The PTSD Trap: Our Overdiagnosis of PTSD In Vets Is Enough to Make You Sick

Standing Watch

Standing Watch. Photo courtesy U.S. Army

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://daviddobbs.net/smoothpebbles/the-ptsd-trap/). 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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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:

Main sources and documents in “The Post-Traumatic Stress Trap.”

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.

 

36 responses

  1. Thoughtful article, and the analysis of the VA system of care was the heart of it for me. My father was blown off a cliff in Korea. He had no trauma narrative. He had suffered a head injury from an explosive device. He came home to college, marriage, two children and a long life (he is 85) of postwar prosperity. But underlying this valiant life, was a debilitating combat injury, no narrative needed, subtext spoke loud and clear. War is hell, no diagnosis necessary. 

  2. As a person who has suffered from this disorder. I think this article is trying to separate red from striped apples as if they are not both apples. People who are healthy and those who have been diagnosed with a preexisting mental disorder such as an anxiety disorder who suffer clear traumas and even those where the trauma does not appear to be real can suffer authentic PTSD because of how the mind works.  The author splits hairs about a person developing PTSD symptoms and memories only after being told they might have that condition as if having a label alone is a prerequisite for that effect. 

    People with anxiety disorders can and will on occasion take ordinary events and build up enough anxiety around them to make them traumatic. When you take even the most ordinary experiences that may occur during military service at a time of war into account it is almost guaranteed that this will happen. It has to do with how the mind works in a person with an anxiety disorder. Such persons can often blend and mix and question recalled events over and over again increasing the level of anxiety over it until it reaches the point of trauma. In time many may develop PTSD like symptoms. This can happen far removed from the actual event and may involve constructed memories. The more associated an event is with a major anxiety generating issue for the person the more likely that is to occur. If you ask the average PTSD expert how associated OCD is with PTSD many might even say it is almost a prerequisite. PTSD seems to occur mostly in people who have or have a strong predisposition for OCD. Given that reality and the fact one’s recall of an event may have become reconstructed, PTSD can happen no matter the person’s real world experience. The issue with PTSD is that specific event real or mentally reconstructed have come to dominate the focus of a person’s anxiety and that event has therefore became highly traumatic thus inducing the symptoms of PTSD. This requires specialized treatment, in addition to their depression and any underlying anxiety disorder. Ultimately both conditions require one learn to change how one evaluates events in a way that lowers their anxiety about them. With PTSD the major difference is the additional effects of the sense of victim-hood which is not present in OCD. In the vast majority of cases the person will need treatment for an underlying anxiety disorder and depression in addition the their therapy for PTSD.

  3. Unfortunately many misinformed people will cling to this article as if it has merit. Using “studies” and “reports” are solicitous hyperbole.

    Working with Vets from various “Wars” police actions, unpublicized combat in the various theaters of SPECOPS and dealing with disenfranchised “Contractors” AKA mercenaries, one can accurately arrive at certain psycho-dynamic truths.

    1) When you take a human life you will be forever changed. The change is generally damaging to the person unless the person is a sociopath or psychopath.

    2) Living under sustained stress of a live or die environment for more than 90 days alters the human body and mind set. Extensive exposure to high cortisol levels in the blood for extended periods creates new neural networks to “re-orient” the human organism. Ergo the being is, for lack of a better term, “re-engineered” to survive.

    PTSD is only a name for a condition that varies. It was manufactured by by health care corporations, Pharm/corps, and others for a generalized way to deal with large amounts of similar symptomatic phenomena. 

    Making a case to dismiss or downplay these ” injuries” to soldiers, police, health care providers, disaster victims and those enduring catastrophic life experiences is, abhorrent and thoughtless.

