Below find #4 in my Best of Neuron Culture Moving Party — a run of 10 of my favorite posts from the blog’s tenure at WIRED, posted as I moved the blog here. This post, “The PTSD Trap,” is a substantially longer version — call it the director’s cut — of a feature I published in Scientific American in early 2009. The article looks at evidence that we’re wildly overdiagnosing PTSD in the United States, particularly among veterans. Though the evidence for this is substantial, this was a very difficult piece to place in the mainstream media, and I’m still impressed and grateful that Scientific American ran it. (They did so enthusiastically. When I warned them it was controversial, the answer was, essentially, “That doesn’t worry us. The science is solid. We’re happy to run it.”) This evidence that we’re overdiagnosing PTSD in the US continues to go largely ignored, however, and fiercely resisted (see the comments on the original post, for instance), even as we struggle to help veterans of our recent wars re-enter civilian life, and many people didn’t have access to the piece behind the SciAm paywall. I ran the piece here at Neuron Culture in early 2012 at the urging of a young Army doctor, who thought this perspective needed to be spread more widely — yet another opportunity provided by the freer media ecosystem that blogs play such an important role in.
The PTSD Trap
Originally posted 22 March, 2012
from reporting done in 2007, 2008, and 2009
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Author’s note: This story originally appeared in Scientific American, April 2009. As the suggestion of U.S. Army medical student Petulant Skeptic (see below), I am re-publishing it here, open access, because the return of veterans of the Iraq and Afghanistan wars renews the importance of examining our ideas about how most soldiers react to combat. As noted in Petulant Skeptic’s preface below, the U.S. press and populace seems all too ready to attribute every trouble suffered or made by combat veterans a sign of searing trauma. We can do better. – David Dobbs
Preface by Petulant Skeptic, U.S. Army.
As America rushes to understand SSgt Robert Bales’ alleged murder of 16 Afghan civilians there will be, and already is (see: here, here, and here), a renewed interest in Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) among those who have served in Afghanistan and Iraq. While the media have been more restrained in blaming Bales’ purported PTSD or TBI than they were with Benjamin Barnes—the Mt. Rainier Shooter three months ago (see here for a recap)—there continues to be precious little examination of PTSD’s prevalence and persistence among veterans. As a soldier, a medical student, and someone interested in these “invisible” injuries of war I find myself often paraphrasing David’s article in order to elucidate the confusing nomenclatures, conflated diagnoses and backwards incentives of how the Department of Veteran’s Affairs handles PTSD. Rather than rush to understand Bales, let’s use this time to let the facts of that case settle and resolve — and take this as an opportunity to reexamine a broken system for the good of those who suffer below the radar of national calamity.
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The Post-Traumatic Stress Trap
by David Dobbs
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, he knew, but as a diagnosis he saw it being dangerously overemphasized.
Stevens led the medics tending an armored brigade of 800 soldiers, and his team patched together GIs and Iraqi citizens almost every day. He saw horrific things. Once home, he had his share, he says, of “nights where I’d wake up and it would be clear I wasn’t going to sleep again.”
He was not surprised: “I would expect people to have nightmares for a while when they came back.” But as he kept track of his unit in the U.S., he saw troops greeted by both a larger culture and a medical culture, especially in the Department of Veterans Affairs (VA), that seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.
“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.
Stevens, now a major, and still on reserve duty while he works as a physician’s assistant, is far from alone in worrying about the reach of PTSD. Over the last five years or so, a long-simmering academic debate over PTSD’s conceptual basis and rate of occurrence has begun to boil over into the practice of trauma psychology and to roil military culture as well. Critiques, originally raised by military historians and a few psychologists, are now being advanced by a broad array of experts, including giants of psychology, psychiatry, diagnosis, and epidemiology such as Columbia’s Robert Spitzer and Michael First, who oversaw the last two editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, the longtime chair of Johns Hopkins University’s psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard McNally, a leading authority in the dynamics of memory and trauma, and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they 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.
