The Problem with PTSD

Vivek Datta, M.D., M.P.H.

January 17, 2013

“The voices, they tell me they gonna kill me, and it’s my fault.”

“Sometimes, when we hear voices, they just reflect our own anxieties, sometimes they can echo things we’ve been told in the past. When the voices tell you that they’re going to kill you, does that echo anything you may have been told in the past?” I ask.

Monique*, a 36 year old African American woman with a long history of crack cocaine abuse and a diagnosis of paranoid schizophrenia pauses, then fixes her gaze intently on me.

“My daddy, he molested me from when I was 6 until I left home. ‘Said he gonna kill me if I tell anyone and ain’t nobody gonna believe me anyway.” She pauses again. “I never told nobody, not my mamma, not my girlfriends, not nobody.” Monique felt a sense of relief, her secret unburdened, her experiences hitherto deemed ‘ununderstandable’ and all the more frightening for it, were now understandable to her. Yet in the 18 years that Monique had been a psychiatric patient, these facets of her mental life were not explored at all. I’m sure she had been asked about trauma in the perfunctory way that characterizes modern psychiatric assessment, but never in a way where she may have made any meaningful connections with her past experiences and the current distress she lived with. For contemporary psychiatry recognizes in diagnostics only one outcome for traumatic experiences, and that is posttraumatic stress disorder.

The Invention of Posttraumatic Stress Disorder

When PTSD entered the psychiatric nomenclature in 1980, it did so at a time when psychiatry had been remedicalized, all remnants of its former psychodynamic self expunged from the official system of diagnosis and classification of mental disorders. Any mention of hysteria, neurosis, reactions and other psychodynamic terms all but disappeared. PTSD was also unique in that it was the only psychiatric disorder in the new classification in which a cause was implied. The DSM-III was supposed to be atheoretical, foolishly attempting to be value-free. And yet, the assumption was made that PTSD was caused by exposure to traumatic stressors, an assumption that has been questioned by the occurrence of symptoms of this syndrome in those who have not experienced a traumatic event. My purpose here is not to discuss the validity of the PTSD construct, but rather to suggest that, by wedding trauma to the diagnosis of PTSD, the role of trauma in other forms of psychopathology was de-emphasized. This was implicit, deliberate, and exacting. The new remedicalized psychiatry of the 1980s had no time to discuss the social world, but was instead captivated by the notion of broken brains, defective genes, and twisted molecules. By creating a new diagnostic category, traumatic experiences could forever be entangled with PTSD, and the rest of psychiatry could be unencumbered by life stories. The recovered memories and multiple personality disorder debacle of the same decade would seek to confirm that there was some terrain that should be left untouched by psychiatry.

Trauma in the Clinic

When a patient attending for psychiatric evaluation today discloses a history of trauma, be this childhood physical or sexual abuse, rape, domestic violence, kidnapping, attempted murder, or combat exposure, the line of questioning takes a predictable turn. The patient will be bombarded with questions about whether they have nightmares or flashbacks, whether there always feel on edge, or whether there are any situations or people they avoid. It is as if these are the only types of symptoms that could possibly occur following traumatic events. This not only flies in the face of the clinical experience, it also flies in the face of epidemiological studies which show individuals are just as likely to experience depression or anxiety following a traumatic event than they are PTSD. My own clinical experience is that even more common than the traditional symptoms of PTSD are physical symptoms – chronic unexplained pains, unexplained neurological symptoms, gastrointestinal disturbance and so on. The effects of trauma are not so much embedded in a fractured mind, but a fractured body.

It has becoming increasingly uncommon for psychiatrists to consider the role of traumatic experiences in other forms of mental disorder, and the more ‘severe’ the disturbance that is experienced, the less likely that traumatic experiences will be considered. Even when life experiences are considered in the onset of severe mental illness, these experiences are rarely engaged with, and it is rarer still for meaningful connections between these life events and the symptoms to be made. Whilst it is true that most of the research into the role of trauma in psychosis is lacking in rigor and quite frankly wanting, there is a distinction to be made in what people experience and why they experience. Traumatic experiences seem to be non-specific to the development of mental illness inasmuch as they are associated with a wide range of problems including, but not limited to depression, anxiety disorders, substance abuse, personality disorders, somatoform disorders, eating disorders and so on. How much of a causal role these experiences play is largely irrelevant in clinical practice. What is relevant is that the narratives of suffering, chaos, vulnerability and resilience are so often interwoven with physical symptoms, delusions, hallucinations and other experiences. The process of meaning-making between these narratives of experience lived through and the ‘symptoms’ of mental and physical distress was irrevocably broken with the invention of PTSD.