    Get imbedded-get educated

    • I keep thinking of the 6 million Jews who were killed with family looking on. Or worse, those in concentration camps who survived and found it in them to keep living despite the horrors that they suffered, some for years. And it wasn’t just the Jews. There were Catholics who spoke out, Gypsies, anyone of conscience who had the gall to oppose the policies of the Nazis only to be sent to “Work Camps” Look at the pictures of the survivors of the death camps (which we have thanks to the US Army who documented in great detail all of the atrocities.) And the partisans who fought in the woods, stepping over the slaughtered bodies of their own families. That was trauma.  Of all the survivors I have had as patients, be they Polish or German or French or Jewish, and of all the ones I have known personally, none ever complained of PTSD or long term disability from the trauma. Some had problems, of course, but they kept going, had families, got jobs, went to school. These survivors went through AT LEAST trauma equivalent to a couple of deployments, if not more with no breaks. Maybe Victor Frankl’s “Man’s Search For Meaning” should be the text book for resilience training for all our troops (and the clinicians as well). Come to think of it I haven’t heard much about resilience training in a long time.

      •  To say that one person survives a tragic experience and that indicates that another should also be able to handle a similar experience is unjust. Many vets, like many Holocaust survivors and rape survivors, and …shall I go on?….keep going, have families and have jobs. That is not to say any of these does not suffer from PTSD. Do you truly think that Holocaust survivors do not have PTSD? PTSD can be found
        among survivors of the Holocaust, of car accidents, of sexual
        assaults, and of other traumatic experiences such as combat. A diagnosis of PTSD does not automatically mean that the individual is in such a state that he or she is totally unable to function, though there are some few who exist in that state. There is no way that I know of that enables us to compare the degree of trauma one ‘should’ experience from crime, war, natural disasters, or other such events in such a way that we can say that one experience is more traumatic to a particular individual than other. For years, people who experienced traumatic events of war were considered weak, cowardly, or users of the system. Only in recent years have we truly begn to recognize that any person, no matter how strong or resilient is subject to the effects of traumatic events, such as combat.

        Would you tell a rape victim that she should deal with it and ‘keep going’ with no regards to the effects the trauma had on her mental and physical health? The idea that our military that experience PTSD are weak in character or lacking in some capacity is to revert back over 100 years in medical science and psychological understandings of the effects of trauma.

    • When veterans are diagnosed with PTSD. who were never in combat nor experienced a traumatic event, by VA doctors and their stressor leading to PTSD is they feared they may be in combat, there is a problem. The VA now states a stressor for PTSD and VA disability COMPENSATION purposes, is a veteran just had to be in fear that they could be in combat. I have been told that VA Disability examiners are told that WILL diagnosis PTSD, it all political…..votes votes and more votes

  4. Really?  This is garbage.  Ever wake up to an ice dispenser dropping one ice cube and run out of the front door of your house looking for a bunker?  Ever duck when an ambulance goes by because you thought it was CRAM?  

    Using an Army Reserve Major PA is not a reliable source.  He is not qualified to offer such a diagnosis.  

    You really should live a few years in a war environment before writing such trash.  Otherwise until you do, keep your google searches to yourself.  Danger room is trash.  A bunch of wannabe, 2 week warzone hoppers that think they have the story.  Grr.

    • If you read the story, you’ll see that neither I nor anyone quoted denies that some soldiers get PTSD. The assertion — and overwhelming evidence — is that the way we respond to the troubles of war encourages both overdiagnosis and a highly dysfunctional response from the VA, one that discourages healing. 

      • Exactly. I have seen the comparison to Australia before. Boy, what a different culture with a socialized health care system.

      • Well David, I wrote a long pos, and deleted it. Put simply, your premise is wrong and so is your article. I’m not going to waste my time.

    • I’m neither a reservist nor a PA.

      Furthermore, this rush to pillory anyone who raises legitimate issues regarding the diagnosis and treatment of PTSD only hinders the cause of doing so effectively.

      Neither David nor I are denying that PTSD is real. My blog (as well as David’s!) offers plenty of examples of me acknowledging the legitimacy of the disorder while decrying the broken system that patients and doctors operate in.

      •  PetulantSkeptic, I believe James Codling meant Matt Stevens when referring to the Army Reserve Major PA (though Stevens was National Guard; but he was a PA). However, I’m not clear why that DQs Stevens from speaking to this issue, as he is a) quite well-informed about the diagnostic criterian of PTSD b) spent extended time on the front lines caring for injured and KIA soldiers in one of the hottest areas and times of the Iraq War (Ramadi 2005-6), and c) tracked the mental reactions and welfare of his troops both in Iraq and then back in Vermont after his return there with the unit. 

