In March 2012 ITV ran a series of news features about the ‘Forgotten Fallen’.1 These are serving soldiers and combat veterans who, at some point in their lives, have suffered badly from a range of psychological problems, leading in extreme cases to suicide. Although different people have suffered in different ways and from different symptoms, the term post-traumatic stress disorder (PTSD) has become somewhat emblematic, almost a diagnostic ‘short hand’ for describing both a set of problems but also the nature of the experiences that soldiers and combat veterans have had to put up with.
Of course, it’s not only combat veterans and serving soldiers that suffer from PTSD (or, to be more precise, the symptoms that constitute PTSD – a subtle difference that I will be returning to). People who work in the emergency services, rape victims, civilian survivors of war, people who have experience childhood abuse – they can also suffer in the same way. Some might even argue that we now live in an age of trauma.
The strange thing is, less than fifty years ago PTSD didn’t exist. This is not to say that people who had experienced traumatic situations did not suffer from nightmares, flashbacks, panic attacks, depression, anxiety, difficulties in concentrating. Rather, this was not called PTSD. As a number of authors have argued, PTSD is a direct legacy of the Vietnam war, and of intense political lobbying by a group of therapists, psychiatrists and veterans. In 1980 the term PTSD was finally recognised as a psychiatric category and took its place in the DSM-III2
Both the DSM-IV and the forthcoming DSM-V3 include PTSD as a distinct psychiatric category. The definition of a traumatic event in DSM-IV is as follows:
….an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
Furthermore, the person’s response to the traumatic event must involve:
……intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior
However, this is where the problems with PTSD begin. The prevalence of PTSD appears to be much lower than the prevalence of traumatic events. The National Center for PTSD has a useful summary of PTSD epidemiological studies up to 2007.4 In the general US population lifetime prevalence of PTSD among men was 3.6% and 9.7% among women (National Co-morbidity Survey, 2005). In other countries, lifetime prevalence figures vary widely: from 0.3% in China to 6.1% in New Zealand (WHO surveys). However, figures for Vietnam Veterans are much higher: 30.9% for men and 26.9% for women (National Vietnam Veterans Readjustment Study, 1986-88). For veterans of Afghanistan and Iraq (the second Gulf War), the prevalence of current PTSD was estimated to be 13.8% (RAND Corporation, 2008).
The NICE guidance on PTSD5 also gives useful information regarding prevalence and incidence (risk) of PTSD. Quoting a large US study in 1995 by Kessler, they give a lifetime prevalence figure of 7.8% (men and women combined). Women are at a much greater risk of developing PTSD following a traumatic event (20.4%) than men (8.1%). Interestingly, NICE also quotes studies that show that different types of traumatic events are associated with different PTSD rates, with rape being associated with the highest PTSD rates – and perhaps it is significant that in the case of rape, it is men who are more likely to reach PTSD criteria (65%) than women (46%).
These figures suggest, therefore, that PTSD is quite common. However, NICE also cite Kessler et al’s research that ‘the majority of people will experience at least one traumatic event in their lifetime’. Litz and Roemer in their paper6 cite research that suggests that around 69% of Americans will have experienced at least one traumatic event, and, not surprisingly, in areas that have experienced widespread conflict, e.g. former Yugoslavia, Somalia, virtually everyone will have experienced some form of trauma.
Therefore, it seems reasonable to ask why PTSD figures are not a lot higher. Of course, there are many possible answers to this, including that fact that not everyone who is actually experiencing the symptoms of PTSD will seek treatment or take part in a research programme. Furthermore, responses to trauma very from individual to individual, and PTSD is only one such response.
However, I think there are some more fundamental problems here. To start with, there is the term PTSD itself. PTSD is not an illness: rather it is a set of symptoms, which include flashbacks, recurring nightmares, difficulties in concentration, depression, panic attacks, anxiety, and in some case disassociation. PTSD is a psychiatric category, which means it is essentially a set of diagnostic criteria. In other words, to say that someone has PTSD, is to say that they fit the criteria for PTSD, which is to say that they exhibit a certain number and type of symptoms following the experience of a particular kind of event. And, as is usually the case with this kind of diagnostic approach, i.e. one based upon symptoms rather than on any underlying clinical structure, the treatment is also focused on the symptoms, i.e. getting rid of them or at least alleviating them as much as possible. For example, as far as talking treatments go, NICE recommend either trauma focused CBT or EMDR (eye movement desensitisation and reprocessing, another form of cognitive-behavioural therapy). Neither of these treatments address the cause of the person’s symptoms, and there is also some doubt whether they are that effective as treatments for PTSD in the first place: see for example Albright and Thyer’s critical appraisal of EMDR in the context of treating combat veterans.7
None of this explains why a particular individual reacts to a traumatic event in the way they do. To begin to understand this, perhaps we need to start asking some different (and difficult) questions. To start with, how does trauma fit into a person’s life? In other words, what does an individual ‘do’ with a traumatic experience? Try to forget it? Tell everyone about it? Become a trauma victim? Seek therapy?
But there is also another, even perhaps more fundamental question: what exactly do we mean, DSM not withstanding, by the term ‘trauma’ in the first place………….?
- http://www.itv.com/news/story/2012-03-06/forgotten-fallen/ [↩]
- Ben Shephard gives a very readable account of the political and psychiatric ‘construction’ of PTSD: Shephard, B. (2000) A War of Nerves. London, Jonathan Cape. See also Wilbur Scott’s excellent paper on the politics of PTSD in relation to the aftermath of the Vietnam War: Scott, W.J. (1990) PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease. Social Problems, 37 (3), pp.294–310. [↩]
- http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165# [↩]
- http://www.ptsd.va.gov/professional/pages/epidemiological-facts-ptsd.asp [↩]
- NICE Post-traumatic stress disorder (PTSD) [Internet]. Available from: http://guidance.nice.org.uk/CG26 [↩]
- Litz, B.T. & Roemer, L. (1996) Post-Traumatic Stress Disorder: An Overview. Clinical Psychology & Psychotherapy, 3 (3), pp.153–168. [↩]
- Albright, D.L. & Thyer, B. (2010) Does EMDR reduce post-traumatic stress disorder symptomatology in combat veterans? Behavioral Interventions, 25 (1), pp.1–19. [↩]