- Email: [email protected]
Posttraumatic stress syndromes: Useful or negative heuristics?
Journal of Anxiety Disorders 21 (2007) 223–229
Posttraumatic stress syndromes: Useful or negative heuristics? James C. Coyne a,*, Richard Thompson b a
Department of Psychiatry, University of Pennsylvania School of Medicine, 3400 Spruce St., 11 Gates, Philadelphia, PA 19014, United States b Juvenile Protective Association, Chicago, United States
Abstract The articles in this special issue provide a wide range of challenges to current conceptions, nosology, and assessment procedures for posttraumatic stress disorders. At best, they overcome the negative heuristic posed by these disorders, reopening issues that have preemptively been closed about dissociation, the presumed causal connection between a life threatening event and the symptoms of posttraumatic stress disorders, and the adequacy of checklist assessments of symptoms. They note discontinuities between current thinking about these disorders and the dominant thinking of the past. We make recommendations for more studies that similarly challenge the validity of current conceptions of posttraumatic disorders and dissociation, and the adequacy of checklist assessments of symptoms. With this goal, we note the value of studying ersatz posttraumatic stress response. Finally, we call for greater transparency in this literature with author disclosure of activity as expert witnesses. # 2006 Published by Elsevier Ltd. Keywords: Posttraumatic stress disorder; Trauma; Malingering; Dissociation; Construct validity; Expert witness
As a group, the articles in this special issue provide some provocative challenges to many entrenched assumptions and standard interpretations of findings in the literature concerning posttraumatic stress disorder (PTSD) and acute stress disorder (ASD). Numerous times, the articles even question the validity of these diagnoses. The articles should add impetus to longstanding calls for a thorough revamping of the classification of the DSM-IV nosology for posttraumatic disorders (Marshall, Spitzer, & Liebowitz, 1999).
* Corresponding author. E-mail address: [email protected] (J.C. Coyne). 0887-6185/$ – see front matter # 2006 Published by Elsevier Ltd. doi:10.1016/j.janxdis.2006.09.008
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1. Overview of the issues These articles variously claim that In sharp contrast to current thinking, earlier in the 20th Century, military authorities and medical personnel strongly presumed that the apparently prolonged adverse psychological reactions to life threatening situations could be explained away in terms of pre-existing vulnerability, secondary gain, or fraud (Jones & Wessley, 2007). Symptoms required for a diagnosis of PTSD are common among a sample of patients recruited for treatment of major depression and their presence is unrelated to whether a traumatic event has occurred (Bodkin, Pope, Detke, & Hudson, 2007). Most persons who eventually develop PTSD did not display ASD, and the presence of dissociative symptoms does not add to the prediction of PTSD beyond what can be learned from other acute stress reactions (Bryant, 2007). Findings from the National Vietnam Veterans Readjustment Study (NVVRS) that over half of Vietnam war veterans suffered full or partial PTSD cannot be entirely explained away by malingering, exposure to traumatic stressors, or deployment to Vietnam without exposure to trauma (McNally, 2007). The defining symptoms of PTSD are ‘‘highly subjective, easily coached, and readily simulated,’’ and there are no dependable ways of distinguishing feigned from actual symptoms, affecting the credibility of available evidence concerning the rates and natural history of the disorder (Rosen & Taylor, 2007). ‘‘. . . those who promote PTSD have: (1) disregarded time-honored lessons about traumatic stress reactions; (2) permitted political and social attitudes to sway their judgments and alter their practices; (3) dispensed with diagnostic fundamentals and so made claims that are regularly (and embarrassingly) misleading; (4) slighted other explanations and treatments for patients with trauma histories.’’ (McHugh & Treisman, 2007). McHugh and Treisman are clearly here to bury, not to praise the diagnosis. About all the praise that a reader can find in this collection of papers for the diagnosis of posttraumatic stress disorders and the literature they have spawned is Rosen and Taylor’s declaration that ‘‘regardless of whether PTSD represents a distinct disorder, it has served at least one useful function; to promote research and advance our understanding of how individuals react to severely adverse events.’’ There is obviously some self-selection in the attitude of the distinguished group of authors appearing here. Yet, four of these papers (Bryant; Bodkin and colleagues; McNally; Rosen and Taylor)present converging examples of how taking an open-minded, skeptical attitude toward the conceptualization, nosology, and assessment of posttraumatic disorders can yield fresh interpretations of the literature and new research. They thus may demonstrate the heuristic value of these diagnoses. But with the troubling issues they raise, the diagnoses become Wittgensteinian ladders presumably to be kicked away in the next version of the DSM. Bryant’s review adds to the weight of evidence that it was a mistake in DSM-IV to make dissociative symptoms such a defining feature of acute stress disorder. Furthermore, the introduction of the diagnosis of ASD has not moved us much beyond the administrative and place holding diagnosis of adjustment disorder, which it was intended to supplement. Discussions of dissociative symptoms often have involved strong neo-crypto-analytic inferences from the weak evidence of thin, ambiguous reports of symptoms. Bryant argues that the standard use of
