Post-traumatic stress disorder

Guernica, Pablo Picasso, Spanish Civil War, 1937

As discussed elsewhere, post-traumatic stress disorder (PTSD) is an anxiety condition which arises after severe and often repeated trauma, usually of violent nature (physically or sexually). The classic example is military trauma, after exposure to the violence and carnage of war.  The classic civilian example is repetitive childhood sexual trauma at the hands of one’s caregivers or parents or other adults.

Diagnostic hierarchy

Again the concept of a diagnostic hierarchy is central, and this condition should not be diagnosed when apparent PTSD symptoms only happen in the context of depressive, manic, or psychotic episodes.  However, people can have PTSD symptoms outside of those mood or psychotic states, in which case, like OCD, a legitimate anxiety condition can be present.

"Trauma": Too broad a concept

A central diagnostic problem these days, in the PL view, is that the phrase “trauma” has been extended so broadly as to include common daily occurrences, such as car accidents.   In its origins, PTSD related to war trauma or to childhood sexual abuse.  We recommend limiting the diagnosis to those conditions of severe and uncommon trauma, rather than to the kinds of common life experiences that happen to the entire population. 

Treatment: Psychotherapies more, medications less

Modest symptomatic benefit has been reported with SRIs, benzodiazepines, and dopamine blockers (antipsychotics). But such benefit is limited, and thus we recommend short to medium-treatment at the lowest doses possible, not routine long-term treatment, which has never been shown to be effective in randomized trials.  In contrast, long-term psychotherapy is likely the most helpful intervention, depending on the type of trauma.  Psychoanalytic methods were developed by Freud and his followers in persons with the so called “hysteria”, which is how PTSD was labeled and presented at that time.  Those patients tended to have experienced childhood sexual abuse, and psychoanalytically-oriented therapy may be most helpful for that kind of PTSD.  Military PTSD can be treated similarly, but may also respond to cognitive-behavioral approaches or mindfulness-based methods to reduce anxiety and depressive symptoms. 

Post-traumatic Stress Disorder: a DSM misnomer

The term is another DSM misnomer.  During the DSM-5 process, some military psychiatrists sought to change the name to “post-traumatic stress injury” as opposed to “disorder”, which would have been a more correct term since this condition happens, by definition, only after an environmental injury. 

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