The Frontal Cortex

PTSD

David Dobbs has a really excellent and thought-provoking article on the diagnosis (and perhaps over-diagnosis) of post-traumatic stress disorder over at Sciam. The essential point is that it’s extremely hard to define a normal psychological response to traumatic events. Are nightmares normal? Is it normal to experience bouts of anxiety or depression? Dobbs profiles several big name psychiatrists who think that PTSD has become too vague for its own good, and is creating a generation of patients who are trapped in a self-fulfilling vision, in which the diagnosis actually makes it harder for them to get over the trauma:

Over the past five years or so, a long-simmering academic debate over PTSD’s conceptual basis and incidence has begun to boil over. It is now splitting the practice of trauma psychology and roiling military culture. Critiques originally raised by military historians and a few psychologists are now advanced by a broad array of experts indeed, giants of psychology, psychiatry and epidemiology. They include Columbia University’s Robert L. Spitzer and Michael B. First, who oversaw the last two editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, former chair of Johns Hopkins University’s psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard J. McNally, a leading authority in the dynamics of memory and trauma and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they assert, represent a faulty, outdated construct that has been badly overstretched so that it routinely mistakes depression, anxiety or even normal adjustment for a unique and especially stubborn ailment.

I thought this study was particularly interesting, as it illustrates how a psychiatric diagnosis can quickly get cemented into self-identity. The end result is a rewriting of our personal narrative, so that it becomes even more traumatic:

A 1990s study at the New Haven, Conn., VA hospital asked 59 Gulf War veterans about their experiences a month after their return and again two years later. The researchers asked about 19 specific types of potentially traumatic events, such as witnessing deaths, losing friends and seeing people disfigured. Two years out, 70 percent of the veterans reported at least one traumatic event they had not mentioned a month after returning, and 24 percent reported at least three such events for the first time. And the veterans recounting the most “new memories” also reported the most PTSD symptoms.

To McNally, such results suggest that some veterans experiencing “late-onset” PTSD may be attributing symptoms of depression, anxiety or other subtle disorders to a memory that has been elaborated and given new significance or even unconsciously fabricated.

“This has nothing to do with gaming or working the system or consciously looking for sympathy,” McNally says. “We all do this: we cast our lives in terms of narratives that help us understand them. A vet who’s having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense.”

Needless to say, this is a very controversial, delicate subject. On the one hand, it’s essential that the stigma of PTSD is removed, so that soldiers and patients don’t deny a real, medical condition. And yet, it’s also crucial that PTSD doesn’t become a catch-all condition, which leads to the neglect of other mental illnesses, such as depression or anxiety disorders. Over at his blog, David features links to many of his sources. And see Vaughan for even more.

Comments

  1. #1 SAH
    March 16, 2009

    “it illustrates how a psychiatric diagnosis can quickly get cemented into self-identity”

    It would be interesting to know if this observation could be demonstrated across a number of psychiatric disorders. Altered or erroneous thought patterns play a huge role in psychiatric disorders so it need not be controversial to suggest that changing the way one thinks about the condition can alter the condition itself. It seems to me that a similar self-fulfilling prophecy may be happening with the diagnosis (or over-diagnosis) of attention deficit disorder. The diagnosis traps patients into consistently believing that they are not as capable of focusing as others and perhaps making people believe that they are unable to learn in the same way as other people. The diagnosis sets them up for exactly this scenario, making it difficult to get past, even if the original basis for the diagnosis is no longer present. That said, I have not looked into the research on this and I am only basing this on personal experience teaching university students.

  2. #2 Anonymous User 1
    March 16, 2009

    I think the only suitable occasion for diagnosis of any mental illness is when it causes a great disturbance on daily life. I often see split-second hallucinations of little furry animals running across the floor and an occasional silhouette of a person walking around at night, but the lack of any serious damage causes me to avoid diagnosis. I can handle it just fine. Having read your article, I now feel especially fortunate about my decision to not seek professional help:
    Who knows what potentially dangerous medicines I could have been put on, let alone the likelihood of induced hallucinations caused by meditation on the question of why I see such hallucinations.

