Post-traumatic stress disorder: a reappraisal.

Abstract

It is virtually impossible nowadays to study a medicolegal report prepared by a psychiatrist or psychologist instructed on behalf of a plaintiff in personal injury litigation which does not conclude that he or she is suffering from posttraumatic stress disorder. Irrespective of the severity of the accident suffered or the clinical condition of the plaintiff, PTSD is the diagnosis. The Diagnostic and Statistical Manual of Mental Disorders IV and the ICD-10 Class?fication of Mental and Behavioural Disorders is broadly in line states that the essential feature of PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stressor with the subject's response involving intense fear, helplessness or horror. There is no doubt that accidents or experiences in civil life may satisfy these preconditions but all too frequently the emotionally traumatic experience does not remotely approach an intensity sufficient to justify the diagnosis. Thus post-traumatic stress disorder has been diagnosed after a miner slipped down some stairs after emerging from the pit bath and landed on his buttocks without any serious resultant physical sequelae. The diagnosis has been made on subjects who have been involved in minor rear-end shunts-in some cases when they have been asleep in a lay-by. Tripping over an uneven pavement has been considered to be of such emotional significance as to induce the condition. The mere process of being arrested is apparently so stressful as to induce PTSD and that is so even when the subject has had considerable conflict with the law and has been arrested on many occasions in the past. Being knocked down by a bicycle has been judged so emotionally traumatic as to cause the subject to suffer from PTSD even when the physical injury sustained was so slight that the subject did not consider it necessary to attend hospital. A shopper was diagnosed as suffering from PTSD as the result of merchandise falling from a shelf and causing what could only be described as a trivial head injury. A professor of psychiatry diagnosed PTSD in subjects who had suffered serious head injuries with retrograde and posttraumatic amnesia and who, on regaining consciousness, were unaware that they had been involved in accidents. In none of these examples and I can offer many others could it be held that the subject experienced intense fear, helplessness or horror. That, however, has not prevented psychiatrists, psychologists, behaviour therapists, counsellors and community psychiatric nurses from making the diagnosis. Furthermore, in instances where an external observer might have doubted whether the stressor had been sufficiently severe, the problem was solved by the subject being asked directly 'Did you think that your life was in danger?'. Since many such subjects are plaintiffs in actions for the recovery of damages for personal injury and are only too well aware that the more dramatic their complaints, the greater might be their compensation, it is not surprising that the reply is very frequently in the affirmative. In fact, such subjects who have been asked this question will often say that initially the idea that their life had been in danger had never entered their minds. It was only when they were being interviewed for the purposes of the preparation of a medicolegal report or were being questioned by a psychologist in a stress clinic was the idea suggested to them. Many such subjects especially those involved in road traffic accidents say that the idea that their life had been in danger had never occurred to them because the accident in which they had been involved was, as it were, 'over in a flash' and-before they had realized what had happened. _ .That experiences resulting in very severe emotional trauma occur in civilian life, there is no doubt. It has been described in individuals involved in earthquakes, volcanic eruptions or fires. Miners trapped underground by falls of rock with delay in their rescue fulfil the criterion as do passengers in an aeroplane hijacked by armed terrorists sitting behind them with weapons pointing to their heads. Lorry drivers trapped in a tunnel fire, passengers on a sinking ship and those involved in armed robberies are severely emotionally traumatized. What is apparent, however, is that all too often any traumatic emotional experience, irrespective of its severity, is regarded as sufficient to trigger PTSD.