The invention of PTSD
How critics of post-traumatic stress disorder explain its status as the disorder du jour.
Barely a day goes by when we do not read of another victim of tragedy now suffering from post-traumatic stress disorder (PTSD). But according to some, a backlash is already brewing against this psychiatric diagnostic category.
A commentary posted on the BBC News website in January 2001 claimed that a number of voices are criticising the way in which ‘what previous generations would have thought of as simple unhappiness can now be defined as one of a range of new-fangled psychiatric conditions ranging from post-traumatic stress disorder to post-abortion syndrome’ (1).
My research into the debate surrounding the psychological effects of abortion has raised a number of concerns about the way in which the anti-abortion lobby has used the concept of post-abortion syndrome to pathologise women’s feelings after abortion, by presenting them as symptoms of mental illness (2). That critics of the growth of the number of alleged psychiatric disorders are gaining notoriety in the UK is welcome. While it would be exaggerated to say there is a ‘backlash’ against the consensus surrounding PTSD, it seems that concerns about PTSD that have already been explored in the USA are finally making it over the Atlantic.
The BBC news report was provoked by an article by Dr Derek Summerfield, honorary senior lecturer at St George’s Hospital Medical School, which was published in the British Medical Journal on 13 January 2001 (3). Summerfield poses the contentious argument that ‘mental health’ and ‘psychology’ are essentially social products. Our relationship to mental health and psychology is based on collectively held beliefs about what is a normal, if unpleasant, experience that we should take on the chin, and what is an abnormal one, which we might expect to result in some form of mental ill-health.
Our collective belief until fairly recently has, according to Summerfield, invoked ‘notions of stoicism and understatement…and of fortitude’. We have accepted unpleasant experiences as aspects of life that we must endure, and not make central to our lives and self-perception. As a result, mental illness has been an experience confined to a relatively small section of the population.
But as a result of what Summerfield terms ‘cultural and socioeconomic shifts’, what is considered normal and abnormal has been reconfigured. Now ‘victimhood’, based on a pervasive sense of experiencing emotional or psychological damage, has become the norm. This reversal in our expectations and experiences of life’s difficulties has created a situation where more of us perceive ourselves as psychologically ill. For Summerfield, PTSD is ‘the diagnosis for an age of disenchantment’.
The logic of Summerfield’s argument is that ‘real’ mental illness is pretty rare. For a psychiatric diagnosis of a mental illness to be made, it must be, says Summerfield, a disease that ‘has an objective existence in the world, whether discovered or not, and exists independently of the gaze of psychiatrists or anyone else’. Psychiatric disorders of this kind are discovered by psychiatrists. In contrast, disorders such as PTSD, are invented. They do not exist independently of social processes, but rather are a construct of them.
The US social-scientific literature discussed below interrogates the social processes through which PTSD is invented.
- Rewriting the history of PTSD
The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder explores in detail the invention of the diagnostic category PTSD (4). The author, medical anthropologist Allan Young, situates his argument about PTSD in relation to debates about memory and remembering, and in particular, how the experience of remembering painful memories is conceptualised.
Young points out that memory is central to our existence as human beings. Unlike other animals, humans have the ability to connect the past and the present. His concern is the way in which conceptions of this connection change over time. Young contends that this conception has been changeable, and his general interest lies in investigating the social practices through which, at different points in time, memories are retrieved, interpreted and narrated. Our understanding and experience of painful memory is therefore, for Young, historically contingent.
Young’s interest in the historically contingent nature of painful memory leads him to dispute the commonly held belief that PTSD has existed at all points in history (although previously known by other names). PTSD was first officially diagnosed in US soldiers returning home after the Vietnam War. But Young notes that, following the acceptance of PTSD as a diagnostic category, there has been a marked tendency to read history backwards, and interpret as examples of PTSD experiences which pre-date Vietnam by centuries – such as those discussed in Samuel Pepys’ diaries, Shakespeare’s plays and even the Epic of Gilgamesh. The psychological effects of wars, including the First and Second World Wars, labelled shell shock and battle fatigue at the time, have been re-diagnosed retrospectively as PTSD.
Young suggests, in contrast, that PTSD can only be properly conceptualised as a condition specific to a much more recent time. It emerges at the point at which traumatic memory moved from being considered a ‘clinically marginal and heterogeneous phenomenon’ (5) into a standard classification. This was the time when – for reasons Young discusses in detail – US psychiatry moved to identify a ‘grab-bag’ of symptoms, which have no obvious unity, as evidence of a definable, diagnosable condition ultimately labelled PTSD *.
