Unpacking a PTSD Diagnosis

The difference between trauma and PTSD (Post-Traumatic Stress Disorder) is this: Trauma is the overwhelming quality of an experience, and PTSD is a way of experiencing life after an overwhelming event. Trauma is an informal word that can vary from experience to experience, and PTSD is a formal term with rules for its application prescribed by the American Psychiatric Association in the DSM (Diagnostic and Statistical Manual of Mental Disorders).[1]

Trauma is the overwhelming quality of an experience, and PTSD is a way of experiencing life after an overwhelming event.

In this article, we will unpack the evolution of the PTSD label, its potential to undermine recovery, and how it can be used in order to build competence in dealing with one's own trauma.

The “Concept Creep” of the PTSD Label

The APA has changed the rules for how to properly use the PTSD label over the past three editions (DSM-III, DSM-IV, and DSM-5), which was introduced originally in the DSM-III because of the casualties of the Vietnam War.[2] These rules are called “criteria,” labelled by letters (Criterion A, Criterion B, etc.). Each “Criterion” was determined by whether certain realities manifested in the counselee. For example, in the DSM-III (1980), in order for a mental health professional to diagnose a counselee with PTSD, he would have to meet Criterion A: “The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone.” The DSM-III even makes the qualifying remark: “The precipitating stressor must not be one which is usually well tolerated by most other members of the cultural group (e.g., death of a loved one, ordinary traffic accident).”

The APA has changed the rules for how to properly use the PTSD label, which was introduced originally in the DSM-III because of the casualties of the Vietnam War.

This, however, is not sufficient to qualify for a PTSD diagnosis. The victim must also manifest 2 symptoms from Criteria B (such as recurring dreams and flashbacks), 3 from Criterion C (such as lapses in memory, and attitudes of avoidance), two from Criterion D (such as irritability, outbursts, insomnia), Criterion E (that each symptom last longer than a month).  

The conception of what qualifies as traumatic in the DSM-IV was broadened from the DSM-III, and thereby made sufficiently generic to warrant concern that the term “trauma” would promote “conceptual bracket creep”[3] or “criterion keep”[4]—this was expressed in the literature as a concern over Criterion A, which describe the necessary conditions for a diagnosis.[5]

“Concept creep” refers to the expanding diagnostic criteria for PTSD—this inflates the public’s conception of “trauma” as both more severe and more common than previously thought.

This idea of “concept creep” refers to the expanding diagnostic criteria for PTSD—this inflates the public's conception of "trauma" as both more severe and more common than previously thought. [6] For example, this conceptual broadening in the DSM-IV included “developmentally inappropriate sexual experiences” as qualifying traumatic events, which would not have qualified in the DSM-III’s Criterion A, which required that traumas involve threats of serious injury or threat of death. So, a child who was exposed to pornography by an adult might fulfill Criterion A in the DSM-IV, but not in the DSM-III.

A child who was exposed to pornography by an adult might fulfill Criterion A in the DSM-IV, but not in the DSM-III.

Notice how different are the criteria for DSM-5 (2013):

Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):

  • Direct exposure

  • Witnessing the trauma

  • Learning that a relative or close friend was exposed to trauma

  • Indirect exposure to aversive details of the trauma (e.g., in medical professions)

Notice that the conception of trauma has been expanded out to learning that a relative or close friend was exposed to trauma. Now, even indirect exposure to trauma qualifies as sufficient fulfillment of Criterion A. Criteria B-H continue to include relatively subjective and “felt” symptoms which qualify counselees for a PTSD diagnosis, which would not have been considered sufficiently disruptive according to the DSM-III. Under the DSM-5, it's hard to imagine anyone who doesn't qualify for a PTSD diagnosis.

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Under the DSM-5, it’s hard to imagine anyone who doesn’t qualify for a PTSD diagnosis.

This history of the term is what makes it possible for people today to consider themselves “triggered” over life experiences common to many. The DSM-5 also made possible the invention of such terms as "microaggression"—if trauma can have small and indirect causes, it only makes sense to have a word for the corresponding threat. In the age of the DSM-5, emotional threat is then conceived, diagnostically speaking, as having the potential to be as equally disruptive as physical threat. In other words, the DSM-5 significantly lowered the standards for a PTSD diagnosis.

