians who suffered from PTSD after the Second World War? The Dutch, sadly, were not so lucky. Most of the survivors of the Japanese camps were civilians and it took a long time before their distress was recognised. Compensation? Yes, after many years, some got a pittance. But that's conspiracy theories for you. Selective evidence and a heavy reliance on generalisation and speculation. Personally, I prefer not to judge the distress of the victims of torture, rape and other inhuman acts. I prefer not to insult these individuals by associating their pain with the selfish behaviour of a few Vietnam vets. As for the APA, I trust that most of those involved in defining PTSD were motivated by a genuine desire to help those affected, and not by the promise of a new source of income. Am I wrong? Competing interests:   None declared
Re: Re: Negotiating with PTSD 3 September 2003
Glenn G. Hakanson MD FAPA, Sutter Center for Psychiatry Sacramento CA 95816 Send response to journal: Re: Re: Re: Negotiating with PTSD	Thanks for your Rapid Response Dr. Goudsmit. As a long time member and recent Distinguished Fellow of the Americian Psychiatric Association (APA), I can assure our foreign colleauges that the APA is far too disorganized to be conspiring with anyone, let alone a large group like the Veterans Administration. I have sat in on groups presenting preliminary conceptualizations for "Diagnostic and Statistical Manual-V", and there are lively debates over psychiatric/psychological models and whether or not research actually indicates that certain symptoms should or should not be diagnostic criteria or whether or not a new diagnosis should be included; in other words, it is pretty boring! As Will Rogers said,"I'm not a member of any organized political party, I'm a Democrat!" Competing interests:   None declared
competing interest of PTSD-believers 3 September 2003
Grace L Heckenberg, ungrateful former psychiatric services recipient City of Portland, Oregon Send response to journal: Re: competing interest of PTSD-believers	Seems like there are competing interests apparent in many of these responses that aren't being acknowledged: How about wanting desperately to believe in the ultimately destructive fantasy of a just world? How about wanting to believe in justice because it is too painful to admit that justice is merely widespread myth to which we pay lip service by compensating only certain special categories of victims at some cost to all, including most victims? How about wanting to be a great healer of the suffering or a great crusader for justice? How heady is that stuff! How about wanting to believe that feelings are important because one cannot accept that one's own emotional state isn't worth the rest of the world getting down on its knees for? Competing interests:   None declared
History is not conspiracy heory 8 September 2003
Yolande Lucire, Senior Lecturer Psychiatry, school of Rural health 2022 Send response to journal: Re: History is not conspiracy heory	The history of the invention of PTSD, and delayed PTSD are a matter of record. One major reference is Inventing PTSD: The Harmony of Illusions, Allan Young Princeton University Press. Young gives detail of the process of inventing PTSD to cover and compensate Vietnam Veterans who presented, as sick people do in a variety of ways. He was present for the process with a team of medical anthropologists. Most psychiatric illnesses socially constructed from an amorphous distress. This notion of social construction does not negate the distress, but makes the presentation of symptoms culture bound and changeable over time. It is generally courteous to read someone’s reference before alleging a conspiracy theory. Competing interests:   None declared
Re: History is not conspiracy heory 8 September 2003
Ellen Goudsmit, Psychologist London TW11 9QX Send response to journal: Re: Re: History is not conspiracy heory	If PTSD was 'invented' by the APA, or the Vets, then why did no one sue the organisations, or their presidents, for fraud? Surely insurance companies have an interest in pursuing such a costly abuse of power? Did they not read the reference offered as evidence? Or did they read it and dismiss the claims as fanciful'? And what did the people with all the symptoms of PTSD suffer from prior to the 'invention' of PTSD? Was it just 'distress'? I think anyone who has seen a genuine patient with PTSD knows it exists, knows the term is useful and would not dream of trivialising these people's experiences. To lump everyone with distress together seems to me not only unwarranted but also unhelpful. Science can do better than