The transformation in the diagnosis of PTSD symptoms created a framework, a ‘distinctive pathology’, in which traumatic memories of the past become central to present experience. Memory is permitted, through this diagnosis, to ‘relive itself in the present, in the form of intrusive images and thoughts and in the patient’s compulsion to replay old events’. Indeed, according to advocates of psychological de-briefing, in order to recover from PTSD, the process of re-living past trauma is essential. This, for Young, makes the experience of PTSD quite different from previous conceptualisations of psychological experience.
- The politics of PTSD
While Young suggests that psychiatric knowledge and approaches to diagnoses of mental illness had undergone sweeping changes beginning in the 1950s, his books detail the specific processes through which PTSD was invented as a category of mental illness. It entered the handbook of US psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM III) in 1980, and resulted specifically from diagnosis of the experiences of soldiers returned from the US war in Vietnam.
The experience of the Vietnam soldiers may have caused the approach of US psychiatry to shift sufficiently to make possible the placing of traumatic memory at the centre of psychiatric diagnosis. But the political and campaigning activities surrounding the Vietnam veterans were crucial in the invention of PTSD. As Young puts it, the rag bag of symptoms now known as PTSD were ‘glued together by the practices, technologies and narratives with which it is diagnosed, studied, treated and represented and by the various interests, institutions and moral arguments that mobilised these effects and resources’ (7).
A collection of anti-war psychiatrists, others involved in the anti-war movement and social workers working with veterans treated and represented the veterans. Angry that military psychiatry was ignoring the needs of the soldiers, offering insufficient treatment and little compensation, they successfully lobbied for a change of approach, on the grounds that the veterans were mentally ill. The American Psychiatric Association came to accept the interpretation given by PTSD advocates of the mental state of some veterans. After a hard-fought campaign, PTSD was born.
In his fascinating comparative historical study of responses to the experience of soldiers in the American Civil War and in Vietnam, Eric T Dean Jr argues: ‘The entire concept of PTSD and its close association with the Vietnam veterans were very much products of the anti-war fervour in the early 1970s, and the determined agitation of a number of anti-war psychiatrists and psychologists.’ (8) For Dean, such psychiatrists functioned as ‘unbridled advocates’, rather than neutral scientists.
Perhaps the most detailed analysis of this aspect of the invention of PTSD has been carried out by the sociologist Wilbur J Scott, in his study of the political activities of those who lobbied on behalf of men who had fought in the Vietnam War. Scott suggests that ‘the struggle for recognition of PTSD by its champions was profoundly political, and displays the full range of negotiation, coalition formation, strategising, solidarity affirmation, and struggle – both inside various professions and “in the streets” – that define the term’ (9). In this analysis, it is the extensive, effective campaigning of the champions of PTSD that led to the official ‘naming’ of the disorder.
Scott also draws attention to the key political point made by advocates of PTSD. Through their argument that traumatic memories of war were being re-lived in the present, and that soldiers should be treated and compensated as a result, a key shift took place in the understanding of the psychological construction of the soldier who fights in war. The focus moved from the individual soldier’s psychological make-up to a concern with the psychological effects of war.
The most significant point about the PTSD diagnosis, suggests Scott, was how ‘this orientation shifted the focus of the disorder’s cause from the particular details of the individual soldier’s background and psyche to the nature of war itself. Its advocates claimed: soldiers disturbed by their combat experiences are not, in an important sense, abnormal: on the contrary, it is normal to be traumatised by the abnormal events of war’ (10).
This approach is a significant contrast with previous approaches, which viewed soldiers who exhibited psychological problems following combat as cowardly or weak individuals. Scott suggests that the impact of this process raises ‘substantive questions about what constitutes the normal experience and response of soldiers to warfare. We see that what psychiatrists once regarded as abnormal behaviour is now thought by many to represent a “normal” response to situations of combat. With the PTSD diagnosis, psychiatrists now say it is “normal” to be traumatised by the horrors of war….PTSD occurs when this trauma is not recognised and is left untreated’ (11).
