Clinician's Guide to Posttraumatic Stress Disorder. Edited by Gerald M. Rosen & B. Christopher Frueh. Wiley. 2010. £47.50 (hb). 320pp. ISBN: 9780470450956

Contributors to this impressive collection include Robert Spitzer, one of the architects of DSM-III, and Jerome C. Wakefield and Allan V. Horwitz, authors of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Oxford University Press, 2007). In a paper entitled ‘Saving PTSD from itself in DSM-V’, Spitzer & Wakefield wrote that, ‘Since its introduction into DSM-III in 1980, no other DSM diagnosis, with the exception of Dissociative Identity Disorder… has generated so much controversy in the field as to the boundaries of the disorder, diagnostic criteria, central assumptions, clinical utility, and prevalence in various populations’ (p. 233). ¹

It is ironic that research spurred by the introduction of posttraumatic stress disorder (PTSD) has come to challenge almost every aspect of the construct’s originating assumptions. These issues are carefully discussed: the idea of a specific aetiology; the distinctiveness of the supposed core symptoms; the loosening of the stressor criterion, which editor Gerald Rosen calls ‘criterion creep’. He quotes Ben Shephard who, in A War of Nerves: Soldiers and Psychiatrists in the 20th Century (Harvard University Press, 2001), wrote: ‘Any unit of classification that simultaneously encompasses the experience of surviving Auschwitz and that of being told rude jokes at work must, by any reasonable lay standard, be a nonsense, a patent absurdity’. Rosen notes that normal and even expected reactions to a traumatic experience, such as anger or uncertainties about the future, can now be referred to as ‘symptoms’, and that this labelling is encouraged by such terms as ‘sub-syndromal’, ‘sub-threshold’, ‘partial’ and (my favourite) ‘delayed-onset’ PTSD. Without a coherent position on the question of specific aetiology, the validity of PTSD rests largely on the distinctiveness of its clinical syndrome, yet its features overlap substantially with other psychiatric categories.

Other chapters concern early intervention in the aftermath of trauma, cross-cultural perspectives, and the spectacular role PTSD has come to play in the courtroom and to the compensation industry. Of treatment-seeking US veterans, 94% also seek compensation and Rosen argues that financial incentives have promoted exaggerated claims and unduly protracted sick roles, as well as undermining the academic integrity of the PTSD knowledge base. I have seen the same things happen in the UK.

This book interrogates the construction of PTSD and can serve as a case example of the way to critique the construction of psychiatric knowledge across the whole field. Such knowledge comes to assume a taken-for-granted status, as if it can be ignored that non-organic psychiatric categories are not nature carved at its joints. They emerge as committee decisions based on symptom clusters – clustered by humans, not by nature. Meanwhile, the DSM-5 version of PTSD may turn out to be even more friendly to indiscriminate practice than the current version is.