In spite of major strides made in the study of posttraumatic stress disorder, our full understanding of trauma as a phenomenon, its mechanisms of actions, and its long-term consequences on the human brain and social behavior is limited. It appears that trauma is a virtual impact between an event (the traumatic event) and the individual (the victim). Both opponents in this impact, however, arrive with a variety of factors and may equally contribute to the outcome. Thus, trauma is an equation with two variables that determine a potential for myriad outcomes. For mental health care professionals, traumatic phenomenology ranges from organized psychiatric syndromes to individual behaviors that often shape the history and legacy of one generation. 

Besides being relevant topics for the contemporary clinician, the articles that follow can be closely linked to major social-historical events of the past 100 years. As discussed in the article by Charles Portney, M.D., intergenerational transmission of trauma as a clinical manifestation became known after the Holocaust and the treatment of its survivors. The article by Rachel Yehuda, Ph.D., reminds us of the Vietnam War and the political upheavals of the 1960s and '70s, when the designation PTSD emerged. In discussing secondary traumatization of mental health care professionals and trauma and violence in childhood, Rose Zimering, Ph.D., and colleagues refer to concepts that underscore the complications of trauma treatment and the need for adequate resources for a more sophisticated mental health care system. Additionally, Yuval Neria, Ph.D., and colleagues bring us to the daunting present.

Currently, psychiatry is exploring the pathological consequences of trauma that easily fit into the DSM: PTSD and depressive anxiety and substance abuse disorders. It is time that we extend this inquiry to the more complex social and group victimizing behaviors that usually remain off-limits for the field of mental health. Some studies have pointed to the added burden on the brain of childhood trauma history in individuals with depressive disorders (e.g., 

 2002;159[12]:2072-2080). This confirms suggestions that trauma per se is a pathogen that may result in a wider spectral variety of manifestations (

 2002;25[4]:775-790), some of them behavioral peculiarities encountered in society. 

As the United States is once again facing another war, consideration has to be given to the long-term and long-long-term consequences of trauma at all levels. We may feel consoled to recognize that during the most perilous times, humankind has concentrated its wisdom, talent and ingenuity to circumvent the catastrophes of war. However, mental health care professionals remain responsible for objectively educating society in an apolitical manner about the effects of witnessing killing and the destruction of civilian life as well as the real effects of trauma on any nation. 

Psychiatric Times gratefully acknowledges Dr. Novac for his guidance in preparing this special report section. 

Articles

In this introduction to our Trauma Special Report, Dr. Novac places the articles in historical perspective and reminds the reader of the importance of understanding trauma within today's global constructs and impending war.

Global and Social Considerations

There are real dangers out there, and some of them yield actual tragedies--the terrorist bombings at resorts in Bali and Kenya among the more recent instances. So in February, when the U.S. Department of Homeland Security upgraded its security alert from yellow to orange (elevated to high; the next to highest stage), many people took the warning of impending violence seriously. 

(The alert was briefly downgraded to yellow until the war with Iraq seemed imminent--Ed.)

Responding to government alarms, duct tape and plastic sheeting disappeared from store shelves as people rushed to build safe rooms secure from chemical, radiological or biological attacks. Supplies of bottled water dried up as worried consumers also hoarded canned goods, batteries, flashlights and transistor radios in a last-minute effort to set aside the self-protective stashes recommended by public officials. At the same time, law-enforcement agencies heightened their readiness, and some people, depending on their levels of anxiety, changed their daily routines in an effort to elude a surprise attack.

And then, just as suddenly, the message changed. In response to what seemed an overreaction, officials in the Bush administration sought to calm fears, telling the public it needed to store emergency supplies, but need not use them--yet. At the same time that they sought to soothe jittery nerves, however, they continued to urge vigilance, further mixing up a by now confused public. 

 columnist Thomas L. Friedman, in a Feb. 23 op-ed piece, asked, "Are we going to drive ourselves crazy long before Osama bin Laden ever does?"

That question is on many minds as the nation struggles to distinguish between legitimate concern and hasty panic. The range of answers, according to experts, varies from apathy to fear, with the entire population affected in some way. For those already suffering from mild-to-severe mental illnesses, practitioners will need to factor in the additional burdens created by terrorist alerts as people trigger coping mechanisms to deal with new anxieties.

"It is a stressor, but in the face of all stressors some will respond  with positive coping, others by withdrawal, some by discovering new parts of life they had forgotten, and some by feeling frightened and overwhelmed," Robert J. Ursano, M.D., chair of the department of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and director of its Center for the Study of Traumatic Stress, told 

. "For some, it may reassure us that what we've been most frightened about is actually true. For others, it's an additional burden added on to a world that already seems overly frightening. And to others, it may be an opportunity to join with other people, where before they've stayed withdrawn and not had a way to discuss [their fears]."

According to Ursano, part of the problem is that the media chooses to report on updated and revised instructions as contradictions, a practice that heightens confusion and worry. "The confusion is a part of these settings, and we can all work together to help clarify, rather than point at, confusion and say something is going wrong," said Ursano.

However, Lee Wilkins, Ph.D., a professor at the University of Missouri School of Journalism in Columbia who consults and conducts research on topics relating to risk communications, explained to PT that there were problems with the way the Homeland Security Department handled the latest alerts. While Wilkins agreed that there will be a certain amount of uncertainty during alerts, media reports that the latest government warnings were distorted were accurate. Other agencies more experienced in disaster responses have exhibited better communication skills during past crises.

"Certainly the message about the terror threat, the one involving plastic and duct tape, was, from a risk-communication point of view, particularly ill done," Wilkins said. "It told people that they should do something, and it gave them only a very general idea as to why. It didn't provide any cues as to when it may be appropriate to do this ... [and] it was, in many ways, overly broad. ... The notion that we have this one-size-fits-all response when the threat is something airborne--could be chemical or could be biologic--is certainly ill-done and certainly doesn't follow any of the recommendations of the Environmental Protection Agency or anyone else that works with this sort of stuff on a systematic basis."

Acknowledging that Code Orange precautions lacked clarity in the early stages, Ann E. Norwood, M.D., chair of the American Psychiatric Association's committee on psychiatric dimensions of disaster, said that later official communiqu,s helped demystify the recommendations so people could act more appropriately. Depending on the region of the country, however, people perceived the level of risk differently--and so reactions ranged widely.

For mental health care clinicians working under myriad circumstances and influences, Norwood explained that it is important to watch patients to see if they become unduly anxious and to help them put things in perspective. "On the other hand, I don't think one can offer the false reassurance that nothing terrible is going to happen, because it very well might."