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interview and self-report checklist items to assess dissociation may be taking normal phenomena like forgetting or not paying attention in the first place and inappropriately inferring pathological phenomena, like amnesia and other alterations in awareness. Problems are compounded with retrospective assessment. Certainly one cannot distinguish between normal and pathological processes solely on the basis of these reports alone. Nor can one be confident that the same processes are not being counted more than once as different symptoms. Furthermore, Bryant argues that what modest success dissociative symptoms may have in predicting later PTSD may be as reflections of hyperarousal or overall intensity of the initial stress response. This does not bode well for the usefulness of the diagnosis of ASD. Bodkin and colleagues show the benefit of taking a skeptical attitude toward the connection that the DSM diagnosis of PTSD has reified between traumatic event and psychiatric symptoms. They provide a clever demonstration that in a depressed population, at least, these symptoms are common and not tied to whether a life threatening event has been faced. We were left wondering (as they apparently were) whether standard assessment procedures might artificially enforce an association between an event and specific symptoms that is less specific to traumatic situations and less tied to a specific trauma. They note how consideration of these concerns has been barred in the standard assessment procedure because questions are only asked about symptoms in relation to the presumed causal events. McNally’s speculations about reasons why the estimated prevalence of full and partial PTSD among Vietnam veterans provided by the NWRS were so high remain quite useful, even though the mystery may now largely be settled. Thompson, Gottesman, and Zalewski (2006) obtained a much lower estimates for rate of PTSD than originally reported by applying adjustments in timeframes and thresholds for accepting reports of symptoms so that re-estimated prevalence were comparable to other studies. Consistent with one of the suggestions of McNally, Dohrenwend and colleagues required documented exposure to a traumatic stressor during the war and impairment for symptoms to result in a diagnosis of PTSD (Dohrenwend et al., 2006). This requirement led to a 40% reduction in the rates of PTSD. Dohrenwend and colleagues also showed how a sophisticated estimate of exposure could be derived from archival and administrative sources, thereby strengthening confidence in their lower estimate of PTSD and establishing a dose-response relationship. But McNally raises some other, more general issues. First, to what extent does appraisal and attribution of PTSD symptoms depend more on current adjustment and life circumstances than the etiological connection presumed in a diagnosis of PTSD? Second, if persons can be mistaken or imagine exposure (while presenting for PTSD), but still have symptoms adequate for a diagnosis of PTSD, what confidence should we have in the role of a life threatening stressor in PTSD? McNally dismisses malingering or faking as explanations for the high rates of PTSD in NVVRS, but Rosen and Taylor take up the issue and discuss the significance of including persons in PTSD research who are involved in litigation. Rosen and Taylor observe how assessment and diagnosis of PTSD are dependent on highly subjective symptoms, and these symptoms can readily be simulated or coached. The immediate point is that the resulting pseudo-PTSD cannot readily be distinguished from what is presumably the real thing. Yet, like McNally, Rosen and Taylor want to take this ambiguity further, questioning whether what is presumed to be the real thing might be the product of recognition, interpretation, and attribution of symptoms driven by social influences. We also infer that assessment efforts include the demand characteristics, highly leading questions, and the presumption of an etiological connection with exposure to an event. Jones and Wessely and McHugh and Treisman remind us that there was a time not long ago when credible authorities would have been dismissive of the diagnosis of PTSD and the claims
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now being made about it. Provocative though some of the rich historical notes they provide may be, we are concerned that the stridence and evidence of one-sidedness that can be found in these two papers could prove off putting and counterproductive in efforts to stimulate reformulation of clinical thinking about posttraumatic stress disorders. Even someone sharing some of these authors’ skepticism about claims in the PTSD literature might paradoxically find themselves disputing their evidence and developing counterarguments, in order to restore some balance to the discussion. It is not so easy as these authors to adjudicate the source of gross differences between older and contemporary sources about the nature of normal and pathological psychological reactions to traumatic events. For example, Jones and Wessely tell us that military physicians believed there were no war neuroses during the Boer war. Yet, we do not have systematic interview data from this period and we are dealing with fallible opinions that cannot be retrospectively substantiated. What prejudices, etiological assumptions, class biases, or institutional loyalties might have motivated these pronouncements? To use a parallel example, what estimates of the rates of masturbation and homosexual acts among for British soldiers would these Victorian gentlemen have given us? If they reassured us that good British soldiers do not do these sorts of things, would we have accepted their opinion as facts or merely as evidence of their quaint attitudes and beliefs rooted in their particular sociocultural contexts? What social factors, including institutional threats and sanctions, might have discouraged soldiers from reporting their symptoms and dysfunction or attributing their problems to the war experiences? It is noteworthy that 300 British soldiers who were executed for cowardice during WWI were recently pardoned, with the explanation that they were likely suffering from shell shock (‘‘300 Soldiers Receive . . .,’’ August 16, 2006). What do these executions and this re-evaluation suggest about the attitudes and institutional response to ‘‘shell shock’’ at the time? Jones and Wessely provoke some thought with their examples and historical analyses, but we fail to see what implications this