Posttraumatic Stress Disorder

This post was edited and updated on July 7, 2013 in the light of comments from readers.  I am grateful for their input.

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One of the anxiety disorders listed in DSM-IV is posttraumatic stress disorder. The criteria for this condition are listed below:

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently reexperiencd in one (or more) of the following:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) , as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g. unable to have loving feelings)
(7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Posttraumatic stress disorder consists essentially of painful memories. Even the most organized and insulated lives are touched by tragedy and misfortune. Painful memories are an integral part of the human condition. Occasionally individuals are involved in incidents that are truly horrific, and the memories associated with these events are commensurately painful. The paradigm example of this is warfare, but traffic accidents, criminal attacks, and natural disasters are all potential sources of painful memories. The APA’s use of the term “…a threat to the physical integrity of self or others” (in A: above) is sufficiently vague to embrace almost any kind of traumatic event.

Everyone is familiar with painful memories and everyone is also familiar with the fact that these memories can and do intrude in our present lives. People who have lived through severe flooding, for instance, tend to react negatively to even light rainfall for months afterwards. People returned from combat sometimes react strongly to loud noises. What has happened in these cases is that the bad memory has in itself become a source of fear or anxiety, even though it poses no actual threat. The fear response, which initially was triggered by the traumatic incident, is now triggered by the memory of the incident. In other words, the person is literally afraid of his own thoughts.

Painful memories are not trivial. They can be extremely difficult to deal with and can interfere with present functioning. But they are not illnesses. Memory is an adaptive device – it helps us to survive and to cope with our surroundings. But memory doesn’t screen out unpleasant material. In fact, memories of particularly unpleasant incidents tend to stay with us longer, because of the emotional significance we attach to them at the time.

It is an obvious fact that our experiencing of the world around us modifies structures within the brain. If we hear a catchy tune a few times on the radio, we find that we can sing the melody without difficulty. Clearly there is some “trace” of the tune inside the brain that wasn’t there before. Similarly it has been shown in several animal studies that repeated exposure to stressful situations can produce long-lasting structural and functional changes in the brain. These studies are often cited as proof that PTSD really exists and that it is a brain disease. The reasoning, however, is muddled. Even if we concede that repeated exposure to stressful events can damage the brain and cause the individual to behave in erratic and destructive ways, this does not prove that all of the people who behave in erratic and destructive ways have damaged brains. The critical point is this: If indeed there is a neurological condition which is brought on by repeated exposure to stress and which in turn causes the individual to behave in an erratic and destructive manner, then this condition needs to be identified as a neurological illness, given an appropriate neurological name (e.g. hypersensitive dopamine receptors), and should be treated by neurologists. Some of the people currently diagnosed with PTSD would likely meet the criteria for the neurological illness, but just as likely, many would not. In particular, the diagnosis of this neurological illness would not rest on criteria that are purely behavioral.

Posttraumatic stress disorder as it is defined in the DSM is not an illness. There is no evidence of anything going wrong in the individual’s body; no diseased organs; no dysfunctional processes; no confirmed neural pathology – nothing that a normal intelligent person would consider necessary for a condition to be called an illness.

A particularly interesting feature of this matter is that people have been dealing with painful memories (and helping others deal with them) since our ancestors hunted and gathered on the plains of Africa. The “secret” to desensitizing this kind of material is to talk about it. In our culture women are better in this regard than men. If a woman is involved in a traumatic incident, she usually recounts the matter many times – to her mother, her sister, her husband, her best friend, etc. With each telling, the memory loses some of its potential to hurt. A man, on the other hand, in the same situation, will often feel that talking about the incident constitutes childish whining, and he keeps it to himself – shuts the memory away – where it remains strong and potent.

An individual who goes to a mental health center or to a VA center for help with painful memories is routinely assigned a diagnosis of posttraumatic stress disorder. He will be prescribed an anti-anxiety drug or an antidepressant to keep him becalmed and he may talk to a counselor. At subsequent “med checks” he may be prescribed a neuroleptic if he is still reporting outbursts of anger. He may get to spend some time with a counselor, but any treatment of this sort is considered secondary to the primary intervention of prescribing drugs.

In addition, PTSD is a major gateway diagnosis, and diagnoses of depression and bipolar disorder are often tacked on for good measure – or to extract more money from insurance companies.