The evolution of the DSM definition of trauma is what made it possible for people to consider themselves “triggered” by words and “microaggressed” by other peoples’ opinions.

The DSM-5 has defined trauma in such a way that the DSM-III’s original qualification no longer stands: The inclusion of very common experienecs into the DSM-5's diagnostic criteria, such as felt harm, liberate therapists to liberally apply a PTSD diagnosis where the term would have been previously reserved for more severe cases.

Connecting Trauma and PTSD

This history helps us to understand two realities about Trauma and PTSD.

1. Trauma and PTSD are very different.

First, trauma and PTSD ought to be conceived as two distinct realities. Trauma and PTSD were originally conceived as very different things entirely—PTSD in particular was intended to capture the effects of guerrilla warfare, child murder, and physical torture in the Vietnam War. This conceptual distinction can help us to make a distinction between every day suffering which is difficult to process (suffering), experiences which overwhelm our ability to cope (trauma), and suffering so severe that it causes unmanageable symptoms that require professional help, which was called PTSD in the 1980s by professional.

1. SufferingTraumaPTSD.png

2. Trauma and PTSD engage to the same realities.

Trauma and PTSD face the same realities, but in different degrees and with different dispositions. The changes made in the DSM recognize that there are some underlying truths between common suffering and PTSD—both bring us into contact with heinous evil, death, and realities which hurt us unfairly and badly. However, the commonality between trauma and PTSD should not incline the traumatized to seek a PTSD diagnosis, but rather should incline those diagnosed with PTSD to engage their suffering as one which humans have for the entire history of the human race sought and succeeded to handle competently.

The chronic pain which can accompany the journey of trauma recovery can manifest itself in two ways: (1) As learned helplessness, and (2) as learned competence.

Note, again, how the evolution of the PTSD diagnostic criteria have expanded from classifying the psychological fallout of shooting a child with a bomb strapped to his chest to encompass emotional threats to close friends. This expansion assumes, and perhaps even facilitates, an assumed decline in both resilience and personal agency in one's own suffering. The PTSD label is should therefore be considered with caution. This caution does not mean that PTSD is easily overcome with a few Jedi mind tricks. It’s not. It can be a lifelong journey of repeated pain and processing.

The chronic pain which can accompany that journey can manifest itself in two ways: (1) As learned helplessness, and (2) as learned competence. If the PTSD label becomes for you an excuse let out your existential gut so that your whole life mimics the DSM criteria, you will forever be incompetent at self-management. But if you make the PTSD label an opportunity to take more responsibility for yourself, rather than less, this will yield competence that will translate into every area of your life. This moral responsibility is not about neglecting self-compassion or becoming overly judgmental toward yourself. It’s about engaging these realities with a mindset of competence, rather than helplessness.

  • “I’m terrified of death. I’m going to learn everything there is to know.”

  • “I drink four glasses of scotch every night. I’m going to learn how to be happier than this sober.”

  • “The whole world feels dull. I feel trapped. I’m going to find out why my trauma affected me this way. And I’m going to make the changes I need to make in order to fix this.”

You can face trauma with a helplessness-oriented mindset or a competence-oriented mindset. These two realities yield three practical conclusions for those who are diagnosed PTSD (and those who think they may ought to be).

How to Use the PTSD Label

First, it is common to conceive of oneself as having PTSD in such a way that magnifies the symptoms, rather than describes them. In other words, those diagnosed with PTSD often interpret all mental suffering through the PTSD lens. For example, they will interpret all of their avoidant inclinations as post-traumatic symptoms because “avoidance” is listed in the DSM. The effective path to recovery from PTSD actually requires the reverse mindset: The purpose of diagnosing PTSD is to give a very complex and profound reality a single name. The label “PTSD” gives the sufferer “handles” for their experience. But it’s important for the label not to become a security blanket that corrodes personal autonomy. The point of diagnosis should be the recovery of autonomy, not the reinforcement of its loss.

It’s important for the PTSD label not to become a security blanket that corrodes personal autonomy.

Second, the PTSD label can be blind to profound realities in trauma. For example, classifying intrusive dreams, flashbacks, and dysregulated emotions as “symptoms” assumes that they are both unwanted and uninformative—yes, they are painful, but they are part of the process of unpacking the information contained in the traumatic wound. That is, the content of the trauma is seen by the typical therapist as something to be eradicated, rather than fodder for recovery itself.

