Annu. Rev. Psychol. 2003. 54:229–52
Copyright c ? 2003 by Annual Reviews. All rights reserved
First published online as a Review in Advance on August 6, 2002
PROGRESS AND CONTROVERSY IN THE STUDY
OF POSTTRAUMATIC STRESS DISORDER
Richard J. McNally
Department of Psychology, Harvard University, 33 Kirkland Street, Cambridge,
Massachusetts 02138; e-mail: email@example.com
PTSD, trauma, memory, childhood sexual abuse, repression, Vietnam
controversy as well as progress. This article concerns the evidence bearing on the most
problems with the dose-response model of PTSD, distortion in the recollection of
stressor, risk factors for PTSD, possible brain-damaging effects of stress hormones,
recovered memories of childhood sexual abuse, and the politics of trauma.
Research on posttraumatic stress disorder (PTSD) has been notable for
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
THE EMERGENCE OF POSTTRAUMATIC
STRESS DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
CONCEPTUAL BRACKET CREEP IN THE
DEFINITION OF TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
PROBLEMS WITH THE DOSE-RESPONSE MODEL
OF POSTTRAUMATIC STRESS DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
DISTORTION IN THE RECOLLECTION OF TRAUMA . . . . . . . . . . . . . . . . . . . . . 233
THE SPECTER OF THE “PHONY COMBAT VET” . . . . . . . . . . . . . . . . . . . . . . . . . 234
GUILT, SHAME, AND TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
RISK FACTORS FOR POSTTRAUMATIC
STRESS DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
DOES TRAUMATIC STRESS DAMAGE THE BRAIN? . . . . . . . . . . . . . . . . . . . . . . 239
RECOVERED MEMORIES OF SEXUAL ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . 241
THE POLITICS OF TRAUMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Research on anxiety disorders has increased dramatically since the early 1980s
(Norton et al. 1995). The scientific literature is now vast, defying ready mastery,
and even the finest, most ambitious works of scholarship are unavoidably synoptic
about these syndromes, but with progress comes controversy, and the field has had
(PTSD). My purpose is to examine the evidence bearing on the most contentious
issues in the field of traumatic stress studies.
THE EMERGENCE OF POSTTRAUMATIC
Military psychiatrists have always recognized that horrific events could trigger
acute stress symptoms in previously well-adjusted individuals (Shephard 2001)
but most doctors believed these reactions subsided soon after the soldier left the
battlefield (Wilson 1994). This conventional wisdom changed in the wake of the
Vietnam War. Antiwar psychiatrists, such as Robert Lifton, argued that many
veterans continued to suffer severe stress symptoms long after having returned
home (Scott 1990). Other veterans, they said, appeared well adjusted upon return
to civilian life, only to develop a delayed stress syndrome months or years later.
Because there was no place in the existing diagnostic system for either a chronic
stress syndrome or a delayed one, these psychiatrists lobbied for inclusion of
“post-Vietnam syndrome” in the forthcoming third edition of the Diagnostic and
believed that certain features of this war—such as difficulty telling friend from
foe, atrocities, and unclear military goals—made it especially likely that it would
produce long-lasting psychiatric illness.
Members of the DSM-III task force were reluctant to endorse a diagnosis tied
specifically to a historical event. Yet they eventually relented when veterans’ ad-
vocates persuaded them that the same stress syndrome occurred in survivors of
other traumatic events, such as rape, natural disaster, or confinement in a con-
centration camp. Converging clinical evidence, pointing to a common syndromic
consequence of trauma, clinched the inclusion of PTSD in DSM-III.
Ironically, historical scholarship has now confirmed that psychiatric casualties
was only 12 cases per 1000 men. In contrast, the rate of psychiatric breakdown
a former member of Vietnam Veterans Against the War, has argued that advocates
for the PTSD diagnosis inappropriately medicalized political dissent when they
conceptualized the problems of veterans as a form of mental illness (Lembcke
1998, pp. 101–26).
