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.
I used to like many of his posts, but these days Bremner gets on my nerves a lot, particularly with his "Before You Take That Pill" rants against everything big pharma. (Or so it would seem.) He's also posted at least a couple of real howlers about cancer that I've been sorely tempted to apply some not-so-Respectful Insolence to, so off base were they.
Maybe the next time.
Quite a few of his comments were out of line... and the more personal attacks seemed a bit, well, childish.
The link to McNally's critique is broken and I was looking forward to reading it-- do you have a fixed link for it by chance?
This guy's a mental health academic and he's calling arguments "retarded"? What a joke.
Also, it's bad enough when Rush Limbaugh talks about "pointy-headed professors", but when a Professor does it, you have to ask yourself if he really deserves that title.
Neuroskeptic - Before You Take That Pill is Dr. Bremner's personal blog, it's not JAMA or Biological Psychiatry or a rebuttal article in Scientific American. Didn't you read Bora's treatise (or diatribe, depending on your point of view) on The Shock Value of Science Blogs? This is the first I've read Bremner's blog, and I rather liked the fact that he used the words "morons" and "idiots" -- I guess you can say whatever you want when you have over 200 publications! That said, referring to a rival's opposing statements as "retarded" isn't the best way to make a reasoned argument.
Dave - Your article and subsequent commentaries have been very thought-provoking, as have some of the critiques (e.g., those of Mike Dunford). Ultimately, what everyone wants is appropriate treatment (and adequate funding) for the returning veterans who need help.
Thanks for the comment, Neuroskeptic; I'm always happy to read anything from your (digital) pen. I'm not with you on this one, however. I did read Bora's "Shock Value of Science Blogs," and had and have a mixed reaction. The informality of the blogosphere bring many benefits. So does the loosening of conventions and idioms that comes with it. But that doesn't change the essentially empty and even counter-productive nature of ad hominem attacks and insults masquerading as arguments. Snark and insult don't make an argument. And sometimes they're a way of avoiding one.
Yes, Bremner can say whatever he wants, and he can do so whether he's written 200 papers or not. But his post wasn't put up as entertainment. He posted it to counter a set of arguments about a deeply consequential issue â the well-being and mental health of hundreds of thousands of combat veterans. But while Bremner pretended to argue the issues in this debate, he didn't. He raised them, threw snark, pretended the issues were settled, and moved on dismissively.
And many of his readers bought it. Look at the comments there. Some clearly now think â or in some cases they did before, and now have their opinions strongly bolstered by the rhetoric of the world's third-most-cited PTSD researcher â that the scientists and historians raising questions about the PTSD Dx and its overextension are really just trying to increase Big Pharma's grasp on psychiatry and American culture. This is a ridiculous, deeply irresponsible accusation to either make or encourage -- and Bremner's support of it in the comments (where he declines to put a check on it and at one point actively encourages it) has effect precisely because he's a scientist. He harnessed unfounded accusations about motives, false representations of positions, insults, and his own authority to baldly misrepresent not just his opponents' arguments but the nature of the debate.
Is this somehow enlightening? Is it constructive? I can't see it.
I disagree. Yes I would argue that I engage in a form of psychiatric populism, but I see nothing in the posts on PTSD about the argument that PTSD is a problematic diagnosis being related to a plot on the part of big pharma. The opinion that the DSM process has been manipulated for the profit of the pharmaceutical industry is not an opinion that I hold in isolation. Go look at their web site and the convoluted attempts to explain away the entrenched ties with the pharmaceutical industry. Then look at the committee and then go to pubmed and count the number of PTSD publications actually WRITTEN by people on their committee. As for the style used, I make no apology for writing in a way that is interesting, and if it is snark, so be it. If I offended anyone unjustly, I apologize, and certainly didn't mean to take on the WRITER of the piece in question.
That said I wrote a reply on my own site.
David: I think you've got me mixed up with the Neurocritic. I was the one defending you :)
Yes, it's true, I am the more sarcastic one...
Dave - I certainly agree with you that dismissive snark, instead of making reasoned arguments in reply to the important issues under debate, is not the way to further the dialog on PTSD diagnosis. Plus, Bremner's overall position can be viewed as inconsistent... he's critical of big pharma and his peanut gallery is the usual anti-psychiatry crowd, yet he does research in biological psychiatry. I do like some of his Photoshopped images, though.