Post-traumatic stress disorder

Editor, – I refer to the excellent article on post-traumatic stress disorder (Aust Prescr 1999;22:32-4). As the authors note, it took millennia for the disorder to be formally recognised. I wonder how long it will be before persistent duress stress disorder (PDSD) is recognised. This disorder carries exactly the same features as outlined in Table 1 of the DSM-IV criteria, except there is no single traumatic event.

Many cases of so-called shell shock or battle fatigue resulted from persistent duress, especially during World War I (compared to World War II) when trench warfare was the main tactic. During Vietnam, tense jungle patrolling without many contacts was the main issue. There is no doubt that many refugees and other victims of the threat of violence, as much as violence itself, suffer PDSD. Often there is no opportunity for sufferers to adapt: the stressors are persistent and unrelenting, and there is no escape.

Unfortunately, our governments have demanded that we ascribe the symptomatology to single traumatic events. As a profession we cravenly comply, thus being iatrogenic contributors to the disorder.

Even though the disorder is simply treated early enough in its genesis just by separating patients from their stressors, if possible, PDSD is not politically acceptable, because governments, large employers and compensation underwriters(the last at great cost to us all) all have a stake in not recognising it. For example, in a report from Griffith University a few years ago, the authors estimated that workplace bullying cost the Queensland Government $2.2 billion annually.

PDSD is thus a major public health issue, carrying considerable, perhaps immeasurable morbidity and cost. It is capable of affecting whole families, groups and even organisations (there is considerable management literature about organizational dysfunction which is the principal aetiology of much PDSD).

Maarten de Vries
MDV Leadership and Management
Ashgrove, Qld

Mark Creamer and Alexander McFarlane, authors of the article, comment:

This letter raises the interesting issue about the extent to which a malevolent environment, combined with a significant threat to personal welfare, can be a major contributor to PTSD. A recent meeting of the Repatriation Medical Authority concluded that this was, indeed, a factor warranting assessment.

The letter also raises the question of how severe the stressor, and the stress response, must be before we allow a diagnosis of PTSD (or, indeed, PDSD). For many reasons, it is important not to 'over-pathologise' normal human distress but, rather, to reserve psychiatric diagnoses for the more severe abnormal reactions. It is important also to ask the question of whether or not the proposed PDSD is actually something distinct and different from other disorders (such as adjustment disorder, depression, or another anxiety disorder). Before introducing a new category of mental illness to our nomenclature, clear empirical evidence is required to demonstrate that it is a distinct entity and not adequately covered by existing disorders.

Finally, the letter raises an important theoretical question as to whether an event such as a tour in Vietnam should be considered as a single event or whether episodes of combat should qualify as separate and cumulative experiences. At this stage, adequate epidemiological work to examine these questions remains to be done.

Editor, – The excellent article by Professors Creamer and McFarlane, 'Post-traumatic stress disorder' (Aust Prescr 1999;22:32-4) did not endeavour to describe this disorder as it affects specific patient groups. It is important however, to highlight the different manifestations of this syndrome depending on the circumstances surrounding the traumatic events that occurred.

Holocaust survivors are of particular relevance in the Australian setting owing to the relatively large numbers who arrived in Australia in the post-war years. On a per capita basis we have the second highest number (next to Israel) in the world. The suppression of their symptoms, the desire by their hosts and themselves to 'leave the past behind', the limited understanding until recent years, about this syndrome, and the more recent prominence in the media and entertainment industries, has brought these issues, and their problems, to light.

The additional dimensions of the ageing of this group, coupled with increasing disability and the prevalence of dementia, have added complexities that not only increase the suffering of patients (and their carers) but also complicate management greatly. The need for doctors to be aware of, and prepared to deal with these complexities is considerable. I hope that the article may contribute to addressing this challenge.

Tuly Rosenfeld
Senior Staff Specialist Geriatrician
Department of Geriatric Medicine
The Prince of Wales Hospital
Sydney, N.S.W.

Editor, – I refer to the article 'Post-traumatic stress disorder' (Aust Prescr1999;22:32-4). I was surprised to find no mention of the existence of this disorder in children who have been exposed to trauma of various kinds, including child abuse. There is an argument that children exposed to trauma are at much greater risk of long-term sequelae than adults, particularly if that exposure occurs during the early years of childhood. There is considerable work on this being undertaken in the U.S.A. where one of the leading researchers in the area, Dr Bruce Perry, has published extensively. His work can be accessed via the Internet site http://www.bcm.tmc.edu/civitas/ .

Graham Vimpani
Director Child Adolescent and Family Health Service
Professor of Community Child and Family Health
Child and Youth Health Network
Wallsend, N.S.W.