Search This Blog

Thursday, December 7, 2006

Conflict of Interest

This morning on NPR they aired a comment by an Army physician, "The Army has a system in place which required questions be asked, but no action be taken." He was told people he'd seen PTSD in were "faking it" to go home or get out of the Army. In my opinion, this is because there is a conflict of interest between the goals of the Army, to train people to fight and keep fighting no matter what, and the health of individuals.
The questions are asked about PTSD symptoms so the Army can say they want to prevent or are preventing PTSD, but the fact that there is no requirement for action means that the service member can't trust that if he or she speaks up, help will follow. "Betrayal of what's right," as Jonathan Shay, MD, called it in Achilles in Vietnam, is one of the significant contributors to PTSD. It makes a mockery of the sacrifices of soldiers.
At the International Society for Traumatic Stress Studies conference a couple of years ago, I saw a presentation by doctors from Walter Reed who were dealing with the PTSD ward. One young, rich, stupid, innocent-of-the-realities-of-war MD told us they were diagnosing personality disorders because some of these guys had been in trouble as adolescents, so it couldn’t have been the war…
This of course is utter bullsomething. The fact that they may have been in trouble before the war may mean they had childhood PTSD, and PTSD gets retriggered by further trauma, but they were functioning well enough to get into the military and go to war, and that means their problems are related to their service. The conflict of interest is that, if they have personality disorders, it is a pre-existing condition and they get bad discharges and no VA benefits. This is wrong. Even a personality disorder can be made worse by war.
There is also a conflict of interest in the VA. Limited resources means that there is pressure not to find PTSD. I know several MD’s who no longer do psychiatric exams for the VA because they were pressured not to find PTSD and could not honestly keep working there when their diagnoses were ignored by the compensation officers.
There is also unforgivable and contemptible professional ignorance. Two recent cases at the Gainesville, FL VA: A young woman psychiatrist says to a vet, “I see you were originally diagnosed with anxiety,” The wife says “Look at the date, 1968,” and the shrink replies, “What difference does that make?” “Well, there was no such diagnosis in 1968…” Even though she is doing compensation exams at the VA, she is completely unaware of the history of PTSD, especially the fact that in 1968, the American Psychiatric Association decided with NO EVIDENCE that the diagnosis of “Gross Stress Reaction” (if you have been through a gross, i.e. big, enough stressful situation like combat or a concentration camp, it can affect you!) was discarded and replaced with “transient situational disturbance,” which meant that if any trauma affected you for more than 6 months you had a pre-existing condition, and the trauma hadn’t caused your problems. No one has ever taken responsibility for this lethal decision. The other case was a woman psychiatrist in the course of a compensation exam, saying to a veteran of Hamburger Hill, “I saw the movie. It can’t have been as bad as the movie.” This ended his ability to speak, as well as indicating an unbelievable inability on the part of the psychiatrist to think or empathize: IT IS WORSE WHEN IT’S REAL.
Then there is the lack of resources for PTSD treatment. These are part of the actual costs of war, but no one but veterans and their families want them paid.
Tomorrow I will talk more about treatment, but right now I am so mad I have to get off the computer and go calm down.

Tuesday, December 5, 2006

The Realities of PTSD

I'm starting a blog to talk about the multiple realities of PTSD: The biological basis of PTSD, the brain and body based keys to human survival which we all have, the historical reality of PTSD in literature, the separate reality of trauma (war, abuse, natural disaster), the reality of having PTSD, the reality of living with someone who has it, the reality of denial by survivors and society, the physical reality (depleted cortisol, changes in amygdala and hippocampus, stress related diseases, early death), the reality of how hard it is to get help, especially good help.
I'm inspired partly by a story on NPR yesterday about soldiers saying the Army is not treating PTSD, (see This story includes many of the elements which make life hard for people with PTSD. Denial by those in charge (they're faking it) when the likelihood is that those in charge are either REMF's (rear echelon bad word bad word) or so numbed out themselves in order to cope with the trauma of war (usually enabled by alcohol or workaholism or some other addiction) that they think they are fine and it didn't affect them. One sergeant actually said that in the story. I see that as evidence of PTSD, like the mother of a molested child saying, "I don't know why she's making such a fuss. I was molested for years and it didn't affect me." Except to destroy your natural human capacity to care. I think people get this numb because they do care and caring is too painful and utterly unsupported in this society. Been there, done that, being one of the numbing rituals we hear a lot.
Poor treatment. We've all heard the Army, Marines, and VA claim that they are treating and preventing PTSD this time. I always laugh when I hear that. First of all, most guys have to be in extremis to ask for help. Second of all, being in a group with a psychologist is not debriefing, one of the things that does help (see for more information). Critical Incident Stress Debriefing is peer-to-peer, not shrink to clients... The military is not doing that. Third of all, you can't change human nature. We all do our best to survive in war and other traumatic situations. Then we all do our best not to feel the pain. The same things that help us survive: hyperalertness, so we can pay attention to threats and move fast; numbing, rapidly adapting to the situations in order to remain in control and do whatever it takes to survive and keep others alive; and re-experiencing, our brain's better-safe-than-sorry warning system, all can become our biggest problems if the trauma is not addressed. So trying to pretend that 17 soldiers and a shrink is debriefing, and that a suicidal, not-doing-his-job drunken or drug-using combat vet is simply a slacker who should be thrown out of the military will leave us with the same problems we had after the Civil War, First World War, Second World War, Korea, Vietnam, Somalia, The Gulf War, Panama, Beruit, etc.
For interesting reads on the effects of war on family life try Even Dogs Go Home to Die by Linda St John, It's All Over But the Shouting by Rick Bragg, or Change Me Into Zeus's Daughter by Barbara Robinette Ross, none of whom had ever heard of PTSD when they were growing up.
I gotta stop here. As you can see, I have a lot to say.