For Frank Ochberg, M.D., clinical professor of psychiatry and adjunct professor of journalism at Michigan State University, who also chairs the executive committee of the Dart Center for Journalism & Trauma, focusing on any single aspect of the message or the messenger is not what is key. "It's about whether in general we have the kinds of conversation between the government and the governed," said Ochberg in an interview with PT. "It's a two-way conversation that either leaves us all feeling as truly informed participants, or has us feeling manipulated and patronized, or has us feeling bewildered, confused and demoralized because there's an appearance that our government leaders are confused or confusing."

The whole population, therefore, is affected to varying degrees, Ochberg said, making the message sent by the government and the way that message is communicated by the media critically important.

"Part of what is going on is some people are legitimately frightened, while others get lulled into complacency or denial and are not as frightened," Ochberg said. "When your coping mechanisms work, they keep your anxiety within tolerable limits while you attend to the task ahead and you maintain your morale and maintain your relationships with significant others. When your coping mechanisms fail, you're not effective; you're alienated from the very people who could support you, understand you, and help you; you are demoralized; and you're anxious."

As the U.S. Department of Homeland Security raises security levels, Americans frantically take extraordinary precautions to prepare themselves for disaster. How is the public affected by the media and what can mental health care professionals and the government do to help minimize this anxiety?

Security Alerts Trouble American Psyche

Fluffy bath robes. In-room Jacuzzis. An evening at the theater with your psychiatrist. Welcome to the brave new world of high-end inpatient psychiatry.

Anxious to boost their bottom line, several established psychiatric facilities have opened exclusively self-pay inpatient units that promise to treat patients like royalty while treating them for a wide range of psychiatric and/or substance abuse problems.

In November 2002, Rhode Island's Butler Hospital opened Duncan Lodge, an impeccably furnished, five-patient unit so service-oriented that it would make executives at the Four Seasons hotel chain jumpy. Duncan Lodge joins The Pavilion at McLean Hospital and The Retreat at Sheppard Pratt as the latest entries to what may be psychiatry's hottest new niche market.

ŎI think there has long been a market out there for upscale, upgraded health facilities, just like hotels started to do five-star resorts,Ŏ William E. Callahan Jr., M.D., a San Francisco-based psychiatrist in private practice, told 

. ŎIn health care, when people are under stress and are not feeling well, [and] if they have the means, a lot of them are not going to want to go into a setting that isn't like a hotel or their home  that's just another stressor.Ŏ 

For rates ranging from $1,500 per day to $2,500 per day, patients can stay in elegantly furnished private rooms that offer high-speed Internet access, fresh flowers and the guarantee that reconstituted mashed potatoes will not be on the menu--unless, of course, the patient requests them. The programs accept patients from a full diagnostic spectrum, provided the patient can manage in an unlocked setting as determined by a thorough intake screening.

Not surprisingly, there are challenges unique to running a small high-end unit. ŎOn one hand, it's kind of cozy and people get a lot of attention, but the interpersonal transference-based things that get stirred up between patients and between staff and patients can get pretty intense,Ŏ Donald R. Ross, M.D., medical director of The Retreat at Sheppard Pratt, told PT. ŎCareful attention to professional boundaries is important.Ŏ

How to figure out where those boundaries lie is another matter. ŎIf you're going to try and treat people in a flexible and creative way, you're going to have to make some difficult decisions around that,Ŏ Alan Gordon, M.D., said in an interview with 

Gordon, medical director at Butler Hospital's Duncan Lodge recently made such a decision when he elected to take an elderly, depressed patient to the theater. In her 70s, the woman was considerably older than any of the other patients and was feeling isolated and alienated. ŎGoing to the hairdresser, looking forward to the event, [and] being able to process enjoying herself built a relationship that may not be a traditional doctor-patient relationship but, in her case, had a lot of meaning and was very important to her,Ŏ he said. ŎIt felt right in the situation but is not likely to be something that would have been done if there was any potential for confusion in the transference or in sending a message of favoritism.Ŏ

Atlanta psychiatrist Saundra Maass-Robinson, M.D., is unimpressed. ŎI think it represents a violation of boundaries,Ŏ she told 

. ŎAll of us have attempted to rationalize, intellectualize and pull on our most mature defenses to explain actions that we take as physicians that we know in our heart of hearts violate good therapeutic guidelines.Ŏ 

Regardless, the notion of self-pay is hardly novel. Places such as McLean and Sheppard Pratt have an established tradition of caring for patients of means. ŎThe place used to cater very much to a self-pay clientele,Ŏ Alex Vuckovic, M.D., medical director of The Pavilion at McLean, told 

. ŎThat was sort of the McLean image for decades. A lot of literary folks and famous people would come here for months at a time.Ŏ In the '80s, the Belmont, Mass.-based institution moved to a managed care and Medicare/Medicaid model, and Ŏit kind of squeezed out the self-pay business to a significant degree,Ŏ he said. ŎThe amount of money we get from a managed care or Medicaid bed pretty much assures that the level of amenities is not going to include a private bath and single rooms. For some folks, that's an important consideration.Ŏ

Administrators at McLean are hoping that The Pavilion will generate enough profit to cover costs elsewhere in the institution. The program offers comprehensive diagnostic assessment--including neuroimaging--as well as individual, group and family work. Substance abuse treatment and specialized modalities, such as dialectical behavior therapy (DBT), also are available to patients. The daily rate for the eight-person unit is $2,500. 

ŎThere is the sense that we're providing an extremely important baselineŎ for patients and their families, said Vuckovic. ŎThey expect you to bring something more to the table.  They're paying big bucks for good clinical ser- vices, and that keeps us on our toes.Ŏ 

While Vuckovic maintains that The Pavilion hearkens back to the heyday of an affluent, self-pay clientele, the similarities end there. The McLean patients of yesteryear remained in intensive treatment for months or even years. In addition, insurance coverage helped many patients afford care at the facility.

The Austen Riggs Center in Stockbridge, Mass., may in fact be the only program in the United States that has been able to stay afloat while it continues to offer intensive, long-term treatment.

