The Beast on My Back

Letters

Vol. 18 No. 14 · 18 July 1996

From Sheldon Litt

I fail to see the point of Gerald Weissman’s article about Post-Traumatic Stress Disorder (LRB, 6 June). Is he trying to say that it is a great advance to exchange one label for another (’the field changed radically when the nomenclature was revised’)? What used to be called Traumatic War Neurosis, or something similar, is now labeled PTSD – what’s the big deal?

As clinicians know, the DSM (Diagnostic and Statistical Manual of Mental Disorders) is a loose hodge-podge of fuzzy theories, speculations etc, paying lip service to the needs of the times. It is hardly a profound scientific document. Yet his review exclaims: ‘the publication of DSM-IV is a signifying moment.’ This must be the overstatement of the year; DSM is at best a useful rough tool for insurance forms and hospital administrators who must fit patients into neat rubrics. Weissman’s high praise for the so-called experts, ‘pioneers of psychiatric nosology’, is high nonsense. When I was a student, the DSM listed homosexuality as a disorder. These rather desultory listings are decided not on the basis of scientific research, but as a result of personal interest, the Zeitgeist, backroom lobbying, trends etc. How about Multiple Personality? Is that in this year? Or just re-labelled Dissociation?

Sheldon Litt
Stockholm

Vol. 18 No. 16 · 22 August 1996

From Allan Young

‘What used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ This is what Sheldon Litt wants to know (Letters, 18 July) after reading Gerald Weissmann’s review of my book, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. The answer depends on the meaning that Litt wishes to give to his first ‘what’. If, as it seems, he is writing about a phenomenon that supposedly transcends the nomenclatures and practices of psychiatry, then one would have to agree that that there is nothing really new about PTSD. But as Weissmann makes clear, it is precisely this idea, that traumatic memory is a timeless essence, that the book rejects. The phenomenon that psychiatry knows as ‘traumatic memory’ is a relatively recent development, and during the century and a half of its existence the character of its symptoms and the identity of its victims have been periodically reconceived. PTSD is the most recent chapter in the history of traumatic memory. Litt is correct when he writes that PTSD shares features with the traumatic neuroses of the First World War, but he is mistaken if he supposes that there are no important differences between these disorders, and that they merely rename a constant underlying reality. The character of the traumatic hysterias and neurasthenias was shaped by the moral sensibilities, political institutions and clinical practices of the 1914-18 period; the character of PTSD has been likewise stamped by American participation in the Vietnam War, by the domestic liberation politics of the Sixties and Seventies, and by the profound technological and social changes taking place in American psychiatry during the same period.

Litt also attacks Weissmann for comments he is alleged to have made concerning the disease taxonomy that has dominated American psychiatry since the Eighties, the so-called DSM system. His argument that the DSM system is not scientific is justified only if one thinks of ‘science’ as a technology for uncovering pre-existing truths rather than as one or more distinctive systems for producing and vindicating knowledge. If science is what scientists do, then the DSM system can be said to have revolutionised the practice of psychiatric science it the United States.

Allan Young
McGill University, Montreal

From Roger House

Sheldon Litt’s letter commenting on the DSM reminded me of this bit of wisdom from DSM-III-R: ‘Beliefs or experiences of members of religious or other cultural groups may be difficult to distinguish from delusions or hallucinations. When such experiences are shared and accepted by a cultural group, they should not be considered evidence of psychosis.’ In short, if we’re all crazy, then we’re not crazy.

Roger House
Sebastopol, California

Vol. 18 No. 18 · 19 September 1996

From Gerald Weissmann

Sheldon Litt (Letters, 18 July) has written a shrill response to my review of Allan Young’s book The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. This book, like my review of it, tries to explain not only the fact that doctors invent new names for old syndromes but why they do so. Young’s book describes in some detail and with a good deal of care why, as Litt puts it in his trottoir style, ‘what used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ Litt attributes to my review, rather than to its source, Young’s book, unqualified praise for the well-meaning attempts of psychiatrists periodically to revise the terms they use to describe mental disease. Quite often they have gone astray, but so have those of us in clinical investigation who have recently changed our minds about peptic ulcers, rheumatoid arthritis or how aspirin works. Only magical practices like homeopathy, chiropractic or ayurvedic medicine hold steadfast to their nomenclature over the centuries. Litt’s perhaps deliberate misreading of my review, and his failure to consult its source, remind me of the principle announced by Oliver Wendell Holmes in The Autocrat at the Breakfast Table (1858), which he called the hydrostatic paradox of controversy: ‘If you had a bent tube, one arm of which was the size of a pipe-stem and the other big enough to hold the ocean, water would stand the same height in one as in the other. Thus discussion equalises fools and wise men in the same way, and the fools know it.’

Gerald Weissmann
Marine Biological Laboratory