  5. One point ignored is that of the multiple combat tours that many of the Iraq, Afghanistan deployed veterans have endured.

    In WWII the Department of the Army found that a unit suffering more than 10% losses (killed or seriously wounded) in one engagement usually resulted in the survivors becoming neuro-psychiatric casualties unfit for further combat.

    Multiple Combat tours have also been found to increase the incidence of PTSD

    Improvements in medical imaging technology are starting to provide the basis for an actual physical diagnosis. Hopefully the improvements will allow a fuller understanding of how PTSD changes the brain and whether or when those changes can be reversed, abated, or treated long term.

    The improvements in medical technology are starting to provide the information needed to construct the models to determine how common PTSD is, how fluid it is, how transient, how permanent.

    The overall goal being to relieve suffering, to enhance the ability to enjoy and participate in life.

    So perhaps technology will allow a more accurate and complete understanding of this malady and
    so cause this debate to fade.

    • My fairly short story didn’t have room to visit the issue of multiple combat tours. Multiple tours do increase PTSD rates, as one might expect. Yet the longer tours don’t fully explain the higher rates of diagnosis in US troops — indeed explain only a bit of the increase — since country-v-country studies that account for difference in tour length in various ways, such as comparing only soldiers with similar tour lengths, also find sharply higher rates of diagnosis in US troops. The international data repeatedly and consistently finds far higher rates of diagnosis in US troops — 2 to 4 times as much — even for similar exposure records and controlling or other factors.
      I too have some hope that imaging might help, although I’m wary that it could also create a new way to overdiagnose. Studies by Wessely, for instance, have already found that the US is finding something like twice the rate of TBI diagnoses in vets than other countries do, even in vets with similar histories of exposure to the blasts that seem to cause TBI. And the links between PTSD and TBI are fuzzy, and, given the history of the field and the bounteous incentives to diagnose PTSD and/or TBI — incentives that are either unique or stronger here in the US than anywhere else, as described in the article — I fear the focus on TBI may only feed into and aggravate the wider problem of overdiagnosis of PTSD.
      As you say, the overall goal is to relieve suffering and restore the capacity to enjoy life. The sad part about the VA’s PTSD system — its patterns of overdiagnosis, its horrid disability system, its broad message that war trauma is a permanent disability — is that it undermines that goal. We should do better.

      • Simon Wessely has worked with medical insurance companies and the British Department of Defence, neither of whom face bounteous incentives to diagnose PTSD and/or TBI – indeed there can be bounteous incentives to avoid diagnosising PTSD and TBI!

        Unum insurance is very keen on promoting a biopsychosocial approach to disability, in order to pragmatically manage those with health problems towards increased ‘functionality’.  These ideas are now guiding the reforms to the British system of disability benefits, which have been roundly condemned by disability campaign groups.  If you think that that American system is bad, that’s only because you’ve never heard of ATOS.

        Some people claim that providing financial support to those veterans with health problems causes problems, and prevents them from recovering?  That’s not a surprise.  When we allow those in authority to treat others pragmatically, this always serves to hurt those in positions of weakness.  Our understanding of PTSD and TBI and how it affects people is still fuzzy – this can easily be used as an excuse to deny people access to the financial support which they deserve.

        It could be that honest and accurate diagnosis of brain injury leads to more patients feeling worse about their health.  Even if that is the case, patients still deserve to be provided with honest and accurate information, so that they can make their own decisions about their own lives.  Allowing for decisions to be affected by paternalistic desires to increase their capacity to enjoy life, or functionality, would leave too much room for manipulation and quackery.

        None of this is to say that there are no problems with the way PTSD is diagnosed and treated, or how the US military approaches disability payments, but there is reason to urge caution of changes that may lead to patients being treated even less well, particularly if reforms are intended and expected to save money. 

  6.  …its broad message that war trauma is a permanent disability

    I think what I was trying to address in my comment regarding my father’s  traumatic brain injury in Korean,was that for sufferers, diagnosis is secondary, always. It is the fallout, through generations, shattering is the word that comes to mind, of combat. Diagnosis is distinct from injury to the wounded. And what constitutes permanent? If your argument is that a good soldier must stop licking his/her wounds and get on with the business of not being a permanent patient collecting disability, then that is a separate argument. But I think the anger here is a disgust with the tin ear of the chickenhawk warrior era. So much pain and suffering.

