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            The concept of post-traumatic stress disorder has been seriously challenged. The way in which this challenge is responded to will ultimately determine the fate of posttraumatic stress disorder so that its validity is confirmed or it becomes just another chapter in the history of psychiatry. Considering only the vast intellectual and financial resources invested into posttraumatic stress disorder-inspired research, the latter outcome seems unlikely.

            Additional resources are now needed to disentangle some of the key conundrums surrounding posttraumatic stress disorder. These include better understanding of the interactions between vulnerability to posttraumatic stress disorder and trauma, elucidation of the mechanisms that lead to various clinical presentations of posttraumatic stress disorder, identification of its unique features, conceptualization of any subtypes of posttraumatic stress disorder, and clarification of what may be specific for posttraumatic stress disorder at the neurobiological level and with regard to psychological mechanisms. All this will play a major role in the process of validating the concept of posttraumatic stress disorder. Once this is achieved, posttraumatic stress disorder will have a greater chance of becoming a ''respectable'' diagnosis, provided also that society does not foster its unjustified use and abuse.

            As with numerous other illnesses in psychiatry and medicine, we cannot wait for the outcome of conceptual debates and for the discoveries that would allow us to understand better why and how posttraumatic stress disorder develops.

            Posttraumatic stress disorder is an important public health problem and a pragmatic approach is essential; much of it should revolve around endeavors to identify more precisely trauma victims who are at high risk of developing posttraumatic stress disorder, and then treat them early whenever possible. Research into risk factors for developing posttraumatic stress disorder has enhanced only to some extent our understanding of the trajectory from trauma to posttraumatic stress disorder. One way of advancing in this area is to improve research methodology, for example, by studying risk factors prospectively, while controlling for confounding variables, and taking into account the ways in which various risk factors are interrelated. The other strategy would be to shift the focus and study resilience in the face of adversity and trauma. Both of these approaches would converge to provide a clearer picture of the pathways leading from trauma to posttraumatic stress disorder, related syndromes, and other forms of psychopathology.

            Perhaps the most puzzling aspect of posttraumatic stress disorder is the fact that most trauma victims do not develop posttraumatic stress disorder and of those who do, the majority recovers spontaneously. Better understanding of this phenomenon might help devise more effective treatments insofar as the natural healing processes can be used both to intervene early in the aftermath of trauma and to treat chronic posttraumatic stress disorder. Treatment results will also improve to the extent that the target of treatment is shifted from symptoms or ''surface'' manifestations of posttraumatic stress disorder to the underlying (pathophysiological and psychological) mechanisms and meanings of the trauma and its consequences. This is likely to reduce polypharmacy and decrease a tendency to assess treatment outcomes mainly through reductions in symptoms.

References:

1. Jacob RG, Furman JM, Durrant  JD, et al. 1996. Panic, agoraphobia, and vestibular dysfunction. American Journal of Psychiatry, 153: 503--512.

2. Purdon C, Clark DA. 1994. Perceived control and appraisal of obsessional intrusive thoughts: A replication and extension. Behavioral and Cognitive Psychotherapy, 22: 269--285.

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