Young—The Harmony of Illusions

The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder

by Allan Young

[Young, Allan. 1997. The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton University Press.]

Points

  • Young argues that the concept of traumatic memory, which is seen by some as having roots hundreds of years ago, is actually quite a recent invention
  • He argues that: “this generally accepted picture of PTSD, and the traumatic memory that underlies it, is mistaken. The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is 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 mobilized these efforts and resources” (5).

He does not deny that the suffering accompanying a PTSD diagnosis is not real:

  • “My job as an ethnographer of PTSD is not to deny its reality but to explain how it and its traumatic memory have been made real, to describe the mechanisms through which these phenomena penetrate people’s life worlds, acquire facticity, and shape the self-knowledge of patients, clinicians, and researchers” (5-6).

The book is broken into threes sections:

  1. an historical overview of trauma theories up to the beginning of WWI
    • Erichsen—”railway spine” in the 1860s—to deal with railway insurance
      • fear is the body’s memory of pain—memories come form physical stimulus, not images or words
      • So the traumatic event itself causes the continued anxiety
    • Janet & Freud
      • Repression and dissociation—horrible buried memory
      • The memory of the trauma (rather than the event) is the cause of the anxiety
    • Rivers, WWI & “shell shock”
      • Although seen by many scholars as the precursor to PTSD, Rivers is “observing that, in most cases, it is not the traumatic memory that produces the physical and emotional symptoms of the war neuroses (anxiety disorder) but rather the reverse: the symptoms account for the memory” (83).
  2. The DSM III revolution
    • 1940s pre and post WWII war neuroses
      • Kardiner—The Traumatic Neuroses of War, based on post WWI studies from the 1920s
      • Grinker & Spiegel—War Neuroses, based on field studies during WWII
      • no matching diagnostic categories between the two, so the War Department makes one…
    • The DSMs
      • DSM I—1952, nomenclature not universal, listed on spectrum from “Mental Illness, to Mental Health”
      • DSM II—1968, better, but still involved “neuroses”
      • DSM III—1980, built from scratch on completely positivist basis, that is, it was all descriptive, some critiqued this “cook book approach … making mental disorder equivalent to their aggregate of their symptomatic parts” (100).
    • PTSD
      • in DSM III, a person “gas experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone (124).
      • system worked like this:
        1. first order feature (PTSD) is defined by
        2. second order feature (an event outside the range of usual human experience),
        3. but then what is the third order (usual human experience)? Unlike the anecdotal research of Rivers, Freud, or Kardiner, the DSM relies on analogical comparison, which has no bounds.
    • so throughout all this time:
      • “What counts as a reasonable question, a satisfactory answer, a significant difference, an anomalous finding, or even an outcome—the criteria for each of these changed during this period. What did not change was the belief in the solidity of scientific facts and the conviction that psychiatry’s facts, being scientific, are essentially timeless” (9).
  3. PTSD in Practice
    • This section is based off of fieldwork in a U.S. Veterans Administration unit for the diagnosis and treatment of Viet Nam veterans suffering from PTSD in 1986-87
    • There is a long section that includes case studies of four different Vietnam War veterans being considered for PTSD diagnosis.
      • The four men all present psychometric and standardized diagnostic results consistent with a PTSD diagnosis
      • The case studies consist of transcripts of narratives from the men, which are significantly different
      • Following the narratives, transcripts of meetings between professionals at the center show how they rationalize these differences back into the requisite parameters using the open ended language of the DSM designation
    • the centers espouse an ideology of PTSD that allows the patients to talk about their own experiences using specific terminology that feeds back into the center, and back into the diagnosis.
      • The seventh chapter has a lot of group therapy transcripts where you can see this happening.

In the end, the book basically shows how the social creation and maintenance of PTSD (like Scott with blindness) can work in the process of creating a “kind” of people (like Hacking with MPD).

Annotation Summary for: Young – The Harmony of Illusions_ Inventing Post-Traumatic Stress Disorder (1997)

Page 3, Highlight (Cyan): Content: “THE HARMONYOF ILLUSIONSI NVENTING POST-TRAUMATIC STRESS DISORDER Allan Young ”

Page 13, Highlight (Cyan): Content: “Introduction”

Page 13, Highlight (Cyan): Content: “AS FAR BACK as we know, people have been tormented by memories that filled them with feelings of sadness and remorse, the sense of irreparable loss, and sensations of fright and horror. During the nineteenth century, a newkind of painful memory emerged. It was unlike the memories of earlier times in that it originated in a previously unidentified psychological state, called “traumatic,” and was linked to previously unknown kinds of forget- ting, called “repression” and “dissociation.””

Page 13, Highlight (Cyan): Content: “The new memory is best known today in connection with a psychiatric malady, post-traumatic stress disorder (PTSD).”

