The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category

British Medical Journal,  Jan 13, 2001  by Derek Summerfield

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Summary points

A psychiatric diagnosis is not necessarily a disease

Distress or suffering is not psychopathology

Post-traumatic stress disorder is an entity constructed as much from sociopolitical ideas as from psychiatric ones

The increase in the diagnosis of post-traumatic stress disorder in society is linked to changes in the relation between individual "personhood" and modern life

A central assumption behind psychiatric diagnoses is that a disease has an objective existence in the world, whether discovered or not, and exists independently of the gaze of psychiatrists or anyone else. In other words, neolithic people had post-traumatic stress disorder as have people in all epochs since. However, the story of post-traumatic stress disorder is a telling example of the role of society and politics in the process of invention rather than discovery.

The diagnosis is a legacy of the American war in Vietnam and is a product of the post-war fortunes of the conscripted men who served there. They came home to find that they were being blamed for the war. Epithets like "babykiller" and "psychopath" were thrown at them by some who had watched on television the US military's atrocities against defenceless peasants. This reception was a primary factor in the well publicised difficulties--such as antisocial behaviour--that some military personnel had in readjusting to their peacetime roles. Those who were seen by psychiatrists were diagnosed as having an anxiety state, depression, substance misuse, personality disorder, or schizophrenia; these diagnoses were later supplanted by post-traumatic stress disorder.

Early proponents of the diagnosis of post-traumatic stress disorder were part of the antiwar movement in the United States; they were angry that military psychiatry was being used to serve the interests of the military rather than those of the soldier-patients. The proponents lobbied hard for veterans to receive specialised medical care under the new diagnosis, which became the successor to the older diagnoses of battle fatigue and war neurosis. The new diagnosis was meant to shift the focus of attention from the details of a soldier's background and psyche to the fundamentally traumatogenic nature of war. This was a powerful and essentially political transformation: Vietnam veterans were to be seen not as perpetrators or offenders but as people traumatised by roles thrust on them by the US military. Post-traumatic stress disorder legitimised their "victimhood" gave them moral exculpation, and guaranteed them a disability pension because the diagnosis could be attested to by a doctor; this was a potent combination. (In both South Africa and Bosnia men accused of politically inspired multiple murders have used post-traumatic stress disorder as a defence.)

At no time was the debate in the psychiatric community in the US about whether or how diseases or disorders exist, merely whether there was one that had yet to be discovered. As Scott wrote:

In the story of [post-traumatic stress disorder] we see again how the orderliness of the natural world is to be found in the very accounts of its orderliness. Theories represent competing sets of assumptions that are inseparable from the interpretation of the evidence taken to support them and their predictions. Hence scientists and those who adopt its discourse evaluate evidence and make claims about what they have discovered. The goal is to move disputed claims along a path towards acceptance as taken-for-granted fact. This calls for appropriate documentation; the ability to command the attention and respect of critical persons and groups, and the skills and resources necessary to marshal this effort. This is how facts are made."[1]

The growth in popularity of the diagnosis

Despite the atypical nature of the experiences of American veterans in Vietnam, the diagnosis of post-traumatic stress disorder has become almost totemic. The National Center for Post-Traumatic Stress Disorder in the United States tracks journal articles, books, technical reports, doctoral dissertations, etc, that are written on the subject. Although coverage is largely limited to publications in English, and even then is only partial, more than 16 000 publications had been indexed by September 1999. One striking development, although not the subject of this paper, has been the global spread of the use of this diagnosis by humanitarian programmes. It is promoted as a basis for capturing and addressing the impact of events like wars regardless of the background culture, current situation, and subjective meaning brought to the experience by survivors. Thus the misery and horror of war is reduced to a technical issue tailored to Western approaches to mental health. This has been criticised elsewhere.[2 3]

In Western societies the conflation of distress with "trauma" increasingly has a naturalistic feel; it has become part of everyday descriptions of life's vicissitudes. The profile of post-traumatic stress disorder has risen spectacularly, and it has become the means by which people seek victim status--and its associated moral high ground--in pursuit of recognition and compensation. An editorial in the American Journal of Psychiatry commented that it was rare to find a psychiatric diagnosis that anyone liked to have but post-traumatic stress disorder was one.[4]