It didn't take long for my Scientific American story on PTSD to draw the sort of fire I expected. A doctor blogging as "egalwan" at Follow Me Here writes
[Dobbs] is critical of a culture which "seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD." To critics like this, the overwhelming incidence of PTSD diagnoses in returning Iraqi veterans is not a reflection of the brutal meaningless horror to which many of the combatants were exposed but of a sissy culture that can no longer suck it up.
Doctor or not, he's seeing politics where my words are discussing diagnostics; I stated quite clearly that the high estimates of PTSD rates are a reflection of an overextended view of how people react to brutal meaningless horror.
He further argues that
Articles such as this, and the research that it depicts, should be seen as nothing but a conservative backlash, an effort to blame the victims. If coping with the scope of PTSD is a problem, deny the reality of PTSD.
And for good measure he accuses me of being "an unquestioning apologist for the untrammeled American imperialist project of power in lawless aggression" and says I argue that we should "mindlessly accept such aggression." He even says my argument is "akin to nothing so much as Holocaust denial."
For the record, I was against the invasion of Iraq from the start, and I remain greatly disturbed that our soldiers' and Reserve and Guard members' goodwill, civic spirit, and sense of duty and courage were exploited -- and many of their lives ended or profoundly disrupted -- for such a foolish, ill-advised, poorly executed, and hasty venture. I don't mindlessly accept such use of aggression. I adamantly oppose it.
Yet egalwan's reaction to the story, though insulting and erroneous, is useful, for it gets at a couple of the central problems with the our culture's concept of PTSD, which is the tendency among many to equate critically examining the diagnosis to questioning the reality of war's horrors and soldiers' distress.
I think I'm as fully cognizant of war's horror as one can be without experiencing it directly. I don't dream that soldiers fight in war and come back untouched. Of course they're changed. Hell, college changes you, so I hope we can all agree that war is bound to. Soldiers are exposed to horrors and do things that no one should have to experience and that anyone would like to forget -- but which are often hard to forget.
Is it possible that we can all recognize that -- and recognize that putting them through this for unnecessary wars is profoundly wrong -- and still discuss the soundness and use of a particular diagnostic description of what ails the most troubled veterans? The question is not whether they're confronted with troubling moral horrors, but how they deal with it -- and how many find themselves unable to do so successfully.
I discuss this in a passage from an earlier, longer version of the article. It opens with a story Matt Stevens, the Iraq-war veteran who appears in my article (and who scored positive on the military's PTSD screens despite clearly not having PTSD) told me.
Matt Stevens's job in Iraq was to oversee the medics for a full armored brigade, some 800 soldiers, stationed in Ramadi from June 2005 to June 2006. It was the war's most violent period there. Along with patching bodies together, Stevens tried to keep tabs on his troops' mental health. He spent a lot of thought trying to gauge how badly people were affected by different events.
The most stressful, he told me one day, were probably mix-ups and miscues where soldiers shot civilians. "For the soldiers that shot them and the medics that treated them, those seemed to be the incidents that bothered people the most."
One day he tried to console a soldier who had shot a suicide bomber who might or might not have really been a suicide bomber. To explain:: At the time, Stevens said, "half the 'suicide bombers' in Ramadi seemed to want to give themselves up, but couldn't, because there's often a second trigger man" -- someone who was watching and who could detonate the bomb vest with a cell phone call. "So you don't know if the bomber is trying to give himself up or get closer to kill you or what. All you know is you can't let them get too close. That can be very traumatic. What do you do there?"
If you're the soldier, you shoot the bomber. If you're Matt Stevens, you tell the soldier he did the only thing he could do in an impossible situation.
The war in Iraq is precisely the sort of war, says Army psychologist Dave Grossman, author of On Killing: The Psychological Cost of Learning to Kill in War and Society [a superb book], that robs soldiers of the contexts and rationalizations that protect them from psychological injury. Grossman's thesis, soundly supported, is that killing, rather than being under fire or seeing friends die, is war's most psychically dangerous aspect. This is why the U.S. Army, studying firing rates among GIs in World War Two, found that one in five soldiers actually fired their weapons in combat.
That finding led the Army to revamp its training. Their new methods sought not just to teach soldiers tactics or marksmanship but also to rehearse "engaging the target" in expected combat scenarios, such as firing in full combat gear at pop-up human-form targets. The soldier is not trained simply to fire or to kill, but to kill certain classes of people in certain situations that his type of unit may encounter. Infantry learn to center crossing fire on human forms. Tank crews practice firing on the move at other tanks and buildings. Snipers shoot cut-out figures hundreds of yards away. Rewarded repetition creates a familiar, conditioned context that provides psychic protection.
