What is post-traumatic stress disorder?

2011·2.8 MB·English

by  Andreasen, Nancy C.

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What is post-traumatic stress disorder? also chronically exposed to new and perversely
lethal threats, such as poison gas, machine gun fire,
Nancy C. Andreasen, MD, PhD mortar attacks, land mines, and tanks. Casualties
were devastating, and fatality rates were frighten-
ing. Men watched their friends die beside them, and
Abstract they confronted the possibility of their own demise
Although post-traumatic stress disorder (PTSD) and on a daily basis. Alternatively they might be maimed
traumatic brain injury (TBI) are categorized as sep- and consigned to a life of chronic disability. As the
arate and discrete disorders, the boundary between war progressed, the high casualty rate made it clear
them is sometimes indistinct. Their separation is that Britain and continental European countries
based on the assumption that PTSD results primar- were losing many of an entire generation of young
ily from psychological stress, while TBI is the conse- men—a social loss from which they would be slow
quence of an identifiable injury to the brain. This dis- to recover. This sense of futility and despair was elo-
tinction is based on an antiquated polarity between quently expressed by British war poets such as
mind and brain, and the separation of the two disor- Wilfred Owen and Siegfried Sassoon:
ders often becomes arbitrary in day-to-day psychi-
atric practice and research. Earth's wheels run oiled with blood. Forget we that.
Let us lie down and dig ourselves in thought.
Beauty is yours and you have mastery,
This issue of Dialogues in Clinical Neuroscienceis Wisdom is mine, and I have mystery.
titled “Trauma, Brain Injury, and Post-traumatic We two will stay behind and keep our troth.
Stress Disorder.” The articles between its covers Let us forego men's minds that are brute's natures,
address both post-traumatic stress disorder (PTSD) Let us not sup the blood which some say nurtures,
and traumatic brain injury (TBI). As the combina- Be we not swift with swiftness of the tigress.
tion of these articles indicates, the various recent Let us break ranks from those who trek from progress.
wars in the Middle East have awakened an old con- Miss we the march of this retreating world
troversy about the relative impact of physical and Into old citadels that are not walled.
psychological stress in causing neuropsychiatric dis- Let us lie out and hold the open truth.
orders. Although the term TBI suggests the occur- Then when their blood hath clogged the chariot wheels
rence of some type of physical lesion, while PTSD We will go up and wash them from deep wells.
suggests a disorder occurring as a consequence of What though we sink from men as pitchers falling
psychological stress, the boundary between the two Many shall raise us up to be their filling
is often unclear and sometimes permeable or over- Even from wells we sunk too deep for war
lapping. Even as one who bled where no wounds were.
The first systematic discussion of the relationship Wilfred Owen
between physical and psychological stress dates Strange Meeting
back to World War I. The history of that discussion Project Gutenberg Etext of Poems by Wilfred Owen
provides an informative context for current contro-
versies concerning PTSD and TBI.1Combat tech- In this context of brutal bloodshed and omnipresent
niques in World War I introduced new types of com- fear, a new and somewhat unfamiliar type of dis-
bat stress that had not existed during previous wars. ability emerged that had not been described in pre-
Soldiers engaged in trench warfare were relatively vious wars: a syndrome characterized by confusion,
immobile and therefore more vulnerable. They were memory impairment, headache, difficulty concen-
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trating, tremor, and sensitivity to loud noises. This developed an extensive explanatory system that
was initially assumed to be due to exposure to explo- could account for the role of psychological factors
sions, leading to concussions of the brain (“commo- in producing symptoms and in developing both
tion cerebri”) in the absence of visible signs of exter- healthy and unhealthy coping mechanisms.9
nal head trauma, and the disorder began to be This debate, and the perspectives provided by the
referred to as “shell shock.” Postmortem examina- competing traditions, had a significant impact on
tion of two cases revealed a variety of abnormalities, policy decisions. This distinction was invoked in
particularly vascular damage and congestion.2As the making decisions about the grounds for determin-