    On another note, I do have a particular instance of what arguably could have been considered PTSD–which I also have yet to bring up in any therapy sessions–rooted around my own Asperger’s Syndrome and terrible interactions with a love interest. The result: Last time I saw someone the same height with the same hair style on the train, I suffered terrible chest pains, had breathing troubles, and had gastro-intestinal problems later that night. I’m sure it makes me sound terrible next to the soldiers coming back from the Gulf War, but is nonetheless of some interest.

  3. #3 chryses
    March 16, 2009

    I’ve just reread the Iliad (Lattimore translation) – and it occurred to me that everyone there by modern clinical standards is probably in a state of PTSD. Makes for a hell of a read

  4. #4 Fiona
    March 16, 2009

    This is fascinating. As if we didn’t have enough of a mental health crisis in the U.S. as it is — but isn’t there a certain amount of suggestibility across the medical profession? Maybe more in psychiatry because the patients are already somewhat emotionally vulnerable.

    P.S. Are you coming to Washington D.C. on your book tour?

  5. #5 Afghanistan Veteran
    March 16, 2009

    This is like denying that The Holocaust ever occurred in Nazi Germany during WWII. Iranian President Mahmoud Ahmadinejad and other lunatics that call themselves leaders in this world are on the record in denying that between 9-11 million people were never exterminated in Nazi territory. Such assertations are captivating and interesting–but for the wrong reasons. Denying that 20-30% of all U.S. forces who have served in Iraq and Afghanistan are not afflicted by PTSD is outlandish! Maybe if those “leaders” cited in the article had ever seen a day of combat action in their lives, then perhaps that would quell their provocative comments that feeds the media’s thirst for “kicking a dog when he’s down.” This type of media attention is not helpful for anyone except the famous doctors who take pleasure in getting the penjulum to swing their way…at least for a fleeting moment. PTSD victims need help, support, and positive attention. Please do not unravel the positive efforts by America to support this credible and advancing psychological affliction. Our nation’s veterans gave their blood, sweat, and tears in support of YOUR freedom. It is criminal to abandon them now in their darkest hours…as hundreds of them decide that life is not worth living with PTSD.

  6. #6 Hannah Jordan
    March 17, 2009

    This is highly interesting. However, just a thought. Doesn’t it seem that the significance of an event can be later realized which had previously been overlooked? Could it be that the event wasn’t newly created or labeled as trauma to scapegoat the person’s current state, so much as it was identified as causal during introspection?

    All of this also makes me wonder if you have an opinion on the spontaneous resurfacing of repressed traumatic memories? (i.e., without the presence of a therapist)

  7. #7 Charles London
    March 17, 2009

    One of the key factors I see in the overuse of the PTSD diagnosis is a lack of sensitivity to the meanings of traumatic events in a cultural context.
    In a fascinating book psychiatrist Lynne Jones, “Then They Started Shooting: Growing up in wartime Bosnia” she looks at how cultural meanings matter in healing and how psychiatric disorders fit into the social contexts. I found similar patterns in my own research in the Balkans and in Africa. You cannot treat wartime trauma in a vacuum. The social context matters as much for a former child soldier in the DRC as for a Marine in North Carolina. A PTSD diagnosis too easily puts the pathology onto the individual, and onto individualized treatment, where a more holistic method could be effective, addressing religious, cultural, and societal meanings and healing mechanisms. Sometimes the meaning assigned to events by those suffering from trauma can surprise us. I know soldiers who claim they are untroubled by death they witnessed and caused, but who weep when they talk about a perceived slight they gave to an Iraqi child. Their concepts of guilt and innocence, justice and fairness, all contributed to what eventually manifested as pervasive memories, anxiety, sleeplessness, depression, etc.
    To help anyone heal from the traumas of war, we have to “treat” the meaning of war as well. As McNally notes “We all do this: we cast our lives in terms of narratives that help us understand them.” As long as a society makes war, PTSD is that society’s problem, not just the problem of the soldier who is suffering from it.

  8. #8 Afghanistan Veteran
    March 17, 2009

    Post-Traumatic Stress Disorder — 1st Person
    by Universal
    Thu Nov 15, 2007 at 04:22:02 AM PDT

    I can’t sleep, can’t feel

    Anything.

