Post-traumatic stress disorder
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7297.1301 (Published 26 May 2001) Cite this as: BMJ 2001;322:1301
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Summerfield (1) alludes to the different models of mental illness
aetiology. Psychiatric "diseases" have reached the 18th Century of
Sydenham, with diagnoses described as clusters of signs and symptoms.
Summerfield is concerned that Post-traumatic Stress Disorder does not fit
a medical model, because an environmental event leads to biological
changes in the body's catecholamine, glucocorticoid, thyroid and opioid
systems, affecting mind and body (2). But how far other psychiatric
diagnoses fit the medical model remains unanswered. "Post-traumatic Stress
Disorder" provides an opportunity to elucidate neurobiology/mind links.
Types of civilian trauma that produce chronic PTSD include:
multiple traumas, intra-familial childhood sexual and/or physical
abuse and kidnapping (3).
It is hardly surprising that post-traumatic stress disorder is co-morbid
with suicide, depression, homelessness, substance abuse and highly
prevalent in psychiatric patients. About 40% of psychiatric patients have
undiagnosed Post-traumatic Stress Disorder (4).
Post-traumatic Stress Disorder is almost certainly timeless, it was
just called something else before, such as "anxiety/depression",
"heartsink patient", "Borderline Personality Disorder", "schizoaffective
disorder".
I find that Foa's validated, 10 minute, diagnostic screening
questionnaire, the PDS, (5), avoids the initial embarrassment of verbal
communication for doctor and patient and improves diagnostic accuracy.
Types of trauma are identified, with a yes/no response. Research before
1997 often did not correctly identify causative traumas for Post-traumatic
Stress Disorder, because questions about childhood abuse, rape and
domestic violence were seldom asked.
Far from "legitimizing victimhood" (1), I find that diagnosing Post-
traumatic Stress Disorder in general practice encourages "survivorhood",
offering hope and explanation to the sufferer instead of blame for
symptoms of "hypervigilance" such as panic attacks. Chronic severe PTSD
can be resolved with Cognitive Behavioural Therapy, SSRI drugs and self-
help books. Other psychiatric diagnoses often limit hope. Community
patients can recover from mild Post-traumatic Stress Disorder in a few
months with reassurance and explanation.
Summerfield worries about "medicalizing" a common condition. But I
find the diagnostic label of "Post-traumatic Stress Disorder" a useful and
humane one, until we can do better.
A practical issue is how to delineate those that need medical help
from those that do not, and encourage a society where causative traumas
are less likely.
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. van der Kolk B. The Psychobiology of Posttraumatic Stress Disorder.
Journal of Clinical Psychiatry 1997;58(supplement 9):16-24.
3. Boney-McCoy S, Finkelhor D. Is youth victimization related to Trauma
symptoms and Depression after controlling for prior symptoms and family
relationships? A longitudinal prospective study. Journal of Consulting and
Clinical Psychology 1996;64(6):1406-1416.
4. Mueser K, Goodman L, Trumbetta S, Rosenberg S, Osher F, Vidaver R, et
al. Trauma and Posttraumatic Stress Disorder in severe mental illness.
Journal of Consulting and Clinical Psychology 1998;66(3):493-499.
5. Foa EC, L; Jaycox, L; Perry, K. The validation of a self-report measure
of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale.
Psychological Assessment 1997;9 (Dec)(4):445-451.
48-60.
Fiona Duxbury
general practitioner and MSc student in Evidence-Based
Medicine, Oxford University
Blackbird Leys Health Centre,
Blackbird Leys Road,
Oxford OX4 6HL
Email: duxburycrosse@doctors.org.uk
Competing interests: No competing interests
I wish to say to Dr. Summerfield that independently of its origin and
motivation post-traumatic stress disorder exists.
Every day we can prove its clinical entity in our doctor's offices.
I don't understand exactly why Dr. Summerfield denies the existence
of this illness.
I did read every one of his articles and I believe that the proof
is insufficient to demonstrate the inexistence of the disorder.
Obviously Paleolithic man may have suffered stress, as well as
tuberculosis, but the names of each illness came very many years after.
If in The United States of America the diagnosis of post-traumatic
stress disorder is used incorrectly, then lawyers should review the penal
code and the civilian code. Physicians should not deny the existence of an
entity.
Competing interests: No competing interests
I would remind you that most of the psychiatric 'diagnoses' are no
diagnosis at all, but classifications according to (possible delusive?)
thoughts and projections in the patient.
If a patient has PTSD(?), a broad range of patients is classified
without a proper diagnose that gives an absolute certainty about causes and
effects.
Without this certainty for the doctors, it's impossible to give a medical
diagnoses; only a classification according to discussable thoughts.
Of course stress can play a big role in symptoms related to PTSD.
But what is stress?
Stress can also be physical and neurological.
Coffee, smoke, chemicals, (brain) allergies (neurogenic inflammation,
disturbed NO-metabolism, allergy on own brain tissue, sometimes related to
food, sometimes to smoke or aerosols), scar-tissue, eye problems and
others physical problems that give physical negative stress, etc.
Maybe in some way there is no real difference between mental and physical
stress in the way it affects biological paths.
PTSD gives a lot of physical symptoms, so it's for real, isn't it?
Without absolute certainty, a medical projection to a psychiatric disorder,
is in my opinion 'quaksalbery'.
All those disorders are classifications.
Take schizophrenia; what is that?
Why not just diagnose that someone has visions and hallucinations?
Another diagnosis is perhaps social isolation.
But not everyone with hallucinations has social isolation.
And also only 80% of people who are thought to be schizophrenic has the specific
deterioration of brain-tissue, so 20% of diagnoses are totally wrong.
But what is a medical diagnosis in 'schizophrenia', is an immune disease
where the patient's brain tissue is attacked.
This can be in (thought to be classification) schizophrenia and in any
other mental disease.
Why not diagnose for these, instead of projecting possible group delusions
in a patient?
Most of the time with so called psychiatric patients, no necessary
research is made.
No functional-MRI, no research for (brain-) allergies, brain-tissue-
allergy, neurogenic inflammations and all other physical conditions.
Instead: unproven quacksalber classifications and narcotic drugs to
surpress symptoms ,instead of investigating the cause(s) and finding real
solutions.
Mark Metzelaar--Amsterdam
Competing interests: No competing interests
I am totally astonished by Summerfield's ignorant comments about the
problems of children of Holocaust survivors. Only the most callous people
would dismiss the experiences of the survivors and ignore all the evidence
showing that some had severe problems in bringing up their children. I
suggest he reads Anne Karpf's excellent book 'The War After' (Minerva,
1996) before he writes more offensive nonsense.
About four-fifths of those who survived the camps suffered long
lasting effects which impaired their functioning. Auschwitz was not a Nazi
holiday camp! It wasn't a 'normal' part of life. Please don't treat it as
though it was!
I take it that no one at the BMJ's office knows anything about this
subject as otherwise, this sentence would have been removed.
Conflict of interest. I am the child of two survivors. The problems
relating to my (interesting) upbringing were thankfully limited.
Competing interests: No competing interests
experiences with PTSD
Dear Editor,
I read with interest Prof. Shalev's comments on PTSD on 26th May
2001 {vol 322 }.
It stimulates this letter as I feel there is a balance that must be
addressed.
Q: Does PTSD exist?
Analysis: Call it what you may -- people experience horror & feel
ill as a consequence. Sometines they will show a collective feature of
symptoms ... which we call a syndrome. PTSD is a phrase we currently give
to such a syndrome. It is human coinage for a human experience ... no
more, no less.
Answer to the Q: Yes of course it does, but debate & analysis must
go further if we are to show balanced science.
When I was a medical student I was taught there were 3 aspects to ill
-health:
i. DISEASE: Scientifically observable pathological process(es).
ii. ILLNESS: The feelings evoked in humans as a consequence of
disease.
iii. SICKNESS: A social role we play consequent to feeling ill.
Where the psychiatric profession I feel sometimes falls short is
their occassional refusal to see the picture from views outside their
office or hospital.
I notice that the Professor is speaking from Israel. I served 4 times
as a UN-associated doctor in the Arab-Israeli "ICA". Hence I feel it
likely that Professor Shalev's experience of severe PTSD probably exceeds
many of his international colleagues. But the fact that people are
subjected to "traumatic events outside the range of normal human
experience" does not negate the social dimensions brought up in BMJ of
13th Jan. & elsewhere.
"Sick role" is a role we adopt. That adoption may be appropriate or
inappropriate. Inappropriate adoption may be in minimizing or maximising
... the latter sometimes for financial gain.
I know of the reputation in medico-legal circles that if a patient
goes to one psychiatrist (call Doc X)... he will always get the diagnostic
label of PTSD ... to his solicitor's delight. If the patient goes to
another ... 'Doc Y' ... he will never get the label. As a primary care
doctor, therefore, I can only conclude: "Something is rotten in the State
of Denmark".
PTSD should be a medical label helping health providers to promote
better health ... not a label used for financial gain. However, in the
Western world it is a fact that injury can sometimes be measured in
dollars. It is the latter observation that makes me reject the heading of
Dr. Cohen's letter: "Doctors should relieve suffering, not debate its
existence". If we are to to truly hold our heads up in the scientific
community we MUST debate its existence.
The fact that the debate may never conclude doesn't negate
professional action. I love the ATLS & ACLS movements, as these show a
need for action before diagnosis. The same might be true of PTSD. Please
do not shut your minds to the honest lawyer, the honest social worker, the
honest employer ... & even the honest IRS representative. Malingering
is a reality, even if we are too scared to face a court & say so. All
doctors who have worked in A/E departments will know that the loudest
patient is often far less sick than the quiet patient ... who may feel too
ill to seek help.
I saw, again, a movie last night called "The devil's own". I will
leave the reader with a quote that struck a cord:
"If you're not confused, you don't know what is going on".
Competing interests: No competing interests