Though there is no doubt that the experiences people have even in the so-called ‘severe’ mental disorders are often related to traumatic occurrences in the life course, I do not wish to over-emphasize the role of trauma or its psychological or physical consequences. Whilst psychiatry has done a great disservice by packaging off trauma with the diagnosis of PTSD as if it were not relevant to any other form of psychopathology, the narratives that I am privileged to hear everyday are not so much narratives of vulnerability but of resilience. My initial reaction is to be amazed and give testimony to our ability to overcome the most horrendous adversity, but the reality is, such a reaction is the product of a culture which cultivates victimhood and sees the effects of trauma as damaging, perpetual, even intergenerational. It is ironic that our society should be so concerned with toxic effects of trauma on the one hand, whilst psychiatry seems oblivious to the meaning of trauma in the phenomenology of mental life on the other. Traumatic experiences neither explain away all psychic woes, nor are they completely irrelevant. How much meaning traumatic experiences take on should not be a matter for psychiatry or cultural pressures, but for the individual in her quest for meaning. For Monique, the recognition that her life experiences, far from irrelevant to her current psychic crisis, were central, made her ‘psychosis’ seem more understandable, less omnipotent, and more manageable.

*For confidentiality reasons, Monique is not a single patient, but represents a composite of different patients
Vivek Datta, M.D., M.P.H.

The Psychopathology of American Life: A British physician explores how the concept of mental disorder has vastly expanded over the past century, reporting from the front line of American Psychiatry.

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5 thoughts on “The Problem with PTSD

  1. Hello, and thanks for writing on this topic.

    It appears to me that many who research and “treat” PTSD, especially in cultures other than their own, seem to romanticize what they believe the impact of trauma SHOULD be. What results is a reluctance by the professional to admit that perhaps this concept of RESILIENCE is indeed central. In other words, an individual’s resilience (pre-existing, or obtained due to the trauma itself) is his best tool for dealing with the truly- as you said- uncategorizable ways past traumatic experiences impact his life. The implications of recognizing that, of course, do not look good in terms of professional growth for a PTSD “treatment” provider.

    To me, this article is a good example of ALMOST concluding that resilience is the most important (and most abundant) resource available to someone who has been through trauma…

    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001371

    …but then it seems they are too enamored by their notions of what trauma SHOULD do to a person, and therefore how necessary “treatment” must be. So instead they highlight all the supposed positive outcomes of THEIR interventions, and reasons for their necessary scaled-up implementation (which these countries cannot even afford to do).

    I work with refugees and I don’t know how many times American-born people say things like “I could never go through what they have been through and still have such a positive attitude.” What would such an admission from the mental health community do to the treatment paradigm for PTSD?

    Thanks again for writing. It’s an important topic and your perspective is very valuable.

    • thank you for your comments. the exportation of the western concept of PTSD was beyond the scope of my article though one i touch upon elsewhere. our responses to trauma and the rituals we use to treat them are certainly constrained by culture, and other cultures have much better ways of dealing with trauma, not least because the response is a collective and not an individual one.

  2. Vivek

    Thanks for writing such a thought provoking post on the PTSD diagnosis. It has helped me grasp even more deeply how Biological Psychiatry has turned reality on its head. Rather than view PTSD as the only diagnosis that makes any sense due to its connection to environmental stressors, it is now clearer to me how this is only used to further promote their flawed paradigm.

    All forms of extreme states of psychological distress (that which gets mislabeled as “mental illness”) involve some type of traumatic relationship or involvement with one’s environment. The proponents of Biological Psychiatry will listen to someone’s narrative only to pull out a set of symptoms to make a diagnosis of their perceived “disease process.” The true narrative or real life experiences of that person means nothing to them. How sick and delusional is this model of treatment that gets passed off as real science?

    Richard

    • thank you for your kind words. it is a conclusion i only came to when writing about this topic. much has been written about the sociopolitical nature of the diagnosis of PTSD and what this diagnosis offered, but little has discussed the wider implications for the rest of psychiatry of this diagnosis which so uniquely marries symptoms of psychological distress to trauma.

      as for what constitutes real ‘science’ – psychiatric research is scientific, rather than pseudoscientific as some have claimed. the question is not how ‘sciencey’ an approach is or not, but rather whether it is useful to have a wholly scientific approach to the problem of human suffering.
      vivek

  3. Ten years ago, just before I turned 50, I took my settlement money from my last, very painful divorce and, in sheer desperation, checked myself into a renowned private psychiatric clinic. My health insurance had been forfeited in the divorce, so I paid my own way. I went into the clinic with enough money to buy a modest house. When I came out of the clinic I was nearly broke. But they had given me back my will to live, so to me it was worth it.

