Diagnostic Fallacies

PTSD is an unusual psychiatric diagnosis in many respects.  Most unusual is the first of the diagnostic criteria because it requires at least one of three specific events to have occurred to an individual to make the diagnosis.  DSM-5: “Exposure to actual or threatened death, serious injury, or sexual violence…”  It then offers a list of circumstances in which exposure must occur, but only requires one of them.  These are direct experiencing, witnessing in person this type of event occurring to someone else, learning that such an event occurred to a close family member or friend, or by experiencing repeated or extreme exposure to aversive traumatic details such as might occur to first responders.  Although some of these are recent modifications of earlier criteria, they are the new standard.

This is the only diagnosis that is so specific in its description of cause, what amounts to a triggering mechanism.  For this reason, it can be fairly easy to determine the time period in which symptoms began and also what caused symptoms.  More than that because the cause is so aversive, a patient or client will literally walk into a practitioner’s door and say straight out what the problem is, what the events were, and will often fully describe the resulting symptoms.  The only thing that may be required is to pull out your copy of the diagnostic manual and match reported symptoms to those described by DSM and even that is not necessary if the clinician is familiar with DSM diagnostic criteria.  As I previously discussed in my own case, this can be done through a checklist.  Prescriptions to take… “and let me know if you are feeling better.”

It is a perfect collusion between a patient who would rather forget, therefore, avoiding any memory of the events that may come up in CBT or talk therapy, and a prescriber who wants to wrap everything up in 15 minutes by writing a prescription.   The problem is that, if conscious awareness of an event is the trigger, the anxiety symptoms may be relieved with medication, but the memories are not suppressed or expunged.  Our minds just don’t work that way.  “So, here’s your pill.  Take it as prescribed.  Then, go see a therapist who will desensitize you to the pesky thoughts and memories that intrude on your mind-space from time to time.”  This is all fair enough.  But what happens if improvement does not occur as predicted?  It often does not.  What do you do then?

Here is one problem with the diagnostic criteria as written and their use in treatment.  Strange to say, yet so easily forgotten, is that a PTSD patient’s life usually did not begin at the time of the traumatic event, although the DSM and those who apply it to specific cases treat the disorder that way.  It’s not like you were living a happy, productive life, that from a diagnostic point of view was uneventful, and then, BOOM! You were struck by cosmic lightning and your life suddenly turned to shit.  That is the rarest of occurrences.  Rather, what more often happens is that you were bumbling along, accepting the crap that was dealt out by God or circumstance or a rotten upbringing and then, BOOM! You were struck by lightning.  In other words, in many people’s lives the trauma that brought them in for treatment was not a beginning, but a culmination that is related to the patient as part of a personal history, a pastiche, a history that was more than a set of random events that may have been upended by a meteor-strike, but that did not begin with the strike. That person may have had other difficult challenges that, when seen in context, were precursors to what became a perfect storm with the sudden appearance of the traumatic event.  It’s not as if the person was born at the moment of trauma, but that the effects of a difficult history have somehow, for some reason, arrived here at the moment that the trauma or traumas occurred.  What seems in treatment like a problem arising from an event or events may not easily be addressed out of the context of the person’s prior life.

So, here is this keg of dynamite going into a therapist’s office, someone who very dutifully took prescribed medication hoping for perfect relief and who may have found partial relief, but somehow not enough. “Let’s go back.” We want you to relive the events of the trauma.  “I want you to remember them as vividly as possible.  And I want you to interact with these events, eventually to react to them differently.  Think about it.  What else might you do other than what you actually did?  Now, tell me what you imagined.”

If the subject is a war veteran, for example, it could be that the reasons for enlisting might have played an important part of the later reactions to trauma.  “Well, my dad used to beat the crap out of me and my mom.  I was too young to defend her short of stabbing him in the back.  And I didn’t want to be put in juvenile corrections, in prison, or in foster care.  So, I put up with it.  When I got old enough, I found the easiest way out was by joining the Army.  There wasn’t anything for me back home.  At least in the military I would belong to something.  And, if someone shoots the shit out of me, well, I don’t belong anywhere anyway.  I just hoped for the best.” 

Put this person on any battlefield in any war and what are presented as traumatic events to a therapist may be very far from the source of the actual trauma.  This may well turn out to be a story about a young man or woman who thought the only decent life investment was to be part of a government sponsored collective effort to create order in a chaotic world.  Core idealism rises up in the foundling who now has a home in the military, but whose actual experiences in battle may be recreating the dysfunction that led him to join up in the first place.  Is the trauma in killing, in being shot at, or is it in the fact that you were a whipping boy growing up and now you are fodder?  How is a clinician to unwrap this puzzle inside an enigma when our best guidelines tell us that PTSD sufferers didn’t have a disorder until they were exposed to the trauma?  And the truth is that they might not have had PTSD before, but it was the exposure to trauma that brought all the pieces of a life experience together to bring definition and intensity to what had previously been thought of as disparate events.

In my case, I had been raised with an older brother who would twist my mind into knots, then tell me how stupid, ugly, and weak I was with sadistic glee.  That was all well and good.  I somehow was able to deal with that, but then the dysfunctional, but stable nest fell apart when my brother became nastier and out of control, there was no one to intervene, and my mother withdrew into herself, finally taking her own life.  My home disintegrated.  Why didn’t I join the military to find a stable environment?  Because I saw betrayal everywhere and expected as much from my Army mentors.  But, of course, they wouldn’t be mentors, but adversaries at least as abusive as my brother ever was.  Better to go to prison.  This was the young man who had knives poking him in the throat, who was fast approaching draft age.

Lives go like that.  You expect safety, but find continuing threat.  Pacts between individuals or between people and their government are so easily broken, usually by the government that is too powerful to think that anything is really owed to anyone, leaving everyone exposed on the battlefield, in the street, and in our homes.  This leads to the conclusion that PTSD may come from an event or more likely from a set of circumstances to which a person is exposed, circumstances that are encountered by thoughts and feelings that are the result of prior experiences, cognitive responses to the hand that was dealt and that continue to be generated by one’s own disposition. 

But, why should the “triggers” stop there?  Why shouldn’t they continue as long as the person continues to think, feel, and experience, given that the context of the inner person hasn’t really changed?  With our cognitive filters, we continue to develop responses that are reinforced by events, events that may look similar to previous events or that are otherwise interpreted as if they were, with the same lack of order that we have come to expect, with a similar chaos to which we may also contribute.  This is how people act who have looked, but have failed to find the security of belonging in themselves and in their own neighborhood.