From the Editor: March/April 2010

Trauma, which literally means “wound,” is a charged word, referring to a severe, even life-threatening physical injury—bones smashed, flesh torn, and body parts twisted—associated with brutality, violence, and sudden calamity. It’s oddly fitting that the idea of emotional trauma—post-traumatic stress disorder (PTSD)—entered psychiatry not as the result of dispassionate scientific research into its diagnostic merits, but as the outcome of an intense, polarized, highly politicized struggle led by angry Vietnam vets and antiwar activists.

PTSD never did fit DSM very well. Virtually all the other diagnoses were assumed to be inside jobs so to speak—issues of personality dynamics, genetics, or character. PTSD, by contrast, didn’t just require an external cause, it required a terrible external cause—an event threatening grave injury or death. In a sense, PTSD broke the rules, destroyed DSM‘s internal logic by dragging in not only the outside world, but, in many cases, the brute reality of human evil. It was a little like dumping a corpse at a tea party—the guests continue sipping, pinkies crooked, trying not to look at the bloody heap in the middle of the room.

PTSD forced acknowledgment that people’s hearts and minds were often damaged by what other people did to them and, sometimes, what they did to other people. Add to this the inherent ambiguity of a disorder that includes within its name the signal word trauma—both a cause and an effect—not susceptible to easy definition. A “trauma” can presumably be anything, from being gang raped and left for dead to watching Curse of the Zombie on late-night TV. Truly horrible events can profoundly “traumatize” some people for life, while leaving others, after a period of recovery, relatively unscathed.

Since PTSD first made its appearance, there’s never been a time when it wasn’t a source of controversy—about the genuineness of veterans’ claims for disability benefits based on war-related PTSD, the reality of women’s “repressed memories” of childhood abuse, and the under- or overdiagnosis of PTSD in the general population (does being fired “cause” PTSD?). And the beat goes on.

In this issue’s cover story, Senior Editor Mary Sykes Wylie chronicles the latest battle in the ongoing trauma wars: the campaign to get a new diagnosis, Developmental Trauma Disorder (DTD), recognized and included in the forthcoming DSM-V.

An attempt to define and categorize the impact of long-term chronic abuse and neglect on the developing child’s mind and body, DTD is unlike most other psychiatric diagnosis in that it has inescapably social and moral dimensions. Thirty-five years ago, while DSM-III was still in the works, child abuse was all but invisible and the incidence of incest was believed to be less than one in a million. Now the recognition of the Developmental Trauma Disorder diagnosis would be, in essence, a formal acknowledgment that as many as a million children a year may suffer deep and pervasive psychological and neurobiological damage caused by the very people charged with loving and protecting them.

Offering yet another controversial perspective on the subject of trauma is researcher Susan Clancy in her article, “The Trauma Myth.” While recognizing that sexual abuse is always harmful and never the child’s fault, Clancy nevertheless questions the assumption that the trauma model is the best way of understanding the experience of childhood sexual violations and proposes that it may, in many cases, even get in the way of offering clients the most effective treatment.

Finally, Mary Jo Barrett’s remarkably personal account of an incest case that changed the course of her career puts forth with remarkable candor and clinical detail the intense emotional challenge of treating families in which children have been abused, exploring how morally complex and far removed from a simplistic “good/bad” dichotomy such families can be.

So readers whose preferred clinical stance is one of safe therapeutic neutrality be forewarned—this provocative issue doesn’t make for comfortable reading.