Trauma reactions have been documented for at least four millennia in Mesopotamian texts, epics, biblical narratives, theatrical works, and medical writings. PTSD, by contrast, entered the DSM-III only in 1980. Forty-five years of clinical categorization versus forty centuries of narrated suffering is not merely a matter of scientific delay: it is a matter of framing. And framing, whether to medicalize or to recognize, is never neutral.
The Tremor of Ur, Pepys’s Nightmares, and the Claim of 1980
In the cuneiform laments composed after the destruction of Ur, between 2027 and 2003 BCE, someone writes in the first person about nights spent “trembling” among corpses, unable to sleep, overwhelmed by images that would not stop returning. Herodotus recounts the story of Epizelus, the Athenian warrior who survived the Battle of Marathon (490 BCE), struck by sudden blindness despite having suffered no physical wound after witnessing the death of a companion beside him. Six months after the Great Fire of London in 1666, Samuel Pepys wrote in his diary that he could no longer sleep a single night without “great terrors of fire.” Lady Macbeth, in 1606, walks in her sleep trying to wash away invisible bloodstains from her hands.
Anyone reading these fragments today through the lens of a psychiatry textbook would say: here is PTSD. Intrusions, avoidance, hypervigilance, cognitive and affective alterations. The four symptom clusters of the fifth edition of the Diagnostic and Statistical Manual.
But there is a question worth asking before closing the diagnostic box: what exactly happened in 1980, when the DSM-III first introduced Post-Traumatic Stress Disorder into its list of mental illnesses? Was it a scientific discovery, the delayed recognition of a pathological entity that had always existed, or was it the translation of something far older and far more human into the language of biomedical psychiatry? And if it was the latter, what was gained, and what was lost, in that translation?
Four Millennia, Three Shifts in Framing
The most interesting finding emerging from a long-term historical analysis is not the continuity of the symptoms although that continuity is striking, but the radical discontinuity of the interpretations. Across history, post-traumatic reactions have been understood as:
- Divine punishment or metaphysical contamination (ancient world)
- Moral weakness, cowardice, or character defect (premodern era and early nineteenth century)
- Organic injury to the nervous system (railway spine, Erichsen 1866; Traumatische Neurose, Oppenheim 1889)
- Unconscious psychic conflict (Freud, Janet, the dynamics of repression)
- A psychophysiological reaction to a stressful event (DSM-III, 1980)
Each framework did not merely describe suffering: it produced, regulated, punished, or treated it in radically different ways. During the First World War in Italy, soldiers with post-traumatic symptoms were labeled scemi di guerra (“war fools”), confined in asylums, and subjected to faradic currents as both therapy and discipline. In Germany, at the Munich Congress of 1916, the psychiatric community formally rejected Oppenheim’s concept of “traumatic neurosis.” The stated reason was scientific. The actual reason, historically documented, was economic: recognizing traumatic neurosis would have opened insurance compensation claims and weakened the war effort.
Anyone who still believes that psychiatric diagnostic categories emerge from a neutral convergence of clinical evidence should revisit that congress. Then they should ask themselves what is happening today in debates surrounding burnout, disability certifications, trauma from microaggressions, or diagnoses that legitimize access to welfare services or, conversely, stigmatize those who receive them.
The DSM as the End of History? A Claim That Does Not Hold
The implicit assumption behind every diagnostic manual is that, with its publication, the history of interpretive errors has ended. Before came superstition, moralism, theories of damaged spinal cords, Freudian metaphors. Now comes science: four clusters, operational criteria, temporal thresholds, specifiers.
A careful historical analysis suggests something very different. The DSM-5 and the ICD-11, the two systems currently in use, do not even agree with each other. The former includes four symptom clusters and twenty symptoms; the latter three clusters and six core symptoms. In the same Dutch population sample, PTSD prevalence according to DSM-5 was 1.3%, while according to ICD-11 it was 1.0%, with an additional 1.6% classified as “complex PTSD” a category not recognized by the DSM. The same suffering individual, in the same population, either is or is not “ill” depending on which manual one opens.
This is not a technical detail. It is evidence that the diagnostic category is not a photograph of a natural reality, but an operational convention constructed for specific purposes: research, compensation, access to services, clinical communication. A useful convention, perhaps even a necessary one in certain contexts. But still a convention.
What Is Lost When Suffering Is Medicalized
What historical analysis reveals most powerfully and what contemporary clinical language risks obscuring, is that pre-DSM frameworks often captured dimensions of traumatic suffering that current categories no longer know how to name.
The “nostalgia” described by Johannes Hofer in 1688, for example, was more than a list of symptoms. It was the recognition that one can suffer to the point of illness through the loss of a place, a landscape, a community. Trauma as a rupture between the individual and the world that sustains them, rather than dysfunction within an isolated brain. Today, when we speak of refugees, forced migrants, or communities displaced by war or climate change, we may realize that the old concept of “nostalgia” perhaps expressed something more precise than our current “negative alterations in cognition and mood.”
Another example: conversion manifestations — paralysis, aphonia, psychogenic blindness — abound in the writings of Charcot, in Egyptian papyri, and in Herodotus. Today they have been excluded from the core of PTSD and relegated to somatic symptom disorders or functional neurological disorders. But the question remains: does this separation represent scientific progress, or the fragmentation of a once-unified understanding of how the body speaks suffering? When a patient today develops dissociative non-epileptic seizures after an assault, we refer her to a functional neurologist; two thousand years ago, she might have been recognized as someone carrying in her body the weight of an experience too overwhelming to contain. Modern categories may treat more effectively, but they may also perceive less.
