This
is an editorial Nancy wrote for the "AMERICAN JOURNAL OF PSYCHIATRY" (she is the
editor in chief of that journal)...The entire issue us devoted to stress.
Nancy is the MD who originally defined PTSD for DSMlll, she based her
definition based on studies of burn patients she interviewed and treated in the
70's.
Terry Gwinn, A/101 Avn, 1966
Andreasen, N. C.
Collections under which this article appears: Posttraumatic Stress Disorder Am J
Psychiatry 161:1321-1323, August 2004
© 2004 American Psychiatric Association
Editorial
Acute and Delayed Posttraumatic Stress Disorders: A History and Some Issues
Nancy C. Andreasen
This issue of the Journal features stress disorders as its theme. The study of
the psychological and emotional consequences of stress has become a burgeoning
and important field in psychiatric research and treatment. In fact, the
diagnoses of posttraumatic stress disorder (PTSD) and acute stress disorder (ASD)
are now so frequently made that one wonders how we once got by without them. The
stress syndromes that we refer to as PTSD and ASD have a very long descriptive
history. In general, their early history was closely linked to the experiences
that soldiers suffered in combat. Before a diagnosis existed, many features of
the syndrome were well-described in literary form in The Red Badge of Courage.
The terrible carnage of trench warfare during World War I led many young men to
return home deeply traumatized, and this led in turn to systematic descriptions
of the syndrome under names such as "shell shock" or "combat fatigue." World War
II was, however, the catalytic event that led to the creation of a formal
diagnostic category to refer to this syndrome: Gross Stress Reaction. World War
II for the first time brought together soldiers, psychiatrists, and other
medical personnel from all over the country, giving them an opportunity to
discover the many things that they had in common and also to recognize the ways
that they differed. Socially, our great melting pot received yet another
incentive to continue to melt—and to meld together all the diverse components of
our society. (The World War II musical, Oklahoma, celebrated this fact—watch it
again some time in the context of our current world situation.) On the medical
and psychiatric scene people discovered that they did not always share a common
vocabulary with which to discuss the syndromes and diagnoses observed in their
patients.
After the war ended, the Veterans Administration (VA) developed a diagnostic
manual, which provided the incentive for the APA to create its own first manual:
DSM-I. The manual was very concise, but it included a diagnosis that covered
victims of stress: Gross Stress Reaction. During that post-war era and after,
psychiatrists also began systematic investigations of the consequences of
exposure to death camps and the POW experience, as well as nonmilitary
stressors, such as mass catastrophes—fires, earthquakes, or plane crashes (1).
However, for reasons that remain obscure but that perhaps reflect the early
links between military combat and the diagnosis of stress disorders, Gross
Stress Reaction was somehow dropped from DSM-II. That manual was written when
our country was not engaged in any major war. However, the scientific study of
the consequences of stress continued. In fact, your editor began her early
research career by studying the consequences of severe burn injuries in the
pre-DSM-III era—identifying symptoms, risk factors for poor outcome, and the
prevalence of severe psychiatric consequences (2–5).
DSM-III was crafted in the post-Vietnam era, a time when our country contained
yet another wave of young men who had been exposed to the trauma of combat. VA
and military psychiatrists had no official diagnosis to give them, as long as
DSM-II was the official diagnostic manual. As a member of the DSM-III Task
Force, I was assigned to this problem. An active group of advocates were
lobbying for the inclusion of a diagnosis of "Post-Vietnam syndrome." The
purpose and the concept were correct, but the name and the specificity were not.
I pointed out the long history of the syndrome, as well as the fact that it
frequently occurred in traumatized civilians as well. A stress syndrome
characterized by reliving, indicators of autonomic overarousal, and other such
features was simply a final common pathway with many different sites of entry.
We worked together to agree on diagnostic criteria, which were rooted in the
extensive literature on stress disorders alread available at that time, and
christened our 100-year-old offspring Post-traumatic Stress Disorder. I wrote
the entire text description of the syndrome, which was based on my experience
caring for burn patients and the substantial literature available at the time.
My burn patients had almost universally experienced this syndrome immediately
after their injuries. So we designated an acute form of PTSD. However, many
soldiers do not develop stress symptoms until they return home, since a stress
reaction in the midst of combat is not adaptive, and so the impact of their
traumatic experiences is delayed. Therefore, we also identified a delayed form.
The concept of PTSD took off like a rocket, and in ways that had not initially
been anticipated. The DSM-III text struggled with many issues: how severe should
the trauma be? What types of trauma could be considered causative? Does it make
a difference if the trauma is inflicted by another human being, by an accident,
or by a natural disaster? What impact does duration of the stressor have? What
impact does premorbid psychiatric status have? And so on. PTSD is a complex
concept. The DSM-III formulation emphasized that the stressor should be
significant—outside the range of normal human experience. It assumed, but did
not explicitly state, that there would be a temporally close juxtaposition
between the stressor and the development of symptoms.