historical analysis has for the current debate about PTSD diagnosis. In short, they appear to have demonstrated a profound historical discontinuity in thinking about psychological reactions to trauma, with little to guide our thinking about the sources of this discontinuity or the best way of resolving it. McHugh and Treisman make several valuable points about the need to go beyond checklist assessments of symptoms and, where possible, to retrieve corroborative information about exposure to event and pre-exposure adjustment so as not to depend on self-report alone. In important respects, these are the key elements of Dohrenwend and colleagues’ strategy for reanalyzing the NWRS data. McHugh and Treisman link these suggestions to the now too often neglected, but valuable psychobiological life history framework of Adolf Meyer. But we are concerned that the harsh and even ridiculing tone of the McHugh and Treisman will lose readers before this contribution is discovered. Issues of tone aside, readers are encouraged to learn more about what a Meyerian perspective can bring to a case analysis (Rutter, 1986). 2. Specific concerns 2.1. Defying the power of the negative heuristic At their best, these papers demonstrate the value of taking assumptions basic to the conceptualization, nosology, and assessment of posttraumatic stress disorders seriously enough to mount an interesting challenge to these assumptions. Current notions of posttraumatic stress disorders thus provide a positive heuristic. Yet, what sometimes makes the conclusions of the authors so startling and provocative is they have effectively resisted the powerful negative heuristic of these diagnoses. Namely, the reification of PTSD and ASD and the presumed
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etiological connection between exposure and symptoms has too often artificially provided settlement to issues that should be subject to skepticism and empirical test. This negative heuristic blocks the raising of particular questions and forces particular, if not overly strong interpretations of weak data. Thus, it has been strongly presumed that dissociation is a related set of alterations in awareness with predictable aspects, that much of the richness of dissociation is not directly observable and therefore not readily disconfirmable, and that dissociation has important prognostic implications. These presumptions have too often driven strong interpretations of weak checklist and retrospective data, rather than being fashioned into testable hypotheses themselves. If the current articles accomplish nothing else, they will be a successful effort if they stimulate doubt in the authority of the prevailing negative heuristic of posttraumatic stress disorders. 2.2. The need for skeptical testing of assumptions A recurring theme among the articles assembled here is the usefulness of research strategies that put to a test what are more typically left as guiding presumptions in the interpretation of data. Thus, Bodkin and colleagues would seem to be encouraging us to examine whether we can obtain reports of traumatic symptoms in nontraumatized clinical populations. Bryant at some points seems to be encouraging us to determine with appropriate probes if reports of dissociation actually involve alterations of awareness and if reports of presumably different dissociative phenomena are actually based on the same experiences. Reynolds and Brewin (1999) have developed interesting probes to distinguish among types, unpleasantness, intensity, and functional character of intrusive thoughts. Thus, with breast cancer patients, it is important to probe whether presumed intrusive thoughts are past oriented (e.g., reliving the delivery of the diagnosis), or forward looking, (e.g., contemplating the ambiguity of the medical information and differences among treatment options). This methodology can readily be extended to probing other symptoms. More generally, we need to know more about the validity of checklist assessments of symptoms: not just sensitivity and specificity with respect to the results of semistructured interviews, but the conditions under which they can and cannot discriminate between normal phenomena and symptoms of stress disorder. We also need to study when checklists can discriminate between symptoms of stress reactions, anxiety and depressive disorders, and when checklist assessments are particularly likely to be ambiguous or misleading. Undoubtedly an answer to the question ‘‘how valid and useful are checklist assessments of symptoms?’’ is likely to be highly nuanced and qualified by context. Implicit in the McNally and Rosen and Taylor articles is a suggestion for another kind of study. Each article implies that symptoms resulting in a diagnosis of PTSD can reflect context effects including leading questions, particularly questions that encourage particular attributions for symptoms and discourage consideration of other attributions (e.g., suggestions that normal experiences be interpreted as symptoms; or other demand characteristics of the assessment context). These authors seem to pose a challenge that we determine the extent to which and under what circumstances a vulnerable person and an interviewer can intentionally or inadvertently coconstruct a diagnosis of a posttraumatic stress disorder that otherwise would not come into being. 2.3. The need for studies of ersatz posttraumatic stress disorders A large group of studies fail to establish whether there has actually been exposure to an event and then assess symptoms with measures of uncertain validity, but clearly incomplete coverage of