    Time passes in chunks now –

    A month passes for me

    Like someone else’s day.

    *

    Zombies don’t have rhythms;

    I go wherever my trance

    Takes me.

    Today I panic in a store,

    Where danger doesn’t lurk.

    Maybe if I stay awake, there

    Won’t be any nightmares tonight.

    But I can’t go without rest forever.

    It’s over, finished. So why am I

    Sweating? Why am I still afraid?

    *

    Today I saw most of my family

    For the first time in a year.

    Nothing felt real; everybody was a

    Stranger I am supposed to know.

    “Dissociation,” I think a doctor said.

    *

    No bumps, no bruises. No broken limbs.

    But my mind is shattered, along with my

    Soul.

    I don’t know how to tell you that, don’t

    Know how to put the genie back in the bottle.

    *

    When my emotions got shut off, I didn’t get to

    choose which ones I wanted to keep;

    They all left; they are all gone.

    And it feels like there is an invisible hand

    Keeping me frozen on my bed.

    *

    I used to care about how I looked, but now

    All I can think about is what I saw, what I

    Experienced; nothing seems to matter beyond

    That. I will do anything — anything at all —

    To keep from repeating that time.

    *

    I think more now, talk less. Months of numbness

    Are followed by a week of depression and tears.

    I am weak, frail, imperfect.

    Broken.

    My identity then irrevocably altered.

    *

    Do I want help, you ask.

    How are you going to help me?

    You weren’t there; you don’t know

    What I saw, what I did.

    What was done to me.

    *

    How does one ‘undo’ a scorched mind?

    Deep within me a voice mumbles ‘help;’

    But you’ll never hear that. All you will

    See is my distant, fixed stare and my

    Clenched jaw. I can’t take the chance.

    *

    How long will it be before you

    Give up on me? I know it’s coming;

    I’m resigned to my fate. Resigned to a

    Lot of things, actually. Here, in my bunker,

    In Hell.

    *
    *

    - Written after talking to a friend with PTSD

  9. #9 Afghanistan Veteran
    March 18, 2009

    Currently, 20-30% of U.S. military service members and veterans suffer from PTSD. If America reverts back to ignoring and mocking its psychologically traumatized, then this epidemic will turn into a pandemic overnight. For those who question the validity of PTSD…read this article http://www.globalissues.org/news/2009/03/10/842:

    Balkans: Images Bring the Wars Back
    Vesna Peric Zimonjic interviews war crimes prosecutor VLADIMIR VUKCEVIC (belgrade)Tuesday, March 10, 2009
    Inter Press Service

    The guns have been silent in the Balkans for more than ten years now, but their images and echoes continue to torment thousands, the first study on health among war veterans in Serbia shows.

    The two-year study among 2,399 soldiers in 40 municipalities shows that 84 percent of war veterans have chronic health problems, most frequently coronary and blood vessels diseases, and 54.1 percent have mental health issues.

    A third of veterans are fighting depression and alcoholism. The average age of the surveyed veterans is now 45.7 years.

    An estimated 400,000 Serbs participated in the 1991-95 wars in Croatia and Bosnia and the 1998-99 conflict in Kosovo. Serbia has a population of 7.5 million.

    ‘War veterans are a vulnerable section of the population,’ Serbian minister for work and social affairs Rasim Ljajic told reporters. ‘However, they are not socially recognised, and their needs were long neglected.’

    The public is deeply divided over Serb role in the wars. Many believe the wars were fought in defence of Serbs living outside of Serbia; others say the wars were a political mistake and a crime, and consider the veterans losers.

    ‘Their health problems are serious and are here to stay for a long time,’ psychiatrist Zeljko Spiric, co-author of the study told IPS. Dr Spiric is from the Military Medical Academy (VMA) that conducted the study together with the Medical Faculty in Belgrade and the Ministry for Work and Social Affairs.

    The study titled ‘Health Status and Health Needs of War Veterans in Serbia’ says the veterans surveyed spent on average seven-and-a-half months on the front. Some 52.5 percent fought in Croatia and Bosnia, 37.3 percent in Kosovo, and 10.2 percent in more than one conflict. All of them witnessed violent deaths, severe injuries and destruction of all kinds.