Next Post: Depression is Not An Illness

  • wrighta835

    I sincerely don’t understand why you would attack a subject as serious as PTSD. There is so much information on the effects that extreme, prolonged stress has on the body. As you mentioned, the changes that occur in brain structures; but what about adrenal fatigue? And we who have suffered the traumatic effects of a violent crime can tell you, we are not simply afraid of a memory! It’s as though our minds and our bodies have been awakened to the fact that we could be hurt like that again! Tragedy is unavoidable. You feel afraid because of the if’s and when’s. And I’m not trying to say that none of it involves memory. It absolutely involves memory. but the way you put it makes it seem like, if people just would stop worrying, then problem solved! (Eccept of course, those who would qualify as having a real neurological disease as a result.) You work through the memory, then, done. It is so much richer, and more complex then that. And in my experience, counseling was not shunned as secondary to medications at all. That is not an all encompassing statement. No more then your claim that, “go to a mental health profession, and this is absolutely how you will be treated.” Or, your consistent theme through out your blog that nothing the mental health profession says has any validity whatsoever.
    835
    PTSD is devastating. It is caused by trauma. It is very real.

  • A.Honda

    I am a disabled veteran from a traumatic brain injury and ptsd. Ptsd is a genuine disfunction. Although there was no treatment known when I was first diagnosed, the VA has now developed Cognitive Behavioral Therapy which helps mitigate the effects and re-wire the brain. Your paragraph starting with: “an individual who goes to the VA center,” continues with poorly researched, ignorant over-generalizing, reducing the credibility of your point of view expressed in your article.

  • Anonymous

    Countries should be utterly ashamed of themselves if these are the things being told to veterans. I mean just listen to this! “rewiring the brain”! This is how we thank them for their service, by doing them the disservice of indoctrinating them with quackery. Unbelievable. On the plus side it shows Hickey’s site is coming up in Google searches when people type in ‘PTSD’ or whatever quack label they’ve had put on them.

  • Francesca Allan

    I don’t think anybody is arguing that PTSD is not devastating. Nor that it is not caused by trauma. Nor that it is unreal. The issue being discussed is what PTSD actually is and how best to approach it. The short version is that PTSD is an injury, not an illness. Except in very rare cases of brain injury, there is no indication that some people have brain disorders that cause them to develop PTSD symptoms. What does seem to be the case is that some people develop troubling thoughts and behaviours in response to stress and trauma. And, as is the case with all mental events, healthy or otherwise, these are reflected in the brain. It doesn’t follow, though, that this makes them brain disorders.

  • T.A. Anderson

    Hmm. Chance, synchronicity, or set up, I am nevertheless glad to see this post. Springing from the popularization of the false memory fad has come the beginnings of another possible fad in psychology. This fad appears to some extent to be abandoning the subconscious mind. Perhaps this is what Lieberman was referring to as the brilliant fiction of Freud. If Dr. Hickey, or any other psychologist, is saying that dissociative amnesia does not exist, they are wrong. People can and have blocked conscious access to memories. Explaining and debating this will take some time. If Dr. Hickey contends that dissociative amnesia does not exist, then I would that he design a real life experiment to test whether his believe is true or not. I am that experiment.

    One can easily say it would not be “fair” or “scientific” for me to argue based upon my personal experience. My response is that nothing about psychology is science and unless you’ve lived that experience of true memory repression your human intuition will not allow you to understand. It is too counterintuitive.

    If we are going to disagree about compartmentalization of the human mind, before doing so I think we should establish some common ground. Dr. Hickey is not saying that painful memories do not cause problems. And I think he is correct in saying that PTSD has become another fad in psychology and almost anyone who could get tagged is getting tagged. By tagging everyone with this label we are helping some and hurting many. Traumatic experience are bad, but not all of what comes afterwards is bad.
    I think we can understand one another well enough to avoid definitional misunderstandings but for the sack on others who may listen along it might help to agree on some terminology. How about TM for traumatic memory, and whether you believe in it or not, RTM for traumatic memories not accessible due to something other than organic brain damage or normal forgetting?

  • T.A. Anderson

    “But memory doesn’t screen out unpleasant material. In fact, memories of particularly unpleasant incidents tend to stay with us longer, because of the emotional significance we attach to them at the time.”

