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Soldiers' Stress: What Doctors Get Wrong About PTSD
April 20, 2009 12:19 PM   Subscribe

Soldiers' Stress: What Doctors Get Wrong About PTSD. A growing number of experts insist that the concept of post-traumatic stress disorder is itself disordered and that soldiers are suffering as a result.
posted by lullaby (34 comments total) 7 users marked this as a favorite

 
He was not surprised: "I would expect people to have nightmares for a while when they came back." But as he kept track of his unit in the U.S., he saw troops greeted by both a larger culture and a medical culture especially in the Veterans Administration (VA) that seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.

It seems ilke it should be more an issue of scale - X amount of stressful nightmares following a traumatic event are normal, more than X makes it a disorder? Saying "the nightmares are normal" is kind of like saying "The hole with the blood coming out is normal, you've been shot! But that's not too alarming an amount of blood, come back if it gets REALLY nasty."
posted by FatherDagon at 12:58 PM on April 20, 2009 [1 favorite]


It seems we've gone from stigma and under-diagnosis to encouragement and over-diagnosis? Certainly there is a happier middle ground.
posted by jabberjaw at 1:04 PM on April 20, 2009


There's no reason to think that PTSD is a single condition.

"Clinicians aren't separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems or who are just taking some time getting over it," Stevens says. He worries that many of these men and women are being pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.

But it's not surprising that a medical bureaucracy like the VA could seize on the unitary label of PTSD and act like it's treating a unitary condition. (This may actually be a common error in mental health. Our language for describing and grouping symptoms is so general that our diagnoses often describe any of several underlying "true" conditions.)
posted by grobstein at 1:08 PM on April 20, 2009


If the Iraq war kid on my caseload is in any way representative I think that determining what is and is not PTSD is going to be hyper-complicated by the fact that the armed forces now accept kids with histories of conduct disorder, burgeoning addictions and other mental health disorders. So after they come home they're in full blown mental health crisis, symptomatic for about five different Axis I disorders combined with legal problems and homelessness. In a case like that where does the PTSD start and the depression, anxiety, heroin and benzo abuse and antisocial behavior -- some of which preexisted the military experience in varying levels of severity -- end? This is my first Iraq war guy, so I'm just trying to get a handle on all of it, it's kind of a total mess. I would imagine there are a lot of other social workers out there chasing these dudes from crisis center to crisis center as we speak, it's very frustrating.
posted by The Straightener at 1:17 PM on April 20, 2009 [3 favorites]


"Getting Over It" by Malcolm Gladwell (New Yorker, Nov 2004, Best American Science and Nature Writing). This article pretty much discredited the idea of PTSD for me.
posted by stbalbach at 1:21 PM on April 20, 2009


Reminds me of "Soldiers Get Strange," really powerful new song from Jason Isbell. (Lyrics)
posted by jbickers at 1:31 PM on April 20, 2009 [1 favorite]


"Getting Over It" by Malcolm Gladwell (New Yorker, Nov 2004, Best American Science and Nature Writing). This article pretty much discredited the idea of PTSD for me.

Wow that is one of the worst articles I have ever read. I'm surprised it was printed in The New Yorker, or anywhere. To summarize, for anyone who doesn't want to click through, the author uses a forgotten piece of fiction from the 1950s as his exclusive argument that the medical condition PTSD (known and documented since at least WWI under the name "shell shock") is not a real problem.

Executive summary: "Walk it off."
posted by drjimmy11 at 1:51 PM on April 20, 2009 [2 favorites]


The Straightener, how closely tied are you with the military mental-health circuit?

And why is the Army letting these people in? Though my cynical side says 'it'll take care of some of the problematic people by killing them', my less cynical but still pragmatic side says 'how do their commanding officers put up with this shit, how does it impact missions in Iraq, and why the hell can't they shunt these people into treatment?' (I'm no anti-mentally-ill person since I had an episode of depression a while back and let me tell you it is an illness and not a personality defect, but shit, the army needs to be pragmatic and cut its liabilities without damaging people. For the record, nor am I a huge fan of the military; I have little sympathy for recruiters who commit suicide because they can't recruit another future corpse and who are so desperate to get new troops that they will fake a recruit's health just to meet a quota )
posted by kldickson at 1:57 PM on April 20, 2009


Saying "the nightmares are normal" is kind of like saying "The hole with the blood coming out is normal, you've been shot! But that's not too alarming an amount of blood, come back if it gets REALLY nasty."