    • The effect is permanent; war changes one. But it does not necessarily disable one. People seem to think I’m proposing that war never damages anyone; that I’m saying the rate of PTSD is zero. I’m not. 

      I’m not trying to have an argument about whether PTSD exists – yet everyone reacts as if I am. I want a discussion about whether we have the rate right. Surely we can’t be absolutely secure that we’ve got it just right? Yet to suggest otherwise, apparently, is to be seen (please see comments elsewhere here) as denying PTSD even exists. 

    • I can understand the anger and frustration. One difficulty here is that any questioning of the PTSD Dx is often interpreted as a) a denial that PTSD exists b) a denial that war is trying (to say the least) and changes one and c) an attempt to remove benefits. This is somewhat understandable, since in the past, some hawkish types have done or pushed all those lines.
      That’s not my agenda. I recognize war is hell and PTSD exists. But I think we’re overdiagnosing it, to the detriment of both those who have the genuine article and those who are misdiagnosed and put into a system that does not treat their real problems and structures disability to discourage healing. To me the solution is to more accurately diagnose everyone — and to structure both treatment and benefits so that it supports those still struggling but providers strong rewards and incentives to heal and return to a full life.

      There’s essentially nothing I want to remove from those injured except the policies and treatment failures that discourage them from returning to fuller and happier lives.

      • Some nob behind the wire that did some clean up work on grunts and hjji’s should know better. Multiple tours. Outside the wire 12 to 16 + hours a day. Never knowing when a IED was going to go off. Picking up chunks of your biddies when they do.That shit burns into your brain after a while. All of y’alls problem is that none of you (VA included) have any idea of how to treat us. The Government is shit scared that they have a whole generation of Americans who have been at War for multiple years and they are burnt out and they are used to a kind of life no one over here will ever understand. 

  7. I was in the Army for 9 years, the last 3 at Walter Reed Army Institute of Research where I was an assistant to the late Col Franklin D Jones in the Division Military Psychiatry, Department of Combat Psychiatry. He was the editor of the 2 volumes of the Textbook of Military Medicine dealing with Military Psychiatry and Combat Psychiatry and author of many of the articles. He was my mentor and encouraged me to think and question. He would have loved your Article.

    I found myself yelling “Yes, Yes, Yes” as I read this, especially in the context of the “scandal” at Madigan where 14 soldiers challenged the changing of their PTSD diagnosis to one without as much monetary gain. As you may know, they were sent to Walter Reed for a reassessment and only 6 retained the PTSD diagnosis. 8 others got different diagnosis. The scandal centered around a forensic psychiatrist telling his colleagues the cost to the nation of each diagnosis of PTSD. What he said was absolutely correct. The only problem was he said it outloud. Now over 300 soldiers whose diagnosis of PTSD was changed are being encouraged to challenge it and use the time of psychiatrists, who are a little busy these days, to rediagnose them.

    There is definitely a problem with diagnosis and I understand that the new DSM-5 takes a more biological approach to all the mental illnesses. But there is another problem that few want to recognize. With the tremendous amount of information about PTSD and TBI available to soldiers and their families, everyone knows the exact symptoms of PTSD (although they don’t know the symptoms of depression or anxiety or panic attacks. I saw many cases of Factitious PTSD when I worked in the VA – many times I wanted to scream “don’t you want to get better?  You are perfectly able to work” But they never seemed to get better and they never showed up for treatment or therapy except the once a year required of them and they always asked before they left, “Do I still get my disability” The pts who were really struggling wanted to get better and pushed themselves through whatever was available to them. They never talked about their compensation.

    War is hell. It changes people. But most people survive, maybe with an extended “Adjustment Disorder with depression and anxiety”, treatable, reversible, cureable.

    I had one Viet Nam Vet who overcame alcohol abuse on his own before I saw him. His course in therapy was like an absess exploding with all the pus coming out and the body healing from the bottom of the wound to the skin. As I told him, at the end there would remain a scar, stronger than the original skin, always there to be seen, but not to interfere with his life again.