This quest to scale back the definition of PTSD 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 reform is conventional wisdom, deep cultural resistance and foundational concepts of trauma psychology. Nevertheless it is time, as Spitzer recently argued, to “save PTSD from itself.”
Casting a Wide Net
The overdiagnosis of PTSD, critics say, shows in the numbers, starting with the seminal study of PTSD prevalence, the 1990 National Vietnam Veterans Readjustment Survey. The NVVRS covered more than 1,000 Vietnam veterans in 1988 and reported that 15.4 percent of them had PTSD at that time and 31 percent had suffered it at some point since the war. That 31 percent has been the standard estimate of PTSD incidence among veterans ever since.
In 2006, however, Columbia University epidemiologist Bruce Dohrenwend, hoping to resolve nagging questions about the study, reworked the numbers. When he had culled the poorly documented diagnoses, he found that the 1988 rate was 9 percent, and the lifetime rate just 18 percent.
McNally shares the general admiration for Dohrenwend’s careful work. Soon after it was published, however, McNally asserted that Dohrenwend’s numbers were still too high because he counted as PTSD cases those veterans with only mild, subdiagnostic symptoms, people rated as “generally functioning pretty well.” If you included only those suffering “clinically significant impairment” — the level generally required for diagnosis and insurance compensation in most mental illness — the rates fell yet further, to 5.4 percent at the time of the survey and 11 percent lifetime. It was not 1 in 3 veterans that eventually got PTSD, but 1 in 9 — and only 1 in 18 had it at any given time. The NVVRS, in other words, appears to have overstated PTSD rates in Vietnam vets by almost 300 percent.
“PTSD is a real thing, without a doubt,” says McNally. “But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD, and thus mistreating them.”
The idea that PTSD is overdiagnosed seems to contradict reports of resistance in the military and the VA to recognizing PTSD — denials of PTSD diagnoses and disability benefits, military clinicians discharging soldiers instead of treating them, and a disturbing increase in suicides among veterans of the Middle East wars. Yet the two trends are consistent. The VA’s PTSD caseload has more than doubled since 2000, mostly owing to newly diagnosed Vietnam veterans. The poor and erratic response to current soldiers and recent vets, with some being pulled in quickly to PTSD treatments and others discouraged or denied, may be the panicked stumbling of an overloaded system.
Overhauling both the diagnosis and the VA’s care system, say critics, will ensure better care for genuine PTSD patients as well as those being misdiagnosed. But the would-be reformers face fierce opposition. “This argument,” McNally notes, “tends to really piss some people off.” Veterans send him threatening emails. Colleagues accuse him of dishonoring veterans, dismissing suffering, discounting the costs of war. Dean Kilpatrick, a University of South Carolina traumatologist who is president of the International Society for Traumatic Stress Studies (ISTSS), once essentially called McNally a liar.
A Problematic Diagnosis
The most recent Diagnostic and Statistical Manual (DSM-IV) defines PTSD as the presence of three symptom clusters — reexperiencing via nightmares or flashbacks; numbing or withdrawal; and hyperarousal, evident in irritability, insomnia, aggression, or poor concentration — that arise in response to a life-threatening event.
Both halves of this definition are suspect. To start with, the link to a traumatic event, which makes PTSD almost unique among complex psychiatric diagnoses in being defined by an external cause, also makes it uniquely problematic, for the tie is really to the memory of an event. When PTSD was first added to the DSM-III in 1980, traumatic memories were considered reasonably faithful recordings of actual events. But as research since then has repeatedly shown, memory is spectacularly unreliable and extraordinarily malleable. We routinely add or subtract people, details, settings, and actions to our memories. We conflate, invent, and edit.
In one study by Washington University memory researcher Elizabeth Loftus, one out of four adults who were told they were lost in a shopping mall as children came to believe it. Some insisted the event happened even after the ruse was exposed. Bounteous research since then has confirmed that such false memories are common. (See, “Creating False Memories” by Elizabeth Loftus, Scientific American, Sept 1997.)
