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I appreciate the comments to the last post. I learned a few things – like the classical twin studies as the hallmark of genetic influence being called into question. I’m not an up-on-genetics person, but it’s infinitely apparent that the Mendel/Watson&Crick genetics I learned has been turned upside-down in these post Human Genome Project days and that we’re starting over. Both exciting and confusing!
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What don’t I like about resiliency? I’m a clinician, and having seen PTSD patients from combat, occupational accidents, and abuse situations, I became used to the self-indictments from the patients themselves. "It shouldn’t have affected me", "Other people didn’t end up like this", or "It was a long time ago. I should be over it." Abraham Kardiner’s books on the War Neurosis describe factors that predispose to developing PTSD, but they’re external. The wartime experience reaffirms the protective power of a visible wound. Many books like Robert Graves’ Good-bye to All That or Erich Maria Remarque’s All Quiet on the Western Front give first-hand accounts of its development in the din of war. Since I believe that subsequent traumatic illness is determined not by the objective trauma, but by a subjective experience of being emotionally overwhelmed resulting in an altered consciousness and dissociation, there are many possible personal pre-determinants. No matter how it’s framed, seeing the traumatized person as not resilient implies that there’s something they could’ve done. That’s what they already think and the notion of resiliency reinforces that belief, which I think is false. If they could’ve, they would’ve. The essence of the post-traumatic illness itself is an attempt to "prevent the past" – eg become more resilient going forward through hypervigilance and other maladaptive mechanisms. Traumatic symptoms are often perceived by the afflicted as a defect, something bad about themselves. It’s hard enough to help them accept that it was something that happened "to them" rather than a weakness or something they did without throwing in un-resiliency to needlessly complicate matters.
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I obviously didn’t care for the Nemeroff/Goldschmidt-Clermont paper. I question suggestions of preventive strategies like the one described. My skepticism about clinically significant inherited or biological forces in PTSD persists. My Mea Culpa was in thinking that the authors had no references, but they did. Still in question, thanks to the commenter. But beyond that, statements like this are what I call FutureThink…Identifying which trauma victims will develop PTSD is the agreed upon “holy grail” for the PTSD research field…The use of such genomic, transcriptomic, epigenetic, proteomic, structural and functional brain imaging, inflammation, and neuroendocrine measures taken together with behavioral and psychological measures will likely achieve the much needed goal of predicting which trauma victims will develop syndromal PTSD and, moreover, will likely help identify predictors of response to the effective treatments of PTSD, both psychotherapeutic and psychopharmacological. In the future, such tools can be brought to bear to help manage the psychiatric sequelae of natural disasters similar to the Haiti earthquake. Immediate intervention for medical-surgical and psychiatric consequences of trauma will surely reduce the resultant morbidity and mortality associated with such events…… extrapolations into the future that outrun any current scientific pathway or findings – the kind of logic designed for grant requests or pop-science magazines. The paper itself was about the school’s response to the earthquake in Haiti. Good for them. But it wove itself into a pitch for a line of research into a self-declared holy grail that inappropriately biologifies and trivializes human tragedy.
This was the sentence that made my blood run cold:
“The use of such genomic, transcriptomic, epigenetic, proteomic, structural and functional brain imaging, inflammation, and neuroendocrine measures taken together with behavioral and psychological measures will likely achieve the much needed goal of predicting which trauma victims will develop syndromal PTSD and, moreover, will likely help identify predictors of response to the effective treatments of PTSD, both psychotherapeutic and psychopharmacological.”
First of all, it’s not even completely clear that we have, or ever will have, a suite of effective treatments for PTSD that we could deploy if we were able to identify the “at risk” population on a global basis. (Ethan Watters explains many of the perils of even the best-intentioned, but culturally incompetent, efforts to do exactly this in “Crazy Like Us.”) There are many excellent reasons why tx for PTSD should probably never be standardized worldwide– we’ve got some decent stuff in the tookit for PTSD in the West, why don’t we just learn that and try to practice it–here– effectively? It’s tricky, but it’s not rocket science.
