Stress From Attacks Will Chase Some Into the Depths of Their Minds, and Stay. The media have begun to speculate in articles like this from the New York Times (rife with commentary from psychiatric pundits like myself) about the extent of psychological trauma that will ensue from the attacks. This is the first event of any such scope so informed by familiarity with post-traumatic stress disorder, and as far as I’m concerned this is both a blessing and a curse. The problem is that this diagnostic concept remains a murky one and a moving target, and that what is in effect a PTSD-treatment industry, invested in its self-perpetuation, has grown up within the profession, with a treatment approach that places us all at risk of self-fulfilling prophecy.

With every iteration of the American Psychiatric Association’s Diagnostic and Statistical Manual, the profession’s official ‘bible’ of diagnoses and their criteria (we’re up to the second revision of DSM-IV now), the PTSD concept changes in scope. The previous notion, in DSM-III, that the traumatic stressor to which the sufferer had been exposed must have been “outside the range of normal human experience” was removed as unreliable and inaccurate. Instead, DSM-IV requires only that the person’s response to the stressor must involve “intense fear, helplessness, or horror.” How diagnoses are defined is informed not only by empiricism but by the balance between ‘lumping’ and ‘splitting’ tendencies in the zeitgeist of the moment, competing political interests, and the commodification of emotional distress to ensure psychiatry’s continuing “market share”), among other influences. Broadening the range of people ‘eligible’ for the diagnosis of PTSD makes a fundamental difference in our conception of what is a normal, expectable response to adversity, what we need assistance dealing with, whether adversity or stress are expectable and tolerable, how empowered and resilient we are as individuals or a culture, etc.

PTSD was originally codified to inform the psychiatric profession’s response to ‘shellshock’ or ‘combat trauma’ in GIs returning from the American foreign military involvements of the ’40’s, ’50’s, and ’60’s. Thereafter, it fused with attention driven by the women’s movement to domestic abuse and incest. At this juncture, in my opinion, the concept lost much of its specificity and utility to describe a specific range of psychological and physiological responses, to explain symptoms and inform treatment. Naive clinicians with politically correct sensibilities find it politically incorrect not to diagnose any psychiatrically distressed patient who has ever been touched inappropriately, or imagines and reports that they have been, with PTSD, and to attribute all the patient’s psychopathology to that abuse! (You’re all familiar, I’m sure, with the ‘false memory’ controversy, but this is only the tip of the iceberg with the profession’s confusion around and abuse of the PTSD concept.) Empirical evidence has begun to suggest that the responses of sufferers in the major categories subsumed under PTSD — combat veterans, victims of torture, sufferers of serious physical abuse, victims of natural or manmade disasters, survivors of incest and other prolonged sexual violation — are different, and that lumping them together within this ‘wastebasket diagnosis’ may be useless. Just as not every experience of sadness or fear should be subsumed under diagnoses of depressive or anxiety-disorder conditions and subjected to treatment, not all severe stress is a condition requiring medical or psychological treatment.

In fact, I’ve noticed, the articles you’ll be reading about our trauma response to the WTC disaster are starting to acknowledge one central, important distinction along these lines. The immediate stress response (so-called “acute PTSD”) may be normal and expectable. Empirical data provides no answer yet about whether the crucial factor in whether this progresses to the true psychiatric syndrome, “chronic PTSD”, is early intervention. Studies and commentaries within the profession have begun to question this central tenet, suggesting that early intervention may be harmful or at best neutral for the victims, although of course self-serving for the clinicians.

“One large survey of Americans’ mental health found that of those who

said they had been exposed to trauma, about 25 percent developed the

hallmarks of post-traumatic stress disorder. Experts said that figure might

provide a rough estimate for those traumatized by the New York and

Pentagon attacks.

Other researchers, including Dr. Edna Foa of the University of

Pennsylvania, have come up with higher numbers for the victims of rape

and other forms of physical assault, at least in the first few months after a

trauma. In such studies, which begin following victims immediately after

the event, up to 50 percent of the subjects showed acute symptoms of

post-traumatic stress a month later, when a diagnosis of post-traumatic

stress disorder can first be made. Three months afterward, the numbers

had dropped to about 35 percent. After a year, up to 25 percent

continued to experience difficulties.

But researchers say the people who develop lasting symptoms are not

always the same as those who show immediate signs of extreme distress.

And because of the tragedy’s size, its resemblance both to natural

disasters and to war, and its human toll, researchers say it is impossible to

generalize past findings to what lies ahead.”

Just as this curmudgeon has been railing in these pages about the peril we’re in if we give over control of our national emotional response to the politicians, we may be in parallel peril if we give it over to the ‘PTSD industry’. Just as the authorities in New York have had to stem the tide of volunteers streaming toward Ground Zero (whose motivation to help has alot to do with combatting their own felt helplessness in this way), we may have to stem the tide of mental health professionals streaming toward emotional Ground Zero in our psyches.

I’m sometimes accused of being peevish without proposing alternatives. I’m by no means saying there’s no role for well-informed mental health clinicians in helping shepherd us through both individual and national suffering at a time like this. Indeed, trauma response has dominated my psychiatric work since 9-11’s events. But let’s be careful not to pathologize the outrage, despair and helplessness, not to disempower the normal range of coping responses, and not to create rather than forestall a national epidemic of dependent patients with an abused diagnosis.

Whatever the perils discussed above, they are nevertheless a fate far better than turning our distressed over to the S*c*i*e*n*t*o*l*o*g*i*s*t*s.

Television viewers who turned to Fox News on Friday for coverage of the terrorist attack also saw a message scrolling across the bottom of their screens — National Mental Health Assistance: 800-FOR-TRUTH.

Unknown to the cable news channel, the phone number connects to a Church of S*c*i*e*n*t*o*l*o*g*y center in Los Angeles, where S*c*i*e*n*t*o*l*o*g*i*s*t*s were manning the phones.

While representatives of S*c*i*e*n*t*o*l*o*g*y claimed theirs was a good-faith effort to provide counselling and support, it is well-known that the cult wages war on the mental health profession and its ministrations. St Petersburg Times [Curious about my markup of the name of the cult? Especially with Google placing weblogs’ content at the top of search results, I don’t want a search for its name to readily reveal my critical comments. It is pretty clear that the group retaliates for unfavorable press. — FmH]