The development of psychoanalytic explanations of PTSD and assoicated disorders with a special focus on the somatic sequelae to torture

University dissertation from Brunel University

Abstract: Abstract PTSD or Post Traumatic Stress Disorder (or, earlier, Syndrome) covers a great variety of symptoms which develop in a variety of contexts – accidents, natural disasters, terrorist attacks, wars and other events where people come face to face with violence and death. PTSD was included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-III, during the early 1980s. The symptoms described in the current manual, DSM-IV, under the diagnostic categories of arousal, avoidance and re-experiencing, include symptoms of anxiety, depression, phobic symptoms, irritation, anger, and repetition of trauma in nightmares and daydreams. This thesis sketches out some of the early debates dating back to the end of the nineteenth century as well as more recent ones which developed after the inclusion of the disorder in DSM-III. These debates have been fuelled by political and economic concerns involving governments and insurance companies as well as aetiological concerns regarding the cause of symptoms. More recent debates have involved questions as to whether or not PTSD is a coherent disorder, what factors might affect the development of symptoms and what evidence there is for unusually clear and persistent memories of trauma. Different theoretical schools have often been pitched against each other when putting forward evidence as to the symptoms and cause of PTSD –and this in turn has been used to question whether there is a coherent disorder warranting an inclusion in DSM-IV. The theoretical and empirical work of this thesis, however, has found that the theoretical stances have more in common when considering the causes and manifestations of PTSD than might be suspected. They largely point towards the same causes, such as the involvement of defence systems against danger which malfunction (neuropsychological and Freudian theories) and the development of unusually clear memories which are either ‘over consolidated’ or stored ‘differently’ (neuropsychological theories, psychoanalytic theories and cognitive theories), causing in turn a lack of integration of the experience of trauma into pre-existing memory structures (cognitive theory, neuropsychological theory and psychoanalytic theory). The inclusion or exclusion of specific symptoms not only affects clinical community work but also has a very real effect on individuals and their fate. One key concern here is somatic symptoms and general anxiety, which were considered to be a part of traumatic neurosis in psychoanalytic theory; but these symptoms were excluded from the DSM diagnosis of PTSD. Torture victims suffer a great number of somatic symptoms; some caused by violence, others with no obvious physiological cause. I put forward evidence in Chapter 1 of this thesis that somatic symptoms are co-morbid with PTSD, specifically when considering subjects who have been exposed to high levels of trauma. In the context of the European Union, PTSD is one of the factors which may be considered in applications for asylum. The lack of understanding of somatic symptoms, in terms of their relation to high level exposure to trauma, may lead to the individual being labelled as a hysteric or a hypochondriac, which in certain cases might lead to a ‘questioning’ of the credibility of their testimony, particularly at a moment when political opinion has turned against the acceptance of asylum seekers. This thesis belongs to the genre of critique of the diagnosis of PTSD in its current form. It takes a predominantly psychoanalytic approach and both uses and develops Freudian and Lacanian theory in considering the major diagnostic categories and defining symptoms of PTSD. However it also takes into account neuropsychological and cognitive theories. It addresses some of the core questions raised in the debates mentioned above. It is argued that PTSD is a coherent disorder that should indeed include not only symptoms of re-experiencing (as it does now) but also symptoms of general anxiety and somatic symptoms. My reading of Freud suggests that symptoms of avoidance also should be included, a point on which Lacanian theory is not conclusive. Further, the thesis demonstrates that the suggested inclusion of general anxiety and somatic symptoms is also supported by neuropsychological theories. Another key point is that Freudian and Lacanian theory suggest that preparedness for trauma might be a factor protecting a subject from developing symptoms of PTSD after trauma and, again, supporting evidence can be found in some neuropsychological theories and also in cognitive theories. All accounts converge on the presence of unusually strong and persistent memories. Freudian and Lacanian theories suggest that traumatic neurosis is caused by a confrontation with violent death, as described in DSM-IV. DSM-IV also suggests that PTSD can develop after observing the suffering of others, where violent death, physical damage or the threat of death and physical damage is involved. Lacanian theory presented in this thesis will offer insight into why being threatened by physical damage or observing others being threatened or wounded can lead to PTSD. The theory developed in this thesis implies that, while PTSD is not dependent on underlying structures of neurosis, psychosis and perversion, it is, however, likely that PTSD will affect underlying structures in facilitating the development of particular symptoms.

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