I don't know. I understood it more as-- if you get a cut and you bleed, that's normal. But if weeks later the cut's still opening and bleeding again and again, you have a problem. So if you survive combat and you have some reaction (nightmares, anxiety, whatever), that's normal, but if it's years later and you're still dealing with night terrors or panic attacks (etc), then you have a problem. The idea being to highlight the disorder part of 'PTSD'.
posted by lullaby at 2:11 PM on April 20, 2009


stbalbach: It seems unfair to use a work of fiction as evidence that PTSD is not read. It also seems unfair to me to compare childhood sexual abuse survivors with returning war veterans, for SO many reasons, not the least of which is, in most CSA stories, there are no dead bodies at the end.

I think the author may have things a bit backwards. "The Man In The Grey Flannel Suit" is a product of the 1950s, when America was spending a lot of its time lying to its collective self about the true nature of its culture. I can easily see the difference between that book and the 1994 novel as, well, the difference between the wish fulfillment of Douglas Sirk films and Todd Haynes' "Far From Heaven." One paints a picture which is safe, the other paints a picture which is more true.

In any case, none of these are real stories anyway and should likely not be taken as proof that PTSD does or does not exist.
posted by hippybear at 2:23 PM on April 20, 2009


er, um.. evidence that PTSD is not real.

No matter how many times I proofread before clicking Submit...

posted by hippybear at 2:27 PM on April 20, 2009


I'm willing to concede that PTSD might be a blanket term used to erroneously diagnose any number of mental conditions that soldiers might suffer from, but if that is the case, let's go back to using a specific term for what they have (I always liked "Shell Shock" because it sounds like something that you would want to help someone with) and for all the other people, even if they don't have the very specific symptoms to this disorder, how about we still get them some fucking help too?

I don't care if it's PTSD or fatigue or onset addiction or brain worms. It doesn't matter. If these people fought for us, they should get treatment. As far as I'm concerned, that's the deal, we asked them to do something ugly for us and in return they get taken care of by us.

Even if we take the most cynical view possible, treating them should still be our top priority, because they are trained weapons with the skill set to do disproportionate amounts of damage should they decide to try to fit the square peg in the round hole. We made them dangerous, it should be obvious that it's in our best interests to make them safe again.
posted by quin at 3:07 PM on April 20, 2009 [4 favorites]


It sure would be convenient for an underfunded VA under fire for under-treating the physical and mental injuries of our soldiers, if it turned out that they were actually *over-*treating and *over-*diagnosing the most common kind of mental damage done to people in war zones.

Then all they'd have to do is back off!

It would be terribly, terribly convenient to a lot of people who have been embarrassed by the job the VA has been doing, the job it's been able to do given its levels of funding and the size of the wars we've gotten ourselves into.

Kind of like how convenient it would be to discover that the government was helping out the poor *too much* and they'd turned into a bunch of Cadillac-driving welfare queens.

Or how convenient it would be if the people our government desperately wanted to invade for their oil turned out to have ties to Al Qaeda and weapons of mass destruction.

How lucky that it turns out the VA is doing *too much* for our soldiers and convincing them they have fake illnesses, instead of doing too little and ignoring real illnesses!
posted by edheil at 3:22 PM on April 20, 2009 [3 favorites]


"Getting Over It" by Malcolm Gladwell (New Yorker, Nov 2004, Best American Science and Nature Writing). This article pretty much discredited the idea of PTSD for me.

That's kind of absurd. The article is written around a work of fiction about a fictional character. Real human beings aren't all like The Man in the Gray Flannel Suit. Spending years with the pressure, boredom, frustration, and terror of combat and watching your friends die in brutal and bloody ways is not something so easily shrugged off. Promise.