“A Fully Human Reaction” — This Is Not Rhetoric
The political point, before it is even a clinical one, is this: if the same constellations of trauma reactions appear in Gilgamesh, Achilles, Job, seventeenth-century Swiss mercenaries, survivors of the American Civil War, civilians enduring the London Blitz, and Vietnam veterans, then calling them a “disorder” is a choice, not an observation.
It is the choice to frame a consistent human response to experiences that exceed the organism’s capacity for integration as something dysfunctional, abnormal, and in need of correction. Yet a response that recurs with such regularity across cultures, genders, ages, and historical contexts is anything but abnormal. It is profoundly, stubbornly, inevitably human. It is what happens to human beings when they are exposed to what human beings should not be exposed to.
Saying this does not deny suffering. It means precisely the opposite: recognizing that such suffering is real, severe, and capable of destroying lives and that this is exactly why it deserves not to be reduced to an ICD code. The nightmares of those returning from war, the intrusive images experienced by witnesses of femicide, the hypervigilance of those raised in violent households are not malfunctions of a broken mechanism: they are the ways in which the human psyche responds to what has been done to it. Pathologizing them shifts attention away from the context that produced them and toward the body that carries them.
Three Lessons from History for Contemporary Clinicians
If the archaeology of trauma teaches clinicians anything, it is three things.
First. Wars have always accelerated medical recognition of trauma, while civilian suffering, that of women, children, survivors of domestic violence, and refugees, has often waited decades to be taken seriously. Kempe’s “battered child syndrome” dates to 1962. Burgess and Holmstrom’s “rape trauma syndrome” appeared in 1974. Diagnostic systems move slowly when victims are not wearing the right uniforms.
Second. Every time a category is codified, a conflict emerges over who is entitled to enter it. PTSD today is a gateway to treatment, compensation, pensions, and social recognition. But it is also a gate that someone decides to open or close: the more restrictive criteria of ICD-11 exclude individuals whom DSM-5 would recognize. Behind every threshold lies a politics of suffering.
Third. The historical continuity of symptoms does not legitimize the DSM: it relativizes it. To say “PTSD has existed for four thousand years” is equivalent to saying “PTSD does not exist in the way we currently define it; rather, something else exists that we now choose to call PTSD.” Categories are tools. Tools are used as long as they remain useful, and discarded when they betray the purposes for which they were created.
Toward a Secular Clinical Understanding of Trauma
This is not an argument for abolishing PTSD as a diagnosis, nor for returning to moralistic interpretations or coercive treatments. It is an argument for remembering that diagnostic categories are useful conventions, not truths. It is about using the DSM as one uses a map, while remembering that the map is not the territory. It is about accompanying every diagnosis with the question: what happened to this person? rather than only: what does this person have?
The ancients who wrote about Achilles, Gilgamesh, or Job did not possess a DSM. They possessed something different, perhaps less efficient, but also less reductive. They possessed a way of seeing that did not separate individual suffering from the historical, communal, moral, and existential context in which that suffering emerged. They could recognize trauma as the weight of history borne by the individual body, rather than dysfunction of the individual body within history.
That capacity is not obsolete. It is precisely what contemporary psychiatry needs today if it wishes to avoid reducing human experience to a series of administrative codes. The task is not to choose between science and humanism, between category and narrative, between neurobiology and meaning. It is to hold them together, with the awareness that every time a clinician writes “F43.1” in a patient’s chart, they are performing an act backed by forty-five years of history and four thousand years of prehistory, and those four thousand years are still speaking.
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Citation: Paganin, W. (2026). Core symptoms of PTSD across four millennia: a phenomenological and nosographic analysis – from ancient Mesopotamian texts to modern psychiatric classifications. Medical Humanities (BMJ). https://doi.org/10.1136/medhum-2025-013623
Well yes , thanks for this and more names and historical periods to be mentioned as welll as other layers not yet explored. If wars create trauma there destructive path creates an almost biological trauma as wel to humans and other species.
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“War fools”. I didn’t think smear on veterans could top “losers and suckers”. Obviously, I was wrong.
Psychiatry is a cancer in every possible way. Anything, including “theories, superstitions, and moralism”, that helps people avoid it should be respected and encouraged.
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Seriously. If you went out of your way to PLAN how to make people’s pain worse and less likely to get resolved, you could hardly do a better job than what psychiatry has come up with. Decontextualizing, pathologizing, victim blaming in sexist and racist and other prejudicial ways, lying to people, locking them up and punishing them for being in distress, forcing drugs that damage their brains, and if that doesn’t work, blaming the “resistant client” yet again and electrocuting them into a grand mal seizure! What part of this is supposed to be “healing?”
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The term “scemo di guerra” is a historical Italian expression, now recognized as stigmatizing and obsolete, used in the post–World War I period to describe soldiers with severe cognitive, emotional, and behavioral impairments related to war trauma. It was not a formal diagnostic category, but rather a colloquial and reductive label for complex clinical conditions. It was commonly used in the Italian language to refer disparagingly to individuals with cognitive deficits, behavioral disorders, or social marginalization (including homelessness), becoming a widespread derogatory term in Italian society while obscuring the profound suffering of young soldiers traumatized by the horrors of the First World War.
