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

Dueling experts: Farcical spectacle that should be abolished?

Dueling psychiatric experts are an appalling farce and "a travesty of the profession and the law," according to an op-ed in yesterday's Boston Globe.

The opinion piece comes in the wake of the high-profile sanity trial of Christian Karl Gerhartsreiter (GAYR'-hahrtz-ry-tur), a German con artist who used a string of fake identities (including "Clark Rockefeller") to establish himself in wealthy circles in New York, Boston and Los Angeles. Last month, a jury rejected the defense theory of insanity and convicted him in the kidnapping of his 7-year-old daughter. He was sentenced to four to five years in prison.

Psychiatrist Stephen Bergman (who writes fictional parodies of psychiatry under the pen name Samuel Shem) critiqued the various experts for, respectively:

• charging too much money (one expert got $10,000, which ain't a whole lot these days)
• giving opinions on TV ahead of the trial
• spending only 2.5 hours with Gerhartsreiter
• not having prior experience testifying in court

The prosecution's expert, psychiatrist James Chu, diagnosed narcissism and sociopathy. He testified that Gerhartsreiter exaggerated his symptoms and knew what he was doing was wrong.

Two defense experts, forensic psychologist Catherine T.J. Howe and forensic psychiatrist Keith Ablow, a Fox News commentator, both testified that Gerhartsreiter suffered from delusional disorder (grandiose type) and narcissistic personality disorder, and was insane when he fled to Baltimore with his daughter during a custody dispute.

Bergman saved most of his vitriol for the DSM diagnostic enterprise, which is so tainted by profiteering and bias that a "circus atmosphere" is almost inevitable when it is brought into court:

"The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the 'Diagnostic and Statistical Manual.' … If psychiatric diagnoses and treatments have an element of fuzziness, how could doctors paid by one side or the other not come up with a diagnosis wanted by their employer?"

His solution?

Do away with experts that are paid by either side. Instead, have a neutral panel whose opinions are binding.

Bergman makes some legitimate points, especially about how flaws in the system of psychiatric diagnosis impact forensic cases. (See my new article on this topic HERE.) And, some of his criticisms of these particular experts may be legitimate (although, ironically, he got their roles backwards*). Indeed, the defense appeal argues that the government's expert was unqualified and applied the wrong legal standard for criminal responsibility.

But, overall, Bergman misses the forest for the trees.

The adversarial system entitles each side to present its best case in court. To foreclose that option just because experts sometimes differ would be fundamentally unfair. After all, as a colleague of mine put it, disagreements are not unique to psychiatry: "Engineers routinely disagree in court over the cause of a collapsed bridge, just as chemists disagree in court over the nature of a substance."

And just because they disagree, that doesn't mean that the experts are dishonest or lack integrity, as Bergman implies.

Unfortunately, high-profile insanity trials like this one skew the perceptions of the public and pundits like Bergman. In reality, insanity (which varies by jurisdiction but generally requires that the defendant did not know the difference between right and wrong) is rarely invoked as a defense, and is even more rarely successful. One eight-state study found that the defense was used in less than 1% of cases, and was successful only about one-fourth of the time. In 90% of the successful cases, the offender had been psychiatrically diagnosed prior to the crime.

Even when the defense is invoked, the "dueling experts" phenomenon is rarer than people think. The vast majority of insanity cases are resolved behind the scenes because the experts for both sides are in substantial agreement. In such cases, a trial -- with its attendant publicity -- never takes place. (See Before and After Hinckley: Evaluating Insanity Defense Reform.)

Another public misconception is that successful use of the insanity defense allows people to "get off" for the crime. In reality, most insanity acquittees are sent to locked state hospitals that look very much like prisons. They often spend more time locked up than if they had been convicted of their crime.

Bottom line: A defendant's right to the best possible defense should not be foreclosed just because of errors or hype in the rare celebrity case.

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* Bergman wrote: “For the prosecution: one psychiatrist, famous from Fox TV and psychiatric thrillers, was paid $10,000 for his expertise as part of an 'insanity defense,' testimony that was challenged by his offering opinions about Rockefeller on TV in advance of the trial; a prosecution psychologist agreed with his diagnosis, basically of a narcissistic character who was 'delusional' -- that is, insane. For the defense: a psychiatrist who had seen the accused once for 2 1/2 hours and had never before testified in court came up with the diagnosis of narcissism and sociopathy -- that is, not insane." In reality, the two experts he said were prosecution witnesses were actually defense-retained, and the expert he labeled as "for the defense" was actually the prosecution's.