    After a full battery of psychological and physical tests, the verdict was that I had PTSD, going all the way back to my childhood. “You are not crazy!” the head psychiatrist told me. “PTSD is a normal reaction to overwhelming trauma, just as it is normal to bleed if you are stabbed!” He went on to explain that, in his opinion, the “schizophrenia” I had been diagnosed with in 1967, back when I was 14 years old, was a “misdiagnosis.” He said I could never have truly been schizophrenic, because I had no signs of psychosis, according to his “highly reliable tests,” and “schizophrenia never goes away.”

    It was like I had been in prison for 3 and a half decades, and the warden suddenly decided that I was innocent all along, and set me free. From the age of 14 to just before my 50th birthday, I had believed that I was born inherently, fundamentally, genetically, and irreversibly flawed. But now I had an “official diagnosis” from a renowned psychiatrist, the co-founder of a nationwide chain of clinics, a man who has authored or co-authored over 80 books, and who had even been on the Oprah Show more than once, telling me that I was, and that I always had been, “sane!” Not only was I sane, he said, I was also amazingly STRONG, to have survived my extreme traumas.

    I left that clinic feeling like I was on top of the world. I wasn’t crazy! I never had been crazy! I was normal! YAY, me! It was better than winning a multimillion dollar lottery!

    The problem, though, is that deep in my heart, I knew that I truly was “schizophrenic” for 2 of my teenage years – that is, if you are going by the DMV definition of schizophrenia. From the time I was 14 until I was 16 I had a multitude of loud, frightening, disorienting voices talking nonstop inside my head, during every waking moment. I also had the occasional visual hallucination. So how I could really believe, deep down in my heart, that I had “always been normal?”

    So, how did my 2-year-long “schizophrenic” episode as a teenager, square with my PTSD diagnosis at age 50? What, if anything, did the one have to do with the other?

    In my case, at least, I believe that both of my “mental illness labels” had everything to do with trauma. Throughout my childhood I periodically went through extreme, multiple, often life-threatening trauma episodes, beginning with one of my very earliest memories at age 2, when my dad, who years later was diagnosed with schizophrenia and multiple personality disorder, stopped the car on the Oakland-Bay Bridge and told me he was going to throw me off the bridge into the water and that I was going to die. I didn’t know what it meant to die, but I knew that falling even a short distance, such as from the sofa to the floor, was painful, and I hated it when water got in my eyes and ears and nose when my hair was being washed in the bathtub. So when my dad pulled me out of the car and walked with me in his arms toward the railing, chanting in an eerie sing-song voice that he was really going to throw me off the bridge, he wasn’t teasing, he really meant it, he really was going to throw me off, and I was going to fall down down down down into the water and die…. I felt….

    Dead already, that’s how I felt. I felt helpless and hopeless and powerless and small, I knew I could not stop him from doing what he was doing, and I went dead inside before he even got to the bridge railing.

    My father didn’t do it, though, obviously. He suddenly turned around and put me back in the car and then he drove on to get my mother from work, and the rest of the day went on like nothing out of the ordinary had happened. That’s what my childhood was like. Most of the time my dad was loving, protective, good, and kind. He was a minister of a small church. He was a faithful husband, a faithful provider. But occasionally, unpredictably, for any reason or no reason, he would do and say the most terrible, terrifying things. My dad really did seem to have more than one distinct personality living in his body.

    But in spite of these terrifying episodes, I was normal throughout the first 12 years of my childhood. Resilient? I guess that describes me! I was actually happy and serene and secure most of the time. I loved school and consistently made top grades. I loved my parents, and loved my little sisters and brothers. It was almost like Leave It To Beaver, most of the time, when I was growing up, with the exception, as I said, of those periodic, unpredictable, episodes of sheer terror. A normal childhood, except for that. Ha…. Until the year I turned 12. That was when, looking back, the first of my PTSD symptoms began.

    It happened when I was awakened from a deep sleep in the middle of the night to the sound of my parents fighting. Dad was talking in his “evil person” voice. He was shouting, growling, really, sounding like a demon from the pit of hell, saying that he was going to kill my mother. I could hear my mother was pleading for her life. I heard scuffling, banging, screaming, yelling, crying… I leaped out of bed, pulled a dress on over my head, and went to the window and took out the screen. I was going to jump out of my second floor window and run to a neighbor for help. But then I heard my mother scream, “NO, NOT THE GUN!”…. and then I heard… I heard… I heard what I thought was the sound of very a loud gunshot… BLAM!… it was LOUD and SHARP and SUDDEN, right beside my ear, right on the other side of the wall. And immediately after that, I heard…. absolute silence.

