Below are materials supplementing my story “The Post-Traumatic Stress Trap,” Scientific American, April 2009. (You can find the story here and my blog post introducing it here.) I’m starting with annotated sources, source materials, and a bit of multimedia. I hope to add a couple sidebars that didn’t fit in the main piece — though those may end up at the main blog, so you may want to keep an eye there or subscribe via RSS or Atom.
These are organized by story section, roughly in the order the relevant material appears. Quoted passages are from the article, with source material following.
• Harvard psychology professor Richard J. McNally’s, “Progress and Controversy in the Study of Posttraumatic Stress Disorder [pdf download],” Annual Rev Psychology 2003:229-52, As the story notes, the PTSD debate has been going on a while now — since the PTSD diagnosis’ creation in the late 1970s — but was fanned into heat in 2003 by this long review essay by McNally.
“This critique, which was originally raised by military historians and a few psychologists, is now being pushed by a broad array of experts…” These have appeared in many venues, but are presented together most comprehensively in Gerald Rosen’s (ed) 2004 Posttraumatic Stress Disorder: Issues and Controversies (also in a Kindle edition and in a special 2007 issue of the Journal of Anxiety Disorders.
• The 1990 National Vietnam Veterans Readjustment Survey, which surveyed over 1,000 Vietnam veterans in 1988 and found that 15.2 percent of them had PTSD then and 30.9 percent had suffered it at some point since the war, is a key document in the PTSD debate. It established the canonical rate estimates — but came under fire almost immediately for not confirming cases and for rate estimates some historians and diagnosticians thought unrealistically high. Its findings are summarized nicely here by Jennifer Price at the VA’s National Center for PTSD.
• In “The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods in Science in August 2006, Columbia University epidemiologist Bruce Dohrenwend and others, hoping to resolve the debate about the NVVRS, presented a reanalysis of the original NVVRS data. They found that the 1988 rate was 9.1 percent and the lifetime rate 18.7 percent — 40 percent drops from the original. Both sides claimed these findings proved their case. The PTSD establishment said the study supported the construct’s basic integrity by confirming most cases and showing a dose-response relationship. Critics said it proved that this seminal 1990 study had overstated Vietnam veterans’ PTSD rates.
• McNally’s “Psychiatric Casualties of War,” presented alongside Dohrenwend’s study in Science, stressed how sharply Dohrenwend’s revision cut the canonical rates established by the NVVRS — and argued that applying standard clinical defintions of impairment would cut the rates even further. The letters section that follows these pieces online gives a good picture of the academic dispute that flared up afterwards.
It was that exchange that drew my attention to the controversy; as editor of Scientific American’s Mind Matters blog, I solicited “The Costs of War,”, a pair of commentaries on the controversy — one by McNally, one by William Schlenger and Charles Marmar — that ran in Mind Matters in the fall of 2007. (Apologies for the post’s present formatting; it did not fare well in sciam.com’s later website overhaul.)
The flap in Science also led to a special, hastily called symposium at the November 2006 annual meeting of the International Society for Traumatic Stress Studies (ISTSS), which featured presentations by Dohrenwend; Terry Keane, a leading PTSD researcher and clinician at the Boston VA; then-ISTSS president Dean Kilpatrick, who is is a PTSD researcher and clinician at the Medical University of South Carolina; and — via an 8-minute presentation delivered via DVD, as he was in Europe on a previous commitment — Richard McNally.
I am hoping to secure ISTSS’s permission to place here an audio recording of the entire symposium. McNally’s video presentation, however, is viewable below.
(It was this presentation that led Kilpatrick to “essentially call McNally a liar,” as I said in the piece. Specifically, after McNally’s presentation aired, Kilpatrick took the floor (it was his turn) and said, “What I would like to do is swear Rich McNally in under oath to tell the truth, the whole truth, and nothing but the truth. If that were done, I think you’d have seen an entirely different presentation.” Kilpatrick later said he meant not that McNally lied, but that he failed to present the entire story — an odd thing to ask, as one observer noted, of an 8-minute presentation)
– A Problematic Diagnosis –
The fourth Diagnostic Statistical Manual (DSM-IV) provides the present diagnostic definition and guidelines for PTSD. This is updated somewhat from the original construct presented in the 1978 DSM-III.
On the reliability of memory: Elizabeth Loftus’s “Creating False Memories,” from Scientific American, Sept 1997, describes how malleable memory can be, as does Daniel Schacter’s Seven Sins of Memory. McNally’s book Remembering Trauma gives a fuller, more trauma-specific account of memory’s foibles. The “1990 study at the West Haven VA Hospital” that explored malleability of memories in veterans of the 1990 Gulf War is by “Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm, ” by Southwick and others.
On PTSD’s endocrinology:Rachel Yehuda’s “Biology of posttraumatic stress disorder,” from 2001, is one of several studies that found evidence of neuroendocrinological pecularities in PTSD; a 2004 study by Lindsey et alia’s is one of several that did not. On the search for correlates of PTSD detectable through brain imaging, see Francati, Vermetten, and Bremner, “Functional neuroimaging studies in posttraumatic stress disorder: review of current methods and findings,” 2006.
On the ties between trauma and PTSD symptoms,: see the Bodkin, Pope, and Hudson study described in the article, “Is PTSD caused by traumatic stress,” which found zero correlation between PTSD diagnoses made by symptom clusters and those made by trauma histories.
“The most effective PTSD treatment is exposure-based cognitive behavioral therapy” – This is asserted by many experts and authorities, including a comprehensive review by a National Academy of Science committee, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2007).
The symptom overlap between PTSD and traumatic brain injury is explored, among other places, in Hoge et alia’s “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq,” New England J of Medicine, 31 Jan 2008.
– Disabling Conditions –
“In civilian populations, two-thirds of PTSD patients respond to treatment.” from, e.g, “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” Am J Psychiatry 162 (Feb 2005) (Search for “Across all treatments”)
“…most veterans getting PTSD treatment from the VA report worsening symptoms until they reach 100 percent disability — at which point their use of VA mental health services drops 82 percent.” From VA Office of Inspector General, “Review of State Variances in VA Disability Compensation Payments” [large download] (Report VAOIG-05-00765-137), May 2005, p ix.
“… although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to over $4 billion annually.” from Veterans Compensation for Posttraumatic Stress Disorder, Institute of Medicine and National Research Council PTSD Compensation and Military Service, National Academics Press, 2005.
The innovative disability program used in Australia is described here.
– Two Ways to Carry a Rifle –
Finally, the conflicting studies of PTSD in US veterans of the Iraq and Afghanistan wars cited in the piece are Milliken et alia, “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War,” JAMA 14 Nov 2007, which found rates of around 20%, and Smith et al, “New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study,” BMJ 16 Feb 2008, which found rates of under 5%.