TRAUMA - Part 4



I am cuddling up with the DSM5 as I write this.


It helps to know that there continues to be a discussion between the developers of the current diagnostic system, DSM5, and the previous DSM-IV.  (For those who don’t know it, the American Psychiatric Association did choose to migrate from Roman to Arabic numerals in titling this Bible-like tome.)  The point of disagreement, as I understand it, is whether symptoms should cluster around clinicians’ observations of their patients or whether they should be statistically grouped using techniques like cluster analysis to find how reported symptoms appear when analyzed objectively and scientifically.  For people using mental health services, this becomes a question of whether you prefer your doc’s clinical observation and interview as the source of your diagnosis or whether a comparison should be made to a statistical sample in order to reach the conclusion that you have a particular disorder, in this case PTSD.  It is well known that PTSD is unique among psychiatric diagnoses because it requires a specific life circumstance to initiate it, i.e. experiencing a traumatic event.  This used to mean directly experiencing the event yourself, but now includes learning of the death of a family member or friend either by accident or violence and also repeated or extreme exposure to aversive details of traumatic events such as collecting human remains.


While writing this, I can’t help but remember refinancing a home after we spent a lot of money to remodel it.  The appraiser, who was considered among the better ones, walked through a complete new kitchen, one that was the most useful I had ever had, one that was both beautiful and new.  He had a clipboard with a form on it as he toured the house into which we had poured what was to us a lot of money.  I watched as his pen checked the box marked “kitchen” and continued touring the house to determine its value for a mortgage.  The only thing of value from the appraiser’s and lender’s points of view was whether the house had a kitchen at all.  The value we placed on it was irrelevant.  Kitchen? Check.


This is pretty much how a DSM5 diagnosis would work.  Boxes would be checked and, as I discussed in the previous post, apples and oranges would be put in the same diagnostic classification because they would cluster just fine, facilitating quicker and presumably more accurate diagnostic decisions, taking the arbitrariness of clinical impression out of it.  Unfortunately, that arbitrariness may prove to be the very content of an individual life, the life of someone who may have been subjected to harsh circumstances.


There are a number of logical problems with this that would make the apples and oranges much harder to group.  However old the diagnostic category, the diagnosis itself is replete with inconsistencies.  Start out with the fact that PTSD’s greatest strength is also its greatest weakness.  Among clinicians, the strength is that the cause (etiology) of the disorder is known.  “You saw someone get shot to shit in front of you?  You have x symptoms?  You have PTSD.”  Check.  Here is your prescription.


For someone who has practiced in the field of treating mental health ills, it should come as no surprise that oftentimes there are traumas that preceded the one that the patient is focused on when he or she comes in for treatment, traumas that the patient may not be eager to discuss.  If you think I’m making this up, then you don’t live in the same world I do and you haven’t seen what I have seen among those who have severe unremitting symptoms that do not improve with standard treatments.  In complex cases, a simple check with a prescription for medication and/or Cognitive Behavioral Therapy won’t solve the problem.


You may add to this other compounding and confounding traumas that are also frequently seen.  This is what happens when someone who has been exposed to one or repeated traumas is not believed either by family, by police who would investigate, by agencies or by people who were previously thought to have been friends.


In combat, this is not an issue since, under the circumstances, exposure is expected.  Some have the inner strength to endure and others don’t. Luck of the draw, we say. Let’s move on. But, where there is sexual and/or physical abuse, a child’s report or one of an adult survivor may be rejected for yet other reasons. Let’s not forget that, in the US and elsewhere, parents are the masters of their home and their children. The methods of childrearing are not often challenged for that reason. It’s said that one of the basic freedoms is that parents should be able to raise their children in whatever way they’d like.  Moreover, according to Proverbs 13-24, the rod should not be spared in the raising of children if you care about them. No harm, no foul as they say in certain sports. If a child is beaten in the home growing up and subsequently is subjected to later abuses, should we ignore the early trauma because the Bible approves it and the State does not recognize it as a crime? In this way, people learn to stuff it and tell themselves that the problem is in themselves. And the community is quick to join them in their self-condemnation. “If you hadn’t dressed provocatively, if you hadn’t hung out in bars, or if you hadn’t been attracted to dangerous people none of this wouldn’t have happened.” This doesn’t even begin to address the problem of learning moral lessons by being beaten with no accompanying explanation or support. “Do you know why I am beating you? I am beating you because I love you.” The Bible instructs us and I am instructing you. Does that make the beatings traumas or not? That can be a problem for those who are busy checking boxes, who are looking at symptoms, but not at history. The result is that you might come to a completely different set of conclusions about the person sitting in front of you. 

This is a reason to take the DSM, in its totality, as suggestive, not prescriptive. It is also the basis for diagnosing in the older system, which gives much wider berth to clinical observation. But, then the burden falls on the clinician to have the experience and good judgment, which is not always the case either. Given the possibility of clinical errors, the psychiatric zeitgeist demands a more scientifically derived system, hence the DSM5.  The push is to make fewer errors under a clearer and more comprehensive system.  The problem is that people, clinicians in this case—after all they are also people—will continue to make errors.  In fact, they are likely to make more errors the more that clinical judgment is taken away from them.  Given all of this, there is much reason to put the clinician back in the decision role and that patients be given more and better information about what is wrong with them so that they can exercise good judgment when selecting a treatment provider.