    A moment later, I saw my dad through my bedroom window. He was running out of the house, out to the car, with his pistol in his hand. I could see the gun, by the light over the driveway, shining on the metal. My father jumped into the old Rambler station wagon and sped away.

    Silence. Utter silence. My mother is dead, it’s too late to go get help, it’s too late to save her, my mother is dead, my father has killed her… my mother needs me, I must go to her, but my mother is dead, my father killed her, it’s too late to get help, my mother needs me, I must go to her, it’s too late….

    I felt, literally, like I was wading through thick molasses, as I tried with all my might to simply put one foot in front of the other and walk the few feet from the window to my bedroom door. I felt like a heavy lead apron was weighing me down. I didn’t understand why it was so hard to just pick up my feet and walk! I was only 12, I did not know what “shock” is.

    Just as I was reaching for the doorknob to open my bedroom door, the door flew open. My mother was standing there, her dark hair wild around her pale while face. Her mouth was moving, moving, moving, moving, and her hands were gesturing, waving all around in the air – she looked like she was talking fast and furiously, but…. I did not hear anything. Not one sound! “It’s her ghost,” I thought dully. “My mother is dead, my father has killed her, and this is her ghost, that must be why I can’t hear her!”

    But then, seeing my frozen immobility, my mother reached out and grabbed my shoulders and shook me. The instant that I felt her solid fingers digging into my flesh, I knew she was not dead – and it was like magic, as a “switch” inside my brain seemed to be flipped back on, and I could hear again!

    My shock feelings lasted for years, though, an unreal, dissociative sense that life was only a dream, that I didn’t really exist. I could not sleep at night, and I walked around exhausted all day. My school grades plummeted. Meanwhile, my dad was arrested for what he had done to my mother, then he was taken to a hospital due to the terrible condition he was in, and that is when he was diagnosed with schizophrenia and MPD. My parents marriage ended after that, as my dad got involved with, and later married, the head nurse of the psychiatric ward. How unethical was that?

    A few months later, when I was 13, my traumatized, deeply depressed mother decided that the answer was to try to gas herself and all 5 of us kids to death while we slept in our beds. Only, I wasn’t asleep, because I still couldn’t ever sleep, and so… long story short, we did not die, after all.

    But again, it affected me the way I had felt on the bridge, when I was 2 years old and my daddy was chanting over and over that he was going to throw me off, and I would die…. I felt as though I had been murdered. I didn’t feel like my mother TRIED to kill me (along with my whole family), I felt as though she DID, in fact, KILL ME. Something inside of me seemed to die when my mother sat me down and explained to me, her eldest child and her only confidante, that the pilot light on the gas furnace hadn’t gone out all by itself, that she had done that on purpose, because she believed she would be doing us all a favor by taking us out of this cruel world that she had brought us into.

    I continued to walk around feeling like life wasn’t anything but a terrible dream for another year, and then, when I was 14, the voices started, after being triggered by a seance with my school friends and a Ouija board.

    So… what was that all about? What really happened to my father, my mother, and me? Was it schizophrenia, manic-depression, personality disorder, PTSD, or – as some of my dad’s church people believed – demons? I am about to turn 60, my first great-grandchild, my granddaughter’s baby, is due to be born next month, and I am finally coming out of the crazy closet and LOOKING at all this. After trying to “pass for normal” for the past half a century, I am bringing my old schizophrenia label out of my closet of shame, and I’m reading and searching and trying to figure out… What Happened?

    All things considered, I believe it was ALL trauma-generated. Not genetic, as many have speculated, but the traumatic environment I grew up in, and my parents grew up in, and their parents grew up in. Right now I do have all the symptoms of PTSD. Years ago, I did have all the symptoms of psychosis. But through it all, I am, and I always have been, a human being who deserves to be treated with CARE: Compassion, Acceptance, Respect, and Encouragement.

    I have lived through many traumas in my life. When I started hearing voices at the age of 14, my mother feared that I was “crazy, like your father,” and she immediately locked me up in a state insane asylum. I was there 2 years, until December 1969, when I was released at the age of 16. To get away from a mother who Did Not Want Me Home, I immediately married a high school dropout who needed a wife to avoid the draft to Vietnam… and so followed a string of abusive loveless relationships, because I was too ‘crazy’ to attract decent loving “normal” men. So truly my life has been trauma after trauma after trauma. BUT, in all of my traumas, nothing has hurt me so deeply and indelibly as: Being Labeled Mentally Ill.

    My “schizophrenia” label has hurt me more than all of my other traumas, combined. I am about to turn 60, and I am only just now beginning to be able to say, without SHAME, that I was given that label and locked up in a notorious state insane asylum more than 45 years ago! I have lived my life being ashamed of me, and hating who I am, because of that! NOTHING hurts worse than hating yourself!

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