    I think this is true for the most part, but not always. Those who are highly imaginative, can easily dissociate, and are highly hypnotizable, can partition off memory, good or bad memories. Whether on not this can be done without the aid of hypnotic trance and later reinforcement you can still question, but the fact that it can be done with hypnosis should give you some cause to wonder whether it may to some lessor extent occur naturally. Again, the majority of the time the intrusive memory will be the rule, but we should not deny the existence of the exception to the rule—repression.

    Conscious Cogn. 2013 Dec;22(4):1305-17. doi:
    10.1016/j.concog.2013.08.003. Epub 2013 Sep 13.

    Increased response time of primed associates following an
    “episodic” hypnotic amnesia suggestion: a case of unconscious
    volition.

    Smith CH1, Oakley DA, Morton J.

    Following a hypnotic amnesia suggestion, highly hypnotically
    suggestible subjects may experience amnesia for events. Is there a failure to
    retrieve the material concerned from autobiographical (episodic) memory, or is
    it retrieved but blocked from consciousness? Highly hypnotically suggestible
    subjects produced free-associates to a list of concrete nouns. They were then
    given an amnesia suggestion for that episode followed by another free
    association list, which included 15 critical words that had been previously
    presented. If episodic retrieval for the first trial had been blocked, the
    responses on the second trial should still have been at least as fast as for
    the first trial. With semantic priming, they should be faster. In fact, they
    were on average half a second slower. This suggests that the material had
    been retrieved but blocked from consciousness. A goal-oriented information
    processing framework is outlined to interpret these and related data

    Neuron. 2008 Jan 10;57(1):159-70. doi:
    10.1016/j.neuron.2007.11.022.

    Mesmerizing memories: brain substrates of episodic memory
    suppression in posthypnotic amnesia.

    Mendelsohn A1, Chalamish Y, Solomonovich A, Dudai Y.

    Two groups of participants, one susceptible to posthypnotic
    amnesia (PHA) and the other not, viewed a movie. A week later, they underwent
    hypnosis in the fMRI scanner and received a suggestion to forget the movie
    details after hypnosis until receiving a reversal cue. The participants were
    tested twice for memory for the movie and for the context in which it was
    shown, under the posthypnotic suggestion and after its reversal, while their
    brain was scanned. The PHA group showed reduced memory for movie but not for context while under suggestion. Activity in occipital, temporal, and prefrontal areas
    differed among the groups, and, in the PHA group, between suggestion and
    reversal conditions. We propose that whereas some of these regions subserve
    retrieval of long-term episodic memory, others are involved in inhibiting
    retrieval, possibly already in a preretrieval monitoring stage. Similar
    mechanisms may also underlie other forms of functional amnesia

    Int J Clin Exp Hypn. 2004 Jul;52(3):260-79.

    Posthypnotic amnesia for autobiographical episodes: influencing
    memory accessibility and quality.

    Barnier AJ1, McConkey KM, Wright J.

    The authors examined the impact of posthypnotic amnesia on the
    accessibility and quality of personal memories. High, medium, and low
    hypnotizable individuals recalled two autobiographical episodes and rated those
    memories. During hypnosis, subjects were given a posthypnotic amnesia
    suggestion that targeted one of the episodes. After hypnosis, they recalled and
    rated their memories of the episodes. The posthypnotic amnesia suggestion
    influenced the accessibility and quality of autobiographical memory for high
    and some medium, but not low, hypnotizable participants. The article
    discusses these findings in terms of investigating and understanding the impact
    of posthypnotic amnesia on autobiographical memory.

    Psychol Sci. 2002 May;13(3):232-7.

    Posthypnotic amnesia for autobiographical episodes: a laboratory
    model of functional amnesia?

    Barnier AJ.

    Extreme variation in the accessibility of autobiographical
    memory is a major characteristic of functional amnesia. On the basis of its
    ability to temporarily disrupt the retrieval of memory material, posthypnotic
    amnesia (PHA) has been proposed as a laboratory analogue of such amnesia.
    However, most PHA research has focused on relatively simple, nonpersonal
    information learned during hypnosis. This experiment extended PHA to
    autobiographical memory by examining high- and low-hypnotizable subjects’
    explicit and implicit memory of two autobiographical episodes, one of which was
    targeted by a PHA suggestion. The effects of PHA were consistent with the major
    features of functional amnesia: PHA disrupted retrieval of autobiographical
    information, produced a dissociation between implicit and explicit memory, and
    was reversible. The nature of PHA’s effect on autobiographical memory and
    the potential utility of a PHA paradigm for investigating functional amnesia
    are discussed.

