Posttraumatic Stress Disorder is Overloaded

Valid disorders are subject to the disease of inflation. Any solid, established diagnosis that is popular and appealing risks overuse and becomes overloaded with excess features. Such is the fate of posttraumatic stress disorder (PTSD). Once a well-defined, well-characterized condition, it has currently expanded from the consequences of terrifying battles to the outcome of purported abuse in childhood. The alleged abuse is sometimes recovered and ranges from forgotten forbidden touching to the most serious and harmful invasion of the bodies and minds of children. It is time to call a halt to the unscientific expansion of PTSD. It harms patients to give them the wrong diagnosis with the wrong assumptions. Modern descriptions of PTSD date from the time of the Russo-Japanese War ( 1904-1905), in which early versions of high-explosive shells were used. These differed from cannonballs and other projectiles in that blasts occurred on impact, producing additional damage to bodies and structures and scattering shrapnel. Contemporary reports recognized a condition amounting to a traumatic war neurosis, marked by confusional states, brief excitement and irritability, fearfulness, and emotional instability. The typical and enduring pattern was further identified in France following explosions of the naval ships Iena and Liberte in Toulon dockyard in 1907 and 1911. After eliminating cases in which organic factors might have been relevant, Hesnard' recorded posttraumatic psychological responses including an initial state of semisomnambulism, automatic mental activity, absorption in some trivial occupation (for example, saving some garment), a strange lucidity or increased clarity, a feeling of exaltation, and a period of anterograde amnesia. The dockyard rescuers also showed symptoms of disturbance for several weeks, including recapitulation of the scene, terrifying dreams, diffuse anxiety, fatigue, and various minor phobias. This knowledge of emotional change after explosions, quickly abstracted in English, became part of the contemporary climate of ideas.1,2 In the First World War, soldiers who became panic-stricken and ran away, or who were too fearful to go into battle, were liable to be executed; more than 300 men in the British forces were shot for cowardice. Thus to complain of anxiety was unacceptable, although, as the war progressed, it was recognized that soldiers who had fought most bravely might lose their nerve after increased exposure to risk-even those decorated for exceptional gallantry might break down with anxiety. Many individuals who were not overtly wounded by explosive blasts but were nearby when they occurred developed paralysis, difficulty with limbs, or other symptoms, which came to be recognized as hysteria. The idea that symptoms were produced by the blast of high explosives caused the condition to be labelled shell shock. The term was applied to individuals who developed symptoms such as paralysis, amnesias, deafness, and visual difficulties. These symptoms, grafted onto the basic anxiety response, served a social and cultural purpose, enabling the individual to retreat from battle with dignity and-for a short while-sympathy. Soon the numbers of individuals given the diagnosis grew too large to be accommodated by armies that needed to keep their soldiers fighting. Diagnoses changed. After shell shock, the ultimate pattern of chronic anxiety related to particular events was recognized fairly well as combat neurosis and then, later, as posttraumatic stress disorder.2 Through the rest of the First World War and during the second World War, a stunned, semiautomatic victim with a pattern of characteristic anxiety symptoms relating to the event was treated with some degree of insight and support, and the pattern was recognized under various terms such as combat neurosis. Later, the same notion-rediscovered in Vietnam-was captured in both DSM-IV and ICD-10 descriptions. Not all individuals who experience stress or trauma, whether in battle or in civilian life, and who develop symptoms, necessarily show the typical anxiety pattern. …

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