    Most have suffered from Post Traumatic Stress Disorder (PTSD), the anxiety disorder that develops after exposure to traumatic events. It is a severe and long emotional reaction to extreme psychological trauma.

    The survey shows that 8.8 percent of war veterans still suffer from PTSD, and that an additional 20 percent suffered from PTSD in the past.

    ‘PTSD is a serious problem, and the study showed it was rarely treated, with patients trying to overcome it on their own,’ Spiric said. ‘International studies show that a third of people suffering from PTSD overcome it on their own, a third seek treatment, while a third remains somehow stuck in it forever.’

    PTSD is a problem across the region. Last weekend, a war veteran in Croatia killed four people after a family dispute over a piece of land. His friends and relatives said he had suffered from PTSD for years.

    In Bosnia, an association of Muslim war veterans from the town Tuzla recently announced that 518 of its members had committed suicide since 1995, and that about another 300 had attempted it. The association asked the Bosnian public to pay more attention to PTSD and other problems of veterans.

    In Bosnian capital Sarajevo a local association of war veterans has reported that one in five of 55,000 demobilised fighters suffer from PTSD but were unable ‘to find adequate help and understanding in society for their problems.’

    According to the independent Centre for Non-Violent Action (CNA), about 800,000 people participated in wars in former Yugoslavia on all sides. The population of Croatia, Serbia and Bosnia is together around 16 million.

    ‘This is a deeply traumatised region, and the veterans are not the only ones who have suffered trauma,’ Nenad Vukosavljevic from the CNA told IPS.

    ‘There were at least three million civilians on all sides (Bosniaks, Croats, Serbs, and ethnic Albanians in Kosovo) who left their homes – some temporarily, some for ever. Some 200,000 people were forced into one or the other form of detention camps, and they have many problems they’re trying to overcome either on their own or with little expert help. This is a region where a lot has to be done in order to provide peace for minds and souls of people and bring reconciliation. And that will be a long process.’

    © Inter Press Service

  10. #10 Maureen McCormick
    March 18, 2009

    Jonah attributed “creating a generation of patients who are trapped in a self-fulfilling vision” to PTSD. Individuals who are treated promptly and effectively do not have to endure long-standing symptoms of this debilitating disorder, or, at the very least, the severity of their symptoms can usually be significantly reduced.

    The diagnostic criteria should not be considered in isolation; rather, a more complete picture – which might reveal the absence of that prompt effective treatment I mentioned for returning veterans, for example – should consider the origins, diagnosis, course of the disorder, treatment, and long-term prognosis, as well as comorbid clinical conditions like depression, anxiety, and substance abuse.

    I agree that we do not have a satisfactory understanding of a “normal” response to trauma. Some writers have suggested that the symptoms of PTSD are a normal response to trauma that should subside over time. The fact that in some individuals the symptoms do not subside may be because of a temporal barrage of traumatic experiences, such as in combat or domestic abuse, or because of some biological or psychological vulnerability of the individual.

  11. #11 Travis
    April 9, 2009

    I do appreciate Jonah Lehrer’s concerns regarding whether there is an over/under diagnosis of PTSD in returning combat veterans. My view, as a several times decorated combat veteran (Vietnam; 101st Airborne Infantry), is that most ‘actual’ combat veterans do return with at least some diagnosable psychiatric disorder. Yet, most of us recovered fairly well, with the help of friends and relatives who had similar experieces. Fortunately for me, my hometown was less than 40 miles from Fort Benning, Georgia. There were retired paratroupers all around me.

    Upon my return, former combat soldier’s shook my hand, bought me a drink, and reminded me that I was just like them. They stressed that, while I felt different now, that time and friends would foster a return to a feeling of normalcy (yet, they always laughed about the definition of “normalcy” for a former combat veteran).

    The point is that, it is what happens to you after you return to the “world” that counts the most in your recovery. Make an effort! If you know of a returned combat veteran, talk with them, buy them a beer, assure them that life can be normal again. Most importantly, direct them to other former combat veterans who now have settled and successful lives. Seeing a good example of recovery makes a great deal of difference.