Soldiers enjoy no immunity from this tendency. A 1990s study at the New Haven, Connecticut VA hospital asked 59 Gulf War veterans about their war experiences a month after their return and again two years later. The researchers asked about 19 specific types of potentially traumatic events, such as witnessing deaths, losing friends, and seeing people disfigured. Two years out, 70 percent of the veterans reported at least one traumatic event they had not mentioned a month after returning, and 24 percent reported at least three such events for the first time. And the veterans recounting the most “new memories” also reported the most PTSD symptoms.
To McNally, such results suggest that some veterans experiencing “late-onset” PTSD may be attributing symptoms of depression, anxiety, or other subtle disorders to a memory that has been elaborated and given new significance — or even unconsciously (and innocently) fabricated.
“This has nothing to do with gaming or working the system or consciously looking for sympathy,” he says. “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.”
To make PTSD diagnosis more rigorous, some have suggested that blood chemistry, brain imaging or other tests might be able to detect physiological signatures of PTSD. Studies of stress hormones in groups of PTSD patients show differences from normal subjects, but the overlap between the normal and the PTSD groups is huge, making individual profiles useless for diagnostics. Brain imaging has similar limitations, with the abnormal dynamics in PTSD heavily overlapping those of depression and anxiety.
With memory unreliable and biological markers elusive, diagnosis depends on clinical symptoms. But as a 2007 study showed starkly, PTSD’s symptom profile is as slippery as the would-be biomarkers. Alexander Bodkin, a psychiatrist at Harvard’s McLean Hospital, screened 90 clinically depressed patients separately for PTSD symptoms and for trauma, then compared the results. First he and a colleague used a standardized PTSD screening interview to assess PTSD symptoms. Then two other PTSD diagnosticians, ignorant of the symptom reports, used a standard interview to see which patients had ever experienced trauma fitting DSM-IV criteria.
If PTSD arose from trauma, the patients with PTSD symptoms should have histories of trauma, and those with trauma should show more PTSD. It was not so. While the symptom screens rated 70 of the 90 patients PTSD-positive, the trauma screens found only 54 who had suffered trauma; the diagnosed PTSD “cases” outnumbered those who had experienced traumatic events. Things got worse when Bodkin compared the diagnoses one-on-one. If PTSD required trauma, then the 54 trauma-exposed patients should account for most of the 70 PTSD-positive patients. But the PTSD-symptomatic patients –were equally distributed among the trauma-positive and the trauma-negative groups. The PTSD rate had zero relation to the trauma rate. It was, Bodkin observed, “a scientifically unacceptable situation.”
More practically, as McNally points out, “To give the best treatment, you have to have the right diagnosis.”
The most effective treatment for patients whose symptoms arose from trauma is exposure-based cognitive behavioral therapy (CBT), which concentrates on altering the response to a specific traumatic memory by repeated, controlled exposure to it. “And it works,” says McNally. “If someone with genuine PTSD goes to the people who do this really well, they have a good chance of getting better.” CBT for depression, in contrast, teaches the patient to recognize dysfunctional loops of thought and emotion and develop new responses to normal, present-day events. “If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT, you’re going to miss the boat,” says McNally. “You’re going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events.”
To complicate the matter, recent studies showing that traumatic brain injuries from bomb blasts, common among solders in Iraq, produce symptoms almost indistinguishable from PTSD. One more overlapping symptom set.
“The overlap issue worries me tremendously,” says Gerald Rosen, a University of Washington psychiatrist who has worked extensively with PTSD patients. “We have to ask how we got here. We have to ask ourselves, ‘What do we gain by having this diagnosis?’”
Disabling Conditions
Rosen is thinking of clinicians when he asks about gain. But what does a veteran gain with a PTSD diagnosis? One would hope, of course, that it grants access to effective treatment and support. This is not happening. In civilian populations, two-thirds of PTSD patients respond to treatment. But as psychologist Chris Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, “In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own.”
