Harvard Mental Health Letter

Rethinking posttraumatic stress disorder

What is a traumatic event, and how does it produce symptoms?

"It could go on for years and years, and has, for centuries," wrote the author of the Sumerian epic of Gilgamesh in the third millennium, B.C., describing the suffering of a character who survived a violent encounter that killed his friend. That terrifying experiences often have lasting psychological consequences was well known for thousands of years before 1980, when the American Psychiatric Association classified posttraumatic stress disorder (PTSD) as a psychiatric disorder in the third edition of its diagnostic manual (DSM-III). PTSD is one of the few psychiatric conditions to which the manual ascribes a definite cause. Although no one doubts that emotional trauma can have devastating effects, a debate about this diagnosis has been ignited, and changes may be in store.

War is a mother lode of traumatic experiences and the chief source of the concept of PTSD. In the American Civil War, the resulting symptoms were sometimes described as battle fatigue. In the First World War, it was called shell shock, and in the Second World War, combat neurosis or traumatic neurosis. Soldiers in those wars who succumbed to posttraumatic stress were sometimes regarded as weak or inadequate, but that view changed as understanding of their experiences improved. Physicians and mental health professionals came to see the symptoms as, in a sense, normal responses to abnormal circumstances. By the middle of the Korean War, DSM-I included a diagnosis of "gross stress reaction," and DSM-II described a "transient situational disturbance."

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