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the full range of symptoms of PTSD. Such studies are common, using the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979). Results of such studies are sometimes qualified with the label ‘‘PTSD-like symptoms,’’ but these results are still often discussed and cited as if they refer to pathological states of established validity. McNally (2003) has lamented the ‘‘bracket creep’’ of studies and Rosen (2005) the ‘‘criterion creep,’’ with the obvious remedy that we discourage the conduct of such studies and not accept the broadened range of traumatic events and inflated estimates of the prevalence posttraumatic disorder. We would argue, however, that there is a pressing need for research that deliberately documents ‘‘bad’’ examples. A model is Lee-Haley, Price, Williams, and Betz’s (2001) administration of the IES to college students with instructions that they complete it with respect to a particularly bad movie that they had recently viewed. Their resulting scores substantially overlap with what is obtained with more serious stressful events (i.e., what are obtained with newly diagnosed breast cancer patients or women who have undergone genetic screening for risk of breast and ovarian cancer). Such studies can usefully undermine attaching any credibility to the use with serious intent of such measures in other populations. Similarly, we believe that it is important to conduct more studies similar to that of Bodkin and colleagues (2007) in clinical populations for whom PTSD would normally be ruled because of failure to meet criterion A, but nonetheless symptom criteria are fulfilled. As in Bodkin et al.’s study, some adjustments in queries about symptoms need to be made, but the possibility is that we can demonstrate that when patients are not induced to attribute their symptoms to a traumatic event, they do not. Such studies would be in the spirit of putting to a test the suspicion of a number of the authors in the present series of papers that the connection between traumatic events and symptoms of PTSD may be an artifact of how these symptoms are assessed. 2.4. Establishing transparency in posttraumatic stress research Rosen and Taylor make a persuasive case that because reports of PTSD may be made to secure advantage in litigation and compensation for disability and because such reports are so readily faked and coached, investigators have a responsibility to disclose the extent to which their research populations include litigants and compensation seekers. We agree, but believe this responsibility for disclosure of conflict of interest ought to be more broadly extended to all authors. Namely, readers have the right to know whether authors have financial interests related to their roles as expert witnesses or in their soliciting of employment in such roles. Publication in peer review journals can be an important basis for establishing the validity of claims for compensation. Such financial gain for authors can be as distorting and contaminating of the literature as financial ties to the pharmaceutical industry (Coyne, 2005). Thus, the now widely ridiculed claim that hearing of a sexist joke on an elevator ought be regarded as a traumatic event (Avina & O’Donohue, 2003) becomes more understandable when it is known that one of the authors who made that claim serves as an expert witness in sexual harassment suits. Clashing conflicts of interest cannot begin to explain the full range of factious quarrels, entrenched points of view, and hidden agenda in this contentious field, but readers have the right to judge the influence of financial ties for themselves. 3. Conclusion At different points in this series of papers, some readers will be enthralled, while at other points they may be simply annoyed and frustrated. We encourage readers to suspend these
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judgments, and to treat the articles as providing a useful heuristic. In doing so, readers can gain a better appreciation and understanding for the numerous issues and controversies that have befallen posttraumatic stress syndromes. References Avina, C., & O’Donohue, W. (2002). Sexual harassment and PTSD: Is sexual harassment diagnosable trauma? Journal of Traumatic Stress, 75, 69–75. Bodkin, A., Pope, H. G., Detke, M. J., & Hudson, J. I. (2007). Is PTSD caused by traumatic stress? Journal of Anxiety Disorders, 21, 176–182. Bryant, R. A. (2007). Does dissociation further our understanding of PTSD. Journal of Anxiety Disorder, 21, 183–192. Coyne, J. (2005). Lessons in conflict of interest: The construction of the martyrdom of David Healy and the dilemma of bioethics. American Journal of Bioethics, 5, W3–W14. Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., Koenen, K. C., & Marshall, R. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science, 313, 979–982. Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209–218. Jones, E., & Wessely, S. (2007). A paradigm shift in the conceptualization of psychological trauma in the twentieth Century. Journal of Anxiety Disorders, 21, 164–175. Lees-Haley, P., Price, J. R., Williams, C. W., & Betz, B. P. (2001). Use of the impact of events scale in the assessment of emotional distress and PTSD may produce misleading results. Journal of Forensic Neuropsychology, 2, 45–52. Marshall, R. D., Spitzer, R., & Liebowitz, M. R. (1999). Review and critique of the new DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 156, 1677–1685. McHugh, P. R., & Treisman, G. (2007). PTSD: A problematic diagnostic category. Journal of Anxiety Disorders, 21, 211–222. McNally, R. J. (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology, 54, 229–252. McNally, R. J. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study? Journal of Anxiety Disorders, 21, 192–200. Reynolds, M., & Brewin, C. R. (1999). Intrusive memories in depression and posttraumatic stress disorder. Behaviour Research and Therapy, 37, 201–215. Rosen, G. M. (2005). Traumatic events, criterion creep, and the creation of pretraumatic stress disorder. Scientific Review of Mental Health Practice, 3, 39–42. Rosen, G. M., & Taylor, S. (2007). Pseudo-PTSD. Journal of Anxiety Disorders, 21, 201–210. Rutter, M. (1986). Meyerian psychobiology, personality-development, and the role of life experiences. American Journal of Psychiatry, 143, 1077–1087. Thompson, W. W., Gottesman, I. I., & Zalewski, C. (2006). Reconciling disparate prevalence rates of PTSD in large samples of US male Vietnam veterans and their controls. BMC Psychiatry, 6, 19 Available online at: http:// www.biomedcentral.com/1471-244X/6/19 Accessed October 17, 2006. 300 WWI soldiers receive pardons British Broadcasting Company News. (August 16, 2006). http://news.bbc.co.uk/2M/uk news/4796579.stm Accessed October 17, 2006.
