badges 2…

Posted on Wednesday 25 July 2012

Much of what we know about traumatic mental illness comes from the military experience during wartime. But for as much as that teaches us, PTSD is hardly the only enduring consequence of military combat. In fact, it’s hard to imagine a situation more likely to have an impact on a person’s life as going to war, and that global effect complicates our understanding of the specific syndrome of post-traumatic stress disorder. I was in psychiatric training following my own [non-combat] military service during the latter days of the Viet Nam War, and after graduating I supervised a number of residents during their rotations in the outpatient clinics at the VA hospital. It was a time when the soldiers had returned to a country deeply divided about the war, and a lot of the anger at having been drafted to fight in an unpopular war and about their cold reception on coming home was focused on the VA system. So there were people from the veteran’s rights groups handing out copies of the DSM-III criteria for PTSD in the parking lot [true]. And then there were the patients who didn’t want to come, but were dragged in by their wives – the ones who said they were fine but were anything but fine. My intent is not to malign the veterans in the parking lot. Many were among the afflicted. I’m rather talking about how tying a psychiatric diagnosis to substantial benefits makes things unnecessarily difficult, often impossible.

One of the cardinal symptoms of traumatic illness is repetitive experience –  reenactments, recurrent dreams, etc. And it seems that one of the cardinal features of conferences and commissions about traumatic illness is similar – to have the same debates year after year, over and over. Here’s the early version of one of those debates:

Late in 1915, the Army Council in London broke with past practice and for the first time officially recognized the existence of a grey area between cowardice and madness. It tried, however, to impose on shell-shock the traditional military distinction between ‘battle casualties’ and sickness: between wounds – which carried honor and dignity – and simple breakdown which did not. This distinction was to be defined by ‘enemy action’ – whether or not the soldier had been under enemy shellfire. The Army in France was instructed that ‘Shell-shock and shell concussion cases should have the letter W prefixed to the report of the casualty if it was due to the enemy: in that case the patient would be entitled to rank as "wounded" and to wear on his arm a "wound stripe".’ If, however, the man’s breakdown did not follow a shell explosion, it was not thought to be ‘due to the enemy’; and he was to [be] labelled ‘Shell-shock, S’ (for sickness) and was not entitled to a wound stripe or a pension.

And in spite of Dr. Wiltshire’ observations [badges 1…] and the experiences of the others working with these soldiers that this distinction was way off the mark, the policy wasn’t officially changed until 1918.

Parenthetically, it’s hard to imagine that there’s a better book on this topic than Shephard’s War of Nerves. It’s authoritative, historically accurate, and manages to be a real page-turner in its own right. And since this is a subject of particular interest to me, I could get diverted in a jillion directions at this point. So I’d best remind myself of the direction of these specific posts. Those debates that arose at the dawn of the 20th century are far from resolved in the 21st. The same questions – etiology, illness versus "faking", treatment, "mind" versus "brain", disability and compensation, diagnostic criteria, even markers [like Stephen Crane’s red badge] – continue to haunt us to the present day.

Note from the author:
These posts are headed towards commenting about this recent article:
Will PTSD By Any Other Name Bring More Troops to Treatment?
Psychiatric News
by Aaron Levin
July 6, 2012
But I can’t seem to get there. PTSD is a topic I know a lot about from a number of directions. But that’s not the reason that I write a bit, then go read or do something else for a while. I come back and look at the screen, google a couple things, then write a bit and delete it and go read some more. I’ve actually read almost two detective novels since I started the last post a few days back. And it’s not the article I’m headed for that hangs me up. Some of it has to do with being with friends from my military days half my life ago while I was traveling the last couple of weeks. Some has to do with living through the Viet Nam Era, seeing The Wall in Washington last week, connecting with some friends whose lives were changed by their time in grade, and remembering a few who never came home. But the biggest impediment is actually some articles from 2005-2006 I revisited while looking up things for this recent article.

