The combat veteran as sheepdog-turned-wolf: PTSD & medicalization

A few weeks ago, Matt Stevens, the National Guard captain and medic who served in Iraq and whom I mentioned in my Scientific American article, "The Post-Traumatic Stress Trap, wrote me an email about the social unease he often encountered when he showed any behavior that might remind people he had served in Iraq -- a greater seriousness, an impatience with petty concerns or inefficiency, or even just talking about the place.

I have begun to think of military PTSD as to some extent a civilian problem rather than a soldier problem. To expand slightly here; civilians/politicians send soldiers off to war. They do their jobs. Which are sometimes horrifically violent, living in a world where violence, both by and against soldiers, is a norm, among people who differ in culture, language, and many beliefs, and then the soldiers return home to the US. The civilian population expects them to come home and re-integrate as if they never experienced these things. They want soldiers to become "normal" again. When soldiers fail to normalize to the satisfaction of whatever civilian population is judging them, they are labeled with PTSD. ....

My analogy that I use to explain this in a few sentences is that; a bunch of sheep dogs are sent away to another land to protect the sheep from wolves. While there they essentially become wolves in order to survive. They return to the herd of sheep as wolves but are expected to live as sheep dogs again -- or in the case of National Guardsmen, they are expected to become sheep.

Given the sensitivity of this subject, I should note that Stevens stressed both in that email and later over lunch, when he articulated this again, that he does not mean to say no one gets PTSD, for he knows soldiers who have. Rather he's saying that the culture he's returned to, in its unease with the changes soldiers go through, seems overready to declare those changes signs not merely of change but of pathology.

I thought of this when I got this comment from Neuroskeptic on an earlier post about my PTSD story:

The issue of psychiatric overdiagnosis goes well beyond PTSD, I think. Many people would also argue that depression, ADHD, and (increasingly at the moment) bipolar disorder are overdiagnosed, in both adults and children.

The problem, as you've discovered, is that it's much easier to diagnose someone than to de-diagnose them. Saying that someone who has problems is ill is easy, and often seems compassionate: "Your kid's not a bad kid, he's a good kid with bipolar" .... I think this is one of the main reasons why diagnoses tend to expand, and never contract.

What we need, I think, is a recognition that someone can have serious problems that require professional help without that meaning that they need a medical diagnosis.

Neuroskeptic has a good point. I would add that we also sometimes medicalize -- that is, give a diagnostic label and purely medical response to -- behaviors and emotions that rise as much from social problems as from inner pathology. This can and does happen with, say, kids who are distressed because their parents are divorcing, and who act out accordingly, and -- when the parents can't seem to create a more reassuring environment -- are diagnosed with ADHD or oppositional defiant disorder. This isn't to say every such diagnosis happens this way; but some do, and when that happens, we're substituting a medical diagnosis for a familial or social problem.

It seems clear to me that this happens too with many returning veterans, some of whom face extremely difficult issues re-entering civilian life: Their families just want them to be the same as they were before (as they themselves may wish they could be); they may face intense challenges finding suitable work, or work at all; their departure from the military may rob them of their circle of friends, so that they find themselves socially isolated far too many of them find themselves without access to health care; and they do not get nearly enough assistance finding work, training for work, or getting an education as they should (The the education front, thank goodness, is being addressed by the recent update of the GI Bill. But we have not provided the employment, business, and training assistance we should for soldiers who don't go to college.)

In short, many vets face problems that can quickly produce or aggravate anxiety, depression, insecurity, or any tendency toward substance abuse or angry outbursts. Do we have a diagnosis for that? No.We offer some programs to help them but not nearly enough. But if they walk into a clinic, they'll likely be told they have PTSD.

Meanwhile, society itself -- a culture that has managed to put our current wars very much out of sight and out of mind -- seems to want to put a PTSD label not just on those who really have it (who do need a medical response as well as a broader societal one), and not just on those who don't have PTSD but who are struggling to make the transition, but even on high-functioning, perfectly health veterans like Matt Stevens.

Why is this? I think it's because we so deeply want to see these returning soldiers just resume their old citizen selves without a bunch of fuss; and at the same time, we want to express sympathy with them in the way we seem most comfortable, which is to tell them we think they're sick, and treat them accordingly. This is much easier -- and casts us as sympathizers and healers rather than people impatient with war and guilty for starting one. We don't want to know that they face serious challenges caused by societal rather medical weaknesses. We don't want to see any sign in them of the war they've returned from. We don't want to face the fact we've sent them off to a war we declared -- and two-thirds of us cheered for -- based on faulty evidence. When they come back changed -- and everyone who goes to war is changed -- we don't want to see it, or acknowledge it for what it is. We don't want to see that a stupid decision we made as country forced you men and women to grow up so fast, to become so serious, to return to a place eager to forget the most transformative force in their lives.

We don't want to see these changes. So we classify them not as a natural but serious thing that happened because of stupid but serious mistake we made, but as pathology.