  • T.A. Anderson

    Dr. Hickey, I searched your site and saw you haven’t done a tear down of dissociative amnesia. If you had one planned perhaps my EVIDENCE, knowledge, and anecdotal experience will help convince you not to.

    I learned a new term just yesterday, “gaslighting.” http://en.wikipedia.org/wiki/Gaslighting
    The term “gaslighting” was new to me, but the experience wasn’t. Back in 2002 my
    reality got shattered, and then I got gaslighted by myself and others. No worse feeling in life to be completely sane but because of the bizarre nature of your experience to be questing your own sanity and having others encouraging you to do so. Confused?
    If not, you soon will be.

    Imagine waking up one day at 43 years of age and reflecting back on your life. What a charmed life you had lived. Met and married a beautiful girl in college. Four years of
    college and then straight to law school. A great legal career, a beautiful wife, a beautiful home, etc. etc. Oh what a lucky man you’d been. Then that evening something triggers a strange itch in your brain. Something is not right. Things have not gone as smoothly as they seem. Your fantasy life, might just be a fantasy.

    And then it begins. In highly disorganized fashion over the course of the next several
    weeks you begin having vivid visual flashbacks of events you think you are
    recalling for the first time. Many of the events are seemingly meaningless and you are amazed by your ability to recall such trivial things. But then like the strokes from a brush these memories begin to paint what appears to be a disturbing picture about you. You had once been a witness to a criminal conspiracy.

    Enough for now. The point I want to make is that with the trendy “false memory movement” Elizabeth Loftus, and others, have potentially been causing mental illness. They have been gaslighting people like me. Gaslighting is not an ordinary human
    experience and no one should be subjected to it because of the ignorance of others. Yes people have false memory, perhaps even more so than true memories. But there
    are people who are experience recall of true memories they previously dissociate from. .

    Why they will not listen to me is beyond me. I can verify for them enough of my story to
    convince them it is true. They don’t want to listen to me because I will destroy their academic beliefs.

  • T.A. Anderson

    Hey, you’re not alone. I couldn’t believe in Dissociative Amnesia either.

  • T.A. Anderson

    I see mostly common ground with Dr. Hickey, but you might not like some of what I
    have to say about psychologist. Thought my response to more appropriate here that under bipolar.

    Ultimately, like the mass illusion/delusion we think of as our reality, amnesia is a subjective experience. I see no reason, or evidence, to support a logically false quasi-scientific position, otherwise known as false memory syndrome, that would routinely deny everyone the validity of an experience with amnesia. Is the human memory fallible? Are there false memories? Absolutely, without a doubt. Can the human mind block retrieval and later allow it? Absolutely, I would stake my life on it. As sure as I know the sun rose today, I know that for almost 13 years I blocked retrieval to a significant amount of autobiographical information. I forgot at a flick of a
    switch. Not one thing, but many things.

    Can the thinking of psychologists, like psychiatrists, be driven by the invisible hand of greed? Yep. And we don’t need to search the multiverse for a Phillip Hickey PhD in an Armani standing between Paula Zahn and Gwyneth Paltrow to find evidence of this. It exists in this universe, on this planet, and it is staring us in the face right now. The false memory syndrome was a “pay day” via expert witness fees to some psychologists.
    Science being driven by litigation and expert witness fees is the junkiest of all. Borrowing in part from the rhetoric of a renowned research psychologist, there is great irony in the rejection of self-reports in favor of the opinions of hired gun psychologist.