    Thank you for this great article. I am forwarding it to my colleagues still working at the VA and the “new” Walter Reed. A few will really red it and think about it. But most will write it off as an attempt to insult our troops and deny them their rightful entitlement. Ah, Well.

  8. As an active duty medical professional with 12 years of service, 4 of which were spent deployed to combat zones, I can tell you that this article is spot-on and a refreshing read. Our society encourages people to be victims and incentivizes disability while providing no incentive for those diagnosed to recover. I have seen soldiers who havent even suffered a traumatic event diagnosed with PTSD, soldiers who falsify their symptoms and/or experiences to generate disability claims. The sad part, that this article does not address, it that the risk factors for developing PTSD are well-studied. It is not the amount of trauma one experiences that is the risk factor. Those who were raised in broken homes, the children of abusive parents, those with pre-existing mental health/anxiety disorders or drug use are well-known to be at greater risk of suffering PTSD. It is those who lack specific coping mechanisms and resiliency (intangibles that are tought from a very young age in supportive familial relationships) who are at risk. Why is the DoD not doing more to screen these people to prevent their entrance into the military? If the disability system is broke, with no real alternatives, let’s get to the root of the problem and do more to prevent victims.

    Well Done, Mr. Dobbs

    • Thank you for this. You are absolutely right about the miltary’s failure to ID those most at risk of developing PTSD. The sad part is they already have a tool to do so — a screen that identifies over half of those who will develop PTSD if if they see action. I wrote it up in this post:

      What if you could predict PTSD in combat troops? Oh, who cares… | Wired Science | Wired.com

      The opening:

      “What if you could predict which troops are most likely to get PTSD from combat exposure — and takes steps to either bolster them mentally or keep them out of combat situations? A new study suggests we could make a start on that right now — and cut combat PTSD rates in half by simply keeping the least mentally and physically fit soldiers away from combat zones.”

    • Your proposition is dismissive of the division in rank structure. The screening process has already been in place for a long time. It’s called Officer Candidate School. Yeah, I agree that over diagnosis is the result of a broken system. And it is pretty upsetting to see that some service members take
      advantage of the process. But if you screened out children from broken
      homes, abusive parents and a history of drug use, you would have a miniscule
      military made up of rich, pretentious, over educated, under skilled, mostly
      white people with little desire to take risks. This is an overly
      generalized statement that does not apply to all commissioned officers, just as enlisted personnel are not all under educated or careless with their careers. But, no officer is forced to take their commission and their decision to leave the enlisted ranks is, ipse facto, career driven. Maybe instead of trying to weed out the unworthy, more can be done in TRADOC and AIT programs to arm service members with the “coping mechanisms and resiliency” that you speak of. To say that they are intangibles that can’t be learned after a certain age is ridiculous. Else, everyone would scoot through deployments, Ranger school, RASP, SFAS, etc. and say, “Hey, that was a breeze.” If you didn’t learn new coping mechanisms and resiliency during your service, then you went through entirely cocksure and discrediting of your mentors and frankly ignorant of those around you.

      • The risk factors are what they are. They are well-studied and I am unsure how race and rank structure are, or should be considered when screening for PTSD, as you suggest

        The military is unlike other jobs. Servicemembers are required to be more physically fit than the average american so they can endure the physical hardships of combat in austere conditions. We ask them to spend lengthy deployments away from their loved ones/support systems while exposing them to the horrors of war. It only makes sense that we would enlist troops who are more mentally/’emotionally fit than the average american as well, so they can endure the mental and emotional hardships that accompany military service. Does it not? The risk factors for ptsd,as mentioned above, are similar to risk factors for mental health disorders. Will all persons with those risk factors develop ptsd or a mental health disorder? No, but Mr Dobbs’ studies cited all suggest thatthey make up the bast majority of cases, so why not prevent those at highest risk from becoming casualties of this condition?

        No one suggested that intangibles cannot be taught later in life, but the intangibles I speak (coping with loss, adversity, stress discomfort etc) are not going to be instilled in basic training/ AIT, at least not how it is currently structured. These are traits that are usually learned from a young age through supportive relationships.

