Does Post-Traumatic Stress Disorder Require Trauma?

Revisiting the role of trauma in PTSD


STRESS is an inevitable part of our life. Yet whether our daily hassles include the incessant gripes of a nasty boss or another hectoring letter from the Internal Revenue Service, we usually find some way of contending with them. In rare instances, though, terrifying events can overwhelm our coping capacities, leaving us psychologically paralyzed. In such cases, we may be at risk for post-traumatic stress disorder (PTSD).

PTSD is an anxiety disorder marked by flashbacks, nightmares and other symptoms that impair everyday functioning. The disorder is widespread. At least in the U.S., it is thought to affect about 8 percent of individuals at some point during their lifetime.

Although PTSD is one of the best known of all psychological disorders, it is also one of the most controversial. The intense psychological pain, even agony, experienced by sufferers is undeniably real. Yet the conditions under which PTSD occurs—in particular, the centrality of trauma as a trigger—have come increasingly into question. Mental health professionals have traditionally considered PTSD a typical, at times even ubiquitous, response to trauma. They have also regarded the disorder as distinct from other forms of anxiety spawned by life’s slings and arrows. Still, recent data fuel doubts about both assumptions.

Shell Shock
PTSD did not formally enter psychiatry’s diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), until 1980. Yet accounts of syndromes that mirror PTSD date back to Sumeria and ancient Greece, including a mention in Homer’s Iliad. In the American Civil War, veterans suffered from “soldier’s heart”; in World War I, it was called “shell shock,” and in World War II, the term used was “combat fatigue.” In the 1970s some soldiers returning from the war in Southeast Asia received informal diagnoses of “post-Vietnam syndrome,” which also bore a striking resemblance to the DSM’s description of PTSD.

According to the DSM, PTSD occurs in the wake of “trauma”—defined by the manual as an extremely frightening event in which a person experiences or witnesses “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” (Less violent experiences such as serious relationship or financial problems do not count.) The most frequent triggers of PTSD thus include wartime combat, rape, murder, car accidents, fires, and natural disasters such as tornadoes, floods and earthquakes.

PTSD is now officially characterized by three sets of symptoms. These include reliving the event through intrusive memories and dreams; emotional avoidance such as steering clear of reminders of the trauma and detaching emotional­ly from others; and hyperarousal that causes sufferers to startle easily, sleep poorly and be on alert for potential threats. These problems must last for a month or more for someone to qualify for the PTSD label.

Immune to Trauma?
After the terrorist attacks of September 11, 2001, many mental health experts confidently predicted an epidemic of PTSD, especially in the most severely affected locations: New York City and Washington, D.C. The true state of affairs was much more nuanced, however. It is certainly true that many Americans experienced at least a few post-traumatic symptoms following the attacks, but most of the afflicted recovered rapidly. In a 2002 study psychologist Roxane Cohen Silver of the University of California, Irvine, and her colleagues showed that about 12 percent of Americans suffered significant post-traumatic stress between nine and 23 days after the attacks. Six months later this number had declined to about 6 percent, suggesting that time often heals the psychic wounds.

Work by epidemiologist Sandro Galea of the New York Academy of Medicine and his colleagues, also published in 2002, revealed that five to eight weeks after 9/11, 7.5 percent of New Yorkers met the diagnostic criteria for PTSD; among those who lived south of Canal Street—that is, close to the World Trade Center—the rates were 20 percent. Consistent with other data, these findings suggest that physical proximity is often a potent predictor of stress responses. Yet they also indicate that only a minority develops significant post-traumatic pathology in the aftermath of devastating stressors. Indeed, the overall picture following the 9/11 attacks was one of psychological resilience, not breakdown.

This article was originally published with the title "When Coping Fails."

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