Journal of Anxiety Disorders 21 (2007) 211–222

PTSD: A problematic diagnostic category Paul R. McHugh *, Glenn Treisman Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Abstract Since the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, posttraumatic stress disorder (PTSD) has become a remarkably dominant theme in mental health discourse and diagnostic practice. This development has been encouraged by the diagnosis being officially presumed to exist in acute, chronic, delayed, complex, subdromal, and even ‘‘masked’’ forms. Here, we present an historical and clinical review that indicates how, since 1980, the term PTSD (along with its dubious embellishments) replaced established views on mental responses to trauma to the detriment of patient care and psychiatric investigation. From this historical perspective, we review and evaluate the natural course of emotional and behavioral reactions to traumatic experiences, and as well their assessment, formulation, and therapeutic management in both civilian and military situations. From this we conclude that the concept of PTSD has moved the mental health field away from, rather than towards a better understanding of the natural psychological responses to trauma. A return to prior standards of diagnostic practice and therapeutic planning would greatly benefit patient care, rehabilitative services to veterans, and epidemiologic research. # 2006 Elsevier Ltd. All rights reserved. Keywords: PTSD; Stress; Trauma; Dissociation; Psychiatric diagnosis; War neurosis; Battle fatigue; Accident neurosis; DSM; Vietnam war

Of all the faddish postulates that clutter the contemporary diagnostic landscape of psychiatry, none is more pervasive than posttraumatic stress disorder (PTSD). Its themes and alleged psychopathology fill the journals and are discussed incessantly in the clinics. Grief and trauma ‘‘counselors’’ now flock to every disaster and intrude upon the survivors, justifying their actions as preventing PTSD. In his authoritative book, A War on Nerves: soldiers and psychiatrists 1914–1994, Shephard (2000) describes how concerns that began amongst

* Corresponding author at: Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer Building 127, Baltimore, MD 21287-7127, United States. E-mail address: [email protected] (P.R. McHugh). 0887-6185/$ – see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2006.09.003

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military psychiatrists early in the 20th century came at its end to spur a ‘‘burgeoning sociomedical movement that aimed to . . . reverse decades of willful ignorance of traumatic acts and denial of posttraumatic suffering’’ (p. 385). He sees a ‘‘culture of trauma’’ enveloping us all and transforming into ‘‘victims’’ hordes of people previously honored as veterans and ‘‘survivors.’’ Since the term PTSD entered official psychiatric parlance with the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-III in 1980 (American Psychiatric Association, 1980), media reports and public testimony from victims of assault, accident, rape, child abuse and the like have made PTSD a household word and courtroom plea. Mental health experts now assert that PTSD comes in acute, chronic, delayed, complex, subdromal, and even ‘‘masked’’ forms. Many teach that it must not only enter into all diagnostic thinking, but should also supersede most other issues in explaining mental symptoms. We, however, believe with Shephard that mental health professionals have overworked this theme and led themselves into diagnostic and therapeutic practices that now confound the discipline. Specifically, those who promote PTSD have (1) disregarded time-honored lessons about traumatic stress reactions; (2) permitted political and social attitudes to sway their judgments and alter their practices; (3) dispensed with diagnostic fundamentals and so made claims that are regularly (and embarrassingly) misleading; and (4) slighted other explanations and treatments for patients with trauma histories. We shall develop these criticisms and cite sources for our opinions. 1. What was known Long before the term PTSD was coined, mental health professionals had seen how frightening events that threaten or produce bodily injuries can evoke a fairly stereotyped distressful psychological state in people. They identified this state as a natural psychological reaction, and in that way similar to the grief reactions produced by personal losses. Their opinions rested on the study of victims of violence and trauma – industrial, natural, political, and military – during the first three quarters of the 20th century. The relative similarity of symptoms across cases and across provocations strengthened their view that states of mind that follow traumatic stresses – whether sudden and acute or protracted and chronic – were emotional reactions with fairly predictable courses. 1.1. Responses to sudden trauma For some percentage of people, the first phase of reaction to a sudden and unexpected trauma, such as an assault, accident, or natural disaster, is often a period of emotional numbness or depersonalization that can last for hours or days. During this phase, the individual may act purposely but report an inner sense of unreality as though in a dream and may appear emotionally blunted and dulled. In these cases, this state subsides within a day or so to be followed by a longer lasting period of anxiety and painful reminiscence, difficulty sleeping, nightmares, vivid waking images (‘‘flashbacks’’), and phobic avoidance of places and activities associated with the trauma. During this phase, the person can be helped, just as the grieving subject can, with sedatives for sleep, reassurance that recovery will come, and sympathetic listening. As with uncomplicated grief, these prominent psychological symptoms gradually fade away. Gradual is the operative word here in that the course of recovery can vary from weeks to months and probably depends on the severity of the trauma, its long-term implications, and characteristics of the individual. The