Combat stress reactions have been recorded in the US since at least the Civil War. Generations and generations of soldiers who just needed to 'get over it'?
posted by lullaby at 4:06 PM on April 20, 2009 [2 favorites]


George Carlin:
There's a condition in combat. Most people know about it. It's when a fighting person's nervous system has been stressed to it's absolute peak and maximum, can't take any more input. The nervous system has either snapped or is about to snap.

In the First World War that condition was called "shell shock." Simple, honest, direct language. Two syllables. Shell shock. Almost sounds like the guns themselves. That was 70 years ago.

Then a whole generation went by. And the Second World War came along and the very same combat condition was called "battle fatigue." Four syllables now. Takes a little longer to say. Doesn't seem to be as hard to say. Fatigue is a nicer word than shock. Shell shock...battle fatigue.

Then we had the war in Korea in 1950. Madison Avenue was riding high by that time. And the very same combat condition was called "operational exhaustion." Hey we're up to 8 syllables now! And the humanity has been squeezed completely out of the phrase now. It's totally sterile now. Operational exhaustion: sounds like something that might happen to your car.

Then of course came the war in Vietnam, which has only been over for about 16 or 17 years. And thanks to the lies and deceit surrounding that war, I guess it's no surprise that the very same condition was called "post-traumatic stress disorder." Still 8 syllables, but we've added a hyphen. And the pain is completely buried under jargon. Post-traumatic stress disorder.

I bet you, if we'd still been calling it shell shock, some of those Vietnam veterans might have gotten the attention they needed at the time. I bet you that.
posted by kirkaracha at 4:16 PM on April 20, 2009 [6 favorites]


Wikipedia says Carlin's wrong, "shell shock" isn't exactly the same as PTSD:

Combat stress reaction, in the past commonly known as shell shock or battle fatigue, is a military term used to categorize a range of behaviours resulting from the stress of battle which decrease the combatant's fighting efficiency. The most common symptoms are fatigue, slower reaction times, indecision, disconnection from one's surroundings, and inability to prioritize. Combat stress reaction is generally short-term and should not be confused with acute stress disorder, post-traumatic stress disorder, or other long-term disorders attributable to combat stress although any of these may commence as a combat stress reaction.

And, sorry English majors, but Carlin was wrong about the magic of short, sharp words. "Shell shock" wasn't necessarily very helpful in getting them much help or respect:

There should be no excuse given for the establishment of a belief that a functional nervous disability constitutes a right to compensation. This is hard saying. It may seem cruel that those whose sufferings are real, whose illness has been brought on by enemy action and very likely in the course of patriotic service, should be treated with such apparent callousness. But there can be no doubt that in an overwhelming proportion of cases, these patients succumb to ‘shock’ because they get something out of it. To give them this reward is not ultimately a benefit to them because it encourages the weaker tendencies in their character. The nation cannot call on its citizens for courage and sacrifice and, at the same time, state by implication that an unconscious cowardice or an unconscious dishonesty will be rewarded
(also quoted in Wikipedia)

Maybe the author of that quote (who Wikipedia doesn't name; it comes from a work of history by Ben Shepherd but he isn't the source of the quote) would get along pretty well with the "growing number of experts" who have no use for the concept of PTSD.

Can't go encouraging the weaker tendencies in their character, can we?
posted by edheil at 6:13 PM on April 20, 2009


Wow, stbalbach, I think you need to read more. As others have pointed out, that article is largely garbage. One of the psychologists he quotes contradicts your take home lesson: "Only a small subset—five to fifteen per cent—struggle in a way that says they need help."

That's still up to 15% who can't just "get over it". While it's absurd to say that all returning veterans are going to have psychological problems stemming from their combat experiences, it's equally absurd to say that none of them will. Gladwell deserves a hard kick in the nuts for trivializing this very real problem with a literary reference. What a douche.

Dave Grossman's take on the PTSD thing is, if your problems last more than a month, seek help. I feel like I pimp this book on the blue all the time, but anyone looking for a more nuanced take on this kind of thing really ought to read his On Combat.
posted by adamdschneider at 6:17 PM on April 20, 2009 [1 favorite]


Sorry, typo. What I meant to say was, "What a colossal douche."
posted by adamdschneider at 6:19 PM on April 20, 2009


Metafilter: Malcom Gladwell has, is, and always will be a colossal douche.
posted by yonation at 6:56 PM on April 20, 2009


Wikipedia says.....