Page 13, Highlight (Cyan): Content: “a contributor to the British Journal of Psychiatry reported that he had discovered evidence of the syndrome in the Diary of Samuel Pepys,inthe pages where Pepys describes his mental condition following the Great Fire of London in 1666 The shadow of traumatic memory was spied beneath the surface of this passage from Shakespeare’s King Henry IV, Part One More recently, evidence of PTSD has been discovered in the Epic of Gil- gamesh,”

Page 13, Highlight (Cyan): Content: “In the following chapters, I argue that none of these writers—neither Pepys, nor Shakespeare, nor the author of Gilgamesh—was referring to the”

Page 14, Highlight (Cyan): Content: “thing that we nowcall the traumatic memory, for this memory was unavail- able to them.”

Page 14, Highlight (Cyan): Content: “In everyday usage, the term “memory” has three meanings: the mental capacity to retrieve stored information and to perform learned mental operations, such as long division; the semantic, imagistic, or sen- sory content of recollections; and the location where these recollections are stored.”

Page 14, Highlight (Cyan): Content: “By connecting self-awareness with the past, memory provides the body with a subject and subjectivity.”

Page 14, Highlight (Cyan): Content: “It is the source of the “I” that initiates the body’s purposeful acts and the “me” who experiences its pleasures and vicissi- tudes and must accept responsibility for its actions.”

Page 14, Highlight (Cyan): Content: “Without memory, the I/me would fail to transcend momentary states of awareness and self-con- sciousness. It would be a string of experientially unconnected points, a “dehumanizing” condition that is associated with certain neurological pa- thologies”

Page 14, Highlight (Cyan): Content: ” Our sense of being a person is shapednot simply by our active memories, however; it is also a product of ourconceptions of “memory.” What occupies me in this book is howcertain ofthese conceptions have changed over time, together with the practicesthrough which memories are retrieved, interpreted, and narrated”

Page 14, Highlight (Cyan): Content: “The discovery of traumatic memory revised the scope of two core at-tributes of the Western self, free will and self-knowledge and justified the emergence of a new class of authorities, the medical experts who would now claim”

Page 15, Highlight (Cyan): Content: “access to memory contents that owners (patients) were hiding from them- selves.”

Page 15, Highlight (Cyan): Content: “I will argue that this generally accepted picture of PTSD, and the trau-matic memory that underlies it, is mistaken. The disorder is not timeless,nor does it possess an intrinsic unity. Rather, it is glued together by thepractices, technologies, and narratives with which it is diagnosed, studied,treated, and represented and by the various interests, institutions, and moralarguments that mobilized these efforts and resources.”

Page 15, Stamp (Star (Frame, Red))

Page 15, Highlight (Cyan): Content: “does this mean that it is not real? ”

Page 15, Highlight (Cyan): Content: “On the contrary, the reality of PTSD is confirmed empirically by its place in people’s lives, by their experiences and convictions, and by the personal and collective investments that have been made in it.”

Page 15, Highlight (Cyan): Content: “My job as an ethnographer of PTSD is not to deny its”

Page 16, Stamp (Star (Frame, Red))

Page 16, Highlight (Cyan): Content: “reality but to explain howit and its traumatic memory have been made real, to describe the mechanisms through which these phenomena penetrate peo- ple’s life worlds, acquire facticity, and shape the self-knowledge of pa- tients, clinicians, and researchers.”

Page 16, Highlight (Cyan): Content: “This book is divided into three parts, the first of which concerns theorigins of the traumatic memory. Until late in the nineteenth century, theterm“trauma” was identified with physical injuries. ”

Page 16, Highlight (Cyan): Content: “Chapter 2 focuses on the war years, 1914 to 1918, and is organizedaround the work of W.H.R. Rivers. Rivers had the opportunity to observea variety of psychiatric casualties—officers as well as other ranks, pilots aswell as infantrymen. His articles on the psychogenic origins of war neuro-ses were widely read, and he was instrumental in establishing a course inpsychological medicine for war doctors. ”

Page 17, Highlight (Cyan): Content: “The second part of my book, consisting of chapters 3 and 4, describes howthe traumatic memory was ultimately transformed into post-traumatic stress disorder.”

Page 17, Highlight (Cyan): Content: “Chapter 3 covers the years following the publication of Freud’s account up through the publication of DSM-III. The adoption of DSM-III was part of a sweeping transfor-mation in psychiatric knowledge-making that had begun in the 1950s.These changes profoundly altered clinical practice in the United States andprepared the way for a new science of psychiatry, based on research tech-nologies adopted from medicine (experimentation), epidemiology (biosta-tistics), and clinical psychology (psychometrics).”