Posttraumatic stress syndromes: Useful or negative heuristics? James C. Coyne a,*, Richard Thompson b a
Department of Psychiatry, University of Pennsylvania School of Medicine, 3400 Spruce St., 11 Gates, Philadelphia, PA 19014, United States b Juvenile Protective Association, Chicago, United States
Abstract The articles in this special issue provide a wide range of challenges to current conceptions, nosology, and assessment procedures for posttraumatic stress disorders. At best, they overcome the negative heuristic posed by these disorders, reopening issues that have preemptively been closed about dissociation, the presumed causal connection between a life threatening event and the symptoms of posttraumatic stress disorders, and the adequacy of checklist assessments of symptoms. They note discontinuities between current thinking about these disorders and the dominant thinking of the past. We make recommendations for more studies that similarly challenge the validity of current conceptions of posttraumatic disorders and dissociation, and the adequacy of checklist assessments of symptoms. With this goal, we note the value of studying ersatz posttraumatic stress response. Finally, we call for greater transparency in this literature with author disclosure of activity as expert witnesses. # 2006 Published by Elsevier Ltd. Keywords: Posttraumatic stress disorder; Trauma; Malingering; Dissociation; Construct validity; Expert witness
As a group, the articles in this special issue provide some provocative challenges to many entrenched assumptions and standard interpretations of findings in the literature concerning posttraumatic stress disorder (PTSD) and acute stress disorder (ASD). Numerous times, the articles even question the validity of these diagnoses. The articles should add impetus to longstanding calls for a thorough revamping of the classification of the DSM-IV nosology for posttraumatic disorders (Marshall, Spitzer, & Liebowitz, 1999).
* Corresponding author. E-mail address: [email protected] (J.C. Coyne). 0887-6185/$ – see front matter # 2006 Published by Elsevier Ltd. doi:10.1016/j.janxdis.2006.09.008
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1. Overview of the issues These articles variously claim that In sharp contrast to current thinking, earlier in the 20th Century, military authorities and medical personnel strongly presumed that the apparently prolonged adverse psychological reactions to life threatening situations could be explained away in terms of pre-existing vulnerability, secondary gain, or fraud (Jones & Wessley, 2007). Symptoms required for a diagnosis of PTSD are common among a sample of patients recruited for treatment of major depression and their presence is unrelated to whether a traumatic event has occurred (Bodkin, Pope, Detke, & Hudson, 2007). Most persons who eventually develop PTSD did not display ASD, and the presence of dissociative symptoms does not add to the prediction of PTSD beyond what can be learned from other acute stress reactions (Bryant, 2007). Findings from the National Vietnam Veterans Readjustment Study (NVVRS) that over half of Vietnam war veterans suffered full or partial PTSD cannot be entirely explained away by malingering, exposure to traumatic stressors, or deployment to Vietnam without exposure to trauma (McNally, 2007). The defining symptoms of PTSD are ‘‘highly subjective, easily coached, and readily simulated,’’ and there are no dependable ways of distinguishing feigned from actual symptoms, affecting the credibility of available evidence concerning the rates and natural history of the disorder (Rosen & Taylor, 2007). ‘‘. . . those who promote PTSD have: (1) disregarded time-honored lessons about traumatic stress reactions; (2) permitted political and social attitudes to sway their judgments and alter their practices; (3) dispensed with diagnostic fundamentals and so made claims that are regularly (and embarrassingly) misleading; (4) slighted other explanations and treatments for patients with trauma histories.’’ (McHugh & Treisman, 2007). McHugh and Treisman are clearly here to bury, not to praise the diagnosis. About all the praise that a reader can find in this collection of papers for the diagnosis of posttraumatic stress disorders and the literature they have spawned is Rosen and Taylor’s declaration that ‘‘regardless of whether PTSD represents a distinct disorder, it has served at least one useful function; to promote research and advance our understanding of how individuals react to severely adverse events.’’ There is obviously some self-selection in the attitude of the distinguished group of authors appearing here. Yet, four of these papers (Bryant; Bodkin and colleagues; McNally; Rosen and Taylor)present converging examples of how taking an open-minded, skeptical attitude toward the conceptualization, nosology, and assessment of posttraumatic disorders can yield fresh interpretations of the literature and new research. They thus may demonstrate the heuristic value of these diagnoses. But with the troubling issues they raise, the diagnoses become Wittgensteinian ladders presumably to be kicked away in the next version of the DSM. Bryant’s review adds to the weight of evidence that it was a mistake in DSM-IV to make dissociative symptoms such a defining feature of acute stress disorder. Furthermore, the introduction of the diagnosis of ASD has not moved us much beyond the administrative and place holding diagnosis of adjustment disorder, which it was intended to supplement. Discussions of dissociative symptoms often have involved strong neo-crypto-analytic inferences from the weak evidence of thin, ambiguous reports of symptoms. Bryant argues that the standard use of