Rather than going to an exclusively self-pay system in the 1990s, the now 83-year-old institution instead chose to diversify. Once a program that offered inpatient treatment exclusively, Riggs implemented a series of painful budget cuts in order to create a wide array of treatment options with corresponding financial flexibility. Medical director Edward R. Shapiro, M.D., told PT that the institution never considered another option and was prepared to gamble on its survival in the service of maintaining their chosen clinical focus. ŎWe were mission driven, interested in responding to a particular clinical need,Ŏ he said. ŎThe adaptation to the world around us was an adaptation to where limited resources were the prevailing concern.Ŏ Given the quickly changing landscape of health care, Shapiro said the pressing question became: ŎCould we help people with limited resources have the longest shot they possibly could at a period of intensive psychotherapy in a community of examined living?Ŏ

In 2002, roughly 60% of patients at the Austin Riggs Center paid for treatment out of pocket, with the remaining 40% having relied partially or entirely on insurance. Finances are candidly discussed with patients and/or their families at admission and beyond to help figure out how to make the most of their resources. Said Shapiro, ŎThis is the place where Riggs has met the realities of the outside world.Ŏ The most intensive level of care at Riggs--in-hospital care--costs $870 per day, while the least intensive--aftercare--costs $105 per day. Patients see their individual therapist four times per week regardless of treatment level and are followed by the same clinical team through the entire stay at the program. When Maryland's Chestnut Lodge (an intensive, long-term, psychodynamically oriented treatment institution) closed its doors in April 2000, it left a vacuum. In Montgomery County, Md., administrators at Sheppard Pratt Health System began receiving inquiries from patients and family members who had been treated at Chestnut Lodge. ŎWe realized the only way we could do that was to make it a private-pay situation,Ŏ said Bonnie Katz, vice president of corporate business development for Sheppard Pratt, in an interview with PT. ŎThe milieu on any of the units is geared toward the majority of the patients, which is one of crisis stabilization--that's all insurance will really pay for.  We had heard from folks that if they were paying, they would be looking for something that offered more privacy and more amenities. We decided to blend those two needs--longer-term psychodynamic milieu and an environment [where] people would feel they were getting the physical setting their payment provided.Ŏ 

Ironically, not a single former Chestnut Lodge patient has been treated at The Retreat since it opened, said Katz.

Inpatients on the six-bed unit are expected to stay a minimum of 20 days, compared to the average three- to five-day stay for patients being treated on other Sheppard Pratt units. The cost is $1,500 per day. The hospital hopes to generate profits of $350,000 to $400,000, which Katz said will go to subsidize less profitable hospital programs.

The $750,000 spent on renovating and furnishing the 19th-century building has resulted in a tasteful, comfortable environment that Katz said, Ŏlooks more like a bed and breakfast than an inpatient unit.Ŏ She added, ŎI don't think we've gone to extremes in terms of the decor.  The focus, regardless of the decor, was to create a safe environment. We still had to pay attention to issues that might interfere with a patient's safety.Ŏ Consequently, draperies, as well as plumbing and electrical fixtures, have been modified, and patients staying in the tastefully decorated rooms will see themselves reflected in mirrors made of safety glass.

The benefits of a self-pay unit may be more than skin deep, according to Michael C. Miller, M.D., editor in chief of 

. The longer lengths of stay on such units afford the clinical team extra time to put together a better aftercare plan, not an insignificant consideration given the ever-increasing limits on both inpatient and outpatient treatment imposed by third-party payers. ŎIf the clinicians have a free hand to do everything in their power to figure out what the person's problem is and how to be most helpful, that seems to be money [well] spent,Ŏ he told 

In addition, the personalized care offered by high-end units enables clinicians to spend more time talking to patients and their families about clinical issues, time that isn't reimbursable on ordinary units. ŎClinicians, whether doctors, nurses or other mental health professionals, are all very busy, and there is very little time for the kind of supportive interactions that any family or individual might like as part of their treatment,Ŏ said Miller. ŎThe shame is that it's not just rich people who deserve that attention, but the way the system is set up, money and time need to be rationed out.Ŏ

Personalized attention is the raison d'etre at Butler Hospital's Duncan Lodge, where patients stay for about 14 days at an average cost of $2,100 per day. The Lodge includes five suites, all of which have the amenities of a luxury hotel room. According to Anne Powers, vice president of marketing and public affairs at Butler Hospital, no modifications related to safety concerns were made in the design or decor of Duncan Lodge, as patients are expected to be able to safely manage in an unlocked setting.

There are no dog-eared issues of magazines lying around common areas. 

 is delivered daily and patients can leaf through current issues of 

Architectural Digest, National Geographic

, the last of which happens to be a popular and fertile source of inquiries for all three programs.

A private chef prepares all meals, and patients are encouraged to take advantage of the on-site nutritionist and exercise physiologist. The Lodge also employs a concierge, whose duties range from making restaurant reservations to arranging transportation for patients who may also happen to be executives required at a board meeting. 

ŎCome into this warm and healing environment, and we'll take care of everything,Ŏ Powers explained. ŎWe'll prepare your meals. If you want to get to the hairdresser, you just mention it, and it's taken care of. It's really a very focused clinical program; you won't have to worry about anything.Ŏ

The emphasis on creature comforts greatly worries Atlanta psychiatrist Maass-Robinson. ŎMy concern is that we've made it too comfortable to get work done,Ŏ she said. ŎBy over-emphasizing the environment of comfort and luxury, I wonder if the reasons for going there in the first place--developing the ability to resolve psychiatric issues--is diminished by the environment itself.  Is it care or [are they] just customized spas with a different name?Ŏ

However, Duncan Lodge's Gordon is unequivocal about his conviction in the program's clinical integrity. ŎThis is not a spa or a place just to hang out,Ŏ he said. ŎIt's a place where a legitimate plan will be put in place, and you'll be expected to participate in that.Ŏ Individual therapy is offered nearly every day and patients are expected to attend community meetings daily. Patients can also participate in DBT and substance abuse treatment available at the main hospital.

Gordon said that a few patients have arrived unprepared for the clinical expectations of an inpatient stay. ŎWe have had the experience of patients coming in and, out of na

Inpatient care for the wealthy has arrived--fluffy bath robes, in-room Jacuzzis, a concierge at your beck and call. Do the luxuries of these "resorts" negate the care that is being provided, or can patients have the best of both worlds?

Psychiatry's Hottest Niche Markets

I'm driving a knife-edge
mountain ridge at midnight,
no lines, no guard rails,

a semi screaming down my lane
ready to crush me with its cargo
of science I still need to learn.

A rusted out Chevy on my tail
scrapes an exhaust pipe and sends
sparks into darkness, their brief light

fading fast as facts I've memorized.
I don't know who will die tonight,
me or them, but I grip the wheel tight,

knuckles lit white by high-beams,
my own heart pounding, heading uphill,
engine moaning, pedal to the metal.

First Night On-Call, Coronary Care Unit

Senseless tragedies have a way of forcing people to rethink previous assumptions in an effort to somehow make sense of them. So, when seven astronauts died aboard the Space Shuttle Columbia in February, policy wonks almost immediately began their utilitarian assessments, struggling amid an array of statistics, budget overrun projections and cost-benefit analyses to determine whether it still made sense to spend billions to send a few people at a time into the dark, frigid void that is space.

For all that money, critics claim, the amount of science and technological advancement that results is a pittance compared to what could be achieved without subjecting humans to the risks of space flight. Perhaps so, but once all the statistical and economic factors have been considered, the intangibles come into play.

"It is the last frontier and it's one of the great explorations," Robert L. Helmreich, Ph.D., professor of psychology at the University of Texas at Austin and director of its Human Factors Research Project, told Psychiatric Times. Helmreich's project has done work for the National Aeronautics and Space Administration (NASA), other government agencies and private organizations. "That's of great value to humankind. But in terms of all of the other costs versus benefits, and the economics of it all, that's not a call for the explorer to make. That's a call for society to make."

The intangibles, and what U.S. culture derives from them, are important, said Chris Flynn, M.D., a NASA flight surgeon and chief of psychiatry at the Johnson Space Center in Houston. "You can see it in the inverse when you see a country like China," Flynn said in an interview with PT. "[It] has a population that certainly requires careful assessment of how money is spent for the country, [and] you see them putting so much funding and so much effort into launching people into space. It gives you a sense of how powerful [is] the emotion of going beyond the limits that are set for us by our surroundings."

There are also important societal values that are modeled by astronauts, Flynn said, including the focus on achievement, education, hard work and patriotism. Eliminating manned space flight would mean the disappearance of heroic icons who symbolize the best human traits. 

"What society loses is this unspoken hope that the boundaries [we're] living with right now are not the boundaries that [our] children will live with," Flynn said. [We] are part of expanding our boundaries. I do think there's a significant degree of emotional connection for many people in that."

For Nick Kanas, M.D., professor of psychiatry at the University of California, San Francisco, School of Medicine, and associate chief of the mental health service at the Veterans Affairs Medical Center, the space program offers practical and psychological benefits that are worth retaining. A principal investigator in a research program called Human Interactions in Space, Kanas and his colleagues have conducted studies in collaboration with Russian researchers that probe the interactions between multinational space station crews who must coexist under conditions of isolation and confinement.

"One can argue that the International Space Station [is] a microcosm of having to get along with people from other cultures and countries on Earth," Kanas told PT. "What we're trying to learn in terms of culture, language [and] background and how [they] impact on multiethnic, multigender crews interacting under conditions of isolation and confinement on the Space Station will hopefully teach us a lot about ways of getting along on Earth."

Kanas agrees that the symbolic elements of the space program also play an important role. In addition to the scientific, technological and medical advancements and the strides in understanding human behavior, the space program also fulfills a basic human need to explore and expand.

"We've always done this. We've always moved out from our neighborhood into other neighborhoods and seen what's over the horizon," Kanas said. "All of these factors, you put them together, and then you take them away and there's a kind of vacuum; and to me, it's a powerful symbol."

Larry Palinkas, Ph.D., a medical anthropologist and professor of family and preventive medicine at the University of California, San Diego, School of Medicine, is also the chair of the external advisory council of the National Space Biomedical Research Institute. Funded by NASA, the institute develops countermeasures for health problems that astronauts are likely to experience during missions of long duration. Palinkas, who has studied behavior, performance and cognition issues related to stress and isolation in space as well as in the Arctic and Antarctic, told PT that the programs that have tested human endurance have also provided role models for U.S. children, encouraging them to pursue higher education and greater achievement.

"My own opinion is that it extends beyond that to an evolutionary drive," Palinkas said. "One of the things about humans that has engaged us as a species capable of adaptation has been this drive for exploration, and that drive typically occurs in the classroom. ... While unmanned space flights add an important element to that notion of exploration, I see manned space flights as the most visible representation of that need to explore, that need to learn."

How Americans will react to any shifts in commitment to manned space programs depends in large part upon how the leadership frames its response, said Richard Bloom, Ph.D., in an interview with PT. Bloom, a professor of political and clinical psychology at the Embry-Riddle Aeronautical University in Prescott, Ariz., said that if the program were simply cancelled because of the Columbia crash, the population would perceive this negatively, and both a political and psychological backlash would likely ensue. On the other hand, if any reduction or cancellation were conveyed as an intermediate step with a return to manned space flight planned later on, people would likely react in a more positive way.

In the near term, however, Bloom doubts significant changes will occur exactly because the symbolic value is so great. "There will be some kind of manned program in the short-term, mid-term and long-term," Bloom said.

But if that prediction is wrong, Bloom said there could be some "collective psychology that [plays] out in this country ... even folks who haven't been following the program ... would begin to think about it and experience almost a sense of mourning." 

In the wake of the deaths of seven astronauts aboard the Space Shuttle Columbia, many critics have called for an end to manned space flights. Psychiatrists, however, point to the intangible benefits--including the societal values and desired psychological traits that are modeled by astronauts.

The Last Frontier: Going Beyond the Limits

Mental health care professionals specializing in the treatment of trauma hear tales of extreme human suffering and observe the emotions of fear, helplessness and horror registered by survivors on a consistent basis. Recent research demonstrates that these occupational duties may cause psychological symptoms in the practitioner who bears witness to the survivors' account of trauma.

Primary posttraumatic stress disorder may be diagnosed in an individual who experienced, witnessed or was confronted with a traumatic event and responded with intense fear, helplessness or horror. Intentional traumas (e.g., combat, sexual assault, terrorism and mass violence), as well as unintentional traumas (e.g., natural disasters, accidents), may cause this pervasive psychiatric condition. 

Secondary trauma is defined as indirect exposure to trauma through a firsthand account or narrative of a traumatic event. The vivid recounting of trauma by the survivor and the clinician's subsequent cognitive or emotional representation of that event may result in a set of symptoms and reactions that parallel PTSD (e.g., re-experiencing, avoidance and hyperarousal). Secondary traumatization is also referred to as 

Secondary trauma is an understudied and controversial clinical phenomenon. In this article we will explore the controversy, review the existing literature, describe the personal and professional consequences, and address prevention of secondary traumatization. 

Detractors of the secondary traumatization phenomenon in health care professionals claim that labeling clinicians with secondary PTSD is pathologizing and best described as a reaction, not a disorder. Just as most individuals directly exposed to a traumatic stressor exhibit some PTSD symptoms that abate quickly over time, many clinicians will have transitory reactions to survivor narratives. Yet in both primary and secondary trauma exposure, a small percentage of individuals will develop the full psychiatric disorder. 

Research findings of primary and secondary PTSD related to the World Trade Center terrorist attacks illustrate this point. Galea and colleagues (2002) showed that in the first five to six weeks following the Sept. 11, 2001, terrorist attacks in New York City, 20% of residents living close to the World Trade Center met criteria for probable PTSD. Thus, the majority of individuals directly exposed to the terrorist attacks in New York City did not meet criteria for PTSD. 

Research on secondary traumatization shows a similar prevalence pattern in mental health care professionals who treated survivors of the World Trade Center collapse (Gulliver et al., 2002). On standardized clinical interviews, many providers endorsed symptoms of PTSD linked to their exposure to survivor narratives, but most did not meet diagnostic criteria for PTSD. However, a minority of professionals met full diagnostic criteria for PTSD in the months following their exposure to survivor narratives.

A second controversial point concerns whether the PTSD 

 Criterion A can include indirect exposure to a trauma. However, the definition of a traumatic stressor can be ambiguous. In fact, PTSD can occur in individuals who have been exposed indirectly to a traumatic stressor. For example, Weisaeth (1989) found PTSD in workers who were not present at the time of an industrial explosion at their workplace. More recently, Schlenger et al. (2002) reported that indirect exposure to the Sept. 11 disaster via the number of hours of television coverage watched per day on and after Sept. 11 was significantly associated with probable PTSD in individuals living outside of the terrorist attack sites. These findings show that the parameters of the Criterion A event which can precipitate PTSD are still evolving.

The current state of empirical literature on secondary traumatization among health care professionals is in its infancy. Although theorists such as Figley (1995), McCann and Pearlman (1990), and Stamm (1995) have written extensively on the phenomena of secondary traumatization, the level of corroborative data is not commensurate with the sophistication of existing theories. A recent review of 

 journal articles found only 17 peer-reviewed articles on secondary traumatization. Of these, only 12 contained data, and the majority of these were descriptive (qualitative) in nature. 

The descriptive studies on secondary traumatization can be categorized as measure development (e.g., Jenkins and Baird, 2002; Motta et al., 2001), predictive variable studies (e.g., Adams et al., 2001; Schauben and Frazier, 1995; Wasco and Campbell, 2002) and one meta-analysis that indirectly evaluated techniques to prevent or treat secondary trauma (Everly et al., 1999). 

The second category of studies explores secondary traumatization as a function of occupational roles and examines the variables that correlate with the development of symptoms. Eight studies describe the phenomena of secondary trauma among counselors with diverse training, caseloads, degrees and socioeconomic status (Adams et al., 2001; Ghahramanlou and Brodbeck, 2000; Everly et al., 1999; Iliffe and Steed, 2000; Jenkins and Baird, 2002; Schauben and Frazier, 1995; Steed and Bicknell, 2001; Wasco and Campbell, 2002). All eight studies describe a stable set of symptoms analogous to PTSD, yet a very low incidence of meeting clinical criteria (range between studies: 0% to 4%) or impairment in occupational roles was reported. This result is difficult to interpret, as the current status of the psychometric utility of available instruments decreases confidence in any conclusion, and each study used a different set of assessments. In sum, trauma counselors are likely to report some negative consequences of their work that maps onto a PTSD typology. What remains to be seen is how often this symptom profile is clinically significant and how symptoms affect patient care.

This same set of studies yields contradictory evidence about correlates of secondary trauma symptoms. The most frequently studied correlate is the therapist's personal trauma history. Jenkins and Baird (2002) found that personal trauma history correlated with secondary trauma symptoms, but Schauben and Frazier (1995) and Adams et al. (2001) did not. In addition, Schauben and Frazier found that the greater the percentage of survivors in a provider's caseload, the greater the number of secondary trauma symptoms reported. 

Other factors suggested by theorists as potentially predictive of secondary traumatization include insufficient training, identification with the victims, insufficient support in the workplace, and insufficient social and familial support. Future research to further assess these characteristics is recommended.

There are three self-report inventories that can measure secondary trauma: the Compassion Fatigue Self-Test (CFST) for Psychotherapists (Figley, 1995), the TSI Belief Scale (TSI-BLS) (Pearlman, 1996) and the Secondary Trauma Questionnaire (STQ) (Motta et al., 2001). These inventories vary by their domain of study and targeted population. While the CFST and STQ items more closely measure trauma exposure and PTSD symptomatology, the TSI-BLS measures changes in cognitive schemas (e.g., safety, trust, esteem, intimacy and control) consistent with the author's theoretical conceptualization of vicarious traumatization. The CFST and TSI-BSL were developed to assess secondary trauma in therapists whereas the STQ was designed for both therapists and the general population.

Standardized clinical interviews specific to secondary traumatization have not been developed. However, Gulliver et al. (2002) used the Clinician Administered PTSD Scale (CAPS) in their study of secondary trauma in disaster relief clinicians. World Trade Center survivor narratives heard by the clinicians were coded as the Criterion A event and the CAPS questions were administered as it would be for primary PTSD.

A recent validational study of the CFST and TSI-BSL self-report mea-sures showed convergent validity between the CFST and TSI-BSL, moderate convergence with burnout, and strong convergence with general distress (Jenkins and Baird, 2002). The next level of measure development will likely provide norms and cutoffs for symptom intensity, that will strengthen current assessment methodology.

If trauma is contagious (Herman, 1992) and the effects of treating trauma survivors may parallel those of primary trauma, a clinician's work with patients may be adversely affected. Herman (1992) suggested that the effects on therapists may include disruptions in the therapeutic alliance, conflict with professional colleagues attempts to rescue or control patients, and violations of therapeutic boundaries.

Therapists overwhelmed by traumatic material may begin to avoid or deny their patient's experiences (Baranowsky, 2002). Alternatively, they might push patients too quickly in an effort to master their own responses. The schematic disruptions associated with vicarious traumatization (Pearlman and Saakvitne, 1995) could also impact clinical work. A clinician whose views of trust and safety have been undermined might be unable to respond effectively to traumatized patients. Researchers interviewing trauma survivors might also introduce bias into studies in their efforts to control their own exposure to trauma material. The recognition of secondary effects requires that we further investigate the implications for practitioners because we cannot assume that the practitioners' responses will not impact the care they provide.

The key components of secondary trauma prevention might be found within practice systems (Herman, 1992). Echoing this sentiment, Pearlman and Saakvitne (1995) stated that four domains are important to the prevention of secondary traumatization in mental health care providers: 1) professional strategies, such as balancing caseloads and accessible supervision; 2) organizational strategies, such as sufficient release time and safe physical space; 3) personal strategies, such as respecting one's own limits and maintaining time for self-care activities and 4) general coping strategies, such as self-nurturing and seeking connection. Thus far, no studies have evaluated the effectiveness of these prevention strategies. 

The empirical evidence indicating secondary effects in practitioners raises the immediate question of how this should be incorporated into clinician training. We have a duty to educate those entering the field to anticipate how the work will affect them and to prepare them to address these effects (Munroe, 1995). 

Although secondary traumatization may adversely affect practitioners and the services they deliver, work with trauma survivors can also be immensely rewarding and has the potential to allow practitioners to grow personally and enhance their compassion, provided responses to this difficult work are used constructively.

Treatment of posttraumatic psychological reactions in civilians became a significant public health concern in the United States after Sept. 11. This public priority should also extend to the emotional well-being of clinicians who are exposed to traumatic stimuli in their occupational duties. Just as ongoing national policy discussions explicitly recommend that health care professionals and other first responders be vaccinated in the event of bioterrorist attacks, similar consideration should be made with first-line trauma and disaster relief clinicians. If clinicians are to maintain pace with the mental health care needs of U.S. citizens living in an increasingly dangerous world then their psychological well-being must also be recognized and protected.

