Post-traumatic stress disorder: Psychiatric management, atonement and justice.
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Date
2015-07
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Abstract
Post-traumatic stress disorder (PTSD), initially described in
Vietnam war veterans, is now a standard psychiatric diagnosis and
used across cultures, contexts and around the globe. It is
incorporated in the American Psychiatric Association’s Diagnostic
and Statistical Manual-5 (DSM-5)1
and is to be a part of the
WHO’s International Classification of Diseases-11.2
Despite its widespread acceptance as a disease label, there are
many unresolved issues related to the category.3–10 Many of the
problems of facing psychiatric diagnoses and classification also
plague PTSD. Unpleasant feelings (e.g. anxiety, dreams and
memory) within the normal range of emotions and purposive
responses of people who are stressed (e.g. efforts to avoid thoughts,
feelings, conversations, activities, places associated with the
traumatic event) are considered pathological.4–6,7 The reasonable
reactions to specific contexts (e.g. hyper-vigilance or numbing)
are labelled aberrant.
The lack of pathognomonic symptoms, marked overlap of
symptoms with other categories (e.g. major depression, specific
phobia, generalized anxiety disorder, dissociative disorder, etc.)
and absence of diagnostic laboratory tests add to the confusion.3,4,6,7
Psychiatry employs symptom checklists for diagnosis and the
process discounts the context; the diagnostic procedure does not
examine the pre- and post-trauma setting, vulnerability and
supports.
The ‘atheoretical’ approach adopted by the current psychiatric
classifications essentially supports the medical model, which
medicalizes personal and social distress.3,4,6,7 The PTSD category
is now also used in people who are victims of violence in the
civilian settings and who have survived rape, assault, accidents,
communal pogroms, industrial disasters, tsunamis, etc.
The diagnosis also assumes that the trauma has past and that
the current context is safe. While this may be true for war veterans
who have come home, it may not be true for other civilian victims
of assault, for women in patriarchal cultures, ethnic, religious and
sexual minorities in traditional societies, where continued threats
and violence are possible.6,7
The concept discounts variation among different people and
does not highlight the strength of the survivors or the meaning of
the event.6,7,10 Problems in living, when viewed through the
medical lens, are construed as mental disorders.3–7 The legal,
insurance and compensation implications of the label are complex
and influence the category and criteria. However, research evidence
for the usefulness of psychiatric treatment after natural and
manmade disasters is thin.11 Similarly, the success of prevention
and treatment programmes for veterans is limited.8
Nevertheless, recent articles about experience in wars have
discussed different conceptualizations, opposed to the medical
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Citation
Jacob K.S. Post-traumatic stress disorder: Psychiatric management, atonement and justice. National Medical Journal of India. 2015 Jul-Aug; 28(4): 198-200.