Negotiating with PTSD
30 August 2003
Each war has spawned its own neurosis, The American Civil War generated of chest pain, da Costa’s syndrome. Shell shock was originally believed to be concussion from exploding shells which damaged the brain and body, even when no direct hit had been taken.
By 1916, the link between shell shock and concussion had been broken. About one third of cases had developed symptoms suddenly in close proximity to an explosion. A third were men going to their billets or trenches who heard distant shells. The last third had developed symptoms before they reached the battle field, some before they left England. This questioned causation by traumatic shock.
The (first) Gulf War spawned its own syndrome, a fear of being affected by toxins, but it was limited to English speakers. Some soldiers have returned from every war, anxious depressed, depleted, exhausted, obsessing, drinking, drugging, becoming withdrawn or mad. They have always been diagnosed and treated according to the beliefs of the medical profession of the day.
That was the case before posttraumatic stress disorder was invented. Now everyone, military and civilian, breaks down in the identical prescribed, way.
Freud‘s language, repression, traumatic memory and resistance still permeate the discourse and underpin the remedies.
Vietnam and its inhuman conditions disgorged debilitated men, preoccupied with clusters of abortions in their wives and cancers in themselves. These were attributed to Agent Orange, particularly to its contaminant dioxin which had the capacity to poison and cause cancer.
This issue was never put to test in science or at law. Monsanto settled one big class action then successfully fought off the admission of further claims to court. This debate never reached closure.
Information from the United States government about where Agent Orange had or had not been used, or indeed where the war had or had not been fought, was not trusted.
Inquiry into dioxin stalled because of the lack of funding to do proper epidemiological studies on widely scattered individuals. Reports of birth defects, sickness and early death continued to emerge from Vietnam where the population lives with dioxin contamination of their food chain.
A Government level joint inquiry between the United States and Viet Nam was announced, is presently inquiring further into the effects on the health of the Vietnamese population exposed to Agent Orange.
In 1973, psychiatrist Robert Jay Lifton interviewed a very frightened veteran who had seen, but not participated in, the My Lai massacre. The veteran had been told that he would be killed if he ever told anyone about it. People came to believe that My Lai was a tip of an iceberg of similar rampages.
Lifton spearheaded a loose body of veterans and clinicians who lobbied the American Government describing, in turn, post Vietnam syndrome, post combat disorder and later, catastrophic stress disorder.
During the Viet Nam war and by the early '70s, drug abuse was rampant. After the soldiers came home, breakdowns began. Researching psychiatrists investigated large numbers of ex servicemen and their symptoms could be accounted for within existing diagnoses. However the range of problems from did not lend itself to distributing compensation.
A legitimating category was needed to accommodate an essential element, causation by war service.
The veterans lobbied the APA to identify a diagnosis that would do this task..
By 1980, the American Psychiatric Association admitted the first of several versions of posttraumatic stress disorder. The stressor, criterion A, the allegedly causal entity, had to be outside the range of normal human experience. This criterion was loosened then tightened up in later editions.
An epidemic followed, and spread to the Civilian world. Enthusiastic vested interests still talk of cases which remain undiagnosed and, so, untreated.
APA diagnoses are the products of committees of vested interests. Its major use is to allow mental health professionals to communicate in shorthand with insurers and other third party payers. .
The APA makes sixty million dollars a year from selling the Manual so the mode is expansionist. 24% of the general population can be diagnosed as having a current disorder. The handbook represents psychiatry’s grab for power and therapeutic jurisdiction. The medicalization of life’s vicissitudes is good for business. Mental diagnoses are created by questions and are categorised according to the DSM. This is called social construction of illness.
The DSM contains warnings to the effect that its contents are not generated by scientific processes, but by committees. The book warns that it is not suitable for legal proceedings. Yet the DSM sits at the right hand of every barrister and judge when their cases involve mental health issues.
The inclusion of posttraumatic stress disorder in DSM III was a victory for the veterans as it meant free treatment and compensation. The act of delivering to psychiatry a grab-bag of symptoms, representing the suffering of thousands of men and women (mainly nurses), was more political than medical.
In l986 the American government asked a veteran’s hospital to devise a treatment for posttraumatic stress disorder, so it could be taught and standardised.
Ultimately, this meant that veterans would pay a price by being subjected to treatment programs ill-suited to their needs.
The daily activities of this hospital were observed and recorded by a medical anthropologist Allan Young and written up in a book called ‘The Harmony of Illusions: Inventing Post-traumatic Stress Disorder.’
Briefly, veterans were treated as in or out-patients. They qualified for in-patient treatment if they did not have too many so-called ‘characterological’ problems, these being with alcohol, drugs, criminality or personality disorders.
The underlying philosophy of the program was primitive Freudian, namely that uncovering of their traumatic memories, bringing them to the surface, would result in a cure.
The veterans were expected to recall their traumas in group and individual sessions; to abstain from illicit drugs.
Veterans were paid full pensions while they were in hospital.
If they could get their previous diagnoses, alcoholism drug abuse, personality disorder, brain damage and occasionally schizophrenia, reversed and, if they could leave the clinic with a diagnosis of Post-traumatic Stress Disorder, then they could get up to $60,000 in back pay.
I stress these men were sick ex servicemen, sick in the same that the non service population were sick. It was highly contested that proportionately, more of them were sick than their matched control group who had stayed at home
Most could not recall having been distressed during their tour of duty. Some had spent the war in an alcohol or cannabis haze. Some had never seen a battlefield but knew of others who had been killed.
