When PTSD was established as a diagnosis in 1980, it was not conceptualized as a pathologic response, but rather as a normative response to the abnormal circumstance of extreme trauma. PTSD was considered to represent ''psychopathology'' only in so far as this ''normative response'' resulted in a maladaptive complex of symptoms. The idea behind PTSD was that victims should not need to justify the existence of symptoms or poor social, occupational or interpersonal functioning, because exposure alone explained symptom formation. The framers of the PTSD diagnosis were concerned that, in the absence of this diagnosis, stress-related symptoms had been viewed as transient, and not requiring intensive treatment (reviewed in 6). Thus, the extent to which the diagnosis of chronic PTSD has become an indication of a psychopathologic response to trauma represents a major paradigmatic shift from the original intention of the diagnosis.
The PTSD diagnosis was initially proposed in the absence of prospective, longitudinal data describing the natural course of symptoms. Rather, it was based on the clinical presentation of chronically symptomatic and often disabled patients. Further, no attempt was made to differentiate the symptoms of trauma survivors who appeared less disabled and showed greater overall functioning. It is now clear that trauma survivors who may not meet full diagnostic criteria for PTSD, and who appear to be functioning well (for example, they do not report high levels of subjective distress and largely maintain pre-exposure levels of occupational and interpersonal functioning) may still endorse experiencing distress at reminders of the traumatic event, and active avoidance symptoms such as forgetting aspects of the trauma, and avoiding reminders of the event. Can these symptoms be considered pathological if they are associated with only moderate or manageable subjective distress, and occur in the absence of functional impairment? Do more specific criteria reflecting functional disability, such as absenteeism from work or family obligations, reduced productivity, loss of employment, and increased utilization of health care systems, need to be included in assessing whether long-term responses are pathological? Moreover, are there some symptoms whose persistence is associated with greater functional impairment than others? Without a critical examination of these issues, it is difficult to consider the trajectory from the acute response to psychopathology.
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