When I hear/read that, I always think of the game "Simon Says" and presume the same education level of the participants.
posted by Nick Verstayne at 8:20 PM on April 20, 2009


There's no reason to think that PTSD is a single condition.

Any textbook disease is probably really a collection of several derangments that share some pathophysiology. Our awareness of this will expand as genomics and epigenetics grow.

"Such is the poverty of our nomenclature" -- Thoreau
posted by neuron at 8:24 PM on April 20, 2009


comment by a MeFite who would prefer to remain anonymous
I'm a longtime MeFi member and am a physician (not a psychiatrist) for the VA.

FYI: Physicians in the VA are required to screen patients for PTSD. I think this has been in place for about two years. I'm not sure how often the screening has to be done, perhaps it's at the first visit and then every 2 or 3 years. The important point is that the screening process is templated as a set of four questions. People who answer yes to 2 or more of those questions are labelled with PTSD. A lot of them probably just have generalized anxiety disorder or other syndromes.
posted by jessamyn at 8:24 PM on April 20, 2009


"It seems we've gone from stigma and under-diagnosis to encouragement and over-diagnosis?"

I don't think this is fair to say, as there are still lots of troops out there -- especially amongst the Marines I know -- who are afraid of destroying their career due to PTSD, being depressed or anxiety-ridden, etc. There are also plenty who have complained about such things, only to be sent back out again for another rotation in a war zone.

I think The Straightener's comment had a point about people coming in messed up coming out more messed up. But the thing is, my friend was supposed to be the best of the best... an extremely technical, precise, stone cold Marine sniper. He was someone who could get into the zone, do the internal calculus, and hit bullseyes from over a mile away with the right weapon... and he did this in Fallujah for a long time. Unfortunately, even when he was there, I could see that he was suffering, doubting his mission, losing his relationship, and generally being broken down by it all.

So, while I can understand Straightener's point about people going there messed up, and coming back more messed up on several fronts, to the point that they're the human equivalent of dealing with a computer loaded with viruses, with bad sectors on the hard drive and chronic overheating problems... so undiagnosable as to practically be junk. Fungible, as Rumsfeld said.

But the thing is, my "elite" friend had no such problems... once. And now, he's messed up on several fronts. It's not just PTSD. How about "nearly unable to process, accept, and deal with the fact that he was sent to kill Iraqis for no good reason" syndrome?

How do you get well from that? How do you find a way to get "well", and still find a way you can manage to live with yourself?!

It's not just war that is horribly damaging to a soldier's mind. It's a war that will never fully make sense to them and can never truly be justified, no matter how many "welcome home" parades they get.
posted by markkraft at 8:35 PM on April 20, 2009


Military blamed for inadequate referral for PTSD assessment. Just a start at looking at some of the problems of PTSD assessment and treatment which I found interesting.

Full disclosure. I was diagnosed with and treated for PTSD from 2002 to 2005. I'm very sure that I was on the milder end of of the thing, as it only affected me badly (read "my every waking moment") for about a year once the treatment started. I had some funky-ass EMDR treatment - and time - and now I'm ok. My experiences had nothing to do with Iraq, (unless you believe Cheney's link to the September 11th attacks) but the article I've linked to above made me think that maybe I was just hyper stressed and traumatized by what happened to me rather than what these people have been through. I guess there are different degrees of it, so where do you draw the line and diagnose PTSD versus extreme stress which will, in time, pass? I haven't got the faintest clue, but the treatment I received certainly helped me.
posted by Nick Verstayne at 9:08 PM on April 20, 2009


Poor health prior to combat linked to later PTSD
posted by homunculus at 9:18 PM on April 20, 2009


Hmm, I'm not sure about the original link, but this thread is pretty educational for me.
posted by serazin at 9:56 PM on April 20, 2009


"So if you survive combat and you have some reaction (nightmares, anxiety, whatever), that's normal, but if it's years later and you're still dealing with night terrors or panic attacks (etc), then you have a problem."

