I write on science, medicine, nature, culture and other matters for the New York Times Magazine, The Atlantic, Slate, National Geographic, Scientific American Mind, and other publications. (Find 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.[snip]
"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The diagnostic criteria for PTSD, [these experts and critics] assert, represent a faulty, outdated construct that has been badly overextended so that it routinely mistakes depression, anxiety, or even normal adjustment for a unique and particularly stubborn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.
"The PTSD Trap" at sciam.com. You may also be interested in a page of supplementary material and links I built.
Humanities & Social Science
Medicine & Health
Comments
Dave - this is tremendous! Thanks for the links to source material. It's rare to be able to read a great piece AND have immediate access to a writer's research. If that's not a great use of a blog, I don't know what is.
best,
David
Posted by: David | March 17, 2009 5:13 PM
Dave, I appreciated your article and your thoughts. I have worked in this field of PTSD as a researcher and clinician for 20 years and I fully endorse the idea that our diagnostic approaches need to be improved. I can also say that I am not surprised at some of the negative responses to your article by clinicians. I have also experienced, firsthand, hostility and anger from colleagues in the trauma field for publishing scientific data that did not fit with the then established "doctrine" in the PTSD field. As I read much of the "hate" mail sent to me by some peers in our field, I began to understand that many professionals working in the field of trauma do not distinguish between advocacy and science; or - if they do - they believe advocacy trumps science. I appreciated your article in that I believe the public has every right to demand that psychiatric diagnoses be evidence based; the public has the right to know our rates of error when making diagnoses. Our science is imperfect and when making diagnoses of PTSD in warfighters we professionals will make mistakes. We will be fooled by some people and believe them to have PTSD; we will miss the correct diagnosis in others. This is not cynical, this is a fact of clinical work. As you have stated, we do not ignore the suffering of patients; we simply do not yet have foolproof, objective diagnostic tools for establishing a diagnosis of PTSD. Given this, and the significant costs associated with chronic disability payments for PTSD, the pubic has every right to have a healthy debate on when, and for how long, disability compensation for PTSD should be awarded. We doctors, as a group, don't take well to having our diagnostic impressions questioned by laymen, but I believe our art and science improve through such a dialogue and debate.
CA Morgan III MD, MA
Forensic Psychiatrist.
Posted by: CA Morgan III | April 24, 2009 7:45 PM
And you are not going after the bipolar child trap why? Or the adult bipolar 2 and 3 trap? Or any of the other DSM diagnoses with faulty constructs why? Maybe because the VA doesn't have to pay benefits for any of these? Do you think you might, just possibly, be being used?
Posted by: Anonymous | May 3, 2009 10:53 PM
I've often had the disquieting sense that one of psychiatry's unspoken roles is to act out society's stigma against disapproved groups. It's a difficult observation to admit.
One point you are making here does affirm my disquiet.
"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."
This is a profound observation. I'm not so sure that well-meaning advocacy for suffering patients would be the only motivation behind the flood of PTSD diagnoses. There is a sense that PTSD, along with some other mental health diagnoses, functions as a kind of modern-day Scarlet Letter. In other words, the diagnosis itself is an expression of social disapproval - in this case, as you powerfully observe, a conflicted social disapproval of these wars.
As you note, the vets trapped in VA treatment never get better. There is a disturbing sense that this diagnosis functions as a subtler, updated expression of the social ostracism that Vietnam vets faced upon returning home.
The vets who do struggle with PTSD and are most disabled by it face the greatest harm from this conflicted cultural dynamic. They are socially isolated by their diagnosis, often in subtle ways, lose social support and livelihoods as other people back off, deferring to experts and clinicians, but are not afforded effective means to recover and cure.
Compliments on a brave and thought-provoking article.
Posted by: kim | December 16, 2009 5:44 PM