Responses to Trauma: Normal Reactions or Pathological Symptoms

Abstract

“A National Longitudinal Study of the Psychological Consequences of the September 11, 2001, Terrorist Attacks: Reactions, Impairment and Help-seeking” raises a number of important questions for the field of traumatic stress. Should indirect trauma be included with directly experienced trauma in Criterion A of DSM PTSD? When does a “stress reaction” become pathological? That is, where do we draw the line between normal and pathological responses to trauma? How should DSM deal with stress symptoms that do not meet criteria for PTSD? When should individuals who have been exposed to trauma be referred for psychological treatment? What therapies are appropriate for recently traumatized individuals and when should these treatments be delivered and by whom? First, should traumas that are experienced indirectly be included in Criterion A? In this study, none of the participants was directly involved in the terrorist attacks of 9/11/2001. They were neither traumatized themselves nor did they directly witness trauma to another person. Instead, all subjects heard about or viewed the tragic events from secondhand sources such as the media. Unlike DSM III, Criterion A of DSM IV includes being “confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” Being “confronted with” includes hearing about but not witnessing. Richard McNally (2003) has referred to this expanded definition of trauma as “conceptual bracket creep” where secondhand exposure and direct experience are accorded the same weight in diagnosing PTSD. But is it reasonable to equate watching a family member being murdered with hearing about the sudden injury of a friend? Psychological and neurobiological responses will likely differ in the two scenarios, and housing them under one roof will “dilute” the diagnosis of PTSD, making it more difficult for researchers to characterize pathophysiological alterations that are specific to PTSD. Second, what constitutes a normal versus a pathological response to trauma, and at what point does a reaction to stress become abnormal? This issue is an active topic of dePsychiatry 67(2) Summer 2004 170