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And yet, to recognize the depth of the trauma caused by recent wars only scratches the surface of our traumatic landscape. Everyone who has been born has experienced some level of trauma (and certainly everyone who has given birth), so who should this field actually include and encompass?
Psychiatry would love it if everyone in society felt they were “mentally ill” or “suffered from past trauma” and sought them out for the healing benefits of their treatments. Yet we have today yet another series of failed psychiatric theories and failed psychiatric treatments. So while corporate and government leaders feel compelled to continue to support Psychiatry, even after its long history of failures, the general population is less so inclined. And so, even though all of us have obviously experienced trauma, few of us would look to Psychiatry for the answers to our suffering.
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“Half asleep near the stars with a small dog licking your face”.
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“The task is not to choose between science and humanism, between category and narrative, between neurobiology and meaning. It is to hold them together”
Excuse me, but when exactly did the DSM become scientific? Based on science? Has sufficient validity and reliability?
The DSM is not backed by science. Never has been. Please stop selling this myth to the public. It is based on mere opinions and professional trends.
The DSM is not very efficient either. Flick Grey has recently reflected on LinkedIn on how her dissociation has been misdiagnosed as 13 other psychiatric labels. How efficient (or reliable) is that? Not to mention the futile clinical treatment that followed these diagnoses. And her story is far from being rare.
https://www.linkedin.com/posts/flick-grey-57a5a27b_i-remember-when-mark-butler-first-became-activity-7452873529601212416-RcCH
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I can see that a lot of thought and research has gone into this article. The writer holds a PhD and is an “expert” in neuroscience.
He names five divergent theories about why people suffer – with the obvious observation that different theories lead to different treatments. But he fails to list ALL the theories (and treatments) that exist regarding suffering caused by trauma, and so paints an incomplete picture of our current situation.
While we must rely on our intellectuals to move this subject forward, we can see from this article – and many others published on this website – that most intellectuals of our day are not fully “wearing their hat” regarding this subject (and many others by the way). In some groups, claiming to be an expert in an area, then failing to fully study it – or ignoring the work of certain others who have studied it – would amount to a treasonous act. So I hope we all recognize what we are up against here. The appearance is that these intellectuals are failing us on purpose. Yet most of them would insist that they are doing the best that they can. Well, someone is intent on deceiving us – and perhaps also them. So let’s be a little more on our toes about this, shall we? We have a problem to solve, and in fact, we are running out of time.
Those who are familiar with my comments should also be familiar with what work I feel (or insist) is being ignored. For those less familiar, I will list those researchers again here: L.Ron Hubbard, Ian Stevenson, Courtney Brown, Steve Burgess. There are others, but these are the major ones I am aware of.
If these people were not getting positive results – even what could be characterized as profoundly positive – it might be seen as justifiable to ignore them. But in fact their results are much more prolific than those of many workers in this field who ARE being taken seriously. This leads one to wonder if the academic community is really interested in results, or would prefer to indulge in mental gyration to the end of time.
In the engineering world, where I have worked on and off for many years, intellectual effort without results is NOT rewarded. But then, that world supports the ideology of materialism, which is the dominant (if also domineering) ideology of our day. Straying away from materialism – even for those pledging to study the immaterial (the “psyche”) – may seem like too great a violation of norms. Yet those who did stray began to get results. So what shall it be? Results or intellectual safety? The choice seems more clear every day.
When Hubbard started, he was under the impression that his work would be taken seriously by the intellectuals of his time. When it wasn’t – at least not by the “experts” in the field he was studying – he had to re-evaluate his whole attitude about the intellectual landscape that innovators in this field are actually up against. And this apparent intellectual resistance to penetrating the secrets of the immaterial realms is also a subject worth discussing, as it has had far reaching consequences across the Sciences, even in Physics and Cosmology.
My personal feeling (but not just mine) is that time is running short for our little civilization here on Earth. So I hope all the brilliant minds that could be helping us find a new way forward will think twice before dismissing all the work they have been ignoring for over 70 years now. It is time to stop ignoring it; in fact, way past time.
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Very interesting. And I agree with those who say that PTSD per DSM is, as the author notes, a kind of map that is useful but far from comprehensive as a description of human suffering.
Though not stated explicitly, there seems to be an assumption that it is impossible to consider suffering on some continuum with some being ‘normal’ and some being ‘abnormal.’ So I’m asking whether it’s possible to do so. Some may think that the normal-abnormal concept has no place here; if you think that, than PTSD cannot possibly exist because disorders ( at least per DSM) have that concept built in. Maybe you can argue that it shouldn’t be based on that, in which case I’m not sure how PTSD could be defined.
This has been applied ( in MIA and elsewhere ) to the idea of pathological grief. If all grief is simply a normal part of human reactions, and ditto for human reactions to trauma, then neither belongs in DSM.
It seems to me that it’s a very practical question for society as to how we answer this.
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You will not be surprised to hear me say this, but IMHO, NOTHING belongs in the DSM. That doesn’t mean grieving people don’t deserve support or that extended grieving can’t indicate other issues may be at play. Please read my article on this point if you have not done so. The point is, there is nothing MEDICALLY WRONG with a person who grieves for an extended period of time. They are not ILL. They are grieving. And I’m not saying this from a theoretical perspective. I’m talking about my own experience here. There is no “scientific” timeline for grieving or any of the other DSM “disorders.” The “spectrum” concept fails miserably when one considers the many, many variables involved in grieving. If a person can’t see that, it’s going to be hard to have a rational discussion on the subject. The same pretty much applies to all the other “spectra” you are referring to.
