Skip this post if you don’t want to read a writer responding point by point to a self-indulgent, insubstantial attack by a major academic.
I should say right off that I’ve long admired the more measured critiques that J. Douglas Bremner, a PTSD researcher and professor of radiology and psychiatry at Emory University, has offered about the pharmaceutical industry’s exploitation of the neurochemical model of depression. My regard for this work made his
critique of attack on my article about PTSD, “The Post-Traumatic Stress Syndrome,” all the more disappointing.
I’m not disappointed because Bremner disagreed with my article. I’ve received several critiques of “The Post-Traumatic Stress Syndrome,” both privately and in blogs and public letters, that disagreed sharply with my argument. I’m disappointed because while these other critiques have ranged from thoughtful and considered to and savage and threatening, none has been so self-indulgently insubstantial. The others offered genuine arguments or genuine reactions. Bremner — the third most-cited PTSD researcher on earth, as he’s happy to tell you — offered snark.
It would give me pleasure to merely insult Dr. Bremner back, but I think it more helpful for the discussion to actually address his points — a good term for them, as he seemed more interested in scoring rhetorical points than in actually dealing with the conceptual, diagnostic, and epidemiological issues raised in the article. To wit, with Bremner’s points — all of them that came even close to substance — quoted:
An example of one of [Dobbs's] (highlighted) retarded statements is “misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.” Since when does the VA want chronic disability?
I never said the VA wants chronic disability. Neither the institution nor its clinicians want chronic disability in their patients, and its extremely hard-working clinicians are trying hard to successfully treat PTSD. But they’re handicapped by a disability system that works against them, but which the VA administration apparently accepts because it’s politically expensive to speak of changing it.
Bremner then offers that
Not everyone develops PTSD, but for those who do, it is real, believe me, and it doesn’t matter what some pointy headed professors (or journalists) who are seeking attention with provocative statements say.
I’m won’t comment on Bremner lamenting about attention-seekers; that’s too easy. The real problem here is the statement that “for those who do [develop PTSD], it is real.” This is an argument? It’s a circle. It’s like saying those who get sunburn really have sunburn. I’m not saying that people who have PTSD don’t have PTSD. I’m saying that some people who are suffering other problems are mistakenly diagnosed with PTSD — with the result that some people we SAY have PTSD don’t actually have it. It’s absurd to hear a doctor argue this can’t be so. Millions are diagnosed with PTSD, which is terribly easy to confuse with depression, and every diagnosis is correct? We’re talking scale here. Bremner wants you to think we’re talking exists versus not-exists.
Dobbs taps into an underbelly of academic psychiatry that looks for approval from others by trying to look like they buck the trend about trauma and PTSD, with the basic message that PTSD is an overblown diagnosis created by a bunch of cry babies.
More insults substituting for arguments. And where’d we get “cry babies”? If you read the critiques, you’ll find that “PTSD is really cry babies” is not the argument being offered. The argument being offered is that we are mistaking other forms of genuine distress for PTSD. To speak of cry babies is to infantalize the entire debate.
Next up, Bremner chastises psychiatrist and researcher Simon Wessely for suggesting that
we should pay attention to the role of secondary gain (e.g. getting disability benefits) in the development of PTSD. Big deal, some people want disability payments, does that mean PTSD is a bullshit diagnosis? I don’t think so.
Again Bremner builds and whacks a straw man. Wessely is arguing not that “PTSD is a bullshit diagnosis” but that the VA’s perverse disability incentives (as described in my article), might in some cases shape patient and clinician behavior. It’s odd that Bremner, having written extensively on how money, gifts, and other incentives have influenced psychiatrist’s prescription practices, should argue that financial incentives never sway patient nor clinician behavior.
Next up: DB tries to convince his readers that Richard McNally’s best evidence for PTSD’s diagnosis is drawn from a study of the psychology of alien abductions:
[McNally] gets a lot of mileage out of pointing to his study showing that people who think they were abducted by aliens have psychophysiological responses that look like PTSD as evidence that PTSD is a bs diagnosis (if those aliens did that to my rectum I think I would have PTSD too, wouldn’t you)?
Readers who examine McNally’s most comprehensive critique of PTSD [pdf download] will find that of its 17 pages, one sentence — noting that people who believe they’ve been abducted have false memories — alludes to that phenomenon. No matter; Bremner highlights this — this weirdest thing he can find — so he can make a rectum joke.
The rest is little better.
I do agree with Bremner on one point: He is right to complain that the DSM-V process is closed, secretive, and quite possibly dominated by a status quo perspective. But why is he claiming in his post title, and implying elsewhere within it, that he is “Striking Back at [the] Psychiatric Establishment on PTSD”? He’s not attacking the psychiatric establishment here; he’s striking at the very people (and one person who wrote about them) who are questioning the PTSD psychiatric establishment. Bremner compains he’s locked out of the DSM-V’s PTSD group. So are McNally and virtually all his fellow PTSD skeptics. Yet Bremner doesn’t mention this, and it certainly doesn’t seem to bother him. It just bothers him that he wasn’t invited.
This is pretty deep irony. Well, no it’s actually pretty shallow — shallow, really, that Bremner, who has railed so effectively about the pharmaceutical industry’s overextension of a paradigm based on increasingly tenuous evidence, should greet so cynically and glibly an evidence-based argument that something roughly similar — and I am not equating the PTSD establishment with pharma here, but merely noting one paralle dynamic– might be happening in his own field. The two fields differ in many ways. But in both, evidence is growing that a shaky model of mental disorder is being overapplied.
Bremner rails constantly about that dynamic in the treatment of depression. Yet when it comes to his own field, he acts as if such a thing is beyond imagining.
NB, 3/24/09: Soon after I posted a v of the above complaint as a comment at Bremner’s blog, he replieed there with a more reasoned and civil response. This was helpful. And though I’m puzzled that I was able to morph in just a few minutes from a “pointy-headed journalist” to “a fine journalist” (unless Bremner’s saying I’m both), I appreciate his gesture and more constructive tone.