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end result though is that except for some continuing sense of loss, occasional bad dreams, and a reluctance to visit quarters where the shock was experienced, the person recovers psychological equilibrium. In other words, resilience is the most common human response to trauma (Bonanno, 2005). The resilience of the citizenry of New York City to the dreadful experiences of September 11, 2001 surprised many contemporary ‘‘Traumatologists’’ who expected and predicted a huge outbreak of PTSD amongst them (Breslau & McNally, 2006). 1.2. Responses to protracted stress The extended, violent war conditions that were common experiences of young men during the first half of the 20th Century provided psychiatrists with subjects exposed to protracted life threatening stress. Psychiatrists from Europe, USA, and Israel all reported similar findings. When the distressing and threatening tumult is severe and prolonged, as in trench warfare or extended military campaigns, soldiers may suffer an insidiously emerging mental condition in which fatigue and tense anxiety combine and provoke several associated features and phenomena. Sleep is disturbed and interrupted by frightful dreams and hypnogogic hallucinations. Tension evolves into a state of hyper-alertness, ‘‘jumpiness,’’ and even transient tremors. Anxiety can be complicated by depressive feelings of hopelessness about survival and shame. If the tumult has no respite, the impairing mental condition will increase and eventually disable the person. Doctors tied these mental states of soldiers specifically to the siege of battle: correlating mental events with data on physical casualties from persisting combat actions (Glass & Bernucci, 1966; Swank, 1949). Even when the soldier remains physically uninjured, the ongoing meˆle´e with its skirmishes, artillery barrages, and growing exposure to casualties provoke and sustain in him an obnoxious level of defensive alertness, apprehension, and physical tension. These military psychiatrists noted that although this description was roughly applicable to all combat soldiers, they saw distinctions amongst cases. Individuals varied in the severity of their breakdown and in their speed of recovery. They also displayed different forms of emotional collapse; again not unlike variations in the expressions of grief that are personal and situation dependent. Factors shaping the expression and course of break-down include: prewar vulnerabilities of temperament and personality; the different worries borne by enlisted men in contrast to conscientious officers (emphasized by MacCurdy, 1918; and vividly portrayed in Sherriff’s 1929 play Journey’s End); and the inner cohesion and morale of the combat team itself (‘‘group identity’’) that depended on how well or poorly men were trained, equipped, and led. How military leadership on the spot and psychiatric services behind the lines understood and managed psychological reactions to combat crucially influenced outcomes. Most psychiatrists came to believe on the basis of these reports that in the continuing bedlam of battle every combatant could potentially succumb to a state of chronic anxiety and military ineffectiveness. However, the tension will ultimately dissipate after the subject is relieved from front line duty, leaving some residual conditioned emotional responses such as occasional bad dreams or nightmares along with a tendency to be startled by noises and sirens that resemble battlefield sounds. These views on characteristic symptoms, course, and prognosis derived from such informative reports as John MacCurdy (1918) in World War I and Roy Swank (1949) in World War II (WWII). Charles Wilson (Lord Moran, 1966) wrote a vibrant memoir mostly from his experiences as a physician in World War I but he included vignettes from both wars. He wrote,