It worked. Firing rates in U.S. combat units are now 90 to 95 percent. This is one reason U.S. forces routinely defeat larger units. But there's a downside: More of our soldiers face the psychic balancing act associated with shooting people. Twenty-five percent of our soldiers in Iraq have fired weapons in battle there. And they're often firing outside the ethical contexts created by training. They're constantly confronting civilians, frequently shooting them because of miscues or mistaken intentions, and, as with the maybe-maybe not suicide bombers, sometimes killing people because they can't tell enemy from civilian, even though they're trying desperately to do so. When a mission's rationale and context and conditioned protections drop away, the soldier stands naked. "The standard methods of on-the-scene rationalization fail," as Grossman put it about Vietnam, "when the enemy's child comes out to mourn over her father's body."
This -- along with watching friends and innocents die, and coming under fire themselves -- is what our returning vets are dealing with.
So hell yes, war is horrible, and dealing with it successfully -- somehow incorporating the experience into their larger sense of the world and themselves -- is what soldiers face when they return. They deserve a much more supportive environment and culture in which to do so. It's shameful that some return and, upon leaving the service, find themselves without health care or financial security or adequate support in pursuing education. Yet most are able to make the transition successfully, or at least without becoming psychically mired in the troubling things they've experienced -- while -- those that get PTSD -- are not. I think egalwan and I agree on this -- that only some portion of combat vets gets the thing we call PTSD. (Unless he's trying to argue that 100% of combat vets get PTSD -- which is an argument I'd love to see him have with a combat vet who doesn't have PTSD.)
So we're arguing about the how big a minority does get PTSD. Egalwan is insisting, based mainly on an emphasis on war's moral horror, that at least 20 or 25% of them do. I'm presenting an evidence-based argument that the rate is more likely 5 to 10% -- and that misdiagnosing the others, who probably have other ailments or problems that would be best addressed with measures meant for them rather than PTSD, is doing them harm.
Regardless of who's right, we should be able to have that argument without questioning fundamental values and positions about war and militarism. Yet for reasons I think we need to examine -- why is this question so touchy? -- that's' not the case. The argument over PTSD, as Dean Kilpatrick put it, is "a proxy for other argument." I publish an article about a dispute over the definition and application of a diagnosis; egalwan accuses me of being a warmonger. We've attached to this diagnosis a mess of arguments over the meaning of war and war's suffering; over who's to blame for war; over how reliably devastating war is; over how the rest of us can and should view and receive those who've been there.
This thing is endlessly rich -- and profoundly consequential. I'll have more on this over the next few days.
- Log in to post comments
... the Iraq-war veteran who appears in my article (and who scored positive on the military's PTSD screens despite clearly not having PTSD) ... Egalwan is insisting... that at least 20 or 25% of them do. I'm presenting an evidence-based argument that the rate is more likely 5 to 10% ...
Isn't this a matter-of-degree question rather than a binary has/doesn't-have issue?
Isn't the issue of prevalance touchy and political precisely because the estimates of rates of PTSD will directly impact how much funding there is for research on it?
Good questions.
'Isn't it a matter of degree q rather than has/doesn't have?' Complicated ... but: Yes & No. Like most every ailment, PTSD dynamics and severity run along a spectrum from mild to severe. But diagnostic guidelines serve to place borders (fuzzy, maybe, but there nonetheless), or a circle, if you will, that distinguishes between have and don't-have. Part of the critique of the current PTSD Dx, both as written and especially as practiced, is that it draws the circle too widely, and that the circle is too often stretched so that it erroneously gives PTSD Dx to either a) someone who's actually suffering from something else (usu depression and/or one or more anxiety disorder) or b) is simply undergoing difficult but normal and nonpathological healing.
In short: Yes, these things are spectral rather than binary in nature; but a Dx -- especially when it triggers not just treatment but otherwise-unavailable access to health care, disability, and social services -- can effectively serve as a binary on-off switch.
As to touchyness being rooted in rates driving funding: There's something to that, of course, as higher estimated rates can create more funding -- as indeed they have of late in VA PTSD centers. That is definitely part of the concern of those who object to lowering estimates of prevalance. And up to a point it's a legitimate concern. But if other aspects of our response to PTSD, such as the dysfunctional structure of the disability benefits, render treatment ineffective, it's time to closely examine the whole shebang.
HA! "Conservative backlash" from you? Cool intersection of science and politics.
Quite a while ago I was injured in a car crash which began when the driver drifted a bit to the right. For the next couple of years, I got severely twitchy whenever I rode in a car that wandered even slightly rightward. The only "therapy" I received was a conscious choice to minimize car travel for several months, and to sit in the rear, preferably to the left, when such trips were unavoidable.
PTSD? I'd say yes, but a mild case (fwiw: I'm not a health-care pro on any level). If (as a USA-ian), I'd had health coverage, the diagnostician would have had to make a decision based on available resources, not on my condition.
Likewise, in an acute triage situation, someone with a broken arm might justifiably be told to take a hike. That may be practical, but it ain't scientific.
Without reading your SA piece, it sounds like you & egalwan are (political overreactions aside) debating where to set the PTSD bar on external considerations, rather than a fixed standard. In a better world, practitioners would be able to say, "further examination needed" in fuzzy cases - but in that world, we wouldn't have so many vets on the edge in the first place.
