This piece, originally posted in October, is a backdrop to some of the Veterans Administration’s recent statements about PTSD.
Returning Vietnam veterans. When Bessel van der Kolk was at the Veteran’s Administration (VA) in 1978, he was one of many clinicians fascinated by the complaints of returning Vietnam veterans. At the time, there was no definition of trauma related to combat, rape, involvement in fatal accidents — none whatsoever. When van der Kolk submitted a grant to do research on trauma symptoms it was denied. “It has never been shown that PTSD is relevant to the mission of the Veterans Administration” the VA stated flatly. (The quote is taken from Mary Sykes Wylie’s excellent profile of van der Kolk and his work “The Limits of Talk” — which you can find here. )
DSM diagnosis. Van der Kolk is well versed in the limitations of defining trauma in terms of diagnostic category. He helped write the definition. Post-Traumatic Stress Disorder (PTSD) first appeared in the Diagnostic Statical Manual III (DSM-III) in 1980. So what’s so important about a diagnosis? Without one you will not get treatment, or your treatment will not get reimbursed.
The current DSM-IV description begins “…exposure to an extreme traumatic stressor involving direct personal experience of an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, seriuos harm, or threat of death or injury experienced by a family member or other close associate.” But at its core, the kernel of the diagnosis is not so much the experience itself as the feeling of helplessness that it arouses in the victim. Another trauma expert, Judith Herman, M.D., describes this in Trauma and Recovery, as “its power to inspire helplessness and terror.”
Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.
It was once assumed that such events were uncommon. In 1980… the American Psychiatric Association described traumatic events as “outside the range of usual human experience.” Sadly, this definition has proved to be inaccurate. Rape, battery, and other forms of sexual and domestic violence are so common a part of women’s lives that they can hardly be described as outside the range of ordinary experience.
Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.
Herman’s book is an excellent place to start for those interested in the history and treatment of trauma. It is relatively short and accessible. You can find out more about it here.
Constructing diagnostic entities. Like many diagnoses, PTSD locates a point on a spectrum of symptoms and sets up camp. This encampment “becomes” the diagnosis. It takes on a life of its own and people begin to believe that the entity, as described in the manual, “PTSD” actually exists. So what happens when one or more of the criteria for diagnosis is not met? Then it’s “not PTSD”. More important than the outlines of any one definition, treatment can be denied based on whether symptoms match the criterion.
As he noted at his presentation to the Los Angeles County Psychological Association (LACPA) convention on Saturday — diagnostic categories are problematic. To paraphrase, “The idea that diagnoses like PTSD are actually out there in the world is a delusional system. You almost never see a case of pure PTSD.”
One thing van der Kolk observes consistently is a marked difference in the outcomes, across treatments, between those that suffer chronic trauma in childhood and those that experience a single traumatic incident. Not surprisingly, those that suffered repeated abuse, such as the child of alcoholic parents, showed less resilience than those that had a single adult traumatic event.
The symptom pattern — trauma does exist! This is not to say that traumatic symptoms do not exist. They do exist, and in consistent patterns. Typical trauma-related symptoms include: persistent, vivid “flashback” memories of the incident; recurrent nightmares; an exaggerated startle reflex; a sense alienation from one’s body; periods of “lost time” or dissociation — where one seems or is disconnected from reality.
The most extreme version of this is dissociative identity disorder, more commonly known as multiple personality disorder — where clinicians find symptoms resembling this phenomenon we also find trauma (almost invariably sexual). This last example would tend to fall under what van der Kolk and others term “complex PTSD”. It is one of the new diagnoses under consideration for DSM-V.
Complex PTSD and trauma related to upbringing highlight an important aspect of trauma. Generally, people are more traumatized by something that is done to them by other people, rather than by a hurricane, an earthquake, a fire. Intimate connection with a perpetrator seems to be particularly harmful.
Next post: Biological underpinnings: Why are some more susceptible to trauma than others?