The reason, says Frueh, is the collision of the PTSD construct’s vagaries with the VA’s disability system, in which every benefit seems structured to discourage recovery.
The first benefit is healthcare. PTSD is by far the easiest mental health diagnosis to have declared “service-connected,” a designation that often means the difference between little or no care and broad, lasting health coverage. Service connection also makes a vet eligible for monthly disability payments of up to $4,000. That link may explain why most veterans getting PTSD treatment from the VA report worsening symptoms until they are designated 100 percent disabled — at which point their use of VA mental health services drops by 82 percent. It may also help to explain why, although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to more than $4 billion annually. Perhaps most disastrously, these payments continue only if you’re sick. For unlike a vet who has lost a leg, a vet with PTSD loses disability benefits as soon as he recovers or starts working. The entire system seems designed to encourage chronic disability.
“In the several years I spent in VA PTSD clinics,” says Frueh, “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. Sometimes I think they should just blow it up and start over.” But with what?
Richard Bryant, an Australian PTSD researcher and clinician, suggests a disability system more like that Down Under. An Australian soldier injured in combat receives a lifelong “noneconomic” disability payment of $300 to $1,200 monthly. If the injury keeps her from working, she also gets an “incapacity” payment, as well as job training and help finding work. Finally — a crucial feature — she retains all these benefits for two years once she goes back to work. After that, her incapacity payments taper to zero over five years. But her noneconomic payments — a sort of financial Purple Heart — continue forever. And like all Australians, she gets free lifetime health care.
Australian vets come home to an utterly different support system from ours: Theirs is a scaffold they can climb. Ours is a low-hanging “safety net” liable to trap anyone who falls in.
Two Ways to Carry a Rifle
When a soldier comes home, he must try to reconcile his war experience with the person he was beforehand and the society and family he returns to. He must engage in what psychologist Rachel Yehuda, who researches PTSD at the Bronx VA hospital, calls “recontextualization” — the process of integrating trauma into normal experience. It is what we all do, on a smaller scale, when we suffer breakups, job losses, the deaths of loved ones. Initially the event seems an impossible aberration. Then slowly we accept the trauma as part of the complex context that is life.
Matt Stevens recognizes this can take time. Even after a year home, the war still occupies his dreams. Sometimes, for instance, he dreams that he is doing something completely normal — while carrying his combat rifle.
“One night I dreamt I was birdwatching with my wife. When we saw a bird, she would lift her binoculars, and I would lift my rifle and watch the bird through the scope. No thought of shooting it. Just how I looked at the birds.”
It would be easy to read Stevens’s dream as a symptom of PTSD, expressing fear, hypervigilance, and avoidance. Yet the dream can also be seen as demonstrating his success in recontextualizing his experience. He is reconciling the man who once used a gun with the man who no longer does.
Saving PTSD from itself, say Spitzer, McNally, Frueh, and other critics, will require a similar shift —seeing most post-combat distress not as a disorder but as part of normal, if painful, healing. This will involve, for starters, revising the PTSD diagnosis construct — presently under review for the new DSM-V due to be published in 2012 — so it accounts for the unreliability of memory and better distinguishes depression, anxiety, and phobia from true PTSD. Mental-health evaluations need similar revisions so they can detect genuine cases without leading patients to impose trauma narratives on other mental-health problems. Finally, Congress should replace the VA’s disability regime with an evidence-based system that removes disincentives to recovery — and even go the extra mile and give all combat veterans, injured or not, lifetime healthcare.
These changes will be hard to sell in a culture that resists any suggestion that PTSD is not a common, even inevitable, consequence of combat. Mistaking its horror for its prevalence, people assume PTSD is epidemic, ignoring all evidence to the contrary.