Recovering one’s sense of control in the very out-of-control symptoms of PTSD is found in engaging what is normal about the symptoms, rather than what is abnormal. So, instead of saying after an alcohol binge, “I have PTSD,” a response that taps into personal control will admit: “There was a reason I did that. It will help me to discover why I did that.” Or, if a man is experiencing intrusive thoughts about his own death, this may be a prompt to read more deeply on the topic.

In so far as therapy is a purely process-oriented practice, it can become its own method of traumatic avoidance, orbiting the therapist’s own philosophical incompetence

This leads us to our third point: the PTSD label can rub against the grain of seeking to address trauma competently. Using the example above, a therapist may attempt to overcome death anxiety with cognitive tactics developed by the discipline of psychology over the past 50 years,[7] rather than strategies from the discipline of philosophy, which has been developing resources on facing death for over 4,000 years.

To the degree that PTSD disinclines the traumatized from becoming competent handlers of their trauma, the label can itself trap them in the trauma.

This is not to say that theology or philosophy make perfect appeals about death which are universally satisfying. But it is better to become competent at engaging traumatic realities rather than avoiding them. Ironically, in so far as therapy is a purely process-oriented practice, it can become its own method of traumatic avoidance, orbiting the therapist’s own philosophical incompetence.[8] To the degree that PTSD disinclines the traumatized from becoming competent handlers of their trauma, the label can itself trap them in the trauma.

Books Referenced in This Article

 

FOOTNOTES

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[1] Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, D.C.: American Psychiatric Association, 2013).

[2] See Hannah S. Decker’s discussion of the inclusion of this diagnosis in the DSM-III in The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (New York: Oxford University Press, 2013), 274-276.

[3] Richard J. McNally, “Progress and Controversy in the Study of Posttraumatic Stress Disorder,” Annual Review of Psychology 54 (2003): 229-252.

[4] Gerald M. Rosen, “Traumatic Events, Criterion Creep, and the Creation of Pretraumatic Stress Disorder,” The Scientific Review of Mental Health Practice 3, no. 2 (2004): 39-42.

[5] See Roger K. Blashfield, Jared W. Keeley, Elizabeth H. Flanagan, and Shannon R. Miles, “The Cycle of Classification: DSM-I through DSM-5,” Annual Review of Clinical Psychology 10 (2014): 25-51.

[6] For example, trauma diagnosis increased by 22% after the conception of trauma was modified in the DSM-IV. T. M. Keane and F. W. Weathers, “The Criterion A Problem Revisited: Controversies and Challenges in defining and Measuring Psychological Trauma,” Journal of Traumatic Stress 20 (2007): 107-121.

[7] See, for example, the infamous book by Elisabeth Kübler-Ross, On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families (New York: Scribner, 1969). In this work, Kübler-Ross introduces the 5 stages of facing one’s own immanent death: Denial and Isolation, Anger, Bargaining, Depression, and Acceptance. It is worth noting three things about Kübler-Ross’s book. First, it has been widely rejected since its publication as a uniform sequence through which all the terminally ill proceed. People die differently—that’s just a fact. Second, Ross focuses purely on process, and not on any meaningful engagement with the problem of death in a philosophical sense—one which allows it to become meaningful in any unified or scalable sense. One might think this too tall an order for a psychologist—and it is, which is our present point. We need to think philosophically about these issues which intersect with trauma as well. Third, Kübler-Ross ends her chapter on “hope” by suggesting that hope is maintained by hoping to live one more day—her patients demonstrated resilience by clinging onto mortal life to the very end and suppressing the facticity of their own death. Maybe it’s just the theology Ph.D. in me talking—and maybe this strategy works for some people—but to me, this version of “hope” is entirely unacceptable.

[8] For example, read the short work by Seneca, On The Shortness Of Life, translated by John W. Basore (Vigeo Press, 2016). Avoid at all costs the wildly overrated book by Paul Kalanithi, When Breath Becomes Air (New York: Penguin Random House, 2016). This book receives praise because it’s written by a neurologist who died while writing his memoir, having found out he was diagnosed with cancer. But his death does not add any profundity to his reflections on death. Most good authors are dead, and it adds nothing to their ideas. In fact, all good authors know they will die, and it likewise does not de facto make their writing better or their arguments stronger.

 
 
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