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Soc Psychiatry Psychiatr Epidemiol (2004) 39 : 913915 DOI 10.



Richard Rechtman

The rebirth of PTSD: the rise of a new paradigm in psychiatry

Accepted: 3 September 2004

Abstract The new conception of psychological grown in relevance during the past 10 years. New no-
trauma that arose in the 1980s with the definition of tions, such as partial PTSD, vulnerability, resilience, and
PTSD in the DSM-III was a major change compared to vicarious traumatization have recently emerged to ad-
the previous traumatic neurosis. While the clinical fea- vance the theoretical framework of trauma studies.
tures were in some way similar, the political and socio- However, in my opinion, these new ideas about PTSD
logical meanings of trauma were absolutely different. At provide an exciting demonstration of what I believe to
that time, the invention of PTSD was much more the be a second major turning point in this research, in par-
consequence of a broad mutation in mentality that in- ticular a second theoretical conception of PTSD. As I am
troduced a new moral perspective in trauma studies not an epidemiologist, I will not review these data.
than of a scientific discovery. In this paper, the author Rather, as a clinician working with Cambodian refugees
underlines from an anthropological point of view the since 1986, but also as an anthropologist working on the
second turning point that occurred in trauma studies in construction of PTSD for nearly 15 years, I will address
the mid 1990s when large epidemiological surveys did the epistemological framework of these new researches.
not confirm the first hypothesis. Readdressing the issues The second turning point was reached in the second
of vulnerability and risk factors that the previous ver- half of the 1990s, precisely at the time when epidemio-
sion of PTSD had withdrawn, this second conception logical surveys around the world brought new data and
raises new epistemological questions that stay unsolved. new hypotheses on the distribution and physiopathol-
ogy of trauma. I prefer this term to psychopathology in
Key words posttraumatic stress disorder DSM order to avoid any confusion with previous conceptions
traumatic neurosis stigma life events of psychological traumatization. The well-known 1996
Detroit Area Survey of Trauma directed by Naomi Bres-
lau made it possible to readdress issues on vulnerability
The road from the discovery of traumatic neurosis at the or risk factors without falling into earlier conceptions of
end of the nineteenth century to the establishment of the fault (Breslau et al. 1991).
category of posttraumatic stress disorder (PTSD) in the Since the end of the 1970s, when American psychia-
1980s represents more than a mere scientific evolution trists were en route to the clearer formulation of mental
in modern psychiatry. Much has been said about the disorder incorporated in DSM-III, PTSD research has
provenance of the concept of PTSD and, in comparison grown very quickly. For example, in 1981, one year after
to the radical change introduced in DSM-III, it might the publication of DSM-III, there were only 2025 refer-
seem that the new research on PTSD has followed much ences in Medline to PTSD or traumatic neurosis,
the same path. With more empirical data, more clinical whereas, in 2001, there were more than 2000. This is due
descriptions, and the refinement of social and cultural both to the proliferation of epidemiological surveys of
correlates, the field of PTSD researches has probably PTSD and the considerable social visibility of this new
disorder. Here, I would like to emphasize the very spe-
cific role played by the political and social context of the
R. Rechtman 1970s and 1980s in the US in the lay acceptance of this
Cesames (Inserm, CNRS, Universit Paris 5)
Paris, France new category. This is an uncommon situation in psychi-
atry. With the exception of multiple personality disor-
R. Rechtman ()
ders (Hacking 1998; Mulhern 1991), or of dissociative
SPPE 874

Institut Marcel Rivire

78321 Le Mesnil Saint Denis Cedex, France identity disorders (Mulhern 1998) in quite a different
E-Mail: context, there is probably no other psychiatric diagnosis