Diagnostic reification in court

Good psychologists think in shades of gray. But the inside of a courtroom is painted black and white. One side wins, the other loses. Here, I discuss an ethical dilemma posed by this disjuncture between scientific uncertainty and the law's pull for absolutes. This dilemma concerns diagnostic labeling in court.

So begins my new "Ethics Corner" column in the July/August issue of the California Psychologist, available HERE.

Diagnosing Michael Jackson

You have probably seen some of the postmortem efforts to pin psychiatric diagnoses on Michael Jackson, in the wake of his untimely demise. It's a pedantic enterprise, with no shortage of diagnostic contenders: Pedophilia, anorexia, body dysmorphic disorder, and a dual diagnosis (that's a psychiatric disorder plus a substance abuse disorder). Most recently, we've got J. Michael Bailey, the man transgender activists love to hate, wading into the fray with erotic identity disorder and a paraphilia called autogynephilia.

"Whoa, folks! Not so fast!" say others.

Calling for a little reflection on this whole paraphilia-hebephilia-whateverphilia diagnostic craze is Scientific American columnist Jesse Bering, a research psychologist at Queen's University Belfast:

Would you really have wanted Oscar Wilde euthanized as though he were a sick animal? Should André Gide, whom the New York Times hailed in their obituary as a man 'judged the greatest French writer of this century by the literary cognoscenti,' have been deprived of his pen, torn to pieces by illiterate thugs? It's complicated. And although in principle we know that all men are equal in the eyes of the law, just as we did for Michael Jackson during his child molestation trials, I have a hunch that many people tend to feel (and uncomfortably so) a little sympathy for the Devil under such circumstances.

I highly recommend Bering's muse, "Pedophiles, Hebephiles, and Ephebophiles, Oh My: Erotic Age Orientation" (which, by way of full disclosure, cites yours truly).

DSM-V: Urgent warning and call to action

Predicting a flawed manual that "will haunt psychiatry for many years to come," the chair of the DSM-IV Task Force has issued an urgent call to the American Psychiatric Association to change course on its revision process for the Diagnostic and Statistical Manual of Mental Disorders (DSM) before it is too late.

Allen Frances' strongly worded appeal in the Psychiatric Times predicts the DSM-V -- scheduled for publication in May 2012 - will usher in a flood of new mental disorders that will medicalize normality, producing "a bonanza for the pharmaceutical industry but at a huge cost to the new false-positive patients caught in the excessively wide DSM-V net."

"In my experience, experts on any given diagnosis always worry a great deal about missed cases but rarely consider the risks of creating a large pool of false positives—especially in primary care settings. The experts' motives are pure, but their awareness of risks is often naive. Psychiatry should not be in the business of inadvertently manufacturing mental disorders."

Frances makes special note of the potential for "unpredictable and consequential" unintended consequences in forensic settings:

"Years after the DSM-IV was completed, we learned about the enormous unintended impact of a seemingly slight wording change we made only for technical reasons in the section on paraphilias. A misreading of our intentions in making the change had led to great confusion -- with forensic evaluators using the diagnosis of paraphilia not otherwise specified to justify the sometimes inappropriate lifetime psychiatric commitment of rapists who had no real mental disorder."

This prediction is prophetic in light of current lobbying efforts by the paraphilias subworkgroup to create a new "pedohebephilic disorder" category that could vastly expand sex offender diagnosis, proving a bonanza for the sexual offender civil commitment industry.

Frances is highly critical of the "inexplicable secrecy and the lack of openness to outside influence and criticism" surrounding the DSM-V revision process.

"Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences…. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls."

He is urging the American Psychiatric Association to create an external committee to review what is going on with the DSM and make recommendations to avoid serious negative consequences in the future.

Frances' important article, A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, is available HERE.

An accompanying Q&A, DSM-V Badly Off Track, is HERE.

Some of my related blog posts are HERE.

NPR: "High court rulings change legal landscape"

NPR Morning Edition Report by Nina Totenberg

The Supreme Court has released three significant decisions:

• The rights of criminal defendants to cross examine crime lab analysts

• When federal courts may act to enforce federal mandates on the states

• When, if ever, school officials may conduct strip searches of students for drugs

The rulings will have far-reaching consequences.

CLICK HERE for a written summary or to listen to a 5-minute NPR report.