war progressed, the number of shell shock casualties ing disability both during and after combat, and it
grew alarmingly. was also significant for determining criteria for
By mid-war, however, it was observed that some sol- awarding pensions.6,10,11Veterans from World War I
diers presenting with the symptoms of shell shock were eligible for pensions as a consequence of suf-
did not have any evidence of exposure to explo- fering from shell shock, but concerns were raised
sions. This puzzling paradox—a concussion-like syn- about the large number of recipients and the possi-
drome in the absence of documentable head bility of malingering. As World War II loomed in the
trauma—challenged the explanatory powers of con- future and then occurred, British policy created
temporary medicine, particularly in an era when no strict criteria for recognizing and awarding disabil-
tools were available to explore the living brain non- ities secondary to shell shock/stress/neurasthenia—
invasively. Ultimately this paradox led to the intro- all in the direction of minimizing or eliminating any
duction of a distinction between a neuras- rewards for disabilities considered to be psy-
thenic/emotional/”nervous” condition and a more chogenic.10
physically based one caused by a specific explosion After the end of World War II, American psychia-
exposure. During subsequent years multiple schol- try decided to create a standard nomenclature that
arly attempts were made to determine whether would be used by all psychiatrists; the impetus came
these two conditions represented discrete disorders initially from the Veterans’ Administration and was
or syndromes and whether clear boundaries could influenced by the World War II experience, which
be set to distinguish between them.3-6 required that psychiatrists from across the United
This debate was paralleled by the rise of two com- States and from diverse training backgrounds
peting traditions within neuropsychiatry: biological develop a common language for discussing psy-
vs psychodynamic explanations for the develop- chopathology, making diagnoses, and determining
ment of disorders. Within the biological tradition disability. This led to the formulation of a diagnos-
one important perspective (particularly relevant to tic category called Gross Stress Reaction, which
the etiological debate and remarkably prescient of appeared in the first Diagnostic and Statistical
future developments) was presented by Selye, who Manual (DSM-I), published in 1952. Its description
coined the term “stress” and hypothesized that it emphasized that the disorder was a reaction to a
was mediated by the hypothalamic-pituitary- great or unusual stressor that invoked overwhelm-
adrenal (HPA) axis.7 He described the General ing fear in a normal personality. It emphasized that
Adaptation Syndrome as a response to stress and the disorder was transient and reversible; if the
considered the traumatic neuroses to be a conse- symptoms persisted, another diagnosis was to be
quence of chronic or severe stress. Walter Cannon given. Thus the definition was more influenced by
also proposed a related physiological basis for fear the psychodynamic traditions that prevailed at the
responses in his description of the “fight or flight” time than by biological models, and it did not lend
syndrome.8 A second important perspective was itself to making frequent diagnoses of service-con-
provided by the psychodynamic tradition, which nected disabilities in the post-World War II era.
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Thereafter the diagnosis went into oblivion. Since it fact, its scientific basis was as strong as that available
was closely linked to the history of warfare, it was for disorders such as depression or even schizo-
completely omitted from DSM-II, published in phrenia. To call it “post-Vietnam-syndrome” (the
1968—23 years after the last Great War and during name chosen by the veteran advocacy groups)
a period of relative peace. would demean its well-established validity and nar-
When the DSM-IIITask Force was assembled in the row its range excessively. It would be best to call it
early 1970s, one of the tasks that it confronted was “Post-traumatic stress disorder.” I wrote the defini-
to decide whether the diagnosis of Gross Stress tion of PTSD for DSM-IIIbased on my recognition
Reaction should be reinstated in the DSM noso- that a variety of stressors can induce a final com-
logical system. The Vietnam War was winding down mon pathway that is expressed by a variety of auto-
and had been very unpopular. Unfortunately, the nomic/physiologic, cognitive, and emotional symp-
general public was not able to distinguish between toms that occur in response to a severe stressor.
