An Expert Analysis of PTSD
As a calculated effort first designed to discredit our efforts in
Vietnam, and to denigrate those who serve in the military as
well, American print and popular media have overwhelmingly and
consistently described veterans returning from conflict as being
drug abusers, mentally unstable, and essentially unfit for
reintegration into society. Now, Iraq vets are being
described as having similarly high levels of mental disorder, and
the cycle of misinformation is again being repeated.
The general theme at the moment is that up to thirty percent of
Vietnam veterans suffered from mental disorders, and that
returning Iraq veterans will suffer similar stress rates. It is
interesting that almost nothing is said about veterans of the
extremely successful operations in Afghanistan, with some
suspecting that this is exactly because they
have enjoyed such success in that
operation. With the Iraq veterans, however, isolated incidents,
such as a recent Massachusetts veteran becoming angry with rowdy
partygoers, receive nationwide exposure, when factual
investigation shows that such occurrences happen no more
frequently than among the population at large, to include
newspaper employees themselves. Such incidents are then widely
publicized along with figures suggesting the thirty percent
mental illness rate, and now a sixty percent rate of
brain injury as well, in order to prove the
case that returning vets are, indeed, mentally ill.
The reality, however, is quite different, and shows a surprising
pattern of resilience that most people demonstrate,
rather than victimization and mental illness after stress. The
official publication of the American Psychological Association,
the American Psychologist, has now reached a
startling conclusion concerning all who undergo severe trauma:
an astounding eighty-five percent of people actually show
surprising and significant resilience, even when
confronted with severe stress; stress which is similar in
severity to combat. The higher thirty- and sixty percent
figures of mental illness seem to result basically from
three types of market forces which promote and publicize
the higher figure.
First of all, there is what is known as a dumbing down
of the definition of psychiatric disorder.
The author of the long-awaited National Comorbidity Study,
a report which astoundingly asserted that a quarter of all adults
in the United States – twenty-six percent – qualify
as mentally ill, has now admitted that many
people with mild and limited depressions grossly
inflated this figure due to the low threshold required to be
diagnosed as mentally ill. He used moving from
one town to another as an example which would trigger
symptoms severe enough to meet study criteria for
illness. A similar phenomenon often happens to veterans when they
endorse items on routine questionnaires, such as "Do you have
repeated memories of a stressful military experience?", "Do you
become upset when something reminds you of a stressful military
experience?", et cetera. Some may endorse such an item if they
recall being stressed by their drill instructor or by being six
thousand miles away from home, stresses everyone routinely
endures, but now, voilà!, they
have earned a diagnosis of Post Traumatic Stress
Disorder.
Secondly, higher figures, such as these, result at least partly from aggressive
diagnostic efforts that are often financially driven by those who benefit. Aggressive
screening and internet websites, which advise vets on how to file for disability benefits
and coach on the symptoms of PTSD, for example, can easily raise such diagnostic
rates.
And thirdly, rates are artificially inflated as a result of just such fraud and
dissimulation. As just reported in the British Journal of
Psychiatry by Burkett and his colleagues, when records were vetted at a
typical Veterans Affairs (VA/USDVA) PTSD clinic, only forty-one percent of the total
sample had objective evidence of actual combat exposure. An astounding
fifty-nine percent of these treatment-seeking Veterans Affairs patients were shown to
have misrepresented their combat involvement in Vietnam, so much so that a massive
review of disability cases is now being undertaken by the VA/USDVA.
In addition, with all the publicity about PTSD, it turns out that, of those veterans who,
without question, and who absolutely suffered the worst trauma imaginable, through
not just a single tour of duty, but through four or five, and up to seven years of the
war, such as the surviving Vietnam Prisoners of War (POW), not a single veteran
survivor of the Vietnamese prison camps currently receives any disability pension as a
result of psychiatric disability.
A variant of the PTSD theme was sparked by a preliminary report by the
Army News Service which suggested that among one hundred five
severe neck and head casualties assessed between June and October of 2003,
doctors discovered about two-thirds, or sixty-seven percent, to have brain
injuries. This figure was immediately picked up by other news services,
with inferences that life-saving Kevlar armor was contributing to undiagnosed brain
injuries which would often show up later in life, be poorly identified or treated by the
military or the VA, and which would cause disastrous results for the veterans and their
families. This more than sixty percent figure was readily
bandied about by the media.
