Post-traumatic stress disorder: Psychiatric management, atonement and justice.

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