They needed a good rationalization for being sick, preferably one that originated in their service so sickness could be attributed to it.
Enter Freud’s discarded concepts of repression and traumatic memory.
If the serviceman could not remember the trauma that had caused his symptoms, he was told that it was because he had repressed both the traumatic event and the feelings associated with it. He had to recall those feelings to be compensated and cured.
Within days or weeks of this treatment, ‘memories’ of war experiences started to emerge, vivid and clear. As they emerged, the men became more disturbed and needed more attention.
Young pointed out two further problems with this treatment program.
First, co-patients who suggested that some were fabricating their experiences were silenced. If medical and therapy staff expressed that idea, they were warned, then dismissed. This scepticism was given a Freudian name, ‘resistance’ and it was treated as an attitude that had to be overcome. No one asked for recourse to the Army historians in the face of recurrent allegations that some veterans were just making it all up.
The second problem was that the expensive and elaborate treatment was never evaluated.
When recovered memory therapy in its various guises did come under scrutiny, it did not make it in into any list of evidence-based remedies.
The servicemen did not want to talk about their experiences or their feelings, and they would get angry about what was going on. They did not like stirring up of old wounds. Those who had experienced atrocities wanted to get on with their lives, but they were told that they had to dredge it up.
Before this remedy was invented, encouraging individuals to stew in their distress was generally considered detrimental to recovery. Therapies which concentrated on the past did not do much for the individual’s future.
When PTSD was first put together, the committee recognised that a disorder with poor validity. Symptoms all of which occur universally for a short time after trauma. A serviceman who had experienced catastrophic trauma had only an 8% chance of experiencing a significant number of the symptoms three months later. In prospective studies, around 20 percent of those exposed to life threatening traumas go on to develop a significant reaction.
Symptom lists were soon being circulated by various Veteran Associations. Films about veterans were written by script writers with the Manual beside them.
The availability of the DSM made instant experts of anyone who could ask leading questions, including lawyers and other veterans.
After the symptoms have been identified in a veterans discussion, or by a report writer in the lead up to a forensic examination, the symptoms list became very familiar to the reporting subject.
The diagnosis is written in American psychobabble and its unnatural jargon makes the phenomenon of learnt symptomatology very easy to identify.
Soon a massive number of claimants in all jurisdictions were able to attend their medical examiners and recite some or all of the following
I have intrusive recollections, I’m hyperalert and I have a startle response. I am detached and alienated. I had a rage and hit my wife because I had a flashback while we were arguing at the kitchen table. I don’t watch television in case something comes on that reminds me of it.
Psychic numbing was harder to describe.
Those who had learnt the symptoms did not know what they did to put an end to their intrusive recollections, so they nursed them and concentrated on them. Stories abounded about the veterans who were concerned that they had not yet finished making their survivor quilt. One of the circulating lists contained a spelling error for ‘survivor guilt’, one of the smaller criteria.
They were doing business with posttraumatic stress disorder
Experienced forensic examiners are embarrassed when they are confronted with a royal flush of symptoms presented in words not consistent with the speaker’s culture or education.
While some veterans never recovered from the war, others had been discharged in good mental and physical health, had enjoyed a marriage or three and had successful businesses or careers and had brought up a family.
The ones I saw had got sick twenty or thirty years later when age, alcoholism, marriage breakdown or disease had caught up with them.
They report symptoms of posttraumatic stress disorder, reciting them in the same order as the DSM, a set of symptoms that would occur together, in nature, as infrequently as 12345678 would win lotto.
I found myself in a sceptical frame of mind so I often asked for recourse to army historians. I soon pleaded off assessing veterans. I found repatriation to be the most ideologically-driven jurisdiction I had worked in, even worse than NSW workers compensation.
I did understand they came to believe that having served was the cause of their latter life problems. American psychiatry texts had told them this was the case.
As any layman with common sense will tell you, you feel at your worst in the days, weeks or months after a trauma, a loss or a bereavement, then you get better. You do not suddenly feel awful 20 years later, unless, of course, you learn something you did not know before.
This counterfactual information did not deter the American diagnosticians. Rather than abandon their caused by trauma paradigm, they shored it up by inventing the concept of delayed Post-traumatic Stress Disorder.
The ability to believe the counter-intuitive view is called the ‘trained incapacity of the expert.’
Cause is a scientific concept, hard to prove. Attribution arises out of politics and preoccupations and masquerades as a medical diagnosis.
We are being asked to reason backwards, from effect to cause. There are always a myriad causes for any given effect. As the song says, ‘Fools give you reasons, wise men never try.’
My dilemma was that, unless the veterans learnt the symptoms with which they were forced to ‘do business’, judges claim that they did not meet the necessary criteria for posttraumatic stress disorder and they are not compensated. If they could recite the symptoms, however, it was abundantly clear that they had been coached.
Tribunals fail to differentiate reports that had been generated by honest clinical examinations from those generated by check lists and leading questions. They distribute benefits in accordance with how many symptoms claimants are able to recall and have documented for them. Alan Young pointed out, ‘if you want your claim to be understood, you'd better use the language of posttraumatic stress disorder -- or other diagnoses -- coined by the DSM. “
Competing interests: I am the author of Constructing RSI: Belief and Desire
Competing interests: None declared
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