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interview and self-report checklist items to assess dissociation may be taking normal phenomena like forgetting or not paying attention in the first place and inappropriately inferring pathological phenomena, like amnesia and other alterations in awareness. Problems are compounded with retrospective assessment. Certainly one cannot distinguish between normal and pathological processes solely on the basis of these reports alone. Nor can one be confident that the same processes are not being counted more than once as different symptoms. Furthermore, Bryant argues that what modest success dissociative symptoms may have in predicting later PTSD may be as reflections of hyperarousal or overall intensity of the initial stress response. This does not bode well for the usefulness of the diagnosis of ASD. Bodkin and colleagues show the benefit of taking a skeptical attitude toward the connection that the DSM diagnosis of PTSD has reified between traumatic event and psychiatric symptoms. They provide a clever demonstration that in a depressed population, at least, these symptoms are common and not tied to whether a life threatening event has been faced. We were left wondering (as they apparently were) whether standard assessment procedures might artificially enforce an association between an event and specific symptoms that is less specific to traumatic situations and less tied to a specific trauma. They note how consideration of these concerns has been barred in the standard assessment procedure because questions are only asked about symptoms in relation to the presumed causal events. McNally’s speculations about reasons why the estimated prevalence of full and partial PTSD among Vietnam veterans provided by the NWRS were so high remain quite useful, even though the mystery may now largely be settled. Thompson, Gottesman, and Zalewski (2006) obtained a much lower estimates for rate of PTSD than originally reported by applying adjustments in timeframes and thresholds for accepting reports of symptoms so that re-estimated prevalence were comparable to other studies. Consistent with one of the suggestions of McNally, Dohrenwend and colleagues required documented exposure to a traumatic stressor during the war and impairment for symptoms to result in a diagnosis of PTSD (Dohrenwend et al., 2006). This requirement led to a 40% reduction in the rates of PTSD. Dohrenwend and colleagues also showed how a sophisticated estimate of exposure could be derived from archival and administrative sources, thereby strengthening confidence in their lower estimate of PTSD and establishing a dose-response relationship. But McNally raises some other, more general issues. First, to what extent does appraisal and attribution of PTSD symptoms depend more on current adjustment and life circumstances than the etiological connection presumed in a diagnosis of PTSD? Second, if persons can be mistaken or imagine exposure (while presenting for PTSD), but still have symptoms adequate for a diagnosis of PTSD, what confidence should we have in the role of a life threatening stressor in PTSD? McNally dismisses malingering or faking as explanations for the high rates of PTSD in NVVRS, but Rosen and Taylor take up the issue and discuss the significance of including persons in PTSD research who are involved in litigation. Rosen and Taylor observe how assessment and diagnosis of PTSD are dependent on highly subjective symptoms, and these symptoms can readily be simulated or coached. The immediate point is that the resulting pseudo-PTSD cannot readily be distinguished from what is presumably the real thing. Yet, like McNally, Rosen and Taylor want to take this ambiguity further, questioning whether what is presumed to be the real thing might be the product of recognition, interpretation, and attribution of symptoms driven by social influences. We also infer that assessment efforts include the demand characteristics, highly leading questions, and the presumption of an etiological connection with exposure to an event. Jones and Wessely and McHugh and Treisman remind us that there was a time not long ago when credible authorities would have been dismissive of the diagnosis of PTSD and the claims
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now being made about it. Provocative though some of the rich historical notes they provide may be, we are concerned that the stridence and evidence of one-sidedness that can be found in these two papers could prove off putting and counterproductive in efforts to stimulate reformulation of clinical thinking about posttraumatic stress disorders. Even someone sharing some of these authors’ skepticism about claims in the PTSD literature might paradoxically find themselves disputing their evidence and developing counterarguments, in order to restore some balance to the discussion. It is not so easy as these authors to adjudicate the source of gross differences between older and contemporary sources about the nature of normal and pathological psychological reactions to traumatic events. For example, Jones and Wessely tell us that military physicians believed there were no war neuroses during the Boer war. Yet, we do not have systematic interview data from this period and we are dealing with fallible opinions that cannot be retrospectively substantiated. What prejudices, etiological assumptions, class biases, or institutional loyalties might have motivated these pronouncements? To use a parallel example, what estimates of the rates of masturbation and homosexual acts among for British soldiers would these Victorian gentlemen have given us? If they reassured us that good British soldiers do not do these sorts of things, would we have accepted their opinion as facts or merely as evidence of their quaint attitudes and beliefs rooted in their particular sociocultural contexts? What social factors, including institutional threats and sanctions, might have discouraged soldiers from reporting their symptoms and dysfunction or attributing their problems to the war experiences? It is noteworthy that 300 British soldiers who were executed for cowardice during WWI were recently pardoned, with the explanation that they were likely suffering from shell shock (‘‘300 Soldiers Receive . . .,’’ August 16, 2006). What do these executions and this re-evaluation suggest about the attitudes and institutional response to ‘‘shell shock’’ at the time? Jones and Wessely provoke some thought with their examples and historical analyses, but we fail to see what implications this historical analysis has for the current debate about PTSD diagnosis. In