Will PTSD By Any Other Name Bring More Troops to Treatment?
Psychiatric News
by Aaron Levin
July 6, 2012
While two generals and two psychiatrists disagree over diagnostic language, they do agree about the crucial need to get troops with posttraumatic stress disorder into care. The general wants to change one word. The psychiatrist wants to keep things the way they are. A Canadian who sees both sides of the argument may offer a way of satisfying both. Earlier this year, then-U.S. Army Vice Chief of Staff Gen. Peter Chiarelli notified APA that the Army wanted the term posttraumatic stress disorder changed to posttraumatic stress injury. Part of Chiarelli’s job then was to lead the effort to reduce suicide in the U.S. Armed Forces and to expand access to mental health care for troops returning from Iraq and Afghanistan. Moving combat-related stress reactions into the same category as bullet wounds would decrease stigma and lead more soldiers to accept treatment, said Chiarelli…
General Chiarelli brings up the problem of the honorable wound that Stephen Crane explored in the Red Badge of Courage a hundred years ago. For the most part, Crane’s novel is written as an interior narrative – a description of the thoughts and feelings of young Henry Fielding. But there’s an place in the book where Henry is described from the outside rather than within. It was when he panicked, turned, and fled from the battle. He’d literally ‘lost his mind’ [as does the reader]. Whether by design, intuition, or serendipity, Crane captured a snapshot of a major feature of traumatic experience – the temporary death of the mind itself in the face of overwhelming experience. Looking back later, Henry feared the stigma of cowardice coming from his fellow soldiers, perhaps the officers. But it was also his own interpretation of what happened. General Chiarelli is correct in trying to deal with the stigma of cowardice or weakness being attached to something a traumatized person really had no control over. But he fails to also mention that the afflicted person feels the same way. Being felled by a bullet is understandable, from within and without. That wound shows. Having literally lost one’s mind, and the first hand knowledge that such a thing is even possible is a vulnerability that neither shows nor recedes over time.
Psychiatrists and military leaders at APA’s annual meeting discussed whether posttraumatic stress disorder should be renamed posttraumatic stress injury as a way to get mental health care to the increasing number of returning troops showing symptoms of the disorder. Proponents argue that making it equivalent to a bullet wound would lessen the stigma of getting care. The problem is not just the stigma felt by soldiers but that held by their officers and their resistance to accepting any mental disorder or its consequence — depression, suicide, substance abuse, as well as PTSD — as a medical disorder, said Darrel Regier, M.D., M.P.H., director of APA’s Division of Research, vice chair of the DSM-5 Task Force, and director of the American Psychiatric Institute for Research and Education.
Good for Dr. Regier. While I’m not particularly a fan of his role in the DSM-5 Task Force, he’s talking right here and is correct in pointing out that PTSD is certainly not the only negative outcome of military service in combat. But then…
Since a visible wound seems more culturally acceptable to service members, presenting objective evidence of posttraumatic injury might lessen the stigma attached to PTSD, suggested Chiarelli. “When we can show soldiers what happens in the brain, they’ll come in for help,” he said. “Something that occurs in the brain is not something to be ashamed of.” Scans of brain injuries might also convince officers that their troops were not malingering, he added. However, current scanning technology is not yet ready for the clinic, Regier pointed out in a later interview with Psychiatric News. “Scans show group differences for patients with and without PTSD, but they are not sensitive or specific enough to use for individual diagnosis,” he said.
General Chiarelli means well here. He apparently believes what he’s been told – that there’s a "brain" cause to post-traumatic stress disorder that can be seen on a scan. And Dr. Regier chimes in by cautioning that brain imaging technology is "not yet ready ready for the clinic" and that’s because the scanners are "not sensitive or specific enough". The implication is that we know that PTSD is a brain disease and it’s just a matter of time until that will be proved definitively. So we’re back to another version of the red badge of courage, a visible and honorable wound – this time seen on a scan.