that has so closely met lay peoples and professionals ex- tioned. During World War I, especially in the German
pectations. Thus, even depression and anxiety have and Austrian armies, soldiers with traumatic neurosis
failed to avoid the stigma eternally attached to mental were systematically suspected of simulation or of weak-
illness. This is not the case with PTSD. As Nancy An- ness and lack of moral fibre (Brunner 200). In either
dreason ironically underlined in the American Journal case, they could expect little empathy from physicians.
of Psychiatry (Andreasen 1995), PTSD is the only diag- Moreover, clinicians had to distinguish simulation from
nosis that patients want to have. A PTSD diagnosis is pathology, or to find the internal psychological reasons
probably the best way to avoid the stigma that is still at- for this lack of warrior quality. The pathology was not
tached to mental disorder. For the first time, a psychi- considered to be the consequence of an event outside the
atric label is not a moral condition. Nothing before or range of human experience, because war experiences
during the event can lead to moral suspicion, and there were supposed to be part of human experience in gen-
is no way of blaming the victim. One could say that this eral. Even within psychoanalysis, traumatic neurosis
is the logical consequence of the external aetiology of was viewed with what I call a clinical practice of suspi-
this specific disorder. As this pathology is exclusively cion.
created by an external event outside the range of normal After World War II, this conceptualization became
human experience, there can be no reason for blaming less prominent in military psychiatry, and also in gen-
the victim. eral psychiatry, because of an appreciation of the severe
However, this was absolutely not the case with the psychological damage caused by incarceration in con-
earlier concept of traumatic neurosis. Something centration camps (Horowitz 1974). However, survivor
changed profoundly in the 1970s and 1980s that has guilt was, in some ways, the survival of this suspicion,
nothing to do with a change in the semiology (PTSD and but this time held by the victims themselves (Rechtman
traumatic neurosis share the same criteria), nor with a 2004, in press). Once again, I do not mean that survivor
change in aetiology (traumatic neurosis was the conse- guilt does not exist, I just want to underline that this fea-
quence of a specific event), nor even with new empirical ture was very consistent with the practice of suspicion
findings. While epidemiology is probably one of the paradigm. Furthermore, in the same period, a corre-
most important supports for this new conception of sponding suspicion was still very apparent with regard
trauma, there are no specific data that can explain why to child or female victims of abuse. Abused women or
PTSD lies, from an epistemological point of view, so far children always had to explore their own fantasy of
from traumatic neurosis. The 1980s introduced an epis- abuse in advance of the possibility of being recognized
temological breakthrough in the conception of trauma. as innocent victims. While this was not a major concern
Following the anthropologist Allan Youngs analysis of for clinicians, the idea of this suspicion was deeply
PTSD, I would say that PTSD is a modern invention rooted in society and strongly supported by the profes-
(Young 1995), but not that PTSD has no separate exis- sion of psychiatry.
tence (also according to Allan Young). By using the term In 1980, DSM-III introduced PTSD and its direct re-
invention, I want to emphasize the profound change it lationship with the traumatic event as a consequence
has introduced to our conception of trauma, and specif- less of a clinical discovery than of a kind of revolution in
ically in the classical relationship between pathology the American mentality. In fact, the battle for womens
and moral fault. rights in the 1960s, and the return of thousands of Viet-
I disagree with Derek Summerfields criticism of nam veterans, created a very specific socio-political con-
PTSD (Summerfield 1999, 2001) for at least two reasons. text where the evidence of trauma became a way to ac-
First, he confuses social constructions and empirical cess a new political condition. The clinical practice of
facts. The fact that a fact is socially or scientifically con- suspicion fell short of this movements expectations and
structed does not support the contention that it has no wants. The decisive influence of Vietnam veterans on the
real existence. From a clinical point of view, there is a work of the taskforce on PTSD has been clearly estab-
major difference between a clinical category and the way lished by Allan Young (2002). However, I think the new
this category might be used (and sometimes misused) in definition of the traumatic event as being outside the
practice, or in a specific political context. The whole his- normal range of human experience and of PTSD as be-
tory of psychiatry is full of examples of categories mis- ing a response possible in almost anyone was not par-
appropriated for other purposes. Secondly, his concep- ticularly shaped to fit the needs of Vietnam veterans,
tion belongs to the very one he attacked, and, especially perpetrators of atrocities. Rather, those essen-
furthermore, establishes a fallacious continuity between tial defining features of the traumatic event are direct
traumatic neurosis and PTSD (Rechtman 2002). consequences of the desire to get rid of the moral suspi-
Despite the long history of theoretical formulations cion attached to the theoretical framework of traumatic
of psychological trauma, I will only emphasize the two neurosis.
major features of the previous paradigm. From the dis- With the same semiology, with the same characteris-
covery of traumatic neurosis at the end of the nineteenth tic features, with the same context of onset, and with
century to the 1960s, the psychological reaction was not quite the same prognosis, PTSD is nevertheless defini-
explained solely as the consequence of the event. The tively not a reconfiguration of traumatic neurosis, it is
personality of the victims themselves was always ques- something else.

There was then the second major turning point in the ical consequences of this later conception of PTSD, they
middle of the 1990s, following the development of inter- are not relevant in the original. They introduce ideas al-
national surveys. The DSM-III definition of PTSD was ready present in traumatic neurosis, but with a very dif-
elaborated without many epidemiological data, but this ferent moral meaning.
later reconceptualization was clearly based on data. This Epidemiological findings in PTSD research have not
is important. In 1980, the challenge was to find a defini- only changed our view on trauma, they have also intro-
tion that would protect victims from suspicion, respon- duced an epistemological breakthrough on the issue of
sibility or accusation. The only way to achieve this was normality.
in fact ideological, by claiming that the event was the This later version of the concept of PTSD is ambigu-
only aetiology, but to assert this, the event had to create ous. It remains a normal reaction, but with many varia-
the same pathology in almost anyone. Two major prob- tions. The traumatic event remains the essential aetiol-
lems arose. ogical feature, but again with many variations. However,
First, the kind of event that could be collectively con- the definition of an event outside the range of human ex-
sidered as outside the range of human experience perience remains strongly connected to highly socially
promptly matched the catalogue of forbidden behav- forbidden or disapproved situations. I think this is gen-
iours. For the first time, what was supposed to be outside uinely a novel situation in modern psychiatry. It belongs
the range of human (I should say psychological) experi- to a new psychiatric epistemology linked alike to social
ence was the same as what was considered as outside the considerations, epidemiological findings and ethical
range of social values. This is a major problem for psy- principles. I hope further theoretical formulation will
chiatry, not only because it gives a naturalistic explana- help to explore this epistemology not so clearly based on
tion for socially forbidden behaviours, but also because data.
it opens the door for radical cultural relativism pretend-
ing that what is accepted in a specific cultural context
cannot be traumatic. References
The second problem arose with the data. The surveys
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