As one of the Army's senior brain injury specialists for years, I was particularly
interested in these assertions and found them implausible. Reviewing the situation
personally with Dr. French, the current neuropsychologist assigned to this unit, I
determined that the figures came from a very small, highly specialized unit to which
only those injured with the very highest risk for brain trauma were admitted. As of
March 2005, out of the estimated half million troops who have served in Iraq and
Afghanistan, about four hundred eighty troops had been determined to have a
diagnosable brain injury, about half of those actually admitted to the unit. This seems
to be the genesis for the more than sixty percent brain injury
figure trumpeted by the press. Nonetheless, 480 out of 500,000 troops still translates
to an incidence rate of 0.00096%. Additional study by Dr. French indicated that part of
the good news of this study was that about half of these four hundred eighty injured
troops, or about two hundred forty, actually had milder concussions, which were in
point of fact expected to resolve within two to three months. And finally, some such
brain injuries are always the unfortunate result of rather mundane accidents, such as
motor vehicle collisions, that could happen anywhere, not just in combat, but these
figures were not available. Such analyses, of course, are not reported by the media.
In summary, stress may take its toll, but stress does not control
the lives of most veterans. It is only a minority, the consensus now being that this
figure is about fifteen percent, who develop problems related to their experiences for which
they genuinely need help — probably about the same as the general population. It is
the resilience, not the exaggerated and overly trumpeted reports of mental
disturbance, which is to be noted and celebrated among our veterans.
Over the recent years, there has been a concerted effort to raise public consciousness about
the mental health of veterans, and to insure that all of our veterans receive the treatments that
they need and deserve. Accurate screening, destigmatization of disorders, and providing
prompt attention to those who need it is all desirable. But we should not define mental illness
down, overestimate the normal adversities of life, or denigrate the service of our veterans by
underestimating their courage and resilience.
Accurate estimates of problems and a genuine recognition of resilience will honor those who
serve, as well as preserve our medical resources, so that they will be available to those who
really need them, and not dissipated recklessly, that we might better follow Lincoln's
admonition to "bind up the nation's wounds; to care for him who shall have borne the
battle, and for his widow, and his orphan."
The model of PTSD presented at the 2004 Texas Psychological Association conference in San
Antonio by B.G. Burkett and C.A. Hopewell has been validated by a recent VA/USDVA
Office of the Inspector General report.
The model shows that the diagnosis of PTSD:
-
carries several major conceptual flaws;
-
is greatly over-diagnosed;
-
has been driven largely by a culture of victimization and an anti-American ideology, rather
than by science;
-
this political ideology has resulted in considerable primary and secondary gain for therapists,
who have established an institution that profits from generating disability
claimants by creating an industry of victimization and a culture of
therapism;
-
that the behavioral correlates of symptom expression and disability are easily and
comprehensively affected by operant and classical conditioning paradigms, which reinforce
and maintain the disorder by both primary and secondary reinforcement.
One implicit conclusion is that Hopewell's model of PTSD as a cascade of physiological and
cognitive/affective/behavioral variables, with the critical variable being an identification and
assumption of the role of victimization, due to the attribution of external events, is a more
viable model rather than most of the current models of PTSD.
Dr. Sally Satel has presented equally viable suggestions for better management of the
PTSD crisis, which is not a crisis of PTSD, but rather a crisis of our creation of
this often faux disability. I would recommend her book One Nation Under
Therapy. This, combined with Dr. Levant's comprehensive work on
resilience with APA, and the integration of psychology as a primary care
modality to help people be resilient, rather than to
create more disability, is the direction in which to go.
by C. Alan Hopewell
... who is a psychologist and psychopharmacologist, a former Army officer now slated for
reactivation, a past-president of the Texas Psychological Association, and is the 1990 recipient
of the Outstanding Clinical Neuropsychologist award. He has
published extensively in professional journals.
|