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Not surprised! And I agree that thinking about grief as somehow medically wrong makes no sense, though it’s at least possible that there could be some biological findings associated with grief.
Part of the reason for the spectrum idea – and I’d be interested in your take on this – is that we as a society provide benefits of different kinds for people dealing with grief or trauma. Those benefits are based on someone making a decision about who’s entitled to those benefits, like time off, disability, work accommodations, etc. Our society somehow ( OK, now based on some medical person’s call) says some are entitled and some are not. So who should make that call, and what do you think it should be based on?
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A fair question. I guess I’m more of a socialist – I figure that anyone who feels they would benefit from a service ought to be offered it, there shouldn’t be a need to prove you are “bad enough” to need it. Of course, there would have to be some kind of limit to spending, which I think is complicated to determine, but it’s clear that the current pseudo-medical approach does both direct and indirect damage to the recipient.
The other point that I think needs to be considered is the prevention angle. We can spend a lot of money curing cancer while we are pouring cancer-causing agents into the environment and creating more cases than we can possibly cure. I think the same applies to “mental health.” We spend time trying to figure out to what extent the “PTSD” phenomenon is caused by environment or some vulnerability in the person’s biology, when we should be looking at HOW DO WE STOP TRAUMATIZING PEOPLE? We know that poverty and unemployment both contribute significantly to what is called “mental illness,” to take two of the least controversial. Why aren’t we working on full employment and ensuring that everyone has a minimum survivable level of income? If we do that, we’d save a lot of money “treating” people who are made “ill” by the failings of the society that raises them. Medicalization prevents anyone looking at social causation seriously – it gives us an “out” and allows us to blame the victims rather than find the sources of victimization and try to bring them to a halt.
As to grief, I don’t really care if there are “biological findings related to grief.” I believe people have every right to grieve as works best for them, and we ought to develop ways to support them, regardless of their “biological tendencies.” Genetic diversity is the key to species survival. Just because people are biologically different doesn’t make them pathological!
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Whether a system is socialist or something else, it has to deal with finite resources, and it has to figure out how to allocate them. Services and benefits on demand is unsustainable unless society wants to pay a lot more than it does now, and even taxing the very-rich more won’t be enough. This also applies to your important point about prevention, and how much we want to allocate to that.
I’d add that if we ask people to pay more for prevention, it’d be fair if they asked us to show that prevention dollars really work. We may be talking big bucks here, so I’m not sure we could just say it makes common sense that providing full employment and minimum income decreases trauma. It does make common sense to me, but if you want me pay a lot more taxes, you owe some data. It may be out there, but I’m just not familiar with it.
I don’t think anybody should make an argument that people don’t have the right to grieve as best works for them. But I think I could come up with some different ways of grieving that would be way way to one end of the normal distribution curve; those are not ‘wrong’, but at least we’d have to say they were statistically abnormal, just as someone 7 foot 6 is statistically abnormal. If my way to grieve is to starve myself as part of a plan to re-unite with the one I lost, I guess it’s my right, but I’d say that would be beyond just different.
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A thriving society where people are paid a living wage creates a very good tax base, as we saw in the 60s in the USA and Western Europe. While unlimited access to resources is unrealistic, the rich and powerful are skimming billions off the top and preventing the kind of generalized “middle class” success that the US surge in economic welfare was built on. Your cynicism and “devil’s advocate” arguments accomplish only driving people who might want to change the system into apathy. “It’s the best we have” isn’t good enough. The system as it is does not do what it promises to do, it wastes billions of dollars in resources and blames the victims of society’s failures for not being “happy enough.”
Your argument about grieving is also completely disingenuous. The vast majority of people who are grieving have nothing wrong with them at all. If someone is starving themselves, they have a different problem than grieving. The decent thing to do is to sit with them and talk to them about why it is so hard and help them find some hope for themselves while acknowledging the incredible depths of their pain. No medical intervention is needed. Unless you think love is a medical intervention?
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There is no way I am aware of to totally eliminate trauma from the human experience. Most births are more or less traumatic, as are many deaths. And that is a baseline level of experience that cannot be eliminated without eliminating humans themselves.
So, a much better question to ask is: How do we proof up people against being badly affected by past trauma? And we have some answers to that question. One method is Hubbard’s “erasure of engrams.” Another similar method is proposed and used by Steve Burgess. These methods get no coverage here even though they are used daily by thousands of people.
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Probably a better framing, actually. My main point is to focus on making lives safer instead of blaming the victims for reacting badly to things like wars and sexual or physical abuse as a child. Of course, some level of trauma is an inevitable part of the human condition, and support should certainly be made available, but not at the expense of letting society off the hook for creating a lot of the trauma that needs to be “treated” in the current model.
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This is actually an important point. But possibly not for the reasons some argue.
Having a relatively “safe” environment creates space for healing – something that is badly needed right now.
Those who don’t want us to heal could be assumed to be the ones that are behind the actions that tend to create unsafe environments.