Through PTSD, the expectation about how a soldier will respond to war changes substantially. The expectation becomes that the soldier will experience war as trauma, and that treatment will be required as a result. The result is a reversal of the situation that existed pre-PTSD. Now those soldiers who are not traumatised by war are viewed as abnormal.
The way in which this reversal has taken place, in constructions of normal and abnormal psychological responses to war, illuminates Dr Derek Summerfield’s point about the cultural and social nature of the PTSD diagnosis.
- Is PTSD real?
Dr Derek Summerfield draws a distinction between ‘real’ mental illness and those conditions, such as PTSD, which are inventions of social and cultural processes. The issue of the ‘reality’ or otherwise of the new disorders and syndromes has also attracted the attention of Scott and Young.
In emphasising the way PTSD has been invented, Scott explains that his aim is ‘not to suggest that this diagnosis – and diagnoses in general – are “merely” a social construction, or simply the result of disinterested psychiatric hegemony’. Rather, he says, ‘in telling the story of PTSD I contribute another case to those that help us understand in detail how objective knowledge – and medical scientific knowledge in particular – is produced, secured, and subsequently used to create other objective realities, such as, in this case, acknowledgements of war’s horrors, populations of treatable clinical cases of PTSD, patients entitled to insurance coverage, and the like. Each new clinical diagnosis of PTSD, each new warrantable medical insurance claim, each new narrative about the disorder reaffirms its reality, its objectivity, its “just thereness”’ (12).
In other words, PTSD is now accepted as a ‘real’ disorder that is objective and ‘there’ for all to see. Scott suggests that the point of his analysis is to show how that ‘reality’ is brought into being in the first place through a social process, central to which is political activity and the creation of alliances and agreement about the ‘rightness’ of the PTSD diagnosis.
Young comments on the interaction between the new category of PTSD, and the experience of individuals or groups of individuals. He suggests his aim is not to deny the reality of the experiences of individuals: those diagnosed with PTSD do indeed experience memory as a painful process. He suggests, however, that his aim is to ‘explain how traumatic memory has been made real, to describe the mechanisms through which these phenomenon penetrate people’s life worlds’, acquire factity, and shape the self-knowledge of patients, clinicians and researchers’ (13).
Whether one concludes that PTSD is ‘real’ or not, perhaps the important point to draw from this scholarship about the syndrome’s invention is that conceptions of our psychological states cannot be divorced from the social and political processes. What is at issue, in this case, is the way normal and abnormal psychological adjustment has been reconstructed around the ‘normality’ of victimhood.
- PTSD as the ‘disorder du jour‘
The story of PTSD does not, by any means, end with Vietnam. As Dean notes, once Vietnam veterans were diagnosed this way, PTSD became the ‘disorder du jour‘. He contends that ‘the possibility was raised that practically the entire population of the United States was suffering from some sort of PTSD or associated guilt syndrome related to the Vietnam War’ (14). For Dean, after Vietnam, ‘The truth of the matter was that expanding categories of disease were including more and more people who would have been considered “normal” in the past’ (15) **.
Young also notes how the acceptance of the category PTSD has impelled the expansion of claims by victims, and those who lobby for victims, that their trauma must be recognised and in some way compensated. ‘The therapeutic act of bringing the secret into full awareness is now inextricably linked to a political act’, he says. ‘Vietnam veterans are the first traumatic victims to demand collective recognition, and they are followed by victims of other suppressed traumas such as childhood incest and domestic rape.’ (17)
Groups other than Vietnam veterans, such as those lobbying on behalf of women subject to domestic violence or those who were abused as children, have followed the model supplied by the pioneers of PTSD. As a result, the definition of groups of people as ‘victims’ of past trauma, who need recognition of what they have suffered, has become a pattern. More and more groups of ‘victims’ have come to base their case on the claim that their trauma must be recognised and in many cases compensated. The construction of women as victims through the recognition of the trauma they have suffered as a result of male violence is an important example. For the US political scientist Donald Downs, it has very significant, and problematic, implications for politics and law.
In More than Victims: Battered Women, the Syndrome Society and the Law, Downs considers in detail the problems that arise where the notion of victimhood, expressed through the claim that the defendant or prosecution witness is suffering from a psychiatric syndrome, is incorporated into the legal system. He notes that this process is widespread, and explains that in criminal law, evidence of victimisation syndromes – all versions of PTSD – have now been put forward as part of legal argument. These include ‘Vietnam War veteran syndrome (VS), rape-trauma syndrome (RTS) (used more by the prosecution than the defence), and hostage syndrome, in situations of violent captivity and kidnapping’ (18).
