My story in the April 2009 Scientific American story, “The Post-Traumatic Stress Trap“, just went online. Here’s the opening:
In 2006, soon after returning from military service in Ramadi, Iraq, during the bloodiest
period of the war, Captain Matt Stevens of the Vermont National Guard began to have a problem with PTSD, or post-traumatic stress disorder. Stevens’s problem was not that he had PTSD. It was that he began to have doubts about PTSD: the condition was real enough, but as a diagnosis he saw it being wildly, even dangerously, overextended.
“Clinicians aren’t separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems, or who are just taking some time getting over it,” says Stevens. He worries that many of these men and women are being pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.
The story presents the case — one being made by a growing number of experts in trauma psychology, psychiatry, epidemiology, and diagnostic science — that post-traumatic stress disorder, or PTSD, is a conceptually flawed diagnosis that is being markedly or even wildly overapplied, especially in veterans, with disastrous results.
The diagnostic criteria for PTSD, [these experts and critics] assert, represent a faulty, outdated construct that has been badly overextended so that it routinely mistakes depression, anxiety, or even normal adjustment for a unique and particularly stubborn ailment.
We are likely overdiagnosing PTSD in veterans by some 300 to 400%. This might be an academic matter if those veterans soon got better. But as the story describes, this flawed construct and overdiagnosis combines with an outmoded, counter-therapeutic Veterans Administration disability system to mire many of them in dysfunction and disability. The number of veterans receiving PTSD diagnoses and disability from the VA has skyrockted over the last decade1999, with a huge surge of new diagnoses in Vietnam Veterans (one that began before the conflicts in Iraq and Afghanistan) now being joined by growing numbers of veterans of the Iraq and Afghanistan wars. Yet the arcane disability system at the VA so discourages recovery that those receiving VA treatment — which is roughly similar to treatments that cure 2/3 of civilian patients — show no treatment effect at all. They’re no more likely to get better than are vets with PTSD not getting treatment.
“In the several years I spent in VA PTSD clinics,” one long-time VA PTSD clinician and researcher told me, “I can’t think of a single PTSD patient who left treatment because he got better. But the problem is not the veterans. The problem is that the VA’s disability system, which is 60 years old now, ignores all the intervening research we have on resilience, on the power of expectancy and the effects of incentives and disincentives.”
This is a real mess. We have a diagnosis whose fundamental mechanism — memory — has been shown to be spectacularly unreliable; a culture and a clinical discipline that reflexively sees any sign of distress as PTSD; and a disability system that actively discourages healing.
For many this will be an unattractive assertion. In the many months I worked on this story, running back to 2006, talking to scores of people, I saw a deep resistance to this proposal that war — which, make no mistake, is greatly stressfult and roubling, hell indeed — might not be as scarring as we like to think it is. I soon began to see that this was not just a medical and a bureaucratic problem but the expression of deep cultural conflicts and anxieties. American culture seems to have a deep investment in the the picture of war as irredeemably toxic, and in its experience as incurably damaging. “I don’t understand why they don’t all get it,” one acquaintance said to me.
I cannot stress this point enough: The point of the story, and the questioning of the PTSD construct and its application, is NOT to question the suffering of soldiers or others exposed to trauma. It’s to suggest that we often misunderstand that suffering and anguish, and that this leads us — especially with veterans — to respond in ways that often fail to help them and sometimes even do them harm. And the history of this diagnosis, and the deep resistance to confronting its problems, speak of not just a troublesome construct and a troubled bureaucracy, but of a culture struggling to come to terms with its participation in war.
The debate over the PTSD diagnosis and its application stands to affect the expenditure of billions of dollars, the diagnostic framework of psychiatry, the effectiveness of a huge treatment and disability infrastructure, and, most important, the mental health and future lives of hundreds of thousands of U.S. combat veterans and other PTSD patients. Standing in the way of a healthy reconsideration is conventional wisdom, foundational concepts of trauma psychology, and deep cultural resistance. As I put it in the story,
PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified, replicated, and finally perhaps become the thing itself — a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis.