It’s time to stop letting the stressor define PTSD.  Not doing so makes the new categories of C-PTSD and DESNOS largely irrelevant.

I’ve been posting on this blog for about eighteen months now, a total of fifty-two posts.  Though I’ve written a couple of books on trauma (my latest is Trauma, Culture, and PTSD),  I still feel like a newcomer to the field.  In this post I want to talk about what still puzzles me about trauma theory.  The experience of writing this blog has led to more questions than answers.

I’ve been able to reconstruct to my own satisfaction the origins of PTSD in the Vietnam War.   The new diagnostic category served political ends, pointing out what war does to the people who fight it.  The introduction of the disorder called PTSD was progressive politics.  It was also a humane diagnosis, helping to explain to those who suffered from it what was happening to them, giving both soldiers and their families a vocabulary for their pain. 

PTSD in DSM-5

At almost the same time as DSM-5 was being released, the National Institutes of Mental Health was refusing to fund any more research based on the DSM.

National Institute of Mental Health (NIMH) announcement
By Thomas Insel on April 29, 2013

Patients with mental disorders deserve better. . . . That is why NIMH will be re-orienting its research away from DSM categories . . . . The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

If the DSM were the model for physical medicine, then a heart attack would be defined as “chest pain disorder,” a symptom without a cause.

Henceforth, the NIMH research goal is to fill in the “Draft Research Domain Criteria Matrix,” which links 5 basic natural formations, such as “systems for social processes,” including attachment and fear, with eight columns of units of analysis, such as genes, molecules, and cells.

The goal is to move from mind to brain, so that there will no longer be any need to talk about mind at all. It’s all about electricity and meat, as Gary Greenberg puts it.  And electricity and meat can be measured.  Not, however, in the language of human suffering. 

American psychiatry and psychology have been cut off from the official world of science, but not from VA funding (over 100 million dollars since 2012 for PTSD).   This has consequences.  One, I believe, is the failure of more trauma specialists to object to the VA’s endorsement of cognitive behavioral therapy (CBT), including exposure therapy, as the treatment of choice, the only “evidence based treatments.”

These treatments are short-term, can be learned from a manual, and administered by lesser trained persons.  CBT is quick and cheap compared to long term therapy by well trained persons.  But consider CBT’s difference not only from traditional talk therapy, but also from the rap groups that sprang up in the Vietnam War era, in which veterans could exchange experiences.  CBT discourages “cross talk,” as people talking with each other is called (Tasman et al., p. 1928).  The potential of PTSD to help sufferers explain to each other the varieties of torment and relief has been lost. 

This does not mean we should abandon the diagnosis of PTSD.  Indeed, when this is proposed it is often sufferers who object most strenuously, for the diagnosis has helped many people make sense of their disrupted lives.  It does mean that we should rethink the category. 

Continue Reading >>