Posttraumatic stress disorder (PTSD): a tailor-made diagnosis for an age of disenchantment and disillusionment?

Post-traumatic stress disorder (PTSD) is one of the most controversial diagnosis in psychiatry as well as in medicine in general (Jakovljević 1998, Stein et al. 2011). PTSD has probably been with us for thousands of years, but it was not until 1980 described as the nosological entity (DSM-III, APA 1980). PTSD was initially defined as a characteristic pathological condition which follows a psychologically traumatic event that is generally outside the range of usual human experience (APA 1980). According to that definition the symptoms result from the trauma exposure. DSM-III and DSM-III-R (1987) processes recognised that differently labelled syndromes like post-Vietnam, warsailor, rape trauma, child-abuse, concentration camp syndromes, etc. were all characterised by a very similar pattern of three symptom clusters: the trauma reexperiencing or intrusive memories of it, emotional numbing or the avoidance of stimuli associated with the trauma, and increased autonomic arousal that formed PTSD diagnosis (Friedman 2011). Prior to the Vietnam war, conventional wisdom was that war indisputably created psychological breakdown (Jones & Wessely 2003). Provided the condition was neither medicalised, hospitalized nor financially rewarded, then the breakdown would be curable and short-lived (Shepard 1999, Jones & Wessely 2003). If it was not short-lived, then it was the consequnce of mismanagement, poor inheritance and/or disturbed early upbringing, and war was merely a trigger. So psychological symptoms related to combat experiences were normal responses to abnormal situations and were transient unless treated in ways that increased secondary gain (Wessely 2005). The DSM-III changed this by stating that the cause of chronic as well as acute breakdown after combat was still the war itself, and that everyone had a breaking point if subjected to sufficient stress. According to DSM-IV-TR PTSD is defined by exposure to a traumatic event in which a person experiences, witnesses, or is confronted with the threat of death, serious injury, or a threat to one's own physical integrity resulting in intense fear, helplessness, or horror (APA 2000). After the wars in former Yugoslavia, PTSD from the Cinderela diagnosis became the most popular and beneficial diagnosis in Croatia. Both patients and their physicians are keen to exchange their less attractive diagnostic currencies for one that yields more, even if to paraphrase Scott (2005), it sometimes means less. The PTSD diagnosis has been inflated and this inflation raises a lot of epistemological, ethical, and axiological as well as social and political questions. In general, there is growing concern that there may be distortions in the PTSD data bases due to exaggeration or malingering related to secondary gain incentives among veterans. It seems that the true origins of PTSD inflation lie more in post-war Croatia, and not so in the war itself as it was the case with Vietnam veterans (see Wessely 2003). The post-war economic and political climate with rising unemployment rates and loss of social security has fostered a sense of disappointment, personal injury, embitterment and grievance as well as demands for compensation. Secondary victimization or revictimization of Croatian veterans with PTSD diagnosis was significantly associated with the process of compensationg pensions and other benefits as well as with the paucity of general social support and paradoxical law (Vukušić et al. 2003). It seems that the role of post-war belief, expectation, explanation and attribution is of great importance in addition to the consequences of combat itself. The posttraumatic embitterment syndrome (PTED), as recenty described by Linden (2003), could contribute to better understanding of the PTSD diagnosis inflation in Croatia. PTED is a universal reaction type that is frequently seen in individuals who are exposed to events of personal injustice, humiliation, frustration, and helplessness associated with a prolonged feeling of embiterment (Linden et al. 2007).