The Evolution of a Diagnosis: PTSD, Part One

Trauma is in the eye of the beholder.                                                                              ~ Dan Metevier

You have probably heard of PTSD, especially if you know someone who has served in the military. This “mental disorder” diagnosis stands for Posttraumatic Stress Disorder. It was developed following the Vietnam war in recognition of the sometimes terrible after-effects of that war on many of the people who participated in it. For example, I once evaluated for disability insurance a Vietnam vet whose job was to load onto a helicopter the bodies of his buddies who had died that day. He did this all day long, day after day. Needless to say, he was not doing so well. I thanked him for his service and sent him on his way, with a tear in my eye.

The condition that the label “PTSD” describes has existed for as long as recorded history (which is often the story of one damned war after another, to paraphrase Winston Churchill). It has gone by such names as railway spine, stress syndrome, nostalgia, soldier’s heart, shell shock, battle fatigue, combat stress reaction, and traumatic war neurosis. In short, it involves the memories, images, and energy that are stored in the brain and body (especially the body) after an unsuccessful attempt to either flee or fight against some experience that one perceives as life-threatening or overwhelming. PTSD refers to a set of symptoms that interfere with your life (hence “disorder”) following (“post”) the overwhelming experience (“traumatic stress”).

I will say more about this process and condition in future articles. For now, I want to report on recent changes to the official PTSD diagnosis as described in the most recent edition, the fifth, of the Diagnostic and Statistical Manual of Mental Disorders® (DSM-5®). Being ever so slightly cynical, I refer to this 947-page publication by the American Psychiatric Association as “the big book of socially unacceptable behaviors.” According to this manual, you are not allowed to be too happy, too sad, too active, too inactive, too imaginative, and so on, or you’ll be labelled with a “disorder.” OK, I’ll get off my soapbox now.

Back to the task at hand. Each diagnosis in the DSM-5® lists the symptom criteria for having that disorder. For PTSD, the symptoms include the body and mind being more aroused than one can easily tolerate, or the body and mind being so under-aroused that one can hardly function. It also includes attempts at avoiding any reminders of the overwhelming experience (understandable) and the existence of memories, thoughts, or visions (waking or dreaming) that intrude on one’s daily life. For the most part, these criteria have not changed much from the prior edition (DSM-IV®). (Please note that somewhere between editions four and five, someone decided to switch from Roman numerals to Arabic.)

One of the significant changes, however, involves what qualifies as a traumatic experience. Previously, the victim (I hope it’s OK that I use that word) had to have a direct experience. For example, they had to be in the car when the horrific accident occurred. Now, in their infinite wisdom, … oops, sorry. Now, the victim can either be in the car accident, standing on the sidewalk watching the accident, at home five miles away hearing on the phone about how their close family member was killed in the accident, or be a policeman who arrives on the scene (after having done this same thing about once or twice a week for many years).

I view this as a good thing, in spite of my general cynicism. This change recognizes the many ways that trauma can affect people. For example, let’s say two best buddies from high school join the Marines. One of them, call him Joe, gets assigned to the infantry and goes to Afghanistan to track down IEDs (improvised explosive devices). The other one, call him Jack, gets assigned to a logistics unit, basically sitting at a desk pushing papers all day long. One day, Jack gets word that Joe has been killed by sniper fire while investigating an IED. This has a strong negative impact on Jack even though he was nowhere near any combat zone. He develops many of the symptoms outlined in the criteria for PTSD and has great difficulty doing his job. He gets sent to the infirmary where he tells the doctor, as best he can, what’s going on.

For a moment, let’s travel back in time and say this all happened in May, 2013, the month before the new DSM-5® was made available. The doctor looks at his copy of the DSM-IV (fourth edition) and notes that the event Jack described does not qualify as traumatic since he did not have a direct experience. Sorry Jack, no PTSD. No soup for you!

Now, let’s shift forward one month to June, 2013 and say that the same doctor has just received his new copy of the DSM-5®. He breaks it out of the shrink-wrap and this time, he sees that indeed Jack’s experience does qualify as traumatic. Yes, this time Jack does have PTSD and therefore qualifies for the appropriate treatment (and a bowl of soup).

Disaster averted!

My sincerest sympathies to those men and women who have suffered from PTSD symptoms prior to June, 2013, and were not given proper treatment. Hopefully, over time, this situation will rectify itself.

Spoiler alert! Part Deux of this series will address changes to the PTSD diagnosis that involve children. Good news! Well, mostly.

As always, I’d love to hear what you think about this or your experiences related to this situation. Thanks!

Copyright 2014 Daniel J. Metevier

DSM, DSM-IV, DSM-5, and Diagnostic and Statistical Manual of Mental Disorders are registered trademarks of the American Psychiatric Association.

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