        The military has one purpose, to go to war, and therefore it should be recruiting those who are willing and already physically/mentally capable to do so already. The military is not a social welfare system/safety net that should be teaching troops the things that their parents should have done long before their entrance in the military. The military can do more to build on resiliency that should already be instilled, but a few powerpoint classes are not going to ready someone at high-risk of ptsd for the rigors of combat if thay arent already resilient

      • First, for anyone getting confused: There are now two David Dobbses on this comment sub-thread: Me, the author of the post; and the David Dobbs I’m now replying to (different avatar, see above), who is my (dear, dear) namesake nephew and an active-duty U.S. Army soldier, recently returned from combat-arena duty in Afghanistan. Just didn’t want anyone to get confused. Nor, I trust, shall anyone speak disrespectfully to him, for his is my blood. 

        I take it a good sign he feels free to disagree with me. 
        However ( speaking to nepher David now), David, I think the issues you raise are in some ways tangential to the notion of using existing (or new) screens to identify those most at risk of developing PTSD if exposed to combat. First, I’m not suggesting that such screen could solve the whole problem; hardly so. I simply offered that in response to a comment lamenting the lack of such screens. But the existing health screen already shows that the lowest-scoring 15% account for over half of all PTSD diagnoses later. One could use that information in any number of ways. Three that come to mind::1. Don’t accept that 15%. Advantage: You probably reduce post-deployment PTSD cases by about 50%. Con: Since not all 15% would develop PTSD, you’re losing a lot of  good soldiers. 2. Accept them, but keep them away from combat duty. 3. Accept them and give them extra training aimed at increasing resilience; then test again, and deploy them according to the results. Other options exist, no doubt, and it’s possible that the Army is pursuing some amid the many programs it’s developing to try to deal with this problem, however clumsily. (There are some really good people in both the DOD and the VA trying to work on these problems; they face huge obstacles of inertia, bureaucracy, logistics, etc.) None of that has much to do with the difference between officers and enlisted. And some of those options I name above are perfectly consistent with your idea that “instead of weeding out the unworthy,” more could be done to increase resilience (or put them in jobs where it wouldn’t be so tested.)Hope that clarifies some. And thanks for chiming in! Hope time stateside is serving you well.

  9. I have been diagnosed with Bipolar Disorder in the military in 1995. Suddenly it became clinical depression and I suffered hypomanic/manic episodes several times over 17 years.  My life became un-manageable and I went back to the doctor (the VA) and they diagnosed me with PTSD.  They refuse to look at my original diagnosis records although I bring it to every appointment.  I am a veteran, but not combat veteran. They said that they do not want to try to re-diagnose me. They “just want to treat symptoms” (and call it PTSD.)  YET they prescribed me an antipsychotic, which is used for Bipolar Disorder.  This is the first med that has worked for me.  Research has shown that antipsychotic is NOT affective for PTSD.  But they want to keep telling me I have PTSD.  Makes me angry when I feel ignored and not listened to. Especially when  it has to do with my health- and I get spewed at by the “VA authorities” with nonsense-like I just have to be stupid or something. I just can’t make sense.  I am another one who the VA has erroneously stamped with PTSD.

    • As a Psychiatric Nurse Practitioner with experience working at the VA, I find Ms. Flowers’ experience appaling but not unexpected. The question is where does one go for an appropriate evaluation and treatment when one is probably not covered by any other insurance. Perhaps the VA is connected with a Medical School and you can ask for a second opinion. I remember when I worked for the VA we were toold to try to fit the diagnosis of PTSD into any pt assessment because they would get more reimbursement. But that does not help the people who do not have PTSD. If you cant get a second opinion from an affiliated Medical School, demand a second opinion outside the VA, paid for by the VA. Or write a really clear history with all your medical records and send it to your Senator with a copy to the Chief at your VA. Sometimes it is easier for the VA to treat you appropriately then to deal with a congressional inquiry. Incorrect diagnoses of PTSD are hot issues right now. Lastly, contact a service organization like DAV. They can get access to all your medical records and review them for you. (Sometimes I think I should start a private practice dedicated only to the appropriate diagnosis of psychiatric illnesses.) Bonnie S. Dank, MPH,MS,RN,CS,CRNP, ALNC
      Psychiatric/Adult Nurse Practitioner
      Advanced Legal Nurse Consultant