In any event, the DSM-III defined PTSD as a syndrome erupting in response
to a “stressor that would evoke significant symptoms of distress in almost every-
one” (APA 1980, p. 238). The diagnosis comprised three symptom clusters. The
re-experiencing cluster included recurrent intrusive thoughts about the trauma,
traumatic nightmares, and “flashbacks.” The numbing cluster included feelings of
detachment from others, loss of interest in activities, and constricted affect. The
third cluster included miscellaneous symptoms such as exaggerated startle, sleep
disturbance, and memory impairment or trouble concentrating.
The ratification of PTSD as a formal psychiatric disorder triggered an outpour-
ing of research on trauma and motivated the founding of the International Society
for Traumatic Stress Studies and the establishment of scholarly journals devoted
to the topic (e.g., Journal of Traumatic Stress, launched in 1988). The field has
been enriched by the efforts of clinical scientists specializing in trauma, and their
findings have placed into sharp relief several contentious issues.
CONCEPTUAL BRACKET CREEP IN THE
DEFINITION OF TRAUMA
PTSD is unusual among DSM syndromes in that the diagnostic criteria specify an
rape, and earthquakes as the kind of event capable of causing the disorder. How-
ever, DSM-IV defines traumatic exposure as “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,” and which
evoked “intense fear, helplessness, or horror” (APA 1994, pp. 427–28, emphasis
the definition of a traumatic stressor. For example, a person who merely learns
about someone else being threatened with harm qualifies as having been exposed
to trauma and is therefore eligible for a PTSD diagnosis (assuming fulfillment of
By broadening the definition of traumatic stressor, DSM-IV codifies a kind of
conceptual bracket creep. No longer must one be the direct (or even vicarious)
recipient of trauma; merely being horrified by what has happened to others now
distinct from being subjected to artillery bombardment for days on end while hud-
dled in a muddy trench. Yet prevailing nosologic practice brackets both kinds of
underlying symptomatic expression.
Noting that a traumatic stressor need not be life-threatening, Avina &
O’Donohue (2002) have recently argued that repeatedly overhearing jokes in the
workplace may qualify as a stressor that triggers PTSD. PTSD induced by re-
peated exposure to sexual jokes and, of course, other more serious forms of sex-
ual harassment in the workplace provides the justification for lawsuits to secure
Overhearing obnoxious sexual jokes in the workplace may provide a legal basis
for litigation, but it seems unlikely to produce the same psychobiological state of
PTSD as violent rape.
Conceptual bracket creep was strikingly evident in the recent national survey
2001 terrorist attacks (Schuster et al. 2001). After interviewing a representative
sample of 560 adults throughout the United States, Schuster et al. concluded that
44% of Americans “had substantial symptoms of stress” (p. 1507), ominously
adding that the psychological effects of terrorism “are unlikely to disappear soon”
(p. 1511) and that “clinicians should anticipate that even people far from the
attacks will have trauma-related symptoms” (p. 1512). This research team asked
respondents whether they had experienced any of five symptoms “since Tuesday”
(i.e., September 11, 2001). Respondents were asked to rate each symptom on a
five-point scale ranging from one (“not at all”) to five (“extremely”). A person
qualified as “substantially stressed” if he or she assigned a rating of at least four
bit” of anger at Osama bin Laden qualified as substantially stressed. As Wakefield
reactions by failing to discriminate between genuine symptoms of disorder and
normal distress reactions.
PROBLEMS WITH THE DOSE-RESPONSE MODEL
OF POSTTRAUMATIC STRESS DISORDER
Pavlovian fear conditioning (e.g., Keane et al. 1985b). Hence, traumatic stressors
of fear. Accordingly, they believe that a laboratory rat’s reaction to inescapable
shock exacerbates a rat’s conditioned fear, so should increasing severity of trauma
exacerbate a victim’s PTSD symptoms.
Some studies are consistent with this prediction. For example, a greater propor-
tion of World War II combat veterans who had been tortured by the Japanese as
prisoners of war (POWs) have current PTSD (70%) than do those who had never
been captured and tortured (18%) (Sutker et al. 1993). Ex-servicemen wounded
in Vietnam are two to three times more likely to have PTSD than are those who
returned unharmed (Kulka et al. 1990, p. 54). Proximity to the epicenter of an
earthquake predicted severity of PTSD symptoms (Pynoos et al. 1993), and the
higher the rate of wounds and fatalities within a combat unit, the higher the rate
of psychiatric casualties (Jones & Wessely 2001).
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