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‘‘men wear out in war like clothes’’ (p. 64). Wilson believed that soldiers had a kind of ‘bank’ of courage that, like any bank account, could be depleted, in this case by prolonged war conditions. Data confirming Wilson’s views relating prolonged combat intensity to psychological breakdown include those of Glass and Bernucci (1966), whose findings displayed the close relationship between surgical and psychiatric casualty rates of combat units in WWII. Other attitudes influenced how the most serious breakdowns should be treated. Many authorities during World War I held the view that such men should be sent back home with dishonor and abandoned to psychiatric care as ‘‘unfit.’’ Eventually in World War II and later, the practice of keeping casualties close to the battle zone (in what has come to be called ‘‘forward psychiatry’’) came to the fore along with the expectation of their recovery and return to duty. This latter concept used extensively by the Israeli army in the Yom Kippur war and the Lebanon conflict did appear to demonstrate that the duration of symptoms and emotional ineffectiveness is reduced if the severely psychologically afflicted person can be temporarily relieved of duties, while assured that his distress is a perfectly natural response from which he will recover. He and his caregivers should share expectations of his psychological recovery along with an underlying assumption that he will be able to return to his customary activities including rejoining his military group or unit. His recovery would be facilitated if treatment could be provided away from battle, but within the region or zone of military oversight. Although it is difficult to be certain whether ‘‘forward psychiatry’’ is serving the military needs (by keeping more combatants available) or the individual’s needs for treatment (Wessely, 2006), it does seem plausible that if a soldier is transferred out of country to distant hospitals – and stigmatized as unworthy as well – he cannot but think that his psychological makeup is defective and his psychological injuries from military experiences more disabling. Further, if the treatment he receives takes the form of repetitively promoting an emotional catharsis of the fearful events and stresses of battle, the soldier risks developing a kind of chronic hypersensitivity about his psychological condition that can persist as a form of emotional invalidism. In the end, though, WWII military psychiatrists concluded that the psychiatric casualties from military stress and trauma were understandable conditioned anxiety states provoked by the distressful experiences of continuous and relentless combat. They were best treated by brief removal from the danger zone to some place where physical comforts, personal hygiene, and occasionally brief sedation could be provided. These rehabilitative efforts were to be accompanied by the teaching that the man’s feelings and states of mind are normal responses to his battle experience and would soon dissipate, permitting him to return to full activity as a soldier now and as an effective civilian at war’s end. The aim was to avoid the invalid state from which the mistreated veterans of World War I tended not to recover. 1.3. Advantages of the Standard Conception When we identify these descriptions and prescriptions as ‘‘standard,’’ we mean they amounted to textbook teaching until the late 1970s. The established American textbook of psychiatry of the time, Kolb’s Modern Clinical Psychiatry in its 9th Edition (Kolb, 1977), spells out these concepts and practices in detail in the section on Gross Stress Reactions (pp. 534–546). It places the conditions amongst the other emotional reactions and presumes them to be situation specific and understandable. Kolb restricted the term ‘‘Posttraumatic’’ mental conditions to the psychiatric effects of head injuries. This standard conception brought several advantages encouraging further study—even studies and considerations that would challenge its presumptions of explanation and management

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(Wessely, 2006). It identified the clinical presentations as psychological responses rather than some form of brain dysfunction—as perhaps the term ‘‘shell shock’’ had implied. It identified aspects of situation, personality, and social role that could shape its expression and explained individual vulnerability and resilience. It offered treatment and prognostic opinions that stood the test of time and was neutral in judgment: neither denying the hero his laurel nor shaming the casualty with the white feather. Perhaps the only issue about mental disorders following trauma that psychiatrists identified, quarreled about, but never resolved was the role of compensation and self-serving litigation in either provoking or sustaining these states of mind. Henry Miller’s classic essay on Accident Neurosis laid out these matters for civilian situations (Miller, 1961). This issue – and particularly its unresolved status – would take on significance when new wars, new politics, and new social understandings influenced how victims thought they should be compensated. 2. PTSD: a new diagnostic construct 2.1. Birth and development of PTSD PTSD, as we know it today, was born in just such changing circumstances. As the 1960s brought unrest with authority and growing discontent over American military involvement in Vietnam, a group of psychiatrists and Vietnam War veterans combined to propose a new approach to the psychological consequences of exposure to warfare and other forms of trauma. Most of the psychiatric advocates for the new approach had strong antiwar opinions, especially about this particular conflict. They saw, as especially deplorable, the suffering of the soldiers who were drafted into what they considered an American war of aggression—a point of view about their service, many of the returning soldiers themselves may have encountered in their home communities. Many of these psychiatrists, especially Robert Lifton and Chaim Shatan, were skilled in combining advocacy for their views in both the news media and the psychiatric corridors of power and authority (Scott, 1993). No evidence suggests that Vietnam veterans were more maladjusted than veterans of other wars. Certainly they were not exposed to the long campaigns of the World Wars from earlier in the century. In fact, their tours of combat theater service were specifically limited to 1 year so as to limit psychological casualties, And yet gradually (sometimes with media encouragement viz., Martin Scorsese’s 1976 film Taxi Driver), some of them, when experiencing chronic distress, unhappiness, alcoholism, and social instability after discharge, came to believe that they were afflicted by some special mental condition tied to their wartime experience. On noting that the Veterans Administration (VA) system did not see these problems as ‘‘war wounds,’’ they gathered in self-help groups to support the concept of a ‘‘post-Vietnam Syndrome’’ and to spread the idea amongst other veterans. Psychiatric advocates soon aligned themselves with these groups (Shatan, 1973). The central assumption carried by both the veterans and their psychiatric supporters was that – in contrast to standard psychiatric opinion – problematic temperaments, personalities, and behaviors were not shaping a subject’s response to trauma but were products of it. The ‘‘post-Vietnam syndrome’’ was an expansive term encompassing many different expressions of mental disorder and distress. By coincidence, the American Psychiatric Association (APA) was transforming the profession’s diagnostic methods and nomenclature in the late 1970s. A radical revision of the official (DSM) was on the drawing boards and its authors and editors were calling for testimony from ‘‘experts’’ in any