The biggest longitudinal study of soldiers returning from Iraq and Afghanistan, led by VA researcher Charles Milliken and published in 2007, seemed to confirm that we should expect a high incidence of PTSD. It surveyed combat troops immediately on return from deployment and again about 6 months later and found around 20 percent symptomatically “at risk” of PTSD. But of those reporting symptoms in the first survey, half had improved by the second survey, and many who first claimed few or no symptoms later reported serious symptoms. How many of the early “symptoms” were just normal adjustment? How many of the later symptoms were the imposition of a trauma narrative onto other problems? Matt Stevens, for one, is certain these screens are mistaking many going through normal adjustment as dangerously at risk of PTSD. Even he, although functioning fine at work, home, and in society, scored positive in both surveys; he is, in other words, one of the 20 percent “at risk.” Finally, and weirdly, both screens missed about 75 percent of those who actually sought counseling — a finding that raises further doubts about the screens’ accuracy. Yet this study received prominent media coverage emphasizing that PTSD rates were probably being badly undercounted.
A few months later, another study — the first to track large numbers of soldiers through the war — provided a clearer and more consistent picture. Led by U.S. Navy researcher Tyler Smith and published in the British Medical Journal, the study monitored mental health and combat exposure in 50,000 U.S. soldiers from 2001 to 2006. The researchers took particular care to tie symptoms to types of combat exposure and demographic factors. Among the 20,000 troops who went to Iraq, 4.3 percent developed diagnosis-level symptoms of PTSD. The rate ran about 8 percent in those with combat exposure and 2 percent in those not exposed.
These numbers are about a quarter of the rates Milliken found. But they’re a close match to PTSD rates seen in British Iraq War vets and to rates McNally calculated for Vietnam veterans. The contrast to the Milliken study, along with the consistency with British rates and with McNally’s NVVRS calculation, should have made the Smith study big news. Yet the media, the VA, and the trauma psychology community almost completely ignored the study. “The silence,” McNally wryly noted, “was deafening.”
This silence may be merely a matter of good news going unremarked. Yet it supports McNally’s contention that we have a cultural obsession with trauma. The selective attention supports too the assertion by military historian and PTSD critic Ben Shephard that American society itself gained something from the creation of the PTSD diagnosis in the late 1970s: a vision of war’s costs that transforms our soldiers from perpetrators to victims — and in doing so, absolves the rest of us for sending them, for we too were victimized, fooled into supporting a war we later regretted. It’s good that we feel soldiers’ 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.
PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified and replicated and institutionalized PTSD until it has finally become the thing itself — a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis.
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The PTSD Trap by David Dobbs is licensed under a Creative Commons Attribution-NoDerivs 3.0 Unported License. You may freely reproduce and distribute, but only in unmodified form and only with authorship credit (David Dobbs) and a link back to this post (http://www.wired.com/wiredscience/?p=101958). Thanks.
Image: Standing Watch, courtesy U.S. Army/flickr, via Creative Commons license.
David Dobbs writes on science, culture, and medicine for various magazines. This is his blog.
Petulant Skeptic is the pen name of third-year medical student in the U.S. Army, who tweets and blogs under a pseudonym, lest he suffer career setbacks for his expressed views.
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Related posts by David Dobbs:
Is PTSD A Product of War, or Of Our Times? | Wired Science | Wired …
How questioning PTSD rates makes me an apologist for imperialist …
Understanding the Effects of Social Environment on Trauma Victims – NYTimes.com
Sources cited:
Richard McNally, “Progress and Controversy in the study of posttraumatic stress disorder,” Annu. Rev. Psychol. 2003. 54:229-52 (pdf)
T.C. Smith et. al., “New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures,” BMJ, January 15, 2008
Dohrenwend et al., “The Psychological Risks of Vietnam for U.S. Veterans,” Science 18 August 2006: 979-982
Richard McNally, “Psychiatric Casualties of War,” Science 18 August 2006: 923-924
Richard McNally’s Vietnam Veterans PTSD reanalysis, a lecture on YouTube
You can find An extensive discussion at the Scientific American site (open access)
See also:
Lisa Richardson and Christopher Frueh, Prevalence Estimates of Combat-Related Post-Traumatic Stress Disorder: Critical Review, Australian & New Zealand Journal of Psychiatry, January 2010. Excellent look at prevalence rates from different methods and countries; shows clear pattern of overdiagnosis in most US studies.