Many psychiatrists liked the DSM-III formulation and began to use the diagnosis
widely. Its application broadened steadily. For example, it was used for victims
of childhood sexual abuse who developed traumatic stress symptoms much later.
Dissociation, a component of the original definition but not its core, received
increasing emphasis. And the requirement that the stressor be outside the range
of normal human experience was sometimes reinterpreted to include less severe
stressors. In fact, that stringent requirement was dropped in DSM-III-R and
DSM-IV, providing a much broader concept than was originally intended. (In my
view,
this broadening should be reconsidered. Giving the same diagnosis to death camp
survivors and someone who has been in a motor vehicle accident diminishes the
magnitude of the stressor and the significance of PTSD.) Acute PTSD, dropped
from DSM-III-R, was fortunately added back in DSM-IV with a new name: Acute
Stress Disorder.
This issue includes several articles on various forms of PTSD. The literature on
this diagnosis is now vast. It goes far beyond the descriptive psychopathology
upon which the original DSM-III definition was based. We now have a multitude of
papers covering topics such as neural mechanisms as revealed in imaging studies,
risk factors, prevalence, comorbidity, symptom patterns, and outcome. The study
of PTSD has enriched our conceptualization of memory in both its conscious and
unconscious forms. The task of summarizing all this literature—and producing a
DSM-V description and definition—will be challenging. Not all the studies
converge on the same conclusions.
Why?
A clue is provided by the articles in this issue. Although the final common
pathway (in the psychological and physical/autonomic sense) is the same, there
are many different kinds of stressors. As detailed by Verger et al.,
experiencing a terrorist bombing in a metro—a man-made and unanticipated
disaster that produced concomitant physical injuries, facial deformities, and
the psychological terror that was intended—is indeed something outside "the
normal human range." A PTSD prevalence rate of 31% was observed approximately
2.6 years after the event. If anything, this seems surprisingly low, but the
assessments were done via phone interview and could be an underestimate. A
companion paper by Fullerton et al. examines both ASD and PTSD in disaster
workers at the site of a plane crash. Their stressors are quite different. A
plane crash is an accident, and therefore has a different impact than man-made
malevolence. Disaster workers have chosen their occupation with foreknowledge of
its risks. To say this is not to diminish the enormous value of their work. But
the psychological impact is different. And, not surprisingly, the prevalence of
PTSD at a 13-month assessment was lower than in the terrorism victims: 16.7%.
The studies examine different predictors of outcome and produce different
results. These articles are but two examples of the many difficulties in
conceptualizing the essence of PTSD and its consequences. A third article by
O'Donnell et al. examines the thorny issue of comorbid depression. (The original
concept of Gross Stress Reaction specified that it must occur in an otherwise
normal individual—which was probably wrong, since stressors do not
preferentially occur in normal individuals, and those with other disorders may
have fewer adaptive resources remaining.)
As the psychiatrist who was also midwife at the birth of PTSD, I have followed
its growth and maturation with great interest. Others have parented it, and
generally well. It is of particular interest in the 21st century, when the
entire world is filled with the spectre of terrorism—a stressor of great
magnitude that can strike any time and anywhere. This is also a time when we
again will have many young soldiers returning from yet another war: the
treacherous combat experience in Iraq and Afghanistan. Unfortunately, the
present world situation is likely to give us many more opportunities to study
ASD and PTSD. For this I have regrets, but I am pleased that I helped create a
diagnostic category and conceptual framework for this important syndrome, so
that its causes and consequences can be examined both clinically and
scientifically.
References
Adler A: Neuropsychiatric complications in victims of Boston"s Coconut Grove
disaster. JAMA 1943; 123:1098–1101
Andreasen NJ, Noyes R Jr, Hartford CE, Brodland G, Proctor S: Management of
emotional reactions in seriously burned adults. N Engl J Med 1972;
286:65–69[Medline]
Andreasen NJ: Neuropsychiatric complications in burn patients. Int J Psychiatry
Med 1974; 5:161–171[Medline]
Andreasen NJ, Noyes R Jr, Hartford CE: Factors influencing adjustment of burn
patients during hospitalization. Psychosom Med 1972; 34:517–525[Medline]
Andreasen NJ, Norris AS, Hartford CE: Incidence of long-term psychiatric
complications in severely burned adults. Ann Surg 1971; 174:785–793[Medline]
All rights reserved. Revised: 08/22/04.