This-life “trauma,” though, is the least important factor in mental well-being. While this-life access to workable treatments is possibly the most important factor. Past-life traumas, forgotten and unhandled, are the major underlying factor in this-life mental problems. In an environment that is too threatening or chaotic, they cannot be handled. And that is the major purpose for making this life less threatening and chaotic.
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“ Whether a system is socialist or something else, it has to deal with finite resources, and it has to figure out how to allocate them.”
While I don’t disagree that finite resources must be managed, I question the assumption that increasingly large, abstract political and economic systems should be organizing life in the first place.
These systems have been operating for centuries and have delivered us to ecological destruction, alienation, loneliness, concentrated wealth, bureaucratic dehumanization, and widespread psychological distress. These outcomes are actual products of the system, not merely (passive) failures of the system. Any solution short of abandoning the system(s) for something better is merely “improving” the system—making it better at what it does.
Sometimes what is treated as unquestionable necessity is the thing causing the problem.
Human beings evolved in communities where people knew one another directly. Modern systems organize life through abstraction: prices, statistics, bureaucracy, labor markets, and centralized administration. As scale increases, relationship is replaced by management. People are treated like cattle.
It seems we’re left asking “Which inherently dysfunctional system best allocates finite resources?” or, “Which bad idea of organizing life is the best bad idea?”
To me, the question is if life should continue to be organized primarily through impersonal, dysfunctional systems of abstraction rather than through smaller-scale relationships, reciprocity, local responsibility, and direct stewardship.
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You’re going to have bigger (or more violent) organizations trying to take over smaller ones regardless of what anyone thinks is the “best idea.”
The question then becomes: How do smaller and more pro-human organizations protect themselves against bigger, more impersonal and more criminal organizations?
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We are dealing here with subjective human experience. Some people can tell for themselves when suffering “makes sense” in a certain context and when it doesn’t. Occasionally, experts must step in when a person seems unable to determine this themself.
In an ideal world, the first rule in the field of “mental health” would be that all patients volunteer for treatment. However, in the real world we must deal with the criminally insane, and with temporary psychoses or “breakdowns.”
That in our current system, many if not most patients DO volunteer, and accept a pill as treatment, is not that relevant to the topic at hand, which is “post-traumatic stress.”
I have a curious experience with the expression “PTS” as I first learned it as meaning “Potential Trouble Source,” which is its meaning in Hubbard’s work. I often suspected that Psychiatry stole the term to confuse people. It in theory did not exist in Psychiatry much prior to 1980, while it has been used among Scientologists since the mid-1960s.
Hubbard introduced a concept similar to post-trauma stress in 1950 in his first book describing a subject he named “Dianetics.” For me, this only amplifies my belief that Psychiatry stole the idea from him and wrapped it in their own terminology. The idea that past trauma can resurface in odd ways as a response to some “trigger” event today seems rather obvious, but in 1950 it wasn’t, and it was Hubbard who made this breakthrough, not a Psychiatrist.
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For Steve about grieving and my scenario about the grieving person starving him/herself: I’m not suggesting here that this calls for a medical intervention, so let’s set that aside.
Since you say that this starving grieving person has a different problem from grieving, that tells me that you have some line that you are drawing that separates grieving from something else, whatever that may be. It suggests that you think that starving cannot be part of grieving as we understand it. It suggests also that if a person says “no, but you’re wrong to tell me that starving is not part of grief, and who are you to tell me that?”, on what basis would we tell that person that something else must be going on? If we’re all entitled to grieve in our own way, then it seems no one else has the right to say it’s something else; seems presumptuous to do so, whether it’s coming from a psychiatrist or anyone else.
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Again, your cynical attempts to “play the devil’s advocate” are not helping elucidate anything. We are not entitled to tell the other person ANYTHING about what is going on for them, it is their job to define the problem and what they think is helpful. I think I’ve made that very clear. I am interested in the personal experience of the person I’m trying to help. That’s all. If you read my article (did you?), you will see that grieving FOR ME brought up a lot of childhood abandonment and neglect issues. This would NOT be true for all people grieving the loss of a spouse, or most of them, though probably some would have similar experiences. Why would we take this wide range of experiences and try to “treat” them all the same as if all grieving people were having the same problem? Does EVERYONE who is grieving need “Internal Family Systems” therapy? Or only those with childhood abuse issues? And who gets to determine if they “need that” or not?
And more specifically – how and why would we settle on a year (6 months for children) as some sort of barrier between “normal” and “pathological” grieving? Does that not seem utterly absurd to you? If it doesn’t, I don’t think we have much to talk about. You can always come up with some creative scenario to make my arguments seem ‘wrong.’ That is again disingenuous. The point is, lumping people who are grieving into one category and making gross generalizations about “them” as a group is absurd and wrong and does not lead to better outcomes. Reaching out to people where they are and communicating about their experience leads to an individualized approach based on the needs of the client, instead of trying to come up with “treatments” that presume some sort of pathology when someone’s grief doesn’t conform to social or medical expectations, or insist on one “treatment” that supposedly will resolve all cases of “grief” in a timely enough manner not to exceed the arbitrary time boundaries psychiatry has decided to invent.