Iris Engelhard and others, Deployment-related stress and trauma in Dutch soldiers returning from Iraq, British Journal of Psychiatry, 2007. Study finding single-digit rates of PTSD in Dutch veterans of Iraq War. The study used both clinical interviews and questionnaires to separately assess the same soldiers; a key finding was that questionnaires — the method used most frequently by US studies — sharply overestimate PTSD rates.
Amy Iversen and others, The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study, BMC Psychiatry, 2009. A study using both questionnaires and clinical interviews. It found single-digit PTSD rates among UK veterans of the Iraq and Afghanistan conflicts, double-digit rates of more common problems; another sign that the US may be systematically mistaking other mental and readjustment problems for PTSD.
Nicola Fear, Simon Wessely, and others. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study, The Lancet, May 2010. Large study of UK soldiers and veterans who had served in Iraq and Afghanistan. Results very close to those in Iverson’s 2009 study (above).
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And here’s a fuller annotated list of sources that I ran on my blog in 2009 when this feature originally ran at Scientific American:
These are organized by story section, roughly in the order the relevant material appears. Quoted passages are from the article, with source material following.
– Introduction-
• Harvard psychology professor Richard J. McNally’s, “Progress and Controversy in the Study of Posttraumatic Stress Disorder [pdf download],” Annual Rev Psychology 2003:229-52, As the story notes, the PTSD debate has been going on a while now — since the PTSD diagnosis’ creation in the late 1970s — but was fanned into heat in 2003 by this long review essay by McNally.
“This critique, which was originally raised by military historians and a few psychologists, is now being pushed by a broad array of experts…” These have appeared in many venues, but are presented together most comprehensively in Gerald Rosen’s (ed) 2004 Posttraumatic Stress Disorder: Issues and Controversies (also in a Kindle edition and in a special 2007 issue of the Journal of Anxiety Disorders.
• The 1990 National Vietnam Veterans Readjustment Survey, which surveyed over 1,000 Vietnam veterans in 1988 and found that 15.2 percent of them had PTSD then and 30.9 percent had suffered it at some point since the war, is a key document in the PTSD debate. It established the canonical rate estimates — but came under fire almost immediately for not confirming cases and for rate estimates some historians and diagnosticians thought unrealistically high. Its findings are summarized nicely hereby Jennifer Price at the VA’s National Center for PTSD.
• In “The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods in Science in August 2006, Columbia University epidemiologist Bruce Dohrenwend and others, hoping to resolve the debate about the NVVRS, presented a reanalysis of the original NVVRS data. They found that the 1988 rate was 9.1 percent and the lifetime rate 18.7 percent — 40 percent drops from the original. Both sides claimed these findings proved their case. The PTSD establishment said the study supported the construct’s basic integrity by confirming most cases and showing a dose-response relationship. Critics said it proved that this seminal 1990 study had overstated Vietnam veterans’ PTSD rates.
• McNally’s “Psychiatric Casualties of War,” presented alongside Dohrenwend’s study in Science, stressed how sharply Dohrenwend’s revision cut the canonical rates established by the NVVRS — and argued that applying standard clinical defintions of impairment would cut the rates even further. Theletters section that follows these pieces online gives a good picture of the academic dispute that flared up afterwards.
It was that exchange that drew my attention to the controversy; as editor of Scientific American’s Mind Matters blog, I solicited “The Costs of War,”, a pair of commentaries on the controversy — one by McNally, one by William Schlenger and Charles Marmar — that ran in Mind Matters in the fall of 2007. (Apologies for the post’s present formatting; it did not fare well in sciam.com’s later website overhaul.)