short, they appear to have demonstrated a profound historical discontinuity in thinking about psychological reactions to trauma, with little to guide our thinking about the sources of this discontinuity or the best way of resolving it. McHugh and Treisman make several valuable points about the need to go beyond checklist assessments of symptoms and, where possible, to retrieve corroborative information about exposure to event and pre-exposure adjustment so as not to depend on self-report alone. In important respects, these are the key elements of Dohrenwend and colleagues’ strategy for reanalyzing the NWRS data. McHugh and Treisman link these suggestions to the now too often neglected, but valuable psychobiological life history framework of Adolf Meyer. But we are concerned that the harsh and even ridiculing tone of the McHugh and Treisman will lose readers before this contribution is discovered. Issues of tone aside, readers are encouraged to learn more about what a Meyerian perspective can bring to a case analysis (Rutter, 1986). 2. Specific concerns 2.1. Defying the power of the negative heuristic At their best, these papers demonstrate the value of taking assumptions basic to the conceptualization, nosology, and assessment of posttraumatic stress disorders seriously enough to mount an interesting challenge to these assumptions. Current notions of posttraumatic stress disorders thus provide a positive heuristic. Yet, what sometimes makes the conclusions of the authors so startling and provocative is they have effectively resisted the powerful negative heuristic of these diagnoses. Namely, the reification of PTSD and ASD and the presumed
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etiological connection between exposure and symptoms has too often artificially provided settlement to issues that should be subject to skepticism and empirical test. This negative heuristic blocks the raising of particular questions and forces particular, if not overly strong interpretations of weak data. Thus, it has been strongly presumed that dissociation is a related set of alterations in awareness with predictable aspects, that much of the richness of dissociation is not directly observable and therefore not readily disconfirmable, and that dissociation has important prognostic implications. These presumptions have too often driven strong interpretations of weak checklist and retrospective data, rather than being fashioned into testable hypotheses themselves. If the current articles accomplish nothing else, they will be a successful effort if they stimulate doubt in the authority of the prevailing negative heuristic of posttraumatic stress disorders. 2.2. The need for skeptical testing of assumptions A recurring theme among the articles assembled here is the usefulness of research strategies that put to a test what are more typically left as guiding presumptions in the interpretation of data. Thus, Bodkin and colleagues would seem to be encouraging us to examine whether we can obtain reports of traumatic symptoms in nontraumatized clinical populations. Bryant at some points seems to be encouraging us to determine with appropriate probes if reports of dissociation actually involve alterations of awareness and if reports of presumably different dissociative phenomena are actually based on the same experiences. Reynolds and Brewin (1999) have developed interesting probes to distinguish among types, unpleasantness, intensity, and functional character of intrusive thoughts. Thus, with breast cancer patients, it is important to probe whether presumed intrusive thoughts are past oriented (e.g., reliving the delivery of the diagnosis), or forward looking, (e.g., contemplating the ambiguity of the medical information and differences among treatment options). This methodology can readily be extended to probing other symptoms. More generally, we need to know more about the validity of checklist assessments of symptoms: not just sensitivity and specificity with respect to the results of semistructured interviews, but the conditions under which they can and cannot discriminate between normal phenomena and symptoms of stress disorder. We also need to study when checklists can discriminate between symptoms of stress reactions, anxiety and depressive disorders, and when checklist assessments are particularly likely to be ambiguous or misleading. Undoubtedly an answer to the question ‘‘how valid and useful are checklist assessments of symptoms?’’ is likely to be highly nuanced and qualified by context. Implicit in the McNally and Rosen and Taylor articles is a suggestion for another kind of study. Each article implies that symptoms resulting in a diagnosis of PTSD can reflect context effects including leading questions, particularly questions that encourage particular attributions for symptoms and discourage consideration of other attributions (e.g., suggestions that normal experiences be interpreted as symptoms; or other demand characteristics of the assessment context). These authors seem to pose a challenge that we determine the extent to which and under what circumstances a vulnerable person and an interviewer can intentionally or inadvertently coconstruct a diagnosis of a posttraumatic stress disorder that otherwise would not come into being. 2.3. The need for studies of ersatz posttraumatic stress disorders A large group of studies fail to establish whether there has actually been exposure to an event and then assess symptoms with measures of uncertain validity, but clearly incomplete coverage of
