Thursday, January 17, 2013

The Problem with PTSD

By wedding traumatic experiences to PTSD we have de-emphasized the role of trauma in other forms of psychopathology

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

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

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

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

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

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

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

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

*For confidentiality reasons, Monique is not a single patient, but represents a composite of different patients

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