Downs’ study focuses on the development and implications of one syndrome in particular – battered women syndrome (BWS). The diagnositic criteria for BWS are, in fact, different to those for PTSD. The latter relies on the notion of repressed memories of traumatic events, which emerge after a delay but can express themselves while repressed in problematic forms of behaviour. The former does not construe a battered woman’s response to violence in terms of repression denial, but instead argues for a ‘slow burn’ effect, where it is the accumulated effects of repeated violent encounters that eventually make the woman snap, and commit a violent act herself.
However, the common point of all the above claims about the psychological effects of events, when used in a court of law, is that they generate a legal argument which rests on the inability of the person concerned to act in a reasonable manner. As Downs argues in relation to BWS and the legal treatment of battered women:
‘The syndrome connection portrays the victims of abuse as incapable if exercising reason and responsibility. Can we not achieve justice in this domain without asking these victims to shed the very attributes that make equal citizenship possible?’ (19)
For Downs, the key problem of the incorporation of syndrome defences into the legal system is that they undermine the very principle on which justice is based – the presumption that citizens act reasonably and rationally. Where a violent act (including murder) is committed, a defence can be made in line with the principle of self-defence. It can be argued that, in the light of all available evidence, the act of murder was reasonable, because it was necessary for the person to defend themselves.
Syndrome defences, by contrast, ‘ineluctably undermine the logic of self-defence, which is the logic of reason’. Downs argues that ‘by signifying mental incapacity, syndrome logic ineluctably labels its recipients as unable to bear the obligations of citizenship’.
While Downs does believe that there may be a positive side to the use of such defences in courtrooms (raising awareness of the special fears experienced by those subject to victimisation), his book as a whole is focused on the negative side. As he points out, for individual women, the argument that the victim was not capable of reason when they committed a violent act means their ability to care for their children is clearly called into question. BWS defences thus lead to problems for the women they claim to help.
Downs also points out that their effect, when accepted by the law, is disastrous, since syndrome defences ‘unnecessarily compromise the presumption of individual responsibility upon which legal justice equal citizenship rests’ (20).
- Making us crazy
Two US professors of social work, Stuart A Kirk and Herb Kutchins, also explore the problematic effects of the expansion of mental illness categories, for both individuals and social institutions. In their book, The Selling of DSM: The Rhetoric of Science in Psychiatry, Kirk and Kutchins put forward a detailed critique of the idea that diagnostic categories that appear in DSM are genuine diseases, discovered by truly scientific research (21). They contend instead that such diseases are invented through a social process, involving the media, government and politics, and psychiatry.
In their later work, Making Us Crazy: DSM, The Psychiatric Bible and the Creation of Mental Disorders, Kirk and Kutchins present a series of case studies of the processes through which psychiatric diagnoses rise and fall (22). These include homosexuality, masochistic personality disorder, and PTSD. In doing so they illuminate the way in which everyday behaviour is today often pathologised. We are increasingly being ‘made crazy’ by the expansion of psychiatric diagnostic criteria and terminology into explanations of our everyday behaviour and feelings.
What, for these authors, is most disturbing of all is that the struggle we are being encouraged to join is no longer to avoid being labelled mad or crazy, but to be accepted as such. Kirk and Kutchins argue: ‘Now, mental health professionals must label their clients as pathological in order for them to be reimbursed by their insurance companies. Suddenly a woman seeking help in coping with an unpleasant boss is defined as clinically depressed; or a housewife who voices concern about her shopping sprees is labeled bi-polar (manic depressive).’ (23)
All this has profound implications. Our claim that our experiences should be taken seriously comes to rest on our insanity, rather than our reasonableness. The story of the UK nursery nurse Lisa Potts, who was injured defending children in her care from a machete attack, exemplifies this trend. She may never work as a nursery nurse again, because her case for compensation relies on her experience of suffering from PTSD. To get the compensation she and her lawyers believe she deserves, she must constantly re-live her traumatic memory of the attack.
As the story of Lisa Potts shows, PTSD has become common in legal defences in the UK as well as in the USA. Its emergence in Britain shortly followed it popularisation in the USA during the 1980s. The first cases of PTSD in the UK were diagnosed in fire-fighters at the scene of the Bradford football stadium fire in 1985, in those present at the King’s Cross Underground fire in 1987, and in policemen and fans at the Hillsborough football stadium disaster in 1989.
PTSD has subsequently spread rapidly, and as journalist Kevin Toolis (24) has noted, it is now a key component of compensation cases in Britain. It has become commonplace for members of emergency services (police, ambulance, army, navy) to sue their employers on the grounds that they have suffered psychologically because of their jobs. A test case involving group of 280 ex-servicemen who had served in Bosnia, the Gulf, the Falklands and Northern Ireland, was initiated last year (25). In the largest group action of its kind to date, they decided to sue the UK Ministry of Defence for compensation for PTSD, claiming medical negligence and loss of earnings. It is notable that even soldiers, whose job involves killing and being killed, are so worried about their physical and emotional health. There have been numerous instances where civilians involved in disasters of various kinds make their experience of PTSD central to the case they make for compensation.
The real expansion of PTSD diagnoses, and the institutional support that has been given to it by the law and medicine (with treatment being offered on the NHS) suggests that if there is a UK ‘backlash’, it is feeble in comparison to the ever-widening scope of the disorder. But while the collection of articles and books reviewed here are unlikely to be able to prevent the further expansion of PTSD and the ‘syndrome society’, the insights they provide about the social processes involved in the invention of new categories of mental illness are extremely valuable. At the very least these can help encourage a more critical attitude to the claims made by therapists, counsellors, psychiatrists and psychologists about the contemporary human condition.
Ellie Lee is coordinator of the Pro-Choice Forum, and a research fellow in the Department of Sociology and Social Policy at the University of Southampton. She is the author of Abortion, Motherhood, and Mental Health: Medicalising Reproduction in the United States and Great Britain, Walter de Gruyter, 2004 (buy this book from Amazon (UK) or Amazon (USA)). She is also the editor of Abortion: Whose Right?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); Designer Babies: Where Should We Draw the Line?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)); and Abortion Law and Politics Today, Palgrave Macmillan, 1998 (buy this book from Amazon (UK) or Amazon (USA)).
* In DSM III, the diagnostic criteria for PTSD are:
- a)The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anybody, eg, serious threat to one’s life or physical integrity; serious threat of harm to one’s children, spouse, or other close relatives and friends; sudden destruction of one’s home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence.
- b)The traumatic event is persistently re-experienced in at least one of the following ways:
Recurrent and intrusive distressing recollections of the event (in young children, repetitive play in which themes or aspects of trauma are expressed); recurrent distressing dreams of the event; sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative (flashback) episodes, even those that occur upon awakening when intoxicated); intense psychological distress at exposure to events that symbolise or resemble an aspect of the traumatic event, including anniversaries of the trauma.
- c)Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:
Efforts to avoid thoughts of feelings associated with the trauma; efforts to avoid activities or situations that arouse recollections of the trauma; inability to recall an important aspect of the trauma (psychogenic amnesia); markedly diminished interest in significant activities (in young children, loss of recently acquired skills such as toilet training or language skills); feeling of detachment or estrangement from others; restricted range of affect, eg, unable to have loving feelings; sense of a foreshortened future, eg, does not expect to have a career, marriage, or children, or a long life.
- d)Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:
Difficult in falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; exaggerated startle response; physiologic reactivity upon exposure to events that symbolise or resemble an aspect of the traumatic event (eg, a woman who was raped in an elevator, breaks out in sweat when entering an elevator).
- e)Duration of the disturbance (symptoms B, C, and D) of at least one month.
Specify delayed onset if the onset of symptoms was at least six months after the trauma.
(Diagnostic and Statistical Manual of Mental Disorders III, American Psychiatric Association, Washington DC: APA 1980, pp250-1)
** The process by which expanding numbers of people are diagnosed with PTSD has been encouraged by the changing definition of the diagnostic criteria.
PTSD was first included in the DSM in Diagnostic and Statistical Manual of Mental Disorders III, American Psychiatric Association, Washington DC: APA 1980 (DSM III), but has been revised subsequently. By1994, in DSM IV, criterion A had been amended, to the following:
The person has been exposed to a traumatic event in which both the following were present:
1. 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;
2. The person’s response involved fear, helplessness, or horror. Note: In children this may be expressed instead by disorganised or agitated behavior.