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Your calling me cynical and disingenuous and a devil’s advocate doesn’t exactly elucidate anything other than how you see me. Then you go on to question a whole bunch of things – treating everyone the same, that people need internal family systems therapy, the idea that normal grief has some fixed time line, etc. – that I never espoused or even agreed with. So wherever that is coming from, it is not coming from things I’ve said. I know how angry you are with psychiatry, and I have no interest in trying to discuss that with you if you’re going to treat me as some object. I don’t care about trying to make you appear wrong or me appear right. I do get that you believe that if I don’t agree that some division between normal and abnormal shouldn’t exist, then we don’t have much to talk about. It’s one of your pre-conditions to conversation here. If we all agreed on such things, there’d be no need for MIA.
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Alright, let’s keep it simple: Did you read my article? And after reading it, do you agree that setting a timeline of a year (or 6 months for children) to diagnose “prolonged grief disorder” is an arbitrary decision that does not take the large range of normal grief reactions into account? Maybe we can start with something we agree on.
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PTSD is a “clinical condition”?
Well…let’s put PTSD under the clinical lens.
David J Morris, author of “The Evils Hours”, was a journalist imbedded during the Afghanistan war. He witnessed moral crimes and lost several friends, and also suffered brain trauma when an IUD blew up his Humvee. Later, while receiving mental health treatment at the VA for “PTSD”, he was in a group therapy that focused on challenging ones thinking to address their PTSD (effectively group CBT). When David angrily complained that he felt betrayed by Bush and Cheney’s lies for going to war, and that he’d lost several friends-and much more-as a result, the group therapist pushed back for David to check his thinking, because it ‘wasn’t grounded in reality”.
Obviously, this is but one clinical example, and therefor anecdotal at best.
But was the clinician’s response to Morris’s protest anything less than today’s standard clinical fare? The clinician’s response was at odds not only with Morris’s ‘lived reality”, but with the fundamental tenants of universally shared material reality (i.e., as universal consequences resulting from political dictates). The clinicians curt oppositional response, then, all but foreclosed dialogue, and thereby any potential for psychodynamic engagement, one in which the “moral wound” at the crux of Morris’s anger and overall distress, could (possibly) begin a process of social repair, save-at least were empathy and moral consciousness “clinically” available-to bring the trauma out from the shadows of the clinical “scemo di guerra” (i.e., from displaced unconscious Italian social guilt and shame, to that of todays updated clinical power and its myriad of salient unconscious shadow objectifications).
IMO, the vast majority of today’s clinicians have been woefully shortchanged a robust secondary and undergraduate humanities education, save any semblance of- though clearly not spared Dr. Paganin, while their graduate education is then tailored around vocationally constrained managerial dictates, of which are further codified by professional training and credentialed obligations replete with punitive consequences (Citations beg). I’ve made these points to suggest that many of today’s clinicians are thus individually and professionally relegated to deliver mental health treatment that isn’t fundamentally any different or clinically less offensive than what Morris’s clinician dispensed.
So… when we talk about the “map”-and I’m confident that Dr. Padganin is exceptionally knowledgeable with McGilchrist’s brain hemisphere hypothesis and its troubling implications surrounding “human mappings of reality’, it seems to me that today’s mental health clinicians are hopelessly wed to their deeply conditioned and grossly reality-distorted neoliberal map, from which their deeply ingrained professional therapy is well suited for homo trumpus, not human relationships or all things relationship oriented (ergo dynamic and complex).
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In response to Steve – yes, we can have a discussion if we’re on the same page as to what we’re discussing and not discussing, so thanks for that.
I have read your article; actually had read it several weeks ago when we were corresponding.
This was your question to me: do you agree that setting a timeline of a year (or 6 months for children) to diagnose “prolonged grief disorder” is an arbitrary decision that does not take the large range of normal grief reactions into account?
Here is my answer: (1) It’s not automatic to me that any DSM diagnosis is made for evil purposes, though that can happen, and I believe that PGD was not created to do evil or to discount normal grief reactions (2) When you use the term “normal grief reactions,” it suggests that you think most are normal but at least some are not. Good mental health includes an ability to adapt to the death of someone close; if a person realizes that they’re not adapting well enough (by their standards), it’s a problem (3) reasonable people can disagree on where the line between normal and abnormal should be drawn, but they do agree that it can be helpful to some grievers that there is a line (4) those on the abnormal side should be identified and offered help – and don’t read it in that I mean drugs or psychiatric help – I just mean help. (5) Yes there is some arbitrariness to drawing that line, but it is not 100% arbitrary or random. We all draw lines in our lives about all kinds of things, hopefully driven by reality and good judgment and information, but not totally so. Your calling the timeline arbitrary is partly accurate but in my view doesn’t make it random or baseless or worse.
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So here’s where we differ, then. I think ALL people who are suffering deserve help. I don’t think someone needs to be “abnormal” to merit assistance, nor do I think someone who is suffering but whose situation is “normal” should NOT be afforded assistance based on their situation not being “abnormal” or “abnormal enough.” I believe the very act of CALLING someone’s reaction “abnormal” allows for an “othering” or diminishment of significance, creating a situation where a person’s reaction is blamed on their own failure to adhere to some “normal” schedule or set of symptoms.
I think the essential error that the DSM makes is that it lumps all people experiencing “grief” or any such manifestation of humanity together, as if all grieving people can be treated as a group, and parameters set as to who grieves “normally” and “abnormally.” As I stated in the article, I believe assistance should be available without any requirement that someone be labeled with anything at all. They describe suffering, they receive whatever assistance seems appropriate to what they describe, no label required. So the damage of the arbitrary timeline is an outgrowth of the mistaken idea that “grieving people” are a homogeneous group having the same problem that ought to somehow follow the same “normal” development, even though there are a huge range of variables that make grieving completely different for any two people.