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mental disorder who could affirm from their experience both the reality of the disorder and the psychological features and manifestations that defined it operationally. The champions of Vietnam veterans seized the opportunity to identify, codify, and affirm their ideas, so to advance their propositions with official diagnostic recognition. They worked deliberately and effectively on the editorial committees of the APA to insert PTSD – particularly in what they held to be its all-encompassing chronic, refractory, or delayed forms – into the official and standardized classification scheme of American psychiatry. They succeeded and PTSD, with all its subtype varieties (acute, chronic, and delayed) emerged with the publication of DSM-III. Like Athena full-grown from the forehead of Zeus, PTSD arose in 1980, only 3 years after Kolb’s text where there was no glimmer of the condition. 2.2. Growing PTSD Three groups worked together to nourish and grow PTSD after it was born. The anti-Vietnam war psychiatrists, who had first studied Holocaust and atomic bomb survivors, identified the psychiatric casualties from Vietnam and then all civilian trauma subjects as ‘‘victims of stress.’’ Veterans with psychiatric conditions found that the diagnosis of PTSD conferred them a status more honorable than personality disorder, alcoholism, or adjustment disorder. Soon other victims of accident and injury saw similar advantages. Finally, the VA saw how the diagnosis provided the justification every care-giving bureaucracy seeks for its services. Before long the VA was devoting special units – almost entire hospitals – to veterans with PTSD, and their numbers began to expand seemingly without limit. Finally and not surprisingly, other psychiatric hospitals and services fell into line finding PTSD in many of their patients. The remarkable growing prevalence of this disorder demanded a closer look at diagnostic thought and practice, especially given the growing clinical expenses for the care of veterans. In 1983, Congress commissioned a ‘‘specific and comprehensive’’ study of ‘‘the mental health status and general life adjustments of Vietnam veterans.’’ This study, the National Vietnam Veterans Readjustment Study (NVVRS), reported in 1988 that 479,000 of the 3.14 million men who served in Vietnam still had diagnosable PTSD, now some 15 years after all soldiers had left that theater (Kulka et al., 1990). It also stated that almost a million (30.9% of the men serving in the Viet-Nam theater) had ‘‘full blown’’ PTSD at some time thereafter. These data evoked amazement and no little controversy as to their credibility. The numbers seemed extraordinary, especially given that only about 300,000 theater veterans had even been assigned to combat units (Shephard, 2000, p. 392). We can date the beginning of the controversy over trauma psychiatry to this report and its incredible figures. Gradually and ever since, many psychiatrists and psychologists have begun to look critically at the ways PTSD was proposed in DSM-III, grew in practice, and identified patients with the condition to be counted as trauma victims. Their work, gathered in several recent books and articles (McNally, 2003, 2005a, 2005b; Rosen, 2004), describes the conflicts over data and interpretation that have surfaced. 2.3. Challenging PTSD The exponential rise in the numbers of publications in the literature (see Fig. 1) and of clinic patients so diagnosed suggested a faddish interest—especially given the fact that the 1980s and 1990s were periods in our history relatively free of violence and trauma. Of course, no life is trauma free and if stressful trauma is expanded to events and experiences listed in DSM-IV, then

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Fig. 1. MEDLINE publications on PTSD by year (1979–2005). This figure represents the number of annual publications found in an English language MEDLINE literature search for keyword search terms: ‘‘PTSD’’ or ‘‘Post-Traumatic Stress Disorder’’ for the years 1979–2005.