That’s not to say that a neurobiological model can’t inform good clinical practice– I’m a big fan of Bruce Perry’s work, but his approach (to childhood trauma) seems to be highly individualized.
Secondly: How do we imagine we could possibly integrate and analyze “genomic, transcriptomic, epigenetic, proteomic, structural and functional brain imaging, inflammation, and neuroendocrine measures taken together with behavioral and psychological measures…” What would be the methodology for such an undertaking, how much technology would it depend on, and who would design and audit that technology (let alone pay for it)? Research protocols have gone to hell, but even if you could figure out what you needed to measure and how to measure it, you probably couldn’t extract this kind of data from most Electronic Medical Records that are currently in place without rebuilding it from the ground up, and the companies that design electronic medical records are accountable to no one, have almost no liability, and little or no incentive to do it properly.
The worst thing that ever happened to a person and the best thing that ever happened are markers. I suspect that one of the impacts of trauma is that it pushes the pleasure/pain mechanisms in the brain to levels that are extreme compared to people who never had a high-impact experience. People who have had extremely brutal experiences may be able to feel lower lows and higher highs as a result of the depths of feelings they have. Perhaps reaching homeostasis in a brain with PTSD is a longer, slower process that involves emotional lability because the reticula is a bigger territory to balance than it is for most after an emotionally fraught time. It used to not be uncommon to see warnings against labeling PTSD as bipolar, but bipolar is the belle of the ball right now, but I suspect that what may look like “mood swings” in people with PTSD who have been triggered recently is a physiological process that is similar to what the pleasure/pain mechanisms a brain goes through when withdrawing from an addictive substance. The worse the addiction, the longer it takes for the pendulum to stop swinging.
Recovery from a particularly bad episode can be very slow. It’s hard to be patient with oneself, sometimes, when the price of not functioning well is too high, and when most people you know think you should get over it or take the drugs they believe are so helpful.
Mickey,
“Exciting and confusing” is exactly the best take-away from all this! It is so hard to keep up on everything (thank goodness for PBS science documentaries which, despite being infommercials for various niche constituencies of Big Science, do help).
I will step back and return to the dark portion of the blog audience after this post, but I just wanted to leave one final comment or two.
Given the continual cycle of hype and disillusionment in American psychiatry over the past century (perhap dating back even to Dorthea Dix and the idea that the asylum itself was the most powerful therapeutic agent), I find any FutureThink literature that proposes the widespread biomedical surveillance of our population for the purposes of identifying “at risk” individuals a bit creepy. And given abundant evidence of the dark side of human nature, an invitation to eugenics as a social and political policy. This Nemeroff paper is a naked attempt to troll for Federal funding that may flow as we try to help the veterans of our two recent wars. Martin Seligman at Penn has been good at doing this, but assuming there are biological markers that put individuals “at risk” for PTSD fits the Brainhood as Personhood discourse and further marginalizes psychosocial treatments which, as the VA knows, are lengthy, messy and very, very expensive. And again, the FutureThink discourse is designed to shift attention and funding from dealing with the people suffering in the present, who always seem to be written off as too far gone for consideration. How inhumane.
Mickey, I have learned, and will continue to learn, a great deal from your blog. You are raising consciousness, making us all aware, making us all think, and deftly stoking the appropriate level of outrage in all of us. Thank you.
I’ve come across a very interesting post on a blog on military issues, written by two social scientists who work for the military. They, like you, also believe “that subsequent traumatic illness is determined not by the objective trauma, but by a subjective experience.” Nonetheless, they believe that it is possible to help protect soldiers from developing PTSD (i.e., increase resiliency), just not by biologically-focused means.
An interesting perspective which shows that lack of resiliency doesn’t have to be viewed as a personal failure on the part of the individual soldier, but rather a failure of cultural and social factors.
Psychiatry seems to be on a search for the seat of original sin, the factor that dooms. Strange to see a belief in predestination as the core of a so-called science.