that! Who will judge how much distress is normal? Imagine the following scale: Falling off your bike without major injury: 10 ml distress. Surviving 3 years in a Nazi concentration camp, suffering hunger, witness to atrocities: 100 ml distress. Surviving 1 year in a Nazi concentration camp, have one's ovaries removed without anaesthetic, never able to enjoy sex after that, losing 40% of your family including a husband and son: 150 ml distress. Anyone reporting 'distress' exceeding the given figure is: a. not coping well. Send for CBT\psychodynamic therapy plus antidepressants if required, b. deliberately exagerating for financial gain. Ignore. c. Deluded for other reasons. Ignore. I think I'll stick to DSM-IV-TR, faults and all. Competing interests:   None declared
Re: Re: History is not conspiracy heory 10 September 2003
Glenn G. Hakanson MD FAPA, Sutter Center for Psychiatry Sacramento CA 95816 Send response to journal: Re: Re: Re: History is not conspiracy heory	Although I have never been a member of an American Psychiatric Association (APA) Diagnostic and Statistical Manual(DSM) Task Force or Work Group(the psychiatrists and other professionals who "write" the DSM) I have attended open meetings at APA conventions regarding the pending DSM-V. Sure, one or more psychiatrists could have an "agenda" regarding a diagnosis; but there were *ONE HUNDRED AND EIGHT* Anxiety Disorders Advisers for the DSM-IV!(See Appendix J,"DSM-IV Contributors," pages 905- 906 of the DSM-IV). The notion that you could get 108 psychiatrists, psychologists, and social workers involved in the same "conspiracy" and manage to keep it "secret" is absurd if one knows anything about group dynamics, especially regarding professionals. The fact that the APA manages to publish an (admittedly flawed) DSM every decade or so (DSM-I was published in 1952) is what is remarkable, given the process involved. Competing interests:   None declared
Democratic Psychiatry 7 May 2008
James A Rodger, Specialty Registrar - AOT Highdown Unit, Swandean, Arundel Road, Worthing, BN13 3EP. Send response to journal: Re: Democratic Psychiatry	Based on the above responses would it be reasonable to conclude that for some individuals a diagnosis of PTSD is meaningful and legitimating of their suffering (perhaps marking out the severity of their distress, from normal day-to-day suffering), where as for others it feels insulting, stigmatising or just culturally alien. Equally for some individuals a diagnosis of PTSD appears bring order to foster a sense of determination, leading to recovery (possibly stemming from a sense of recognition and meaning), where as for others it may simply serve to reify their symptoms, further confining them to this state of extreme distress, and not providing an obvious framework for change. For a smaller minority, the diagnosis may be seen as self-justifying their chronic occupation of the sick role, and the condition will be feigned, by some, for deliberate gain. And in all of the above examples, the perspective of the survivor may differ from that of the observer - which will itself depend on what framework is being differentially applied by each party (including questions of culture). Questions of the social utility of diagnosis then depend on such frameworks - whether purely economic, ethics driven, or based on quality of life measures, to name a just a few examples. These outcomes may be inter-related or conflictual. Doctors often have the difficult job of policing sick roles, acting as agents of the state - but this in itself is a reflection of universal pressures on, and competition for, resources. Legitimation of suffering by doctors/healers may become in conflict with such economic imperatives, when it does not seem to help the victim [sic] return to a meaningful social role. Many responders have highlighted the importance of taking each situation on it's own merits - and surely "democratic psychiatry" (c.f. Moncrieff 2008) is the solution to the vehemently opposed views presented above. Linked to the technique of psychotherapeutic attunement we might ask our clients / patients "does thinking about your problem this way seem helpful or unhelpful" - and of course we will be entitled to offer, in dialogue, our own views "I'm pleased you feel more understood, but I wonder if viewing the problem in this way, also, sometimes prevents you moving forward”. References: Moncrieff, Joanna (2008). Deomocratic Drug Treatment: Implications of the Drug-Centred Model. In The Myth of the Chemical Cure. A Critique of Psychiatric Drug Treatment. Palgrave Macmillan. Competing interests: None declared