epidemiologists can show that close to 90% experience something of the sort in their lifetime (Breslau & Kessler, 2001). Given all these facts, closer study of diagnostic and treatment methods gained support and ultimately taught us much. Although the Vietnam war differed from previous American military campaigns (e.g., as a guerrilla war many supportive and ostensibly noncombatant personnel such as airport workers, truck drivers, and even doctors, nurses or cooks had brief encounters with enemy fire), the numbers from the NVVRS would make anyone skeptical about the validity of the PTSD diagnosis. Allan Young (1995) in a careful, indeed masterful, analysis of methods for diagnosis employed in VA Medical Centers demonstrated that throughout the VA system, case identification came to rest on symptom searches and questionnaires that, in a kind of ‘‘check-list’’ fashion, probed for DSM’s criteria symptoms for a PTSD diagnosis. The logic of DSM-III encourages these ‘‘top-down’’ diagnostic methods because it identifies all psychiatric conditions by their phenomenological features. Symptom search questionnaires are typically used now with all victims of trauma. However, these ‘‘top-down’’ methods differ radically from the method more standard to psychiatrists since Adolf Meyer’s teaching, a method that had for over a generation demonstrated its clinical sense and coherence (Kolb, 1977, p. 18, 19). By this method, a psychiatrist drew diagnostic formulations from a ‘‘bottom-up’’ assessment that evaluated a subject’s full biography and took into account his previous psychological problems, temperament, and mental state in explaining presenting complaints. This method emphasized ‘‘external informants’’ as sources providing and confirming facts in the clinical history. It was specifically noted that ‘‘one cannot depend on the patient for the previous history as is usually done in general medicine cases’’ (Lewis, 1943, p. 14). When thinking ‘‘bottom up,’’ a diagnostician naturally considers all the various forms of psychological maladjustments that people, soldiers or not, can experience and express with mental symptoms. The check-list or any similar ‘‘top-down’’ symptom-probing method has many flaws, not the least one being its assumption that the subject understands the question and what it seeks, in the same way as does the questioner. As important, symptom-seeking diagnostic methods are vulnerable to being over-inclusive. This is especially true of psychiatric diagnostic exercises given that the symptom repertoire of mental life is far smaller than that of physical life. Quite different psychological conditions manifest themselves with similar mental symptoms, and some

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cognitive or affective responses to distressful or threatening situations are normal rather than expressions of disorder or psychopathology. This in part explains why VA centers, where checklist methods were employed, produced PTSD cases by the carload. Again perhaps coincidentally, a new idea about how the human mind deals with traumatic stress emerged at this time: an idea that further confused and expanded the PTSD diagnosis by rendering it mysterious and enigmatic. Many mental health professionals came to believe that the memory of a severe trauma could be banished from full consciousness—by being ‘‘repressed’’ or ‘‘dissociated.’’ Now such subconscious ‘‘traumatic memories’’ could act to provoke all kinds of psychopathological expressions, including anxiety states, depression, interpersonal troubles, alcoholism, and drug addiction. Professionals used this idea to explain why in wars prior to the Vietnam war, clinicians had failed to identify, as forms and varieties of PTSD, all those other presentations such as personality disorder, current life failures, alcoholism and the like. They believed that some events, if their threatening meaning was ‘‘dissociated,’’ might fail to register on a subject as traumatic, while still carrying a powerful pathogenic role. Many students of psychiatric methods had followed the lead of Karl Jaspers (General Psychopathology, Johns Hopkins Press, 1997, pp. 530–532), who taught that ‘‘dissociation’’ is one of the mechanistic concepts of mind working by analogy, and thus a description cloaked as an explanation. But now dissociation was evoked to gather many other mental disorders as ‘‘masked’’ forms of PTSD. It thus increased still further the numbers of patients alleged to have PTSD. Closer study of these presumptive links amongst the causes and presentations of PTSD led to direct challenges to the new ideas. A telling study was Southwick’s follow-up of 59 veterans of the first Gulf War (Southwick, Morgan, Nicolaou, & Charney, 1997). Many of these veterans changed their descriptions of their combat experience as time passed, thus memories provided two years later were different than the reports taken right after the battle. In 90% of the veterans, these later memories of combat trauma had increased in their estimate of the distressing severity of combat experiences. With their new and perhaps ‘‘recovered’’ memories, the subjects reported that ‘‘PTSD symptoms’’ increased significantly. The Southwick study raised questions not only about how correct were these later histories, but also about whether the ‘‘cardinal’’ symptoms of PTSD identify people who had traumatic experiences. Other critical studies came from VA psychologists who demonstrated that veterans with PTSD complaints tended to exaggerate their symptoms on psychometric studies—especially showing on MMPI testing extreme elevations on the validity scales in a ‘‘fake bad’’ direction (Fairbank, Keane, & Malloy, 1983; Frueh, Hamner, Cahill, Gold, & Hamlin, 2000). These psychologists concluded that ‘‘self-reports should be corroborated, whenever possible, by independent data sources’’ (Frueh et al., 2000). Again this was not a new idea to psychiatrists who employed the ‘‘bottom-up’’ diagnostic method. They always presumed that historical information was to be checked with ‘‘external informants’’ (Slater & Roth, 1969, p. 34). But this practice had fallen into disuse and ultimately was discredited by an emerging – ostensibly more sympathetic assumption – to ‘‘trust the patient.’’ Trust was shaken by the book Stolen Valor by Burkett (himself a Vietnam veteran) and Whitley (1998). Employing the Freedom of Information Act, these authors demonstrated how frequently men claiming Vietnam related PTSD had not only never been in combat, but had also never served in the military! On the basis of their studies, Burkett and Whitley estimated that close to 75% of people receiving Vietnam PTSD compensation are pretenders. These devastating findings and opinions were vindicated by Frueh et al. (2005), who reviewed archival data on 100 patients in a VA Medical Center. Frueh et al. found that although 94% had been diagnosed with PTSD, only 41% had evidence of combat exposure clearly documented in their military