    I am also reminded of the stable of expert psychologist available to testify in defense of personal injury and workers compensation claims on the issue of malingering. These “expert” psychologist actually commonly refer to the Dopey Stigma Manual (DSM) to tell us that in their “expert” opinion the injured claimant is faking it. These situations are not just irony, they are also ridiculous. Surely, I am not the only one who sees this? Sorry friends, but I learned my first year out of law school that I could hire a psychologist to say virtually anything. The good news is that the APA does note that malingering is “not a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.” Well . . . maybe I spoke too soon. LOL

    Getting back to my personal experience . . . now I will try to take the rabbit hole deeper. Unless one has experienced, OR WITNESSED, a dissociative amnesia, their human intuition will preclude their understanding. I not only experienced a dissociative amnesia from 1989-2002, in 1978 I had the great privilege, and great misfortune, of
    watching one develop in someone else, right before my eyes. What the women refer to as “stuffing it.” That someone would become my wife.

    So who is likely to know more about dissociative amnesia, the psychologists who don’t believe it exists, or someone like me who saw it develop first hand in a trauma victim and then 10 years later using hypnosis was able to create the virtual equivalent and hold it for 12 years. I will point out this, I sense something different between the forgetting of my wife and that of my own. The depth of my forgetting, and the amount of
    information forgotten, appears to have far exceeded that of hers. I cannot put myself in her mind to know the entirety of her experience, but from our conversations it does not sound to me that her memory was blocked like mine, and instead her memories were avoided for a long period of time, perhaps diminishing their quality. My memories were blocked. And when they returned they did so in outstanding visual detail. Prior to my
    breach of the amnesia you could have offered me $100 million to recall the information,
    and I would have categorically denied its existence.

    The most difficult thing to grasp about my experience is the concept of the “hidden observer.” My hidden observer was on watch 24/7 protecting me from the information, and even more incredibly, on rare select occasions tricking my conscious mind into affirmatively acting out on this hidden information. With this recognition, I think hypnosis allowed me to catch a glimpse of into the minds of those who perceive the presence of multiple personalities within themselves. To the world of psychology, of course you are free to ignore me. Fitting that is the prefix to the word which would describe such behavior.

  • Guy Stridsigne

    “Everyone is familiar with painful memories and everyone is also familiar
    with the fact that these memories can and do intrude in our present
    lives. People who have lived through severe flooding, for instance, tend
    to react negatively to even light rainfall for months afterwards.
    People returned from combat sometimes react strongly to loud noises.
    What has happened in these cases is that the bad memory has in itself
    become a source of fear or anxiety, even though it poses no actual
    threat. The fear response, which initially was triggered by the
    traumatic incident, is now triggered by the memory of the incident. In other words, the person is literally afraid of his own thoughts.”

    You are entirely correct. You have summed up PTSD quite nicely. This is an illness that needs treatment; not just via medication, but also therapy. PTSD and other Anxiety disorders are highly treatable, and the treatments for them are extremely effective.

    As a person who has worked in the mental health field, I will tell you the BIGGEST reason we diagnose people with a mental illness is so we can treat a patient effectively, and so that insurance companies and governing agencies allow us to treat them. It is the reason why “Grief” is listed as a mental illness now. Without treatment, people with PTSD and other Anxiety disorders will experience even more pain, and potentially will hurt themselves or others. This is completely avoidable if people like you stop saying that these illnesses don’t exist. These people need help, and the best way to get it, is by determining the diagnosis of best fit. Every person is different, and proper diagnosis is essential for determining their care plan.

    Without a diagnosis, insurance companies (including Medicare and Medicaid) will not pay for services. If a patient cannot afford the proper treatment, then they will be unable to heal. Diagnosis ensures (usually) that a person will be able to afford the treatment they need to heal.

    Stop disseminating your false propaganda. You are only hurting people who need help. If these people do not receive the help they need, then they might end up on the evening news after having gunned down a shopping mall or school. Their victim’s blood would be on your hands.

  • Guy Stridsigne

    Also, mental health professionals are not paid per diagnosis. they are paid for the time they spend with their patient. So “tacking on depression or bipolar disorder for good measure or to extract more money from insurance companies” is ludicrous and would not benefit the patient or health care provide in the slightest.

  • Guy Stridsigne

    “Posttraumatic stress disorder as it is defined in the DSM is not an
    illness. There is no evidence of anything going wrong in the
    individual’s body; no diseased organs; no dysfunctional processes; no
    confirmed neural pathology – nothing that a normal intelligent person
    would consider necessary for a condition to be called an illness.”

    So according to this passage, you then would not consider Alzheimer’s Disease or Dementia an illness?