I protest. And I think all of psychiatry should protest, even the people who actually believe that PTSD is a piece of undetected neurology. I don’t happen to personally believe that and doubt that it will be shown to be true in the future. I’m not even sure that I believe that "Scans show group differences for patients with and without PTSD," in part because of the co-occurrence of PTSD and Traumatic Brain Injury [TBI]. But it’s not a question of conflicting opinions. Partly, my protest is about evidence-based medicine. If we’re going to preach a gospel of evidence-based medicine, we shouldn’t present a hypothesis or a theory as if it’s a fact, present or future. We don’t know what some super-scanner in the future will show so we’d best stick to what we know now. And there’s a possibility that this might become a diagnostic requirement, like the Shell-shock,W of WWI. But mostly, the evidence from thousands and thousands of soldiers in a very war-filled century is that combat can regularly cause a sometimes devastating mental illness that persists – a wound in the mind.
There’s another oft-quoted piece of speculative neuroscience – "The IOM also noted that PTSD was a true disorder because it met standards for validity, having distinct clinical features that had been consistently documented in a variety of settings and cultures, longitudinal stability, and some evidence that genetic factors accounted for about one-third of PTSD symptoms" [VA to Keep Using DSM To Diagnose PTSD in Vets, 2006]. The quote here is from an interview with Dr. Regier about the 2006 Institute of Medicine review. That comes from some studies attempting to show that resilience [or its absence] is inherited – that there’s an inherited susceptability. Again, the thrust of these comments is to pull PTSD into the biological realm. The person I’ve most heard pushing this idea is Dr. Charles Nemeroff. It is, in fact, the line of thinking for which he has received a recent NIMH grant. I doubt that resiliency is genetic for lots of reasons, but again that’s not the point. That idea is a hypothesis, not a fact. Throwing in speculative biomarkers doesn’t help patients with PTSD. The symptoms themselves are the marker.
Dallaire, now a member of the Canadian Senate, headed the United Nations military mission to Rwanda at the time of the genocide there in 1994, an experience that induced his own case of PTSD, he said. The increased deployments of Canadian troops to the war in Afghanistan and peacekeeping operations in Africa, Cambodia, and the Balkans had serious effects on soldiers and their families, he realized. The injuries they sustained to the mind were as real as physical wounds but did not get the same recognition, he said. “We must render to the troops the sense that this injury was honorable and not a sickness,” said Dallaire. “The troops saw a ‘mental health problem’ as pejorative, so we had to restate the injury in language that they could understand and not feel stigmatized so they could get help.” Dallaire’s solution—now accepted by Canadian Forces—was to use “operational stress injury,” a term covering not just PTSD but other injuries to the mind, he said. The use of conventional diagnostic terms has not changed. “That established a framework in which individuals could define themselves in an honorable position, seek support, and end the stigma from both the chain of command and from their peers,” said Dallaire.….Since 2008, Canada has awarded the Sacrifice Medal [equivalent to the Purple Heart] to soldiers with “mental disorders that are, based on a review by a qualified mental health practitioner, directly attributable to a hostile or perceived hostile action.” Changing terminology is not enough, however. Changing military minds is another critical component. “There is now a stigma in the chain of command if someone denigrates someone who’s been injured with PTSD or some other injury of the mind,” said Dallaire. “The injury is not specific,” said Regier. “It’s what the injury did that produces the disorder, and it’s the consequence of the injury that needs to be accepted.” PTSD is indeed a stress-related injury — like a broken ankle, concluded Ursano. “What we call that stress-related injury is a separate question,” he said. “The diagnosis needs to direct care, and it needs to improve the patient’s health. How to get those who need care into effective care is the goal of everyone on the panel.”