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personnel record. Some of the patients had never been to Vietnam and, even more surprising for VA patients, some had never seen military service. These studies by Burkett and Whitley, and Frueh and his associates drive home the importance of seeking external information in evaluating patients, by demonstrating how information that was but a computer click away was, to everyone’s embarrassment, never sought. As these investigators were devastating the methods being used to make the diagnosis of PTSD, a crucial study conducted at the National Center for PTSD in West Haven Connecticut brought into question its treatment. This study demonstrated that 4 months of intensive hospital treatment provided by specialists to Vietnam veterans with severe chronic PTSD had no longterm beneficial effect. All patients received group therapy, evocative individual psychotherapy, behavioral therapy, family therapy, and vocational guidance directed to their memory, their primary symptoms, and those behavioral features that seemed to derive from their PTSD. On discharge from the hospital, the patients claimed some improvement in drug and family problems and thought that they may have developed more self-esteem. After 18 months, however, their psychiatric symptoms, family problems, and all other personal relationships were actually worse. They had made more suicide attempts and substance abuse problems were as serious as ever (Fontana & Rosenheck, 1997). Israeli studies on battle-weary veterans (Solomon, Bleich, Shoham, & Nardi, 1992) clarified the findings on US veteran casualties, and brought forth alternative approaches for their treatment. The Israelis demonstrated that long-term treatment in hospitals, as well as the kinds of cathartic emotionally evocative treatments offered in the VA, make trauma victims hypersensitive rather than less aware of their symptoms. By provoking the patients to concentrate too much on their psychological wounds from combat, the therapists distracted them (and everyone else) from individual ‘‘here-and-now’’ causal issues, to the detriment of recovery and rehabilitation. Yet more problems were identified. A therapeutic offshoot of the idea that ‘‘dissociated traumatic memories’’ can develop an unconscious, inaccessible character was the flocking of grief and disaster ‘‘counselors’’ to accident and injury sites to prevent ‘‘traumatic memories’’ and thus PTSD from forming. Here too, objective studies have not borne out their utility. Thus in 1995, Rafael and associates demonstrated that despite the confidence in debriefing built up in the late 1980s, there was no evidence that such an intervention worked to prevent symptoms. McNally, Bryant, and Ehlers (2003) reviewed the literature on debriefing and concluded similarly that debriefing had no effect on the overall rate of PTSD in survivors. In fact, for some individuals, debriefing may increase the rate of morbidity. Another attempt to bring validity to PTSD and dissociated memory rested on seeking brain changes that explained the symptoms, supported a memory loss, and predicted the outcomes. In most of these studies, as many have noted (e.g., Shephard, 2000), the brain work is ‘‘high-tech’’ with MRI, PET, SPECT, Quantitative EEG, etc., but the psychiatric work is ‘‘low-tech.’’ The patients are ‘‘DSM cases of PTSD’’ diagnosed by questionnaires and symptom probes, but not by thorough review (‘‘bottom-up’’) of their life time psychiatric history, their previous responses to stress, their personality characteristics and the like. The investigators at first announced that the brains of patients so diagnosed with PTSD had structural abnormalities— see, for example, reported ‘‘shrinkages’’ of the hippocampus by Bremner et al. (1995). Gilbertson et al. (2002) however debunked any suggestion that the hippocampus had been damaged or ‘‘shrank’’ because of trauma. These latter investigators indicated that a smaller hippocampus volume was genetic in etiology, and at most, might represent a source of vulnerability to more severe psychological reactions to all life stresses. The complex

