Education And Debate

The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category

BMJ 2001; 322 doi: http://dx.doi.org/10.1136/bmj.322.7278.95 (Published 13 January 2001) Cite this as: BMJ 2001;322:95

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drinking, drugging, becoming withdrawn or mad.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

Competing interests: No competing interests

30 August 2003
Yolande Lucire
Senior Lecturer School of Rural Health
Australia
Sydney 2025
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