The flap in Science also led to a special, hastily called symposium at the November 2006 annual meeting of the International Society for Traumatic Stress Studies (ISTSS), which featured presentations by Dohrenwend; Terry Keane, a leading PTSD researcher and clinician at the Boston VA; then-ISTSS president Dean Kilpatrick, who is is a PTSD researcher and clinician at the Medical University of South Carolina; and — via an 8-minute presentation delivered via DVD, as he was in Europe on a previous commitment — Richard McNally.
I am hoping to secure ISTSS’s permission to place here an audio recording of the entire symposium. McNally’s video presentation, however, is viewable below.
(It was this presentation that led Kilpatrick to “essentially call McNally a liar,” as I said in the piece. Specifically, after McNally’s presentation aired, Kilpatrick took the floor (it was his turn) and said, “What I would like to do is swear Rich McNally in under oath to tell the truth, the whole truth, and nothing but the truth. If that were done, I think you’d have seen an entirely different presentation.” Kilpatrick later said he meant not that McNally lied, but that he failed to present the entire story — an odd thing to ask, as one observer noted, of an 8-minute presentation)
– A Problematic Diagnosis –
The fourth Diagnostic Statistical Manual (DSM-IV) provides the present diagnostic definition and guidelines for PTSD. This is updated somewhat from the original construct presented in the 1978 DSM-III.
On the reliability of memory: Elizabeth Loftus’s “Creating False Memories,” from Scientific American, Sept 1997, describes how malleable memory can be, as does Daniel Schacter’s Seven Sins of Memory. McNally’s book Remembering Trauma gives a fuller, more trauma-specific account of memory’s foibles. The “1990 study at the West Haven VA Hospital” that explored malleability of memories in veterans of the 1990 Gulf War is by “Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm, ” by Southwick and others.
On PTSD’s endocrinology:Rachel Yehuda’s “Biology of posttraumatic stress disorder,” from 2001, is one of several studies that found evidence of neuroendocrinological pecularities in PTSD; a 2004 studyby Lindsey et alia’s is one of several that did not. On the search for correlates of PTSD detectable through brain imaging, see Francati, Vermetten, and Bremner, “Functional neuroimaging studies in posttraumatic stress disorder: review of current methods and findings,” 2006.
On the ties between trauma and PTSD symptoms,: see the Bodkin, Pope, and Hudson study described in the article, “Is PTSD caused by traumatic stress,” which found zero correlation between PTSD diagnoses made by symptom clusters and those made by trauma histories.
“The most effective PTSD treatment is exposure-based cognitive behavioral therapy” – This is asserted by many experts and authorities, including a comprehensive review by a National Academy of Science committee, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2007).
The symptom overlap between PTSD and traumatic brain injury is explored, among other places, in Hoge et alia’s “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq,” New England J of Medicine, 31 Jan 2008.
– Disabling Conditions –
“In civilian populations, two-thirds of PTSD patients respond to treatment.” from, e.g, “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,” Am J Psychiatry 162 (Feb 2005) (Search for “Across all treatments”)
“…most veterans getting PTSD treatment from the VA report worsening symptoms until they reach 100 percent disability — at which point their use of VA mental health services drops 82 percent.” From VA Office of Inspector General, “Review of State Variances in VA Disability Compensation Payments” [large download] (Report VAOIG-05-00765-137), May 2005, p ix.
“… although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to over $4 billion annually.” from Veterans Compensation for Posttraumatic Stress Disorder, Institute of Medicine and National Research Council PTSD Compensation and Military Service, National Academics Press, 2005.
The innovative disability program used in Australia is described here.
– Two Ways to Carry a Rifle –
Finally, the conflicting studies of PTSD in US veterans of the Iraq and Afghanistan wars cited in the piece are Milliken et alia, “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War,” JAMA 14 Nov 2007, which found rates of around 20%, and Smith et al, “New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study,” BMJ 16 Feb 2008, which found rates of under 5%.
Changes/corrections:
03-22-12, 11.38 EDT: Changed “Veterans Administration” (old name for agency) to “Department of Veterans Affairs” in two spots.