Adams KB, Matto HC, Harrington D (2001), The Traumatic Stress Institute Belief Scale as a measure of vicarious trauma in a national sample of clinical social workers. Families in Society: The Journal of Contemporary Human Services 82(4):363-371.
 

Baranowsky AB (2002), The silencing response in clinical practice: on the road to dialogue. In: Treating Compassion Fatigue, Figley CR, ed. New York: Brunner-Routledge.
 

Everly GS, Boyle SH, Lating JM (1999), The effectiveness of psychological debriefing with vicarious trauma: a meta-analysis. Stress Medicine 15(4):229-233.
 

Figley CR (1995), Compassion fatigue as secondary traumatic stress disorder: an overview. In: Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized, Figley CR, ed. New York: Brunner/Mazel.
 

Galea S, Ahern J, Resnick H et al. (2002), Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 346(13):982-987 [see comments].
 

Ghahramanlou M, Brodbeck C (2000), Predictors of secondary trauma in sexual assault trauma counselors. Int J Emerg Ment Health 2(4): 229-240. 
 

Gulliver SB, Knight J, Munroe J et al. (2002), Secondary trauma in disaster relief clinicians at ground zero. Presented at the 18th Annual Meeting of the International Society for Traumatic Stress Studies. Baltimore; Nov. 9.
 

Herman JL (1992), Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror. New York: Basic Books.
 

Iliffe G, Steed LG (2000), Exploring the counselor's experience of working with perpetrators and survivors of domestic violence. J of Interpersonal Violence 15(4):393-412.
 

Jenkins SR, Baird S (2002), Secondary traumatic stress and vicarious trauma: a validational study. J Trauma Stress 15(5):423-432.
 

McCann IL, Pearlman LA (1990), Vicarious traumatization: a framework for understanding the psychological effects of working with victims. J Trauma Stress 3(1):131-149.
 

Motta RW, Hafeez S, Sciancalepore R, Diaz AB (2001), Discriminant validation of the Modified Secondary Trauma Questionnaire. Journal of Psychotherapy in Independent Practice 2(4):17-25.
 

Munroe JF (1995), Ethical issues associated with secondary trauma in therapists. In: Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators, Stamm BH ed. Lutherville, Md.: Sidran Press, pp211-229.
 

Pearlman LA (1996), Psychometric review of TSI Belief Scale Revision L. In: Measurement of Stress, Trauma and Adaptation, Stamm BH, ed. Lutherville, Md.: Sidran Press.
 

Pearlman LA, Saakvitne KW (1995), Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors. New York: W.W. Norton.
 

Schauben LJ, Frazier PA (1995), Vicarious trauma: the effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly 19(1):49-64.
 

Schlenger WE, Caddell JM, Ebert L et al. (2002), Psychological reactions to terrorist attacks: findings from the national study of Americans' reactions to September 11. JAMA 288 (5):581-588 [see comment].
 

Stamm BH (ed.) (1995), Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators. Lutherville, Md.: Sidran Press.
 

Steed L, Bicknell J (2001), Trauma and the therapist: the experience of therapists working with the perpetrators of sexual abuse. The Australasian Journal of Disaster and Trauma Studies 2001 (1):1-9.
 

Wasco SM, Campbell R (2002), Emotional reactions of rape victim advocates: a multiple case study of anger and fear. Psychology of Women Quarterly 26(2):120-130.
 

Weisaeth L (1989), The stressors and the post-traumatic stress syndrome after an industrial disaster. Acta Psychiatr Scand 355(suppl):25-37.

What is secondary traumatization? The authors discuss current research and implications for this controversial and emerging field of study.

Secondary Traumatization in Mental Health Care Providers

Posttraumatic stress disorder develops in response to experiencing, witnessing or even learning about a terrifying event. The event--or trauma--is usually life-threatening, or at least capable of producing bodily harm, and it typically involves either interpersonal violence or massive disaster (e.g., rape, assault, torture, terrorism, car or plane crashes, earthquake, tornado, or flood). Traumatic events have in common the ability to elicit intense and immediate fear, helplessness, horror and distress. These subjective responses lead to a cascade of adverse psychological reactions that can result in the symptoms of PTSD and the resultant disability that is associated with this condition.

The diagnosis of PTSD did not appear in the DSM until 1980. This reflected the reluctance of the mental health field to recognize that the psychological effects of traumatic experiences could be long lasting. Prior to 1980, stress-related symptoms were generally viewed as transient and not requiring intensive treatment. This was in keeping with the pervasive feeling that, with time, people ought to be able to "get over" the effects of a traumatic experience and "move on" without noticeable impairment. According to the 

, people who developed long-term symptoms following trauma were perceived as constitutionally vulnerable (Yehuda and McFarlane, 1995). The diagnosis of PTSD was meant to pave the way for an improved understanding of the long-term, and possibly even permanent, impact of trauma exposure. Ultimately, systematic testing of hypotheses about the relationship between trauma exposure and long-term symptoms has led to a better understanding of the causes of PTSD and its longitudinal course and biologic basis. 

Posttraumatic stress disorder defines a rather specific syndrome in which trauma survivors are unable to get the traumatic event out of their minds. Three symptom clusters are associated with PTSD: 1) reexperiencing symptoms refers to distressing images, unwanted memories, nightmares or flashbacks of the event that cause distress and attendant physical symptoms such as palpitations, shortness of breath and other panic symptoms; 2) the avoidance of reminders of the event, including people, places or things associated with the trauma and becoming emotionally numb, constricted or generally unresponsive to the environment; and 3) hyperarousal, which is reflected in physiological symptoms such as insomnia, irritability, impaired concentration, hypervigilance and increased startle responses. To meet DSM criteria for PTSD, symptoms in each of the three domains must not only be present, but also must be severe enough to cause substantial impairment in social, occupational or interpersonal domains. Furthermore, symptoms must be present for at least one month. 

Posttraumatic stress disorder is the fourth most common 

 disorder, afflicting 7% to 14% of the population at some time in their lives (Yehuda, 2002). Although exposure to trauma is thought to be the major cause of PTSD, there is a marked discrepancy between the number of people exposed to trauma and the number of people who develop PTSD. If one considers the prevalence of PTSD solely among individuals who have been exposed to a potentially traumatic event as defined by the 

, it would become clear that only about 9% of men and 20% of women who are so exposed develop this disorder (Kessler et al., 1995).

The nature of the trauma experienced seems to be a highly significant factor in determining whether PTSD will develop. Events involving interpersonal violence, such as torture, rape, assaultive violence and combat, are more potent elicitors of PTSD than experiences such as motor vehicle accidents and natural disasters. The former events produce PTSD in as many as 50% to 75% of trauma survivors, whereas the latter types of events often result in PTSD 

The majority of people experience acute stress symptoms following trauma, but the development of posttraumatic stress disorder is the exception rather than the rule. Some investigators hypothesize that PTSD develops following increased nervous system response to trauma. Why only a minority of individuals experience this response, what their risk factors are and when should they be treated is the subject of ongoing research.