the war and the people that our country had drafted Because I knew from my research with burn
to fight in it, and so Vietnam veterans quite under- patients that individuals with prior disabilities (eg,
standably felt defensive, undervalued, and angry. A epilepsy, abuse of alcohol or illegal drugs, depres-
small but militant subgroup of Vietnam veterans sion) were more vulnerable to developing PTSD, I
clamored for the introduction of a diagnosis that threw out the requirement that the symptoms had
would recognize the potential consequences of to arise in a previously normal individual. This
experiencing the stress of combat, and that might opened the gate a bit, as compared with the defini-
perhaps provide disability and treatment benefits tion for Gross Stress Reaction. But I also narrowed
for the psychiatric disorder that combat stress the gate by requiring that the stressor—the actual
induced. Bob Spitzer, the Task Force chair, asked etiological factor—had to be “outside the range of
me to deal with the problem; he knew that I was normal human experience” in order to avoid the
hard-working and intellectually agile; but he did not risk of overdiagnosis.
know that I was actually already an expert on the Once the diagnosis of PTSD became available after
topic of stress-induced neuropsychiatric disorders. I the publication of DSM-III in 1980, it quickly
began my psychiatry career by studying the physi- enjoyed widespread use, often in ways that were not
cal and mental consequences of one of the most anticipated. The genie was out of the bottle and
horrible stresses that human beings can experience: began to actively intervene in psychiatric practice
suffering severe burn injuries. Within this model of and research. Although the precipitating stressor was
stress, I had already examined brain abnormalities supposed to be “outside the range of normal human
using electroencephalography, the pattern of acute experience,” and was conceptualized with death
and chronic symptoms, the long-term outcome and camps and life-threatening combat experiences as a
its predictors, and the role of coping mechanisms.12-16 model, this concept was steadily broadened. The
I was also well aware of the extensive research that recognition that the response to the stressor might
had been done to identify symptom patterns that be delayed (largely because it is maladaptive within
arise as a consequence of exposure to a wide vari- the context of combat) was also broadened in unan-
ety of stressors, ranging from natural disasters to ticipated ways: for example, the diagnosis became
death camps to military combat. widely used for adults who described themselves as
The answer to the veterans’ request was obvious to being abused by their parents when young children.
me: there is a well-established syndrome, defined by Subsequent revisions of DSM adapted to these
a characteristic set of physiological (autonomic) and applications by steadily broadening the definition of
cognitive and emotional symptoms, that occurs after the stressor and modifying its relationship to the
exposure to severe physical and emotional stress. In onset of the disorder in a variety of ways.
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Since the introduction of the concept of PTSD into troversy about “physical” vs “emotional” injuries;
psychiatric nomenclature in 1980, the controversy these have been the subject of three Institute of
between the role of biological and psychological fac- Medicine reports written to clarify diagnostic, treat-
tors has re-emerged. The maturation of the discipline ment, and compensation issues.17-19
of neuroscience, which is now widely perceived as the What is PTSD? And how is it related to TBI? There
“basic science of psychiatry,” has had a significant are still no easy answers to these questions. This
influence. The development of the tools of neu- issue of Dialogues in Clinical Neurosciencemakes a
roimaging has provided an opportunity to conduct in significant and useful contribution to addressing
vivo exploration of the brain in individuals who are them. It makes it clear that the disorders have many
diagnosed as suffering from PTSD. And the neu- overlapping features, both symptomatically and bio-
ropsychiatric casualties of the wars in Iraq and logically. It highlights the progress that has been
Afghanistan, who have been exposed to new combat made in understanding the underlying biology of
techniques and new types of combat stress much as both disorders by using the tools of neuroscience
occurred during World War I, have reawakened the and neuroimaging. And this progress makes it clear
controversy about the relationship between physical that the old polarity between physical vs emotional
and psychological injuries. Terrorism, guerilla warfare, underpinnings for PTSD is an antiquated way of
and patrols confronting IEDs (improvised explosive thinking that is no longer useful in the 21st century.
devices) and land mines have replaced the mortars Whatever PTSD is, it is a disorder that cannot be
and trench warfare of World War I. TBI has been dismissed as purely psychological or a refuge for
called the “signature injury” for these wars, much as malingerers. As this issue illustrates, psychological
shell shock was during World War I. And the same trauma has neurobiological effects, and these effects
policy issues concerning provision of pensions and can now be visualized and measured in the living
health care for veterans are the subject of concern brain. To some extent, the legacy of the World War I
and debate, and they are informed by the same con- controversy has finally been resolved.
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