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Your friend has been changed for life by what he has been though. My husband was too. (Robert Mason) One of the things that helped him was to write his book Chickenhawk. It did not cure him, but it helped. I knew him before he went to Vietnam, so I know he was not weak or weird, but he came home with PTSD when it didn't have a name and was not supposed to exist. He never got anything but pills at our VA and the chance to sometimes be told by some inept psychiatrist to "Watch the flowers grow and the wind in the trees and you won't have such a bad time." If he could have done that he would have.
We lived through a long period of pain and despair (67 to 82) before we came across the pamphlet "Readjustment Problemns Among Vietnam Veterans" by Jim Godwin, Psy. D. which described our lives. I wrote a book that has helped many vets and their wives (Recovering from the War)and I still keep my hand in studying and writing about post-traumatic reactions. There is an article called "Home from War" on my website.
I was shocked to see you accepting the idea that one can generalize from a study about treatment seeking civilians who can afford McLean Hospital to treatment AVOIDING veterans and military members.
I was also sad to see you fall for the insanity of the study of Gulf War vets making up worse things on re-interview if they had PTSD. Common sense and a knowledge of human nature should tell you that they lied at the first interview. They had just made it back and they were FINE and no guy in a white coat was gonna hear anything else from them. Then after a few years, because the symptoms don't go away, they get more honest... It boggles my mind every time someone quotes that study or the similar one on the Somali vets. How can you think they would tell someone in a white coat what happened? I said this to one of the principal investigators in the Somali study, and he said to me, "Oh, they know who I am." (He helped found the vet centers). Believe me, no soldier knows who he is, and they do not trust psychiatrists or psychiatry, with good reason.
I also need to point out that Elizabeth Loftus did not have an easy time creating false memories. She only succeeded when the parent also told the kid it had happened. Her very unscientific (as in ignoring evidence) ideas about traumatic memories and false memories can never be proved because you can't rape and torture people in the lab. You might try reading Freyd, J. J. (1996). Betrayal Trauma: The Logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.
The people who want guys to be fine and not have post-traumatic reactions are idiots. The reactions cause a great deal of disorder in life.
I don't like that you have to be diagnosed to get help in this country, but I do know that over-diagnosis of PTSD is not the real problem, because most people who have it are never diagnosed. They never go for help. They do think they are nuts, though, and their families are suffering.
I think it is normal to have PTSD after you have been to war. When they first reported on the NVVRS at a meeting of the ISTSS, I think I was the only person who noticed the most pertinent statistic: of those in the study who had "high war zone stress", 66% had had PTSD at some time since they got home, and 33% still did... What's more two VA studies on WWII combat vets and WWII POW's who were in the VA for medical reasons found that over 50% of both populations had undiagnosed PTSD at some time in their life and something like 29% still did. That is why they started screening for it.
It is normal to be affected by what you live through.
Disorder follows war.

The issue of medicalization goes beyond discomfort with returning veterans, as was pointed out above. One interesting treatment of this social phenomenon is found in a short book entitled "The Careless Society: Community And Its Counterfeits." The author, John McKnight, argues that the accelerating atomization of society into nuclear families and finally isolated individuals has eliminated larger social structures that facilitated coping with tragedy and grief, reintegration into the group,and so on. With nothing left to provide that sort of resilience the response has been to medicalize all sorts of human experiences. If someone you know dies violently (or unexpectedly, or at all), you need a grief counselor. Sitting shiva (in my Jewish tradition), or attending a wake (in the Irish) as a way for the community to help people process the experience and move beyond it are becoming increasingly rare. Normal human behavior, which I think is pretty broad, is defined more and more narrowly, and everything falling outside of those artificially narrowed norms is defined as abnormal (duh) and requires professional help. An entire professional class has grown up to service these (some would say artificial) needs, and resistance is taken as an indication of just how much professional help is really needed. An interesting read, if anyone is interested.

By Immunologist (not verified) on 27 Mar 2009 #permalink

I think Patrice Mason speaks the truth when she says that:

I do know that over-diagnosis of PTSD is not the real problem, because most people who have it are never diagnosed. They never go for help.

But PTSD could be both over-diagnosed and under-diagnosed. Depression, for example, is almost certainly over-diagnosed in many countries. People are diagnosed and treated for depression when in fact they are just suffering from normal stress or sadness. But there are also many people who do suffer from clinical depression, and need treatment, but don't get it. I used to be one of them - until I eventually sought help. No matter how broad the criteria for a diagnosis are, someone won't be diagnosed unless they seek help.

Thanks for the comments. Neuroskeptic, you hit upon a key point: It is perfectly possible that we can overdiagnose a condition -- that is, mistakenly give diagnoses of Condiction A to a lot of people who have something else -- while also missing and failing to treat people who actually have Condition A. If you're mistakenly making 100,000 Condition A diagnoses while missing 50,000 genuine Condition A cases, you're still overdiagnosing Condition A, even though you're missing a lot of people who have it.

The evidence is quite strong that this is occuring with PTSD. We are giving PTSD diagnoses to a lot of people who don't have it. And -- partly because the PTSD treatment system is thus so overwhelmed (and also because patients don't necessarily come forward) -- we're also missing genuine cases.

If the VA, the DOD, and the APA can clean up the PTSD diagnosis and remove the perverse health-care access and disabilty-benefit structures that so grossly encourage overdiagnosis of PTSD, it'd be a lot easier to give all vets the proper treatment for what truly ails them, rather than what bureaucratic structures and cultural forces seem to prefer.