Ethnic differences in prisoners: Describing trauma and stress

I read with interest the two articles by Coid et al (2002a , b ) but was puzzled by the use of the term ‘post-traumatic stress’ to describe the psychiatric response of prisoners who had experienced adverse or negative life events. The authors use the term post-traumatic stress without specifying whether they are referring to the specific diagnosis of post-traumatic stress disorder (PTSD), a recognised psychiatric condition in the DMS–IV (American Psychiatric Association, 1994) or simply a vague amalgam of neurotic symptoms which the authors infer are a consequence of the various stresses the prisoners experienced in their lifetimes. The confused terminology in this respect, which is present in both papers, is unhelpful in assessing what precisely is psychiatrically wrong with these prisoners. A Criterion A trauma, that is a trauma that may precipitate PTSD in some individuals, is specifically defined and described in the DSM–IV as an event in which the person experiences, witnesses or is confronted with an event or events that involves actual or threatened death or serious injury to the self or to others, and to which the individual responds with intense fear, helplessness or horror. The experiences that were screened for in the original study by Singleton et al (1998) would not normally be considered to represent a Criterion A event, but merely negative or adverse life events which have no specific aetiological links with any distinct clinical diagnosis. The experiences included by the authors in their screening include bullying and marital separation, which do not constitute Criterion A events for the purpose of making a PTSD diagnosis. Similarly, many other traumatic experiences were not apparently screened for by the authors, such as rape or adult sexual assault, combat, being assaulted in the street (although violence in the home or at work are included). Thus, the selection, definition and description of these events as traumatic is misleading, while the inclusion of negative life events that are clearly more traumatic makes the interpretation of any resulting phenomenology extremely difficult.

It is also clear from the original publication by Singleton et al that no specific assessment for PTSD was carried out, although validated and reliable instruments for this exist (e.g. the Clinical Assessment for PTSD, Blake et al (1995) or the Posttraumatic Stress Symptoms Interview (PSSI) or Posttraumatic Stress Symptoms Self-Report (PSS–SR), Foa et al (1993)). The authors did a partial screen for a few recognised PTSD symptoms, such as re-experiencing and avoidance, but there was no systematic assessment of the condition that would have allowed them to diagnose the full disorder. It should be recognised that PTSD is a major psychiatric disorder that constitutes a serious burden for the individual and for society (Kessler, 2000). A diagnosis of PTSD has implications in terms of assessing the individual's risk and in terms of treatment recommendations. It is important that the term post-traumatic stress should not be confused or conflated with the term ‘post-traumatic stress disorder’. The description of post-traumatic stress made by Coid et al cannot be evaluated without deconstructing more precisely what this means. As there are now well-recognised instruments to assess PTSD and lifetime experience of traumatic events in a range of settings, without these being used then terms such as post-traumatic stress should be avoided.