I think that's the thing though - everyone reacts to combat. I have a lot in common with markkraft's friend, simply being outstanding at what you do doesn't turn you into a heartless psychopath. It's been a bit for me. Before I went in, slept like a log, at least on days I put in time at the gym. Psyche as stable as a rock. But I still have insomnia.
Nothing Earth shaking. I don't wake up thinking someone's going to kill me or I have to take someone out. Just can't sleep. Sometimes for days. Nothing particular on my mind. I don't obsess. Just don't sleep though. And some days I'm a little standoffish. Took me a while to just get back to who I was before.
And that is the real problem. You survive combat and of course you're going to have reactions. No normal human being wouldn't.
But the thing is - it's YOUR problem. The training, the combat, everything else, - hey thanks. C-ya.

That's without considering a thinking man and what he might take away. Markraft's friend obviously has some thoughts about what went on and the meaning of it. There are still deeper layers - philosophy. Religious. Etc.
Most people haven't had the experience of someone trying, very hard, to kill them. Nor have they taken anyone's life. When one realizes that with some application of skill and a bit of willpower they can pretty much kill anyone they wish, drops a big weight on you.
If you can kill, you can do other things. If you can survive combat, you can do most anything.
So - what do you do?
Hell, I understand most college freshman go through some kind of meltdown even without the existential "what do I do with my life" question.
But there it is? What do you do? You have a wider understanding of the world. You know what you (and other people) are capable of - what now?

Some people run for office. Some raise families. At some level though you can't UN-see the abyss. And we know what Nietzsche said about fighting monsters, and I think most people who have been in combat pick that up intuitively.
Many people fight against war, or certain wars, and often these go on anyway. And for veterans they feel the same frustration. Perhaps more keenly in some ways for having been there and still not able to show the stupidity.
In part too, most people are ferocious up until they get a sucking chest wound or traumatic injury, and then compassion becomes their sworn virtue. Something you pick up about people being in combat or being wounded yourself.

And still - what do you do? What now?

"Then, without determining as yet whether war does good or harm, thus much we may affirm, that now we have discovered war to be derived from causes which are also the causes of almost all the evils in States, private as well as public." Socrates.

And Socrates was not just a philosopher all his life. He was in the infantry (in Delium and Amphipolis) in the Peloponnesian war.
So it's not a new problem. And that's the existential horror of it. That's not just the guys coming home, not thinking that deeply, but not knowing how the hell to deal with it.
It is, quite literally, "their" problem.

And it's not surprising that the evils of the state which cause war are the same that refuse to acknowledge that the state of war is an unusual one. That being in combat is basically corrosive to the psyche. So it has to, in effect, not address decompressing or detoxifying someone who comes back from it. To do otherwise would underscore that being in war is a disruptive, even unhealthy, state of affairs.

It has to seem normal. Hell, anyone really feel the effects of Iraq while Bush was in office that didn't have family or friends there or deal with anyone coming back directly? Wasn't even on the news that much, considering. And that whole no photographing coffins, etc - dead giveaway.
And when vets come home they don't seem normal. So they have a problem. They. Not the war. Not the combat. Not the country. It's their problem that they can't deal with the perfectly wholesome state of affairs of people planting explosives for other people to trip over and detonate or drawing a bead on them.

And I don't know what's worse - that they don't get over it or they do.
(Oh, I know there are some people that need to be killed. I've seen them. They make life completely unlivable until they get their way and even then - they'll only do it more (the Nazi high command comes to mind). Or it's circumstances. They won't yield. (The Somali pirates come to mind - the ones that were shot.) But I'd always thought the idea was to prevent war. Take, say, Hitler, Himmler, etc. out in the early stages of the war, you don't use a lot of men, not too much destruction. It's all good. Small wars.)