Just as an example: My brother (in my perception) was not that close to his wife. His wife died of cancer. He was remarried within a year, dating within 5 months. My wife and I were extremely close. I still feel an intense sense of loss at times, 13 months later, though it is less frequent and less intense than it once was. How can the two of us be considered to have the “same problem?” Is there anything remotely similar about our situations? Is the fact that he grieved a much shorter period of time a reflection that his “mental health” is better? Or simply that he was not nearly as attached and didn’t feel the same sense of loss that I did? Or is he perhaps “abnormal” for not grieving long enough – did he suppress his grief and is it going to come out later in destructive ways? Is one way of grieving “normal” and the other “abnormal?”
So yes, selecting a year as a length of time is most definitely arbitrary, and I don’t know how you can suggest that there isn’t a degree of randomness in that selection. How was it arrived at? As I noted in the article, it was agreed on by committee. Are you saying the choice of that timeline is the result of comparison and analysis of scientific studies? Or is the vast experience of the “mental health professionals” involved in the selection sufficient to make it no longer qualify as arbitrary?
Bottom line, no two grieving people can be expected to grieve the same way. I don’t see any purpose to qualifying which of them is pathological based on a committee meeting. I believe we could easily come up with a way to provide the necessary services without putting the grieving person in a position to feel s/he is abnormal. From my at this point fairly extensive experience supporting grieving widows/widowers, normalization rather than pathologizing is what helps most people feel less alone and more capable of living their new life without their partner.
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Of course all suffering people deserve help. Nowhere did I say otherwise. I do think that those more impaired or more distressed are a higher priority. Though calling someone abnormal MAY create an othering, it’s also true in our world that calling someone abnormal increases the chances that they’ll be offered help. It’s where we should put our limited resources.
I disagree that the DSM and the prolonged grief disorder diagnosis lumps all grief together. I think the facts bear me out if you read those sections.
One does not have to have a grief diagnosis to get mental health help; if a person says they’re struggling or suffering, they qualify. True that someone will have to enter some DSM code for billing, but there are others who take cash and that’s just a non-issue.
You say that it’s a mistaken idea that grieving people are homogeneous. I don’t know who has that idea, certainly not me. We do know enough about both mental and physical healing to say that there are generally (not always) predictable patterns of healing and adaptation. Just as someone who has a physical injury may develop a huge and disfiguring scar – which no one considers a normal pattern – the same is true for mental injury. Some reactions to trauma or grief are more normal than others, and some, I think, are abnormal. That does not pathologize all ( or even most) such reactions. To say that it’s all normal is a place we differ.
I believe I already said that selecting a time is arbitrary, but as I also said, not all arbitrary decisions are random or haphazard. Nobody is saying that the line is fixed and perfect and might not be changed ( as has happened with other diagnoses), but your alternative is to say that there is no line to be sought. Again, without a line, with limited resources, those with lower needs may well get services which deprive those with greater needs, and that’s not fair.
Thanks for the exchange. I’ll leave you the final word.
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You two can keep going on like this if you wish, but I get emails for every comment and I read them all. And I must say, I am getting a bit weary.
Most doctors get into Medicine because they want to help. And many of them feel like they do. To challenge their specialty as somehow “fraudulent” is an affront to them, and contradicts their lived experience.
Yet we do that here, and most of us feel for very good reasons.
It is one thing to hear an individual doctor defend himself for deciding to remain in the profession. But that’s not what this is all about. The profession, as a group, has done tremendous harm. We are here to address that and perhaps explore what, if anything, can be done about it.
Attacking structures like the DSM or “Psychiatry” will be one expected response, but not that helpful, as that doesn’t get to the root cause of the problem. The problem has to do with the fact that people do harm. Now, if a person identifies as a drug dealer, then you would expect them to do some harm in playing that role. But when someone identifies as a doctor, you don’t expect them to do harm in playing that role. So the first person is being bluntly honest, while the second is being deceptive. So, the second part of our problem is that some people do harm while pretending to do good. And that’s insane.
The larger problem, then, is insanity itself. And part of the problem we have with the insane is that they tend to think they are the sanest people in the room. So they are not only other-deceptive; they are self-deceptive. And that’s a rough situation. The point here is that the LAST PLACE we want that is in the field of “mental health.” So the big challenge is: How do we eliminate that trait from the profession, or decrease it so markedly that it becomes manageable? And the weird thing is that Psychiatrists are the ones who should have the best answer to that challenge, but they don’t.
So my message to Psychiatry in general, or any psychiatrist in particular is: We need you to either fish or cut bait. Stop defending your profession as it exists today; it is not defensible. Stop telling us “we don’t know enough yet;” we do! Stop worrying about whether labeling someone “mentally ill” stigmatizes them; of course it does!
Help us figure out how to eliminate arrogance and deceit from the profession, if not from all of society. Or follow the path of people like Kelly Brogan, denounce drugs and teach people meditation (or whatever). Help get alternative non-drug treatment methods covered by insurance. Help broaden the subject to include people who are not using drugs and who are having success with their techniques. And if you can’t do some of those things, then you can’t stand with us. All those things are completely doable, and if you think they aren’t, look around and find out who’s lying to you. Because someone is.
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I can see how it is wearying to read some of these exchanges; too bad there’s not an option to selectively opt out of the wearying ones.
