PTSD: the Latest, Hottest, Maybe Most Controversial Diagnosis
In a recent Scientific American Mind article, Scott Lilienfeld provided a rundown on the currently controversial diagnosis, “post traumatic stressdisorder. “ http://www.scientificamerican.com/article.cfm?id=when-coping-fails&WT.mc_id=SA_CAT_HLTH_20120508
Lilienfeld reviews the history of the PTSD diagnosis, notes that it is now used in the absence of trauma, and suggests that when people demonstrate the characteristic symptoms of PTSD, they might legitimately be diagnosed with PTSD. Lilienfeld noted that trauma and PTSD expert, Harvard based Richard McNally, questions this current trend, warning about what McNally describes as “criterion creep” –or getting rather fuzzy with criteria used in diagnosing a patient. McNally may be right.
The literal flood of PTSD diagnoses now being used for people whose therapists believe suffered from “childhood trauma” is suspect. What is considered “childhood trauma” is almost ludicrous in some cases, and carries the assumption that people are fundamentally weak, fragile and vulnerable, instead more ordinarily highly resilient. When we claim someone has been “traumatized” by ordinary life situations, ordinary stressors and disappointments, for example, parental divorce, parental depression, neglectful parenting, or in adulthood, loss of a job, marital strife, workplacemobbing, or loss of a long-time friend or partner, something is off and we’re trivializing the experience of seeing a buddy blown to pieces, or seeing a friend or family member murdered.
We’re a sturdy species, and as Lilienfeld remarks, we’re quite resilient. We evolved with psychological mechanisms that allow us to recover even from extreme natural disasters, wars between neighbors, and in some cultures extremely harsh methods of child-rearing. In our own European-American culture it used to be standard to spank (and in some cases what today we consider beating) children (“spare the rod, spoil the child”), and while today most (or at least many) parents have learned there are better methods by which to teach their children, at the moment mental health providers are far too eager to blame ordinary experiences –translated into “traumatic childhood experiences”– for all kinds of psychological problem and even severe mental illnesses. Perhaps the PTSD label has become part of the myth of childhood trauma, and needs to be reconsidered from multiple perspectives. That said, there is something we’ve found in our studies, that support an authentic PTSD diagnosis, best described by having the experience of witnessing extreme danger or threat to someone loved, or cared about.
Last year my dissertation student, Joanna Morgan, conducted an anonymous online study of 79 active members and veterans of the U.S. Military who had been in Iraq and/or Afghanistan, using instruments designed to measure PTSD, depression, and empathy-based guilt. She was specifically trying to find out if members of the military were using Facebook for support related to PTSD symptoms. Her hypothesis was not supported. In addition, she was investigating the nature of the “flash-backs” that occur as part of the PTSD syndrome, with the question: “What are those flashbacks about?” Her hypothesis was that in most cases the events that were repeatedly revisited later by people suffering from PTSD involved witnessing extreme harm coming to someone else, and her data supported this hypothesis.
Morgan’s results also supported what I’ve been noting anecdotally, while being a consultant to therapists working with soldiers who suffer from PTSD. In most cases, they are focused on harm they have witnessed, and that’s associated with severe survivor guilt. “Why did it happen to him instead of me?” or “If only I been in a different position, he would still be here today.” Whatever happened, the soldiers find some way to take on the blame (irrational responsibility, pathogenic guilt) for the event. As Morgan’s study involved a small number of soldiers, we are trying to collect new empirical data online, focused entirely on the nature of flashbacks, with the hypothesis that as a highly prosocial species, witnessing extreme harm to another, and particularly to a loved one or close friend, is often (significantly) the content, or the driver of PTSD.
In another study of local (Bay Area) college students done in my lab two months after 9/11, we found that students who were highly prone to empathy-based guilt, including survivor guilt, (using a measure that assesses a trait, rather than a state), demonstrated significantly higher levels of PTSD-like symptoms (such as depression, panic and other forms of anxiety) compared to those students who were lower in guilt-proneness. While we were not measuring PTSD directly, our results suggested that people who are prone to have irrational beliefs about their power to help others, or to cause others’ distress, may be at greater risk of developing PTSD after witnessing a trauma happening to someone else, which Lilienfeld’s discussion touches upon briefly.
It may be time to reconsider the PTSD diagnosis from the ground up. Something is wrong if we look at a cluster of symptoms and then diagnose PTSD, even in the absence of trauma. We’re armed with multiple mechanisms designed to render us resilient in the face of earthquakes, volcanic eruptions, violent wars between neighbors. It may be that witnessing extreme and violent events, while being safe oneself, evokes extreme survivor guilt in some people. Survivor guilt is one of those odd psychological mechanisms that may hinder a person and be detrimental in within group selection, while being highly adaptive at the level of between group competition, or group selection. We hypothesize that it may be the most obvious descriptor present in almost all cases of PTSD.