      • You were told to try to fit the diagnosis of PTSD into an assessment because they would get reimbursement, this sounds extremely unethical. I work at the VA and know this is a fact. The diagnosis is not only for reimbursement but for a disability check, the VA disability compensation program has become a scam on the American Tax Payer. And it is not just the dx of PTSD, when every veteran has a “disability” due to service, there is a problem and I am not referring to combat veterans. Politicians will not address the problem because if the media portrays a politician as trying to fix the VA disability compensation problem which could lead to not compensating veterans for every ache and pain they ever had, they could lose votes. Eventually politicians will have to do something because there will be no more $$$. If the American people only knew the amount of money paid to veterans for so called disabilities that have nothing whatsoever to do with ones military service they would be appalled. Especially all the drug addicts, alcoholics, felons who VA sends checks to every month to fund their bad habits, pretty sad and disturbing.

  10. I work at the VA, there is a problem when every other veteran is diagnosed with PTSD, veterans who were not in combat or even near combat. The diagnoses are made by a VA examiners for disability “compensation” purposes who may see the veteran only for this one time examination. When you review outpatient treatment records, if the veteran is even getting treatment, and see that a treating doctor has diagnosed a different mental condition; there is a problem. The VA disability compensation is broken, there is a problem when no one gets better only worse and it is all for financial gain and I am not just referring to PTSD. Don’t get me wrong, I do believe that PTSD is a true mental disorder and it is unfortunate for the veterans who truly suffer from the condition as I see the over diaganosing PTSD it as a slap in the face to those truly suffering.

  11. Wait wait wait. Last sentence of penultimate paragraph: “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.” When an article or person frames the recovery of any of psychiatric disorder in terms of “strength,” I can no longer take the source seriously. This is akin to saying that soldiers who lost limbs in combat “lack the strength” to grow those limbs back or that those who lost, say, hearing because of ruptured TMs “lack the strength” to regenerate their TMs. Psych disorders have NOTHING to do with willpower.

  12. What a joke. Where are these numbers from? I am 100 disabled with PTSD.I am 27 years old and was in the corps from 2002 to 2010. I served in some of the bloodiest battles in iraq history. I will tell you this. Not enough people are coming forward with PTSD. most service members dont even look into it. They just keep on truckin or they are in denial. The fact is you cant go over there and live out an infantry day and not come back with it. Its not normal for people to see that shit and shrugg it off. If you saw what we saw and came back fine ide say you were the screwed up one. Every infantry fighter in any service that saw combat should be diagnosed with it period. Overdiagnosis???????? get a life.The facts are wrong saying some dont get PTSD!!!!!

  13. I am 100 percent disabled with PTSD. I dont work and I dont seek treatment.The money given to the VA is not so much for treatment as it is for benefit payments. The benefits in lower percent cases like 50 percent for a working veteran is 797 a month. It eases the problem,not treats it. Next time you go somewhere and find yourself dead because you mouthed off to a PTSD brainwashed killer just remember maybe he got better and they took his disability away. now money problems and PTSD led to murder not cuz they took his money cuz hes better. ITS CUZ WE HAVE A MENTAL PROBLEM!!!!!!!! WE ARE NOT FIT FOR SOCIETY SO WE LIVE ALONE ON BENEFITS. TAKE OUR BENEFITS WE WILL SEE YOU ON THE STREET. TAKE THE DISABILITY PAYMENTS AS PAYING FOR US TO STAY AWAY FROM YOU

    • PTSD can be treated. Let me repeat that. PTSD CAN BE TREATED. If a soldier broke his leg in combat and refused to have it set so as to heal, should he get disability for the rest of his life? If someone gets a facial injury in combat recieved a disfiguring injury and refused to allow competent plastic surgeons repair it so that it was no longer disfiguing, should he get a psension for the rest of his life, I don’t thins so. People chose to be sick and choose to be well. We should not reward people who choose to be sick when effective treatment is available to them. Disability should be determine by the injuries and illness that have been treated but where disability remains- not for those who don’t seek out help.

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