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the full range of symptoms of PTSD. Such studies are common, using the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979). Results of such studies are sometimes qualified with the label ‘‘PTSD-like symptoms,’’ but these results are still often discussed and cited as if they refer to pathological states of established validity. McNally (2003) has lamented the ‘‘bracket creep’’ of studies and Rosen (2005) the ‘‘criterion creep,’’ with the obvious remedy that we discourage the conduct of such studies and not accept the broadened range of traumatic events and inflated estimates of the prevalence posttraumatic disorder. We would argue, however, that there is a pressing need for research that deliberately documents ‘‘bad’’ examples. A model is Lee-Haley, Price, Williams, and Betz’s (2001) administration of the IES to college students with instructions that they complete it with respect to a particularly bad movie that they had recently viewed. Their resulting scores substantially overlap with what is obtained with more serious stressful events (i.e., what are obtained with newly diagnosed breast cancer patients or women who have undergone genetic screening for risk of breast and ovarian cancer). Such studies can usefully undermine attaching any credibility to the use with serious intent of such measures in other populations. Similarly, we believe that it is important to conduct more studies similar to that of Bodkin and colleagues (2007) in clinical populations for whom PTSD would normally be ruled because of failure to meet criterion A, but nonetheless symptom criteria are fulfilled. As in Bodkin et al.’s study, some adjustments in queries about symptoms need to be made, but the possibility is that we can demonstrate that when patients are not induced to attribute their symptoms to a traumatic event, they do not. Such studies would be in the spirit of putting to a test the suspicion of a number of the authors in the present series of papers that the connection between traumatic events and symptoms of PTSD may be an artifact of how these symptoms are assessed. 2.4. Establishing transparency in posttraumatic stress research Rosen and Taylor make a persuasive case that because reports of PTSD may be made to secure advantage in litigation and compensation for disability and because such reports are so readily faked and coached, investigators have a responsibility to disclose the extent to which their research populations include litigants and compensation seekers. We agree, but believe this responsibility for disclosure of conflict of interest ought to be more broadly extended to all authors. Namely, readers have the right to know whether authors have financial interests related to their roles as expert witnesses or in their soliciting of employment in such roles. Publication in peer review journals can be an important basis for establishing the validity of claims for compensation. Such financial gain for authors can be as distorting and contaminating of the literature as financial ties to the pharmaceutical industry (Coyne, 2005). Thus, the now widely ridiculed claim that hearing of a sexist joke on an elevator ought be regarded as a traumatic event (Avina & O’Donohue, 2003) becomes more understandable when it is known that one of the authors who made that claim serves as an expert witness in sexual harassment suits. Clashing conflicts of interest cannot begin to explain the full range of factious quarrels, entrenched points of view, and hidden agenda in this contentious field, but readers have the right to judge the influence of financial ties for themselves. 3. Conclusion At different points in this series of papers, some readers will be enthralled, while at other points they may be simply annoyed and frustrated. We encourage readers to suspend these
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judgments, and to treat the articles as providing a useful heuristic. In doing so, readers can gain a better appreciation and understanding for the numerous issues and controversies that have befallen posttraumatic stress syndromes. References Avina, C., & O’Donohue, W. (2002). Sexual harassment and PTSD: Is sexual harassment diagnosable trauma? Journal of Traumatic Stress, 75, 69–75. Bodkin, A., Pope, H. G., Detke, M. J., & Hudson, J. I. (2007). Is PTSD caused by traumatic stress? Journal of Anxiety Disorders, 21, 176–182. Bryant, R. A. (2007). Does dissociation further our understanding of PTSD. Journal of Anxiety Disorder, 21, 183–192. Coyne, J. (2005). Lessons in conflict of interest: The construction of the martyrdom of David Healy and the dilemma of bioethics. American Journal of Bioethics, 5, W3–W14. Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., Koenen, K. C., & Marshall, R. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science, 313, 979–982. Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 41, 209–218. Jones, E., & Wessely, S. (2007). A paradigm shift in the conceptualization of psychological trauma in the twentieth Century. Journal of Anxiety Disorders, 21, 164–175. Lees-Haley, P., Price, J. R., Williams, C. W., & Betz, B. P. (2001). Use of the impact of events scale in the assessment of emotional distress and PTSD may produce misleading results. Journal of Forensic Neuropsychology, 2, 45–52. Marshall, R. D., Spitzer, R., & Liebowitz, M. R. (1999). Review and critique of the new DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 156, 1677–1685. McHugh, P. R., & Treisman, G. (2007). PTSD: A problematic diagnostic category. Journal of Anxiety Disorders, 21, 211–222. McNally, R. J. (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology, 54, 229–252. McNally, R. J. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study? Journal of Anxiety Disorders, 21, 192–200. Reynolds, M., & Brewin, C. R. (1999). Intrusive memories in depression and posttraumatic stress disorder. Behaviour Research and Therapy, 37, 201–215. Rosen, G. M. (2005). Traumatic events, criterion creep, and the creation of pretraumatic stress disorder. Scientific Review of Mental Health Practice, 3, 39–42. Rosen, G. M., & Taylor, S. (2007). Pseudo-PTSD. Journal of Anxiety Disorders, 21, 201–210. Rutter, M. (1986). Meyerian psychobiology, personality-development, and the role of life experiences. American Journal of Psychiatry, 143, 1077–1087. Thompson, W. W., Gottesman, I. I., & Zalewski, C. (2006). Reconciling disparate prevalence rates of PTSD in large samples of US male Vietnam veterans and their controls. BMC Psychiatry, 6, 19 Available online at: http:// www.biomedcentral.com/1471-244X/6/19 Accessed October 17, 2006. 300 WWI soldiers receive pardons British Broadcasting Company News. (August 16, 2006). http://news.bbc.co.uk/2M/uk news/4796579.stm Accessed October 17, 2006.