Thanks for raising this extremely important issue, David.
The issue of psychiatric overdiagnosis goes well beyond PTSD, I think. Many people would also argue that depression, ADHD, and (increasingly at the moment) bipolar disorder are overdiagnosed, in both adults and children.
The problem, as you've discovered, is that it's much easier to diagnose someone than to de-diagnose them. Saying that someone who has problems is ill is easy, and often seems compassionate: "Your kid's not a bad kid, he's a good kid with bipolar"
However, it's much harder to argue that someone who has previously been considered "ill" isn't. To take a kid who's been diagnosed with ADHD or bipolar, say, and say that they don't in fact have that condition seems like you're saying that the kid either doesn't have any problems, or has purely moral problems - they're a "bad kid" after all (or they have "bad parents").
I think this is one of the main reasons why diagnoses tend to expand, and never contract. Once someone is "inside the circle", "kicking them out" seems like a hostile act.
What we need, I think, is a recognition that someone can have serious problems that require professional help without that meaning that they need a medical diagnosis.
Neuroskeptic raises a good point. I address it more fully in a post about the cultural load that both drives and ladens our responses to the changes we see in people we've sent to war.
This bastard is still exploiting the psychologically afflicted combat veterans. Dobbs has no conscience...it is unconscionable to keep beating on people who can hardly get themselves out of bed in the morning because they have lost the will to live. Trying to rationalize why you would assault an innocent target makes you a terrorist. I can only assume that Dobbs is pure evil or he is a prostitute--i.e. just trying to sell a story because it incites the good natured people in this world. Dobbs attempts to overanalyze the root causes of the problem instead of acknowledging the magnitude of the firestorm. You have to be willing to "stand inside the fire" if you want to fight for freedom and justice. Instead, Dobbs watches from the watchtower--ready to snipe women, children, and the afflicted at will. Although I can barely drag myself out of bed each day, I subconsciously ignore my family and friends, and I am haunted by a war I continue to fight in my head...I still have a sense of duty. As a former major, my duty now is to spear whores like Dobbs and to continue to educate the compassionateless society who discards their veterans like yesterdays trash: http://afghanistanveteran.newsvine.com/.
I'm sorry to have made Afghanistan Veteran feel as if he's under assault in some way. I'd ask him to consider that the article does not question or propose to take away anything he has. I don't question whether war is a hot fire. I don't question the value of his service. I don't question whether PTSD exists. I don't question whether he has it. I don't question whether he should receive proper care and help to deal with the repurcussions of his service -- and in fact propose a system that provides better benefits than he has now. So exactly what is threatened and assaulted here?
Mr. Dobbs: I will trust your claim that you had no overtly political biases or objectives in composing your PTSD article. Nevertheless your piece does come across as very one-sided, relying heavily on the conclusions of a leading PTSD dissenter, Richard McNally, which you seem to accept rather uncritically. The fact is that you purposely dove into a controversial subject and allied yourself strongly with one camp, and it should therefore come as no surprise that you would incite some hostile reaction. The current political context of your article is that the Pentagon is trying to reduce the burden of health care and disability related to PTSD and that pressure is being placed on military psychologists and psychiatrists not to make the diagnosis (see, for instance, recent coverage at Salon.com). The likely impact of McNally and those who extoll his work would be to add grist to this agenda, with the risk if not certainty that PTSD will increasingly be under-diagnosed. You claim, as does McNally, that by correcting the problem of PTSD over-diagnosis you would be helping veterans by ensuring that a correct treatment was being offerred for the correct problem. The more probable result, as perceived by vets who are in the system and their advocates, is that those with bona fide PTSD will go unacknowledged and untreated. It is difficult for some to believe you would be naive to this.
Mr. Dobbs: I will trust your claim that you had no overtly political biases or objectives in composing your PTSD article. Nevertheless your piece does come across as very one-sided, relying heavily on the conclusions of a leading PTSD dissenter, Richard McNally, which you seem to accept rather uncritically. The fact is that you purposely dove into a controversial subject and allied yourself strongly with one camp, and it should therefore come as no surprise that you would incite some hostile reaction. The current political context of your article is that the Pentagon is trying to reduce the burden of health care and disability related to PTSD and that pressure is being placed on military psychologists and psychiatrists not to make the diagnosis (see, for instance, recent coverage at Salon.com). The likely impact of McNally and those who extoll his work would be to add grist to this agenda, with the risk if not certainty that PTSD will increasingly be under-diagnosed. You claim, as does McNally, that by correcting the problem of PTSD over-diagnosis you would be helping veterans by ensuring that a correct treatment was being offerred for the correct problem. The more probable result, as perceived by vets who are in the system and their advocates, is that those with bona fide PTSD will go unacknowledged and untreated. It is difficult for some to believe you would be naive to this.