My complaint is about the insertion of the brain/neuroscience ideas into these deliberations. They are as speculative as they were in the era of Shell-shock long ago. I know that talking about the mind has been out of favor in psychiatry for a long time. But the wisdom of time is that anyone can develop PTSD and that the concept of a wound in the mind is more than just time-honored, it’s an integral part of how these soldiers [and traumatized civilians] need to be approached and need to learn to approach their own symptoms. I’m not out to trash this article, or the session it reports from the APA meeting. On a whole, these comments represent a century of progress, and I particularly liked the parts high-lighted in red above. My complaint is that by introducing the biological hypotheses, they’re falling into the red badge of courage trap and undercutting the centrality of the need to accept the wound in the mind and how it perpetuates the illness.
From the outset [1915] to the present, the distinction between PTSD, the mental illness, and anything else [particularly malingering] is best made on clinical grounds rather than the various pseudo-objective criteria that have been suggested. That’s why I like the criteria suggested by Dr. Terr:
[1] Altered states of consciousness including dissociation
[2] Reenactments – repetative behaviors, dreams, etc.
[3] Trauma specific fears
[4] An altered view of the self and the world
The specifics of the first three are unique to each patient, molded by the unique traumatizing event[s]. And so long as I’m in this deep with psychological thinking, there’s a point from Freud’s original thinking about traumatic illness that’s diagnostically important. In his thinking before looking at these patients, he had seen neurotic symptoms as having some kind of gain for the patient – either a gain in life [secondary gain] or a gain in the mental economy [primary gain]. In the war neuroses, he found no evidence that the symptoms did anything for the patient at all. Malingering is all about gain. But the traumatized person usually hates their symptoms and develops a negative self concept around having them. "I’m weak", "I’m a coward", "I’m broken", "I should be able to …". The specificity of symptoms [1-3] and the self-reviling [4] are important clinical tools for making the distinction.
I skipped over Dr. Satel’s comments in the last post, but I’ll mention just one thing about them here. She advocates something of a ‘pull yourself up be the boot-straps’ approach avoiding much talking about the trauma itself, blaming the social deterioration in the patients on misguided psychological approaches. I don’t want to agrue with her or her experience, but my own has been that a lot of the chronic disability and deterioration I’ve seen has come from their dismal view [4] of the world and themselves. It’s a symptom of the illness that needs to be reframed and understood, not ignored. I think that’s what these panelists mean by, "The diagnosis needs to direct care, and it needs to improve the patient’s health. How to get those who need care into effective care is the goal of everyone on the panel."
In Agnes’ Jacket there was an account of thousands of Holocaust survivors in an Israeli hospital that had been diagnosed with schizophrenia and institutionalized for life. It was 2003 before there was a psychiatric study done on the people in the light of their Holocaust experience. Wanting to know more, I kicked around the internet and saw an article that put this issue into the public eye— the director of the hospital was suing the government for German reparation funds to improve conditions in the squalid hospital that was—- wait for it—-
built and used for prisoners of war.
And what about those who suffer PTSD because of things they did? What about the women using their breasts and menstrual blood to humiliate prisoners who had simply been rounded up for a bounty and had nothing to do with terrorism? What about those who engaged in other kinds of torture, including sodomy, threatening the wives and children of prisoners, etc.? Is it healthy for them not to be disturbed by what they had done? Are sociopaths healthier and more resilient?
The classification and approach to PTSD is as much for protecting the hegemonic masculine culture of our military as it is with treating our troops. If the question of whether or not a person’s heart, mind, and identity was crushed by having participated in pathological behavior is not on the table, then much of what breaks soldiers in a time of war is protected and we can expect nothing but more of the same in the future.
I call my PTSD BPM for being properly mortified. If there is nothing that a person can do to affect a pathological environment or behavior then being forever disturbed by it could be the healthiest way to deal with it and retain love for the human race.
The bio-bio-bio approach is stupid, arrogant, presumptuous, and unscientific as ever.
I am all for changing the language to something less stigmatizing. If it gets more people into treatment, I am all for it. The proposed changes in the DSM5 look really weird and random, but if we’ve got to take the odd stuff, I hope we get some useful too.