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The Origins of the Posttraumatic Stress Disorder (PTSD) Diagnosis

The Origins of the Posttraumatic Stress Disorder (PTSD) Diagnosis

The PTSD diagnosis was a result of intense advocacy and was created against huge opposition. As late as 1982 the opening line of a response to a research grant I had submitted to the Department of Veterans Affairs (VA) read: “It has never been demonstrated that the diagnosis PTSD is relevant to the mission of the Veterans Administration.” At that time the VA’s position was that the war had nothing to do with veterans’ pathology. The people who advocated for the PTSD diagnosis came from outside of academia: Vietnam veterans and two psychoanalysts, Robert J Lifton and Chaim Shatan, who wanted to create a diagnosis that was not stigmatizing. This meant that there had to be a diagnosis in which the symptoms were directly linked with the war experience. The centerpiece thus became Criterion B of PTSD: having “flashbacks and nightmares” about specific events. That linked the disorder to a particular set of traumatizing experiences.

Lisa M. Najavits conducted an interview with Bessel van der Kolk, MD.

Please address correspondence to: Bessel van der Kolk, The Trauma Center at Justice Resource Institute, 1269 Beacon Street, Brookline, MA 02446. E-mail: bvanderk@traumacenter.org

In my research, I also started with flashbacks and nightmares. I happened to be interested in nightmares because the first research I ever was involved in was in a sleep laboratory, and the nightmares of the veterans I was treating provided me with a link to a topic I knew something about. So, we studied nightmares and REM interruption insomnia, but those were not the presenting problems of our patients. They usually complained about their uncontrollable violence and their lack of concentration:

However, as the anthropologist Allan Young has documented, the moment we created a diagnosis in which the B criterion was central, the veterans started to present more frequently with those symptoms because on some level they understood that they would get a better hearing if their complaints matched what the textbook of their doctors said. People’s clinical presentations adapt themselves to the prevailing cultural norms.

It’s important to remember that there were no field trials before the diagnosis was formulated, other than some informal compilation of symptoms of fewer than 200 veterans by Sarah Haley and Jack Williams, a small study of burn victims by Nancy Andreasen, and two excellent books: Mardi Horowitz’s description of Stress Response Syndromes (originally published, 1976), and Abram Kardiner’s 1941 book, The Traumatic Neuroses of War. Anne Burgess had already described a posttraumatic diagnosis, “rape trauma syndrome,” in the late 1970s, but without institutional backing that did not go very far. The criteria for that diagnosis were vastly different from those for PTSD and focused on shame blame and self-depreciation.

A Body Neurosis

Probably the most important inspiration for PTSD was Kardiner’s book, The Traumatic Neuroses of War. This described his observations of World War I veterans, whom he thought suffered from a “physio-neurosis”: Their bodies continued to react as if they were back at the moment of trauma and took the same physical actions that they made at the time of trauma, like blowing up, fighting back, ducking, or becoming frozen. So, the first view of trauma was as a body-based disorder–the whole organism is reliving, reenacting, and replaying the threat, and much of the initial research most of us did focused on physiology: biological systems that had gone awry.

Complex Trauma

Shortly after the PTSD diagnosis came into being, a group of us, including Judy Herman Jim Chu, and David Pelcovitz, noticed that there were other populations beyond veterans that had major trauma histories–victims of incest, child abuse, and domestic violence. Their problems had some overlap with those of combat soldiers, but they were different in that many of them had never developed the skills that soldiers had a chance to accumulate before their war trauma. These complex trauma patients lacked large aspects of normal emotional, cognitive, and neurobiological development: They dissociate, have major problems with chronic hyperarousal, somatization and concentration, and loathe themselves for what’s happened to them.

518 Journal of Clinical Psychology: In Session, May 2013

Our group focused on civilians with long histories of trauma that occurred in the context of interpersonal relationships. In those innocent days nobody claimed that they had the answers, and when we told Bob Spitzer, who then was still running the DSM-IV process, about the problems of this vast psychiatric population, we were met with openness. Bob Spitzer told us: “You see these people in your offices all the time, and I am just trying to figure out what clinicians need to make useful diagnoses.”

The American Psychiatric Association gave us $10,000 to do a study of over 500 patients at five different sites, comparing the symptoms of adults with acute trauma to those with histories of domestic violence, and a group with histories of childhood abuse. This was probably one of the first field trials where the diagnostic system was put to the test. We found that these three populations had very different symptom pictures, particularly those with childhood trauma, who suffered much more than the other two groups from self-hatred, amnesia, confusion, somatization, dissociation, amnesia, self-harm, and behavioral reenactments.

We wrote up our field trial and the PTSD DSM committee voted almost unanimously to create a second PTSD diagnosis called “complex PTSD” or “Disorders of Extreme Stress Not Otherwise Specified” (DESNOS). But the higher-ups in the DSM process vetoed the new diagnosis without giving us a reason, and with the disappearance of DESNOS this gigantic group of traumatized people lost the chance for a diagnostic home. Because studies are funded and conducted according to DSM diagnostic categories, it has been virtually impossible to systematically study the treatment of victims of domestic violence and child abuse, except under the rubric of their PTSD symptoms, which rarely are their most problematic issues.

Little Pure PTSD

I guess that, having done this work for about 40 years, I probably have seen as many traumatized people in treatment as anybody by now. I’ve seen thousands of them, but I have seen only a handful of cases of pure PTSD. Traumatized people often become alcoholics or drug addicts; they gamble; most have somatization problems; they are depressed and they dissociate; they have issues with eating and self-injury; they reenact their trauma. None of that is captured by “PTSD.” The Treatment Guidelines for PTSD nonchalantly suggest that if your patient has comorbid disorders besides PTSD, then you should consult the relevant treatment manuals for those conditions. That blasé recommendation may be fine if your principal concern is to keep your research lab going, but if your job is to heal your patients from their traumatic injuries, buying additional treatment manuals may not be the best way to restore them to a joyful and productive life.

The Myth of PTSD “Just Happening”

Another important point about the PTSD diagnosis is that it doesn’t usually “just happen” to people, yet it is often seen that way–you’re just driving along and somebody hits your car, or you walk along the street and somebody rapes you, and then you have PTSD. But, in fact, most trauma responses, particularly in women and children, occur in the context of intimate relationships.

In my very first study with Vietnam veterans, we looked at what preceded traumatic reactions in veterans. We found that they had started their military careers going to basic training, where they learned to become part of a powerful, self-confident fighting unit. They then went to war and continued to feel powerful and effective until a comrade was killed. Seeing a friend being blown away enraged them to the point that they often violated their moral principles and committed atrocities. Just as Homer wrote about in the Iliad, these were acts of revenge for the death of a friend, which set the stage for the recurrent reliving and reenactment of the trauma.

Trauma usually has much more of an interpersonal aspect than what the PTSD diagnosis recognizes. Ignoring this leaves out the vast majority of traumatized individuals. Most women and children are traumatized in the context of intimate relationships. Child abuse and molestation and family violence are all traumas at the hands of people who were supposed to love you.

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