Changes in the Concept of PTSD and Trauma

Students of human nature have long grappled with questions about the replication of parents' traits into their offspring. Nonmedical writings have alluded to the fact that "sins" may be transmitted from parents to children. However, the first extensive elaboration on the impact of parents' neuroses on their children came in the late 1800s from the emerging field of psychoanalysis. All subsequent schools of psychology examining trauma have been concerned with the handing down of neurotic traits. It was only in the post-Holocaust era that a consistent literature on the intergenerational effects of parents' traumas emerged. Soon after the description of the Holocaust syndrome by Niederland (1961), Rakoff et al. (1966) reported on the transmission of the effects of the Holocaust trauma to the "second generation." Since then, several hundred articles on intergenerational transmission--mainly limited to clinical cases and anecdotal reports--have been published, raising criticisms about the initial lack of systematic empirical studies. This initial paucity of systematic research was partly due to a lack of consensus about what was being transmitted. There were early hints of a certain complex of symptoms or even specific psychopathology in children of Holocaust survivors (Barocas and Barocas, 1973).

Meanwhile, pointing to the heterogeneity of this group, Danieli (1981) identified four subtypes of families of Holocaust survivors: victim families, numb families, fighter families and families of "those who made it." In a seminal study, Solomon et al. (1988) examined Israeli soldiers who developed posttraumatic stress disorder during the Lebanese war and found that soldiers who were offspring of Holocaust survivors had a more protracted course of PTSD. Thus, the existence of a factor of vulnerability carried by healthy children of survivors was raised. Nader (1998) reported similar findings in children whose parents experienced significant traumata in life. Such children were more likely to present symptoms of PTSD after witnessing a violent incident. 

Drawing on findings that repeated trauma exposure may alter the responsiveness of the hypothalamus-pituitary-adrenocortical axis even before the onset of PTSD, Yehuda et al. (1998) found that healthy offspring of Holocaust survivors are more likely to develop PTSD after traumatic events and report a larger number of symptoms. Similarly, Novac and Huber-Schneider (1998) reported increased comorbidity in previously healthy children of survivors who were seen in a psychiatric clinic for anxiety and depressive disorders. The authors hypothesized on the different mechanisms of transmission of trauma. 

Other studies have further confirmed that offspring of Holocaust survivors are more vulnerable to psychological distress after developing breast cancer (Baider et al., 2000) and that healthy children of war veterans may show abnormalities in the Stroop Color Test (Motta et al., 1997). Danieli (1998) also covered a large number of studies in detail, including animal models for transmission. 

The importance of this subject has also been recognized by the International Society of Traumatic Stress Studies (ISTSS), with the founding and maintaining of a Special Interest Area Group on Intergenerational Transmission of Trauma and Resiliency. At the annual ISTSS meetings, there are an increasing number of presentations on intergenerational transmission. There are also progressively more reports of psychopathology in the "third generation" (i.e., grandchildren) of Holocaust survivors.

In clinical practice, patients with parents suffering with PTSD often describe damaged, preoccupied parents who are emotionally limited. Symptoms in parents such as traumatic reliving, emotional numbing and dissociative phenomena do not help a child develop a reasonable sense of safety and predictability in the world. These parents are also less able to respond optimally during usual developmental crises and help the world to be more comprehensible to the child. The parent suffering with PTSD also has difficulty modeling a healthy sense of identity and autonomy, appropriate self-soothing mechanisms and affect regulation, and maintaining a balanced perspective when life challenges arise. Instead, they can model catastrophic or inappropriately numbed and disassociated responses. Therefore, the parent's high levels of anxiety can significantly interfere with the child's developmental progress.

Children's self-image and object relations are also obviously affected by their image of their parents. Parents' success in coping and being resilient determines whether the child can be proud, ashamed or confused about their parents.

. A woman in her late 30s was referred for treatment of obsessive-compulsive disorder, depression, past substance abuse and general chaos. Her most striking symptoms were extreme anxiety, apprehension and confusion in the face of interpersonal tasks that seemed within the scope of someone so intelligent and articulate. She had not responded to therapy with several different psychiatrists in the past. In the initial history-taking, it emerged that she had been raped in her late teens but denied that it produced any lasting effects. After several months of therapy, she revealed that--before she was born--her mother and maternal grandfather had witnessed the murder of her grandmother. The mother and grandfather had both been chronically depressed, anxious, fearful and preoccupied with reliving experiences since the murder. It became clear that the patient's OCD was partially an attempt to create some sense of predictability and safety. Significant improvement in functioning was achieved through a combination of antidepressants, lamotrigine (Lamictal), some family therapy, and individual therapy and psychoeducation regarding traumatic effects in each generation.

. A male professional in his late 20s presented for treatment of bulimia, depression and several anxiety disorders. In initial history-taking, he denied a history of trauma. As therapy progressed, he mentioned that his paternal grandparents were Holocaust survivors who were very involved in his upbringing. They were loving and overprotective but also very anxious and highly critical. Therapy clarified that the criticism was in the service of trying to make everything perfect to avoid some new, unspecified catastrophe. The patient's bulimia was an attempt to have a perfect body and, therefore, avoid bad things. When seen in family therapy, the patient's father clearly had second-generation problems and accepted a referral for therapy. The father's treatment greatly aided the patient, as his father could now model for him how to navigate through life's shoals in a calm, reasonable manner. Individual therapy, antidepressant treatment and the father's improvement resulted in almost complete recovery.

Intergenerational transmission of trauma seems to have a particular significance in offspring of parents with a history of major trauma and subsequent PTSD. The phenomenon is not just limited to Holocaust survivors. Children of parents who suffer from PTSD are most likely to develop a specific lifetime vulnerability to traumatic stress and are possibly more likely to develop comorbidity. 

Future studies will have to shed more light on the different types of transmission. For instance, it is not known whether the transmission of trauma in Holocaust families is similar to the cycle of violence seen in families with other types of trauma. Similarly, the relationship between such factors of vulnerability and the social resiliency seen in some offspring of trauma survivors has to be further explored. In addition, there needs to be more research and better understanding of the genetic traits that make certain traumatized individuals most likely to develop PTSD. This would lead to better theories about what has been potentially genetically transmitted to the second (and third) generation that might influence their response, among other things, to their parent's psychopathology.

Parents who have witnessed traumatic events may pass dysfunctional life views on to their children. How much more vulnerable are these second-generation victims to PTSD and other psychiatric disorders?