Page 17, Highlight (Cyan): Content: “PTSD is a disease of time. The disorder’s distinctive pathology is that it permits the past (memory) to relive itself in the present,”

Page 17, Highlight (Cyan): Content: “there are numerous clinical cases that resemble PTSD in every respect except that time runs in the wrong direction, that is, fromthe present back to the past.”

Page 17, Highlight (Cyan): Content: “Critics of the PTSD classification have argued that, in cases of delayed onset and chronic PTSD, time and causa- tion usually take this form, going from present to past.”

Page 18, Highlight (Cyan): Content: “Chapter 4 describes how PTSD knowledge-workers have responded to this criticism by developing technologies thatprovide the disorder’s otherwise invisible pathogenic process with a visiblepresence.”

Page 18, Highlight (Cyan): Content: “The third part of the book describes how PTSD is made real through psychiatric practice and psychiatric science. Chapters 5, 6, and 7 are about diagnosis and clinical practice, and they focus on a specialized psychiatric unit of the Veterans Administration Medical System, the pseudonymous National Center for the Treatment of Post-Traumatic Stress Disorder.”

Page 19, Highlight (Cyan): Content: “an effective treatment program is a clinical milieu in which patients are enabled and obliged to confront their traumatic memories and lengthen the periods during which memory content is pro- cessed, and patients are provided with realistic—that is to say, rational— cognitive schemas to replace their old self-defeating ones. Chapters 6 and 7 describe the efforts undertaken at thecenter to create this milieu. ”

Page 19, Highlight (Cyan): Content: “The historical formation of the traumatic memory in the twentieth cen- tury is tied to concurrent changes in the ideas and practices of psychiatric science. This is the subject of the book’s concluding chapter.”

Page 19, Stamp (Star (Frame, Red))

Page 19, Highlight (Cyan): Content: “What counts as a reasonable question, a satisfactory answer, a significant difference, an anomalous finding, or even an outcome—the criteria for each of these changed during this period. What did not change was the belief in the solid- ity of scientific facts and the conviction that psychiatry’s facts, being scien- tific, are essentially timeless.”

Page 20, Highlight (Cyan): Content: “the scientist’s phenomena are products of his technol- ogies, practices, and preconditioned ways of seeing. Every scientific phe- nomenon is simultaneously a techno-phenomenon.”

Page 20, Highlight (Yellow): Content: “techno-phenomenon.”

Page 20, Highlight (Cyan): Content: “The techno-phenomena of psychiatric science are possible because they are preceded by tests and standards that can tell the researcher whether the things that he is examining are comparable and whether his findings are worth keeping and circulating To say that traumatic memory and PTSD are constituted through a re- searcher’s techno-phenomena and styles of scientific reasoning does not deny the pain that is suffered by people who are diagnosed or diagnosable with PTSD.”

Page 20, Highlight (Cyan): Content: “Standards and tests are them- selves possible because psychiatric researchers have access to systems of measuring and calibrating,”

Page 297, Highlight (Cyan): Content: “Conclusion”

Page 297, Highlight (Cyan): Content: “IN 1994, the American Psychiatric Association published a fourth edition of its official nosology. The new manual, DSM-IV, perpetuates the Kraepe- linian framework established by DSM-III.”

Page 298, Highlight (Cyan): Content: “In DSM-III and DSM-III-R, the event that triggers PTSD is associ- ated with two features: Feature 1: Atraumatic event is outside the range of usual human experience. Feature 2: Such an event is markedly distressful to almost anyone who experi- ences it.”

Page 298, Highlight (Cyan): Content: “In the early 1990s, the DSM-IV Task Force created a committee to assess the adequacy of the PTSD classification and to recommend changes.”

Page 298, Highlight (Cyan): Content: “The DSM-IV Task Force accepted the committee’s criticisms and adopted their recommended changes:”

Page 299, Highlight (Cyan): Content: “Feature 1: The traumatized person experienced, witnessed, or was confronted with an event or events involving death (either actual or threatened) or serious injury (including threats to the physical integrity of oneself or others). To be “confronted” with traumatic events would include “learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associates.” Feature 2: The traumatized person’s response to these events involved intense fear, helplessness, or horror. (Amer. Psychia. Assoc. 1994:424, 427–428).”

Page 299, Highlight (Cyan): Content: “According to the revised criteria, one must now accept not only that encounters with death and injury affect different people in different ways but also that different people can have profoundly different conceptions of what constitutes a realistic “threat.””

Page 300, Highlight (Cyan): Content: “Despite these continuities between the revised PTSD entry and previous ones, the publication of DSM-IVis a signifying moment. It signals the repa- triation of the traumatic memory, the act of bringing it back home fromthe jungles and highlands of Vietnam.”

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