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interactions of individuals facing traumatic events need to be unraveled before any of these ‘‘high-tech’’ brain discoveries can be employed. 3. Conclusions What do we conclude now at the end of this long experience in ‘‘Traumatology’’? PTSD, as presently diagnosed, described, and treated, has failed to improve on what had been standard teaching. It has redefined and overextended the reach of a long-recognized natural human reaction of fear, anxiety, and conditioned emotional reactions to shocks and traumas. It has been a seedbed for outlandish ideas about mental life. Social and political reasons, more than medical and psychiatric ones, gave it energy. Although it promised to explain and relieve much suffering, it delivered much disorder and chronic psychiatric invalidism, all at great cost to individuals and society. What should we do today to acknowledge the psychological effects of shocks and traumas, but avoid exaggerating those effects in our diagnoses, mental health practices, and public policies? We can teach that after such a distressful event (as after a grief-inducing personal loss), we expect to find everyone troubled with feelings of anxiety, loss of sleep, nightmares, and occasional conscious flashbacks. The extent of these symptoms and their duration we likewise expect to relate to the severity of the stress. For someone who has been in a minor traffic accident (a ‘‘fender-bender’’), we understand a few days of discomfort that will take the form of anxiety on driving, some sleep disturbance, unpleasant anticipatory dreams or nightmares, and some foreboding when next at the wheel. We expect symptoms to be worse and last longer with more shocking or repetitive events. For those symptoms, we may elect to offer the patient some sedation at night and antianxiety treatment during the day for a limited period. We also are likely to provide sympathetic support that encourages the individual to eventually return to customary life and daily role functioning. If in contrast to our expectations, the patient’s day-to-day work, family relations, or physical health grow more impaired and mental distress expands rather than recedes, then he or she must be reassessed rather than presumed to have a complicated (i.e., chronic, delayed) form of PTSD. The reassessing psychiatrist or psychologist should keep in mind that many of the symptoms of PTSD are nonspecific – as for example (quoting directly from the DSM-IV) ‘‘difficulty falling or staying asleep,’’ ‘‘difficulty concentrating,’’ ‘‘diminished interest or participation in significant activities,’’ ‘‘restricted range of affect,’’ ‘‘irritability,’’ etc. – and that many psychiatric disorders produce symptoms of this sort. The nonspecificity of symptoms is particularly crucial to note, given that mental health workers must ever steer clear of the logical fallacy, ‘‘post hoc ergo propter hoc,’’ i.e., because one event follows another, it is caused by it. These nonspecific symptoms, even when they follow after a shocking trauma, may be caused or sustained by something entirely distinct from the trauma itself: for example, the onset of a depressive illness, progress of an addiction, or even a search for the ‘‘sick role’’ now promoted in the patient by the social rewards and suggestive attitudes of physicians and other mental health workers singlemindedly engrossed with PTSD. In all these psychiatric conditions, symptoms identical to those used to define PTSD are common. The identification of these alternatives calls for a richer differential diagnostic practice than has currently been routine. Therefore, a patient complaining about the long persistence of such symptoms must receive a full ‘‘bottom-up’’ diagnostic appraisal that reviews all diagnostic possibilities and considers aspects of family history, social adjustments, previous personality, habit history, past medical and psychiatric conditions, and immediately present life problems. A mental health professional should

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draw this information from the patient, from pertinent records, and from informed family members. Therapy and prognosis will depend on the proper formulation of the individual case. Bipolar and Major depressions, demoralizations tied to persisting life circumstances and to such personality vulnerabilities as high ‘‘neuroticism,’’ and alcohol or drug abuse/dependency syndromes (bringing as they do their own emotional and cognitive disturbances) are just a few of the conditions that demand therapeutic plans for treatment and rehabilitation distinct from PTSD. These more complex explanations for symptoms will only come to light when a full ‘‘bottom-up’’ study of each individual case (i.e., a Meyerian ‘‘work-up’’) is made the standard of care in mental health centers. The unmindful diagnosis of PTSD based on symptoms alone does not do justice to these complexities of formulation and will mislead the therapeutic, rehabilitative, and prognostic proposals offered to these patients. When all is said and done, the concept of PTSD as (1) formulated in the late 1970s; (2) given breadth by DSM III and IV; and (3) made enigmatic by the concept of dissociated traumatic memories moved the mental health field away from not towards comprehending the psychological responses to trauma. Whether judged by promoting differential diagnosis, by fostering coherent psychological explanations, by initiating successful treatment programs, by improving the long-term outcomes of psychological casualties, or by advancing our discipline’s body of knowledge through research, PTSD has generated a huge misdirection of effort and many victims of its own. Acknowledgements We thank our student Kareem Ghalib M.D. for his help in developing data from Medline on PTSD. We also are conscious of a deep debt of gratitude to Richard J. McNally and Simon Wessely who, on hearing of this manuscript in an earlier form, helped resuscitate it from oblivion and generously offered many important suggestions from their own work and that of others to improve and bring it up to date. References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC. Bonanno, G. (2005). Resilience in the face of potential trauma. Current Directions in Psychological Science, 14, 135– 138. Bremner, J. D., Randall, P., Scott, T. M., Bronen, R. A., Seibyl, J. P., Southwick, S. M., Delaney, R. C., McCarthy, G., Charney, D. S., & Innis, R. B. (1995). MRI-based measurement of hippocampal volume in patients with combatrelated posttraumatic stress disorder. American Journal of Psychiatry, 152, 973–981. Breslau, N., & Kessler, R. C. (2001). The stressor criterion in DSM-IV posttraumatic stress disorder: an empirical investigation. Biological Psychiatry, 50, 699–704. Breslau, N., & McNally, R. J. (2006). The epidemiology of 9/11: technological advances and conceptual conundrums.. In: Y. Neria, R. Gross, R. Marshall, & E. Susser (Eds.), September 11, 2001: treatment, research and public mental health in the wake of a terrorist attack. Cambridge: University Press Cambridge (UK). Burkett, B. G., & Whitley, G. (1998). Stolen Valor: how the Vietnam generation was robbed of its heroes and its history. Dallas: Verity Press. Fairbank, J. A., Keane, T. M., & Malloy, P. F. (1983). Some preliminary data on the psychological characteristics of Vietnam veterans with posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 51, 912–919. Fontana, A., & Rosenheck, R. (1997). Effectiveness and cost of three inpatient treatments of post-traumatic stress disorder: comparison of three models of treatment. American Journal of Psychiatry, 154, 758–765.

