The Psychiatrist: When is stress an illness?

It is hard to quantify but many people seem to consider “stress” an illness. Certainly plenty of GPs use the phrase “stress and depression” when signing people off work, and the phrase “work stress” gets insinuated into debates about occupational health. But is stress always bad for you? If you do not keep your muscles stressed, for instance, they will start to shrink: your thighs’ circumference reduces by about 1cm if you are in bed for a few days. Going back to work can be a relief after a bereavement.

There is a category of stress in the psychiatric diagnostic system known as post-traumatic stress disorder (PTSD), which is unique in having causation as well as a particular group of symptoms as part of its make-up. Thus you need “an exceptionally stressful life event” or “a significant life change leading to continued unpleasant circumstances” to enable this label. Many symptoms are indistinguishable from panic attacks and depression but they also include – specifically – the presence of intrusive memories, as flashbacks or dreams; a sense of numbness and emotional blunting; a tendency to be hypervigilant; and to have your nasty memories triggered by reminder events. While shocking events have been recorded for many years as disabling people psychologically or affecting their character, it has taken the effects of warfare on large civilian armies to delineate official diagnoses. “Soldier’s heart” emerged from the American civil war, “shellshock” from the first world war, and PTSD from the Vietnam war.

While those who experience PTSD have a most unpleasant time (although it usually fades over the course of months, or perhaps a year or two), it can also be a condition with compensations. Getting Vietnam war veterans to give up their PTSD label is virtually impossible, since without it they would lose hospital care, benefits and status. Car crash victims in the UK are compensated (assuming the crash did cause the injury) via a menu system, and PTSD comes out top in terms of value. Some 20 per cent of people in car crashes develop, unsurprisingly, “persisting travel anxiety” (degrees of fearfulness at travelling in a car, sometimes never getting in one again) and this often goes hand in hand with that other diagnostic gluepot, “whiplash syndrome”. But if you’ve just been a bit concussed, it’s highly unlikely you will have PTSD, because it is the intrusive memories, of say being trapped in a life-threatening situation, that seem to create the symptoms.

Jack was driving a post office van one misty morning when he collided head-on with a tractor. His van flipped on its side, he was trapped in it for 45 minutes while the firemen cut him out, and there was petrol and smoke everywhere. He tried to get back driving but panicked within a few minutes of sitting in the cab. He now cycles to work, does not do deliveries, and still jumps when he sees crashes or near crashes on TV, the road, or in dreams.

So, when is stress an illness? Is being “stressed” an understandable reaction when your elderly father dies or you suffer a miscarriage? These events have been happening ever since time began, so are we moderns somehow psychologically brittle, or is it quite right and sensible to look for healing and support in lives that Hobbes called “nasty, brutish and short”? Jack partially recovered with trauma-focused therapy, but made sense of his disorder as “concussion”, disliking the “mental” stigma of PTSD, which made him feel stressed.

Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity