Olff et al (2005) sampled farmers during a foot and mouth epidemic, concluding that half whose livestock were culled had ‘post-traumatic stress at levels requiring professional help’, and ‘the high prevalence of post-traumatic stress symptoms is an underestimation of the real levels of psychopathology’ (p. 166). What was the ‘traumatic event’ implicated in these ‘post-traumatic’ reactions? According to DSM-IV-TR criteria for post-traumatic stress disorder (PTSD) (American Psychiatric Association, 2001), a traumatic event requires that ‘the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ (further requiring that ‘ others’ must be persons, not animals) and that ‘ the person's response involved intense fear, helplessness, or horror’ (p. 467). We seriously question livestock loss as a traumatic event.
Loosening criteria for a traumatic event represents a progressive ‘ conceptual bracket creep’ in defining trauma (McNally, 2003). Will the next study examine PTSD in children ‘traumatised’ by their pet hamster's death, or from watching Bambi die in the famous Disney movie? What about being exposed to offensive remarks by others (Avina & O'Donohue, 2002)? With the current trajectory all negative experiences will be synonymous with traumatic events, trivialising the experiences of real trauma victims. We ask where will researchers finally draw the line in what is considered traumatic? Continued disregard for the criteria will lead to anyone being considered trauma-exposed and eligible for a PTSD diagnosis. With healthcare resource limitations, truly trauma-exposed and symptomatic patients could consequently be denied care (at a minimum subjected to extensive waiting lists), and our courts would be crippled with unnecessary PTSD litigation.
Olff et al (2005) claim that ‘Although the foot and mouth crisis is not a traumatic event in the usual sense, the consequences do resemble features of PTSD’ (p. 166). This statement minimises (without justifying) the authors' disregard for trauma criteria, and poses a circular argument in contending that the presence of PTSD symptoms confirms trauma exposure. However, trauma exposure must be distinguished from PTSD, since minor stressors (e.g. taking a nightshift job) can result in symptoms (e.g. difficulties in sleeping, problems concentrating) that are aetiologically distinct from PTSD.
- © 2005 Royal College of Psychiatrists
Post-traumatic stress disorder is unusual among DSM disorders in that the diagnostic criteria specify an aetiological event: exposure to a traumatic stressor. In their letter Elhai et al cite examples that do not meet the stressor criterion, the symptom criteria for PTSD, or the criteria of distress or impairment. The DSM-IV symptoms (re-experiencing, avoidance/numbing and hyperarousal) are defined in terms of their connection with a traumatic event. The ‘conceptual bracket creep’ (McNally, 2003) refers to the broadening of the stressor criterion in DSM-IV, especially to the inclusion of ‘ second-hand exposure’, such as learning about the unexpected death of a close friend/relative or watching atrocities on television (see Rosenbaum, 2004). This seems to increase the eligible events by about 20% (Breslau & Kessler, 2001). However, more important is the question addressed in the DSM-IV guidebook ‘ whether or not to include reactions to the numerous stressors that are upsetting, but not life threatening (Frances et al, 1995: p. 259) or even to eliminate the stressor criterion altogether. The fear that more inclusive definitions will vastly increase the frequency of the diagnosis seems to be unrealistic. More minor stressors simply will not result in the other diagnostic criteria for PTSD.
McNally (2003) makes an important point in stating that with the inclusion of such diverse events it will be difficult to identify common psychobiological mechanisms underlying symptomatic expression. In our opinion, to develop PTSD the stressor - often associated with severe sadness - should be intense enough to evoke a psychobiological dysregulation of the fear system, which results in the event being re-experienced, avoided and leading to a state of hyperarousal where the person feels that danger could strike again at any moment. This psychobiological stress response is dependent on subjective appraisal of the event and not on objective criteria of stressor severity (Olff et al, 2005). This would suggest that ‘second-hand exposure’, non-typical traumatic stressors or even life events might in some instances evoke an intense psychobiological dysregulation leading to ‘PTSD’ symptoms. Apparently, this was the case for the farmers who witnessed (saw, heard, smelled) all their animals being destroyed, an event that was beyond their control and is certainly ‘outside the range of their normal experience’.
Mental healthcare should be available to those with significant mental health problems, even if these are considered sub-threshold for PTSD. By conducting a large epidemiological survey in The Netherlands we hope to determine what kind of stressors (including life events) evoke what kind of ‘ post-traumatic’ symptoms, as well as the implications for mental healthcare.