July 17, 2009

PTSD: Pandemic like swine flu?

Just about every week, an attorney calls me wanting a client evaluated for PTSD. Virtually everyone in forensic practice has probably seen highly dubious diagnoses of PTSD, deployed for obvious secondary gain. But even outside the courtroom, our cultural obsession with trauma and victimization may be creating an epidemic of wrongful PTSD diagnoses, at a public cost of billions of dollars.

Such is the controversial position that is "splitting the practice of trauma psychology and roiling military culture," writes science writer David Dobbs in a lucid analysis in Scientific American Magazine.

Critics contend that both the larger American culture and the medical culture within the Veterans Administration (VA) reflexively regard all bad memories, nightmares, and other signs of distress as evidence of Posttraumatic Stress Disorder (PTSD). Returning soldiers are encouraged to create a "trauma narrative" to explain their problems. This, unfortunately, gives them monetary benefits in the short term, but sucks them down a dead-end path that will mire them in chronic disability and "a psyche permanently haunted."

"This has nothing to do with gaming or working the system or consciously looking for sympathy," says Harvard University psychologist Richard J. McNally, an authority on memory and trauma and a leading critic. "We all do this: we cast our lives in terms of narratives that help us understand them. A vet who's having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense."

Unlike most psychiatric diagnoses, PTSD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) must be caused by a traumatic event. However, the tie is really to the memory of an event. And, as research shows, memory is highly unreliable and malleable: "We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit."

Unfortunately, the fuzziness of the PTSD construct makes it very hard to distinguish from other disorders with overlapping symptoms, including depression and traumatic brain injury, increasingly common among soldiers returning from Iraq.

And giving treatment for PTSD (typically, controlled exposure to trauma triggers) may make other problems worse:

"If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT [cognitive behavioral therapy], you're going to miss the boat," McNally says. "You're going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events."

Critics such as McNally are calling for revisions in the upcoming edition of the DSM, due out in 2012, to better distinguish depression, anxiety and phobia from true PTSD.

They are also calling for an overhaul in the VA's disability system, to "remove disincentives to recovery and even go the extra mile and give all combat veterans, injured or not, lifetime health care."

Such changes, of course, are unlikely, given our entrenched "cultural obsession with trauma."

Interestingly, military historian Ben Shephard posits that the PTSD diagnosis benefits American society by absolving it of moral responsibility for the Vietnam war. As Dobbs summarizes it, American society gained:

"a vision of war's costs that, by transforming warriors into victims, lets us declare our recognition of war's horror and absolves us for sending them for we were victimized, too, fooled into supporting a war we later regretted. We should recognize war's horror. We should feel the soldier's pain. But to impose on a distressed soldier the notion that his memories are inescapable, that he lacks the strength to incorporate his past into his future, is to highlight our moral sensitivity at the soldier's expense."

Shephard, in his book A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century, is not arguing that PTSD does not exist. Indeed, "shell shock" or "battle fatigue" was recognized long before PTSD became a formal diagnosis in the wake of the Vietnam War. Rather, he argues that the construct overemphasizes permanent psychic damage when resilience is actually more common among humans exposed to traumatic stress.

It is this capacity to recover that is lost when combat veterans (and others) are encouraged to take on the identity of chronically broken men and women.

Photo credit: "Helplessness" by Dr. S. Ali Wasif (Creative Commons license)

Hat tip: Tim Derning

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