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Frueh, B. C., Elhai, J. D., Grubaugh, A. L., Monnier, J., Kashdan, T., Sauvageot, J. A., Hamner, M. B., Burkett, B. G., & Arana, G. W. (2005). Documented combat exposure of US veterans seeking treatment for combat-related posttraumatic stress disorder. British Journal of Psychiatry, 186, 467–472. Frueh, B. C., Hamner, M. B., Cahill, S. P., Gold, P. B., & Hamlin, K. (2000). Apparent symptom overreporting among combat veterans evaluated for PTSD. Clinical Psychology Review, 20, 853–885. Gilbertson, M. W., Shenton, M. E., Ciszewski, A., Kasai, K., Lasko, N. B., Orr, S. P., & Pitman, R. K. (2002). Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5, 1242–1247. Glass, A. J., & Bernucci, R. J. (1966). Neuropsychiatry in World War II. Washington, DC: Office of the Surgeon General, Department of the Army. Kolb, L. C. (1977). Modern clinical psychiatry (9th ed.). Philadelphia: WB Saunders Company. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. Lewis, N. D. C. (1943). Outlines for psychiatric examinations (3rd ed.). Albany: The New York State Department of Mental Hygiene. Lord Moran (Wilson, C. M.). (1966). The anatomy of courage. 2nd ed. London: Constable & Co. MacCurdy, J. T. (1918). War neuroses. Cambridge: Cambridge University Press. McNally, R. J. (2003). Remembering trauma. Cambridge: Belknap Press/Harvard University Press. McNally, R. J. (2005a). Troubles in traumatology. Canadian Journal of Psychiatry, 50, 815–816. McNally, R. J. (2005b). Debunking myths about trauma and memory. Canadian Journal of Psychiatry, 50, 817–822. McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4, 45–79. Miller, H. (1961). Accident neurosis. British Medical Journal, 1, 919–925, 992–998; Journal of Orthopsychiatry, 43, 640– 653 (1973). Raphael, B., & Meldrum, L. (1995). Does debriefing after psychological trauma work? British Medical Journal, 310, 1479–1480. Rosen, G. M. (2004). Posttraumatic stress disorder: issues and controversies. Chichester: John Wiley & Sons. Scott, W. J. (1993). The politics of readjustment: Vietnam veterans since the war. New York. Shatan, C. (1973). The grief of soldiers: Vietnam combat veterans’ self-help movement. American Journal of Orthopsychiatry, 43, 640–653. Shephard, B. (2000). A war of nerves: soldiers and psychiatrists 1914–1994. London: Jonathan Cape. Slater, E., & Roth, M. (1969). Mayer-Gross Slater and Roth Clinical Psychiatry (3rd ed.). London: Bailleiefe, Tindall and Cassell. Solomon, Z., Bleich, A., Shoham, S., Nardi, C., et al. (1992). The Koach Project for treatment of combat-related PTSD: rationale, aims, and methodology. Journal of Traumatic Stress, 5, 175–193. Southwick, S. M., Morgan, C. A., III, Nicolaou, A. L., & Charney, D. S. (1997). Consistency of memory for combat traumatic events. American Journal of Psychiatry, 154, 173–177. Swank, R. L. (1949). Combat exhaustion; a description and statistical analysis of causes, symptoms, and signs. Journal of Nervous and Mental Disease, 109, 475–508. Wessely, S. (2006). Twentieth century theories on combat motivation and breakdown. Journal of Contemporary History, 41, 286–287. Young, A. (1995). The harmony of illusions: inventing post-traumatic stress disorder. Princeton, NJ: Princeton University Press.