This shift in definition, and in particular the removal of the criterion that the event has to be ‘outside the range of usual experience’ and ‘markedly distressing to almost anyone’, is greatly significant. It reflects an important and ongoing debate about what constitutes a traumatic experience. Criterion A has traditionally served as a ‘gatekeeper’ to the diagnosis of PTSD. As two commentators on the definition of PTSD have put it:
‘If a person does not meet the required definition of a stressful event, it matters little whether all the other criteria are met because the person cannot be diagnosed with PTSD. If criterion A is loosely defined and over inclusive, then the prevalence of PTSD is likely to increase, whereas a restrictive definition will reduce its prevalence’ (‘Diagnostic issues in post-traumatic stress disorder: considerations for DSM-IV’, JRT Davidson and EB Foa, Journal of Abnormal Psychology 100, 1990, pp346-355, Cambridge Mass and London: Harvard University Press).
As these writers indicate, the way in which Criterion A is defined will affect the prevalence of PTSD. A looser definition means that more people can be defined as sufferers of the condition. As the revision of Criterion A in DSM IV indicated, a looser definition has been accepted. It is therefore perhaps unsurprising that the prevalence of PTSD has increased. This aspect of the diagnostic criteria for PTSD is also discussed by Kutchins and Kirk (1997).
(1) ‘A suitable case for treatment’, Chris Horrie, BBC News 15 January 2001
(2) ‘Post-abortion syndrome: reinventing abortion as a social problem’, E Lee, in Joel Best (ed) Spreading Social Problems: Studies in the Cross-National Diffusion of Social Problems in press
(3) ‘The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category’, Derek Summerfield, British Medical Journal: 322; 95-8, 13 January 2001
(4) The Harmony of Illusions, Inventing Post-Traumatic Stress Disorder, Allan Young, Princeton: Princeton University Press 1995
(5) The Harmony of Illusions, Inventing Post-Traumatic Stress Disorder, Allan Young, Princeton: Princeton University Press 1995, p7
(6) The Harmony of Illusions, Inventing Post-Traumatic Stress Disorder, Allan Young, Princeton: Princeton University Press 1995, p5
(7) Shook Over Hell, Post-Traumatic Stress, Vietnam and the Civil War Eric T Dean 1997, p200
(8) ‘PTSD in DSM-III: a case in the politics of diagnosis and disease’ Social Problems 37, W Scott, 1990, p295
(9) ‘PTSD in DSM-III: a case in the politics of diagnosis and disease’ Social Problems 37, W Scott, 1990, p308
(10) ‘PTSD in DSM-III: a case in the politics of diagnosis and disease’ Social Problems 37, W Scott, 1990, p295
(11) ‘PTSD in DSM-III: a case in the politics of diagnosis and disease’ Social Problems 37, W Scott, 1990, p295
(12) The Harmony of Illusions, Inventing Post-Traumatic Stress Disorder, Allan Young, Princeton: Princeton University Press 1995, p5
(13) Shook Over Hell, Post-Traumatic Stress, Vietnam and the Civil War Eric T Dean 1997, p15
(14) Shook Over Hell, Post-Traumatic Stress, Vietnam and the Civil War Eric T Dean 1997, p201
(15) The Harmony of Illusions, Inventing Post-Traumatic Stress Disorder, Allan Young, Princeton: Princeton University Press 1995, p142
(16) More Than Victims, Battered Women, the Syndrome Society, and the Law, Donald Downs, 1996, p4
(17) More Than Victims, Battered Women, the Syndrome Society, and the Law, Donald Downs, 1996, p7
(18) More Than Victims, Battered Women, the Syndrome Society, and the Law, Donald Downs, 1996, p8
(19) The Selling of DSM, The Rhetoric of Science in Psychiatry, Stuart A Kirk and Herb Kutchins, Hawthorne NY: Aldine de Gruyter 1992
(20) Making us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders Stuart A Kirk and Herb Kutchins, Hawthorne NY: Aldine de Gruyter, 1997
(21) Making us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders Stuart A Kirk and Herb Kutchins, Hawthorne NY: Aldine de Gruyter, 1997 sleeve
(22) ‘Shock Tactics’. Toolis, Kevin, The Guardian Weekend 13 November 1999
(23) ‘Veterans sue MoD for war trauma’, Hartley-Brewer, The Guardian 22 April 2000
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