There was an Institute of Medicine Conference in 2005 requested by the VA because of a spike in application for disability claims, some being belated claims from Viet Nam. I have no knowledge and nothing to say much about those claims because I just don’t know anything about them. But there was a series of articles around that time, many written by a psychiatrist, Sally Satel, who is a fellow at the American Enterprise Institute, the conservative think-tank that spawned the Project for the New American Century in the late 1990s and supplied the Neoconservatives that populated the Bush Administration, the architects of our invasion of Iraq. It was re-reading those particular articles that shut me down. I found them disturbing at the time and again on re-reading them now – even if some of the points were valid. I saw them as politically motivated, dismissive of patients and the mental health workers involved in their treatment, and from my perspective, had no place in a dialog representing psychiatry or the agencies involved in mental health care. At the time, I wrote Dr. Satel a civil letter and received a civil reply, but I obviously didn’t feel all that civil from the amount of emotion they brought up even now.

What I’ve decided to do is just list a few of those articles without comment. I’ve said what I feel about them. I don’t need to go into detail. If I don’t at least acknowledge them, I’m likely to spill the feeling they evoke into my comments here, and the article I want to review doesn’t deserve the overflow.

Flashing forward to 1980, I thought the naming and inclusion of PTSD in the DSM-III was a step in the right direction, but I much preferred the criteria described by Lenore Terr in her book Too Scared to Cry about the course of the children kidnapped and buried in Chowchilla, CA in 1978. For me, her description captured the flavor of the mental illness better than the DSM-III which required that the traumatic event[s] be known, which isn’t always the case:

  • Altered states of consciousness including dissociation
  • Reenactments – repetative behaviors, dreams, etc.
  • Trauma specific fears
  • An altered view of the self and the world
Some of her ideas were incorporated into the DSM-IV version. However, including PTSD in the diagnostic manual was hardly the end of controversy, this time concerning domestic PTSD. It was as if we’d suddenly discovered that children could be traumatized too, just like soldiers in war, and the issued of child abuse and specifically childhood sexual abuse moved to the front burner in the mental health world. We went through the same gyrations that accompanied the debates about the neuroses of war, only this time it wasn’t simply an epidemic limited to the military theater, it was everywhere, and had a profound impact on American culture. It’s another invitation to get diverted that I’ll decline except to say something about the real topic here – psychiatric diagnosis.

When is a reported symptom a genuine indicator of the presence of a mental illness, or part of a conscious ploy for personal gain? Is the soldier afflicted, or is he looking for a quick way out of a really unpleasant situation? Is the patient reporting childhood abuse really in the throes of a traumatic mental illness or using that report for other ends? even making it up to ‘get attention’ or to externalize blame? Is the psychiatrist or psychotherapist filling out the insurance form truthfully, or as a way of assuring income? Is the person answering an ad for a clinical drug trial filling out the assessment instrument accurately, or are they trying to qualify for a paid berth in the study? In the absence of the objective biological markers of physical medicine, patients with mental illness and the professionals who treat them are never free of the kind of skepticism and confusion that surrounded that whole question of Shell-shock in the early twentieth century, or PTSD in Viet Nam, or the consequence of child abuse, or almost anything else in the psychological realm. It’s little wonder that we long for biomarkers, laboratory tests, badges
    July 25, 2012 | 10:20 PM

    My experience is that it’s impossible to convince a mental health professional that I did not suffer PTSD from the wretched bits of my childhood, but do suffer it from my military experience and have suffered profoundly from it. One difficulty I have with trying to have a fair conversation about it with a mental health professional is that the condition has been reified so that no matter the cause and conflict that caused the PTSD, it’s treated as if it were an endogenous glitch that is the same for everyone who suffers the symptoms and should be treated the same without having to deal with the trauma itself and the meaning of that trauma.

    There is a human need to make sense even of the most senseless events. A trauma must be evaluated and reevaluated during the rest of the life of a person who suffers with PTSD, because it will rear its head again and again no matter how unwelcome and unbidden that may be.

    When the trauma includes being in a killing role, the burden cannot, IMO, be dealt with simply from the point of view of being the victim of a violent event. Shame is indelible and, at times, unbearable.

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