Tag Archives: bipolar

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.

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