Intergenerational Transmission of Trauma: An Introduction for the Clinician

!" paints a picture of a world that--fortunately for all of us--does not exist. The article is peppered with absurd claims about how the 

 is perceived. According to the author, the 

 is the cause of a large number of extremely serious problems, such as the precipitous decline of psychiatry in the eyes of the general public, primary care, and other specialty physicians and mental health care practitioners. The 

 is even cited as a major reason medical students do not enter psychiatry.

, the author presents no evidence to support his claim that it is universally regarded as useless to clinicians. In fact, the contrary is true. Surveys of clinicians regarding their attitudes toward the 

 is generally viewed as clinically useful. For example, in a 1989 survey of more than 1,000 psychiatric educators, researchers, practitioners and senior residents, 95% reported a "willingness to continue to use the 

 even if it was not required" (Jampala et al., 1992). In a 1989 survey of 460 child psychiatrists, 98% reported that they found "a criterion-based diagnostic system to be useful" (Setterberg et al., 1991). In a more recent survey of 205 psychiatrists from 66 different countries conducted by the World Health Organization and the World Psychiatric Association, 80% reported that the 

 was "highly valuable" or "fairly valuable" for clinical care (Mezzich, 2002).

Our own considerable experience with colleagues, many of whom are involved in teaching medical students and residents, as well as our own experience with primary care physicians (American Psychiatric Association, 1995; Spitzer et al., 1994), runs entirely counter to perception presented in the point article. Medical students generally find the succinct presentation of the 

 criteria to be a useful introduction to psychopathology that enables them to recognize patients with psychiatric disorders and to formulate treatment plans. Not surprisingly, primary care physicians--to the extent that they are familiar with 

 classification far too complicated for their use. But does the reader really believe that psychiatrists who work with other medical colleagues feel the need to apologize for the 

, specialists in other medical domains (e.g., headaches, gastrointestinal disorders) have consulted with us to develop their own classifications, using the 

In the point article, discussion of the changing picture of bipolar disorder (BD) is telling. The author prefers, "with no apology," to idiosyncratically diagnose schizoaffective disorder for drug-taking young patients with BD than use the 

 diagnosis of superimposed drug-induced psychosis or BD with psychotic features. Surely having each clinician creatively adopt their own definitions is no solution and would inevitably lead to a diagnostic Tower of Babel. Although the definition of schizoaffective disorder has been recognized as problematic since 

, the availability of standard diagnostic criteria facilitates much-needed research.

 has no clinical value (and, in fact, is detrimental to the practice of psychiatry), it should be abandoned. While we agree that 

 is far from perfect, we strongly disagree with this assertion. One of the most important goals of the 

 is to facilitate communication among mental health care professionals, between mental health care providers and health care administrators, and between mental health care professionals and the public at large. The 

categories provide a convenient shorthand for describing an individual's symptomatic presentation. When referring a patient to a colleague, saying that "this patient has major depressive disorder" communicates a plethora of important clinical information, including the fact that the patient has either depressed mood or pervasive loss of interest, has a number of other symptoms that cluster with depressed mood (e.g., sleep disturbance, appetite change, cognitive difficulties and so forth), and that the syndrome has persisted for at least a couple of weeks. In addition, the term 

indicates that the clinician has considered and eliminated a number of important disorders in the differential diagnosis, including BD, schizophrenia and schizoaffective disorder, substance-induced mood disorder, and mood disorder due to a medical condition. Furthermore, by using this term, one can communicate the range of treatments that may be expected to work, as well as expectations about possible future outcomes (e.g., higher risk of developing additional episodes of depression in the future). Of course, there are many clinically important aspects of the patient that are not captured by this label, including the psychosocial context in which the depression developed, psychodynamic factors that might be perpetuating the depression and many others. We believe that most mental health care professionals can appreciate this main limitation of the 

 diagnosis provides only a part of the story.

 convention of favoring the assignment of a number of 

 diagnoses to describe complex clinical presentations. This convention allows for the communication of the maximum amount of clinical information without forcing the clinician to make an ill-informed judgment about underlying etiology for which there is little or no evidence. Take, for example, a young female patient who drinks heavily, has severe recurrent depressive episodes, binges and purges, and has panic attacks. Following the 

 convention, the clinician may choose to assign up to four different diagnoses in order to communicate the various foci of treatment: alcohol abuse, recurrent major depressive disorder, bulimia nervosa and panic disorder. We believe that clinicians are sophisticated enough to recognize that the 

 is not asserting that the patient has four separate pathological processes. Most likely, there are one or two underlying processes that are being expressed in a complex way. Unfortunately, given the current limitations in our understanding of psychiatric disorders, it would be total speculation to assign a single diagnosis to this patient. Which one would you choose--the alcohol use disorder? The mood disorder? Beginning with 

 has taken the conservative approach of describing the clinical picture in terms of clinically relevant patterns of symptoms until the day arrives in which there is enough understanding of psychopathology to allow for a more parsimonious solution to the comorbidity problem.

We are the first to acknowledge that the 

 categories do not always jibe with the ever-evolving body of scientific research and that they sometimes conflict with clinical reality. For example, findings that suggest a common genetic basis for major depressive disorder and generalized anxiety disorder (Kendler, 1996) and for BD and schizophrenia (Berrettini, 2000) run counter to the 

 convention of having these conditions classified in separate sections. Furthermore, the fact that psychiatric symptoms occur on a continuum, without hard boundaries separating disorder from normality (and between various disorders), suggests that the 

 categorical approach has significant limitations that may be addressed by adopting a dimensional approach, especially for the diagnosis of personality disorders (First et al., 2002). It is precisely for these reasons that the 

 is periodically revised after conducting a comprehensive review of the literature, in order to ensure that 

 stays in step with the research base and that the initial work on 

 consists of establishing a research agenda (Kupfer et al., 2002) that stimulates the research needed for future changes. However, does the fact that the 

The author of the point article wisely acknowledges that he is "better at tearing down" than proposing an alternative. But he does propose an alternative: the mental disorders section of 

. There are several reasons why this suggested alternative makes no sense. First, the 

 does not have diagnostic criteria. Users are obligated to use their own idiosyncratic definition(s) of the terms--setting psychiatry back 30 years. In recommending 

, the author ignores the fact that it closely resembles--both in structure and diagnostic criteria--

. This is further evidence that, rather than being ridiculed, the 

 principles have been embraced by world psychiatry. Furthermore, the developers of 

 did not have the resources that enabled the 

 work groups to conduct comprehensive literature reviews. They had to rely exclusively on expert consensus in developing diagnostic criteria.

To paraphrase what Sir Winston Churchill said about democracy, 

 may not be such a wonderful system, but it is better than any other existing alternative.

The DSM may be flawed, but it is the best available system for organizing and diagnosing mental disorders, and it remains a model for other medical specialties.

Psychiatric Times Vol 20 No 4