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Post-Traumatic Stress Disorder

What Is Trauma?

Is it time to dump the diagnosis of PTSD?

My dictionary defines trauma as a deeply distressing or disturbing experience. Defined like that, the events which can be considered traumatic are wide-ranging indeed—from what might be considered the stuff of ordinary life such as divorce, illness, accidents, and bereavement to extreme experiences of war, torture, rape, and genocide.

Insofar as we adopt this wide-ranging definition, trauma is the stuff of everyday life.

The American Psychiatric Association's current definition of post-traumatic stress disorder (PTSD), introduced in 1994, states that a person must have experienced or witnessed an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and which involved fear, helplessness, or horror.

While the American Psychiatric Association's definition is more restrictive than my dictionary definition, it is still far more wide-ranging than the original 1980 definition of PTSD, which stated that an event had to be outside the range of usual human experience. Then, only the most horrific events would qualify.

Looking to the future, debate rages in clinical and scientific circles about whether the next definition of trauma in DSM-V should be more or less restrictive.

Should we go back to something closer to the original idea—that trauma was an experience that, when encountered, would psychologically overwhelm all who encountered it? Or should we move in the direction of thinking that all life events have the potential to be perceived as traumatic?

Not surprisingly, the elastic nature of the concept of trauma over the years has caused a great deal of public confusion. And the topic of PTSD seems charged with emotion. There are two points of view.

First is the view that PTSD results from a stressor that is so overwhelming that no matter what the person's resources, they will develop PTSD. As such, the diagnosis of PTSD does not reflect any personal vulnerability.

The second is that people who develop PTSD are vulnerable in some way. As such, the diagnosis of PTSD does reflect some kind of inner vulnerability. Those who do not develop PTSD are resilient.

Sometimes, people who take the former view are dismissive of those who have received a diagnosis of PTSD following more "everyday" events—as if their PTSD is somehow less valid. It has also been claimed that PTSD is being over-diagnosed.

But the fact is that since the 1994 definition, research has defined PTSD in such a way that trauma is necessary but not always sufficient to produce PTSD—so both these points of view are right. The current definition has it both ways by understanding PTSD as the outcome of an interaction between trauma intensity and personal vulnerability.

An "extreme" event may be sufficient to produce PTSD in all who experience it so that personal vulnerability is not a factor. But a less "extreme" event may only produce PTSD in those who are already vulnerable.

Not surprisingly, in a culture in which mental illness is stigmatized, the issue of whether PTSD is caused by an event or by personal vulnerability is one that is charged with emotion. As the public understanding seems closer to the original definition of PTSD, the current definition is fraught with problems.

How should the next definition of PTSD deal with this issue—or is it time to dump the diagnosis of PTSD?

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