I sense that your comments are mostly geared toward the profession of psychiatry and not directly to me, but hard to say that some of it is not at all for me. For reasons you’d need to take up with Bob Whitaker, the mission of this site explicitly states that psychiatrists are invited to participate, without there being some requirement to admit to each and every one of psychiatry’s evils. I’m pretty sure that just about anything I said now that was not a denunciation of the field would be something you placed no credence in. So I won’t get into that. And it’d be a major distortion to say that I am on MIA just to say that psychiatry is full of nothing but good deeds and intentions.
I did take some time today to go on Kelly Brogan’s site; thanks for pointing me there. Clearly she’s been a help to many; good for her.
I almost hesitate to say this, anticipating your refuting me, but every one of the articles she has on her site from journals are case studies, even though her site initially touts them as “randomized clinical trials.” Unless she has published the latter, it’s misleading to call them that. That said, case reports do clearly identify some benefits, so I’m not discounting that.
I suspect neither one of us wants another wearying exchange. I say that matter-of-factly, not trying to be cute or sarcastic. But I’ll read any response you opt to make, and I’d suggest we leave it there for now.
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These reflections emerging from my article are highly productive and meaningful.
One aspect that deserves attention in this discussion is the distinction between fear-based trauma and what is increasingly conceptualized as “moral injury.” In some patients, the core dimension of suffering does not appear reducible to conditioned fear responses, cognitive distortions, or hyperarousal alone. Rather, the experience may involve betrayal, guilt, moral disillusionment, loss of meaning, or the collapse of previously held ethical assumptions regarding oneself, institutions, or society itself, phenomena that have repeatedly emerged throughout history in the aftermath of collective and interpersonal trauma.
In this sense, an important concern is being raised: when clinical practice becomes excessively protocol-driven, there is a risk that existential or moral suffering may be translated too rapidly into the language of symptom management. Under such circumstances, a patient’s protest or anguish may inadvertently be interpreted as a “cognitive distortion” rather than as an attempt to articulate a profoundly fractured moral experience.
At the same time, I would be cautious about concluding from this that diagnostic models are inherently invalid or harmful. Clinical classifications are imperfect and historically contingent tools, certainly open to criticism, yet they still attempt to identify individuals whose suffering becomes persistent, disabling, or clinically significant. In the case of PTSD, they also allow for the recognition of a causal relationship between traumatic exposure and the patient’s clinical condition.
Perhaps the more relevant question is not whether psychiatry should classify suffering at all, but whether our current models are sufficiently capable of integrating the relational, moral, cultural, and narrative dimensions of trauma without reducing them to purely technical constructs.
This is where I believe approaches informed by phenomenology, psychodynamic theory, trauma theory, and contemporary neuroscience may still provide an important contribution to psychiatric understanding and clinical care.
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I think the question of whether psychiatry should classify suffering is, in fact, the most relevant question. I worked several years as a counselor and never felt the need to categorize anyone I tried to help. I simply had them describe the situation and used their language to talk about it. The only time diagnosis ever came up was for billing. I tried to “, diagnose” everyone with “adjustment disorder” if I could, as it seemed least stigmatizing. If a client asked, I explained that diagnoses were really billing codes and didn’t affect our interactions in any way.
Not one person ever complained about not having a diagnosis.
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I basically agree with Steve that the process of “classification” seems to amount mostly to an attempt to over-think or avoid confronting what is going on with the person in front of you.
Though certain terms may be helpful in discussions between professionals about their cases, the number of different and unique phenomena that can produce roughly similar symptoms is quite amazing, as anyone who has really dug in and worked closely with many people can attest.
Further, the profession – or perhaps it is its academic arms – insists on continuing to wear blinders and disregard the accumulating mountain of evidence about what is really going on with people. Each personal experience is indeed unique.
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I would rather suggest that approaches informed by phenomenology, psychodynamic theory, trauma theory-the implicit subtext in my first reply-are the most substantively valuable and effective care available to people. And let’s be real for a moment if we may. These ‘approaches’ rarely see the light of clinical day, save mostly and only when the patient/client has the financial means (time, education, social capital!) to ‘shop’ for the mere representation of these approaches-not to be confused with an informed skilled execution of their principles therein (one needn’t but peruse the Psychology Today website to see that every (always) smiling social worker is an ‘expert’ in these approaches-which is utter bullshit). And when they are located in an actual clinician with a rarely institutionally availed education and hard-won skill set-as opposed to the poorly educated assembly line of social workers systematically relegated to storefront businesses (downstream policing), they are at a prohibitive cost to those who most need these ‘approaches’, and nary if ever from the office of a psychiatrist, however otherwise increasingly populist with the virtue hoarding psychiatric ivory tower.
And what of these ‘approaches’ when they intersect with the ‘psychiatric understanding’ of traumatized foster children (40% of which are psychiatrically drugged-most to egregious excessiveness and systematically put to psychiatric pasture), save a dozen other ill-fated demographics? And what is the “psychiatric understanding” of these approaches when diagnoses like depression, anxiety, oppositional defiance disorder, and a dozen-more other ‘psychiatric disorders’, are but masking or otherwise telegraphing the (systematic) clinically unacknowledged lived experiences and ‘relationships’, conducive if not endemic to the clinical associations of PTSD and C-PTSD? Somehow, I think it matters not…
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