I think that some people come home and live normal lives is a testament to that compassion. Just a shame more people don't keep that in mind when they get to thinking about war.
I think every politician who is considering a vote to dedicate troops to combat should get shot - once - in the guts. Just one - BANG! They can have a medical team standing by, all that (which would be a helpful reminder of the need for compassion in the world).
Do it (relatively) safely. But they have to vote yay or nay with the bullet in their guts.
If it's really worth going to war, I think they'd vote for it. I would.
But I do think it would certainly make them reconsider whether it was really necessary.
posted by Smedleyman at 10:08 PM on April 20, 2009 [2 favorites]


I know of a "cognitive vaccine" for PTSD. It sounds like this:

beep...boop beep bip...beep boop bop..boop bip... (peer reviewed research)

If something horrible happens to you don't let it burn itself into your brain. Find something else to concentrate on, and do it fast. Get your mind somewhere else -- anywhere else. If you can avoid thinking about it for a few hours, it might end up being no more than a horrible memory.

If you insist on getting your treatment in pill form, you could try this.
posted by justsomebodythatyouusedtoknow at 1:17 AM on April 21, 2009 [1 favorite]


Poor soldiers
posted by Eugenek at 3:57 AM on April 21, 2009


So, while I can understand Straightener's point about people going there messed up, and coming back more messed up on several fronts, to the point that they're the human equivalent of dealing with a computer loaded with viruses, with bad sectors on the hard drive and chronic overheating problems... so undiagnosable as to practically be junk.

No, dude, they're not. They're not fucking junk hard drives loaded with viruses and bad sectors. That is an incredibly fucked up way to describe a war veteran coping with mental health issues exacerbated by combat service.
posted by The Straightener at 6:45 AM on April 21, 2009 [2 favorites]


Wait...the VA isn't treating anyone, according to salon.com soldiers can't get a PTSD diagnosis as a matter of course, and this is saying that PTSD is over-diagnosed?

I can buy that PTSD is a tricky diagnosis. But I'm leery of anything that suggests our returning military personnel are getting *too much* help.
posted by QIbHom at 10:39 AM on April 21, 2009


"If something horrible happens to you don't let it burn itself into your brain."

It's a nice thought. But uh...

Cmdr. ROACH: For the most part, I try not to get into the individual, because there are several hazards that I'm very conscious of -- the invasion of the privacy. The act of war, you'd be surprised if you've never been in a war, you don't understand that privacy is one of the things that -- it's hard to find. And to invade that privacy is almost a violation of one's space, of somebody else's space. Because even among your friends, you don't reveal what is in your innermost thoughts and soul. And there's a reason for that. It's an instinct for self-preservation. So, I don't try to penetrate that, at least not often.

I violated that with one exception, and that was the beautiful painting I did of that young Marine, and there I wanted to dig, I wanted to dig deep. Because, first off, it was a once- in-a-lifetime occasion where you find an individual who is a universal individual, at least in my mind. Now this is from the painter's heart. Remember, I'm still primarily a storyteller. And in telling that story, I wanted to get as many good things work- ing for me as possible. And in that one individual, I found it.

INTERVIEWER: What do you think you captured?

Cmdr. ROACH: The soldier's question.

INTERVIEWER: His question?

Cmdr. ROACH: The question that every soldier asks of the nation who sent him: "I'm here. I don't want to be here. But I am here because I am called. And if called, I will serve and I will serve well. But I ask you in return," as that face looks at you, the viewer, "is this what I am supposed to do?"

posted by Smedleyman at 10:14 PM on April 21, 2009


If something horrible happens to you don't let it burn itself into your brain. Find something else to concentrate on, and do it fast. Get your mind somewhere else -- anywhere else. If you can avoid thinking about it for a few hours, it might end up being no more than a horrible memory.

Easier said that done, especially when the "something horrible" happens to be rather explosive injury, and the gruesome death of those around you. "Think positive!" is not sufficient in any way, shape or form.
posted by FatherDagon at 10:44 AM on April 22, 2009 [1 favorite]


If something horrible happens to you don't let it burn itself into your brain. Find something else to concentrate on, and do it fast.

Aside from the obvious, I think the problem with this is that it assumes that combat stress is only about singular traumatic events. It's not. It's also about spending a long time with your guard up and the pressure on and the continual exhaustion, isolation, frustration that comes with it all. Trying to think happy thoughts during a particular traumatic event won't erase anything, much less everything. Like Smedleyman said, you can't unsee the abyss.
posted by lullaby at 11:03 AM on April 22, 2009


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