Saturday, July 08, 2006

Trauma is "Easy?"

This post is a collaboration between Respectful of Otters and Idealistic Pragmatist.

Think of the most terrified you've ever been. Heart pounding, mouth dry, sweat beading on your forehead, muscles locked rigid, violent or frightening images flooding your mind, screaming so loudly on the inside that you're barely aware of your surroundings. Now imagine being dropped randomly into that state a few times a day, every day, triggered by some innocuous thing or nothing at all.

This is Post-Traumatic Stress Disorder (PTSD), an anxiety disorder in which a person who has experienced or come into close contact with serious trauma later experiences crippling levels of anxiety, combined with vivid re-experiencing of the traumatic event and an intense desire to avoid anything that might bring the trauma to mind or trigger anxiety symptoms. PTSD is known to have a strong biological component; severe stress causes lasting alterations in brain neurochemistry. Trauma appears to damage specific receptors responsible for regulating catecholamines, which are hormones essential to the stress response. In people with PTSD, these stress hormones are elevated, leaving them constantly on the verge of a neurochemically-induced panic. "It's not fashionable," according to Canadian conservative columnist Margaret Wente, to be derisive of people going through that experience. But she courageously does her best all the same.

Wente's got a column up in The Globe and Mail, a Canadian national newspaper, that's been attracting favorable commentary even from bloggers who are ordinarily thoughtful and intelligent. (The column is behind a subscribers-only link, but you can currently access it through Google here). In the column, she suggests that PTSD in soldiers and veterans (and especially in the Canadian forces) is exaggerated and overdiagnosed, and insinuates that servicemembers diagnosed with PTSD are either whiners ("War is hell. But life can be pretty rough, too. You don't need battle trauma to cope badly with it.") or goldbrickers out for an easy life on disability benefits ("some people will abuse the system if it is financially attractive"). Her claims demonstrate little acquaintance with the scientific literature on PTSD; instead, they are heavily based on arguments by an American psychiatrist named Sally Satel, who is affiliated with and funded by the ultra-conservative American Enterprise Institute. Satel's - and, by extension, Wente's - claims about PTSD are baseless. Let's look at them one at a time.

Claim 1: PTSD rates among recent servicemembers are too high.

It's hard to know exactly what Wente means by this. We doubt she means that it's a terrible thing that so many servicemembers are suffering, although if she did, we would certainly agree. At times, she seems to mean that soldiers didn't used to suffer from PTSD, back in the high-moral-fibre days of World War II. She treats an elevation in rates over time as prima facie evidence that current diagnoses are overinflated. In fact, although PTSD has always been with us - previously it was called battle fatigue or shellshock - military strategists argue that aspects of the military and social context of modern wars increase the likelihood of PTSD. The increase in PTSD diagnoses is also due to changes in diagnostic criteria. Prior to the Vietnam era, psychiatric diagnosis was vague and tended to be based on Freudian theories rather than observable symptoms. Modern diagnostic systems, based in empirical research, have led to wider agreement about who has specific psychiatric illnesses, including PTSD.

Claim 1a: Therapists encourage veterans to blame everything that goes wrong in their lives on combat stress.

Wente implies that veterans who have moral or behavioral problems, such as a violent temper or an inability to hold a job, are encouraged by therapists to attribute their problems to PTSD rather than trying to fix them - thus, also, inflating PTSD diagnosis rates. But PTSD simply cannot be diagnosed without the presence of the three core symptoms listed in the second paragraph: intense anxiety, vivid and intrusive memories of trauma, and avoidance symptoms. You don't get to just go to a doctor and say "My life problems are caused by PTSD, now fork over a check."

Claim 1b: Servicemembers and veterans are just faking PTSD to get disability benefits.

Wente cites no evidence for this, which is probably because there is none. The Dart Center for Journalism & Trauma demolishes this claim completely:
Matthew J. Friedman, M.D., is the executive director of the National Center for PTSD, a division of the Department of Veteran's Affairs. In an e-mail to the Dart Center, Friedman said that Satel's argument was based on a "misreading or inability to appreciate the meticulous process by which personal reports of combat exposure were verified by military records" in the 1990 National Vietnam Veterans Readjustment Study. Friedman noted that the vast majority of veterans surveyed had not applied for medical disability because of their PTSD.

The notion of veterans falsely claiming to have PTSD is also contradicted by statistics published by the U.S. Department of Veteran's Affairs. In 2002, 65,154 Vietnam veterans claimed 100 percent disability for "Psychiatric and Neurological Diseases" (about 2.1 percent of the 3.14 million soldiers who served in Vietnam). A total of 202,183 Vietnam veterans claimed a partial level mental-health disability (about 6.4 percent of all Vietnam veterans).
The National Vietnam Veterans Readjustment Study found that 31% of Vietnam vets met full diagnostic criteria for PTSD. Given the low percentages of vets actually receiving benefits for psychiatric disability, there can hardly be an epidemic of false claims. And if And if Wente is going to claim that things are different in Canada, it is incumbent on her to provide proof. She hasn't. She can't.

Claim 2: Therapists are brainwashing PTSD patients into believing that they'll be disabled for life.

The vast majority of cases of PTSD either resolve on their own or are responsive to treatment. According to the Diagnostic and Statistical Manual of Mental Disorders - the very manual used by the mental health establishment that Wente denigrates - half of all cases of PTSD resolve within a few months. Another 20% of cases resolve within the first year after the trauma. Even among chronic cases that last for years or decades, treatment is often effective in reducing the severity of symptoms and allowing people to return to normal social functioning even if symptoms of anxiety continue. (A good overview of treatment options can be found here.)

But early identification and intervention are critical. According to the Veterans Administration:
Extensive research indicates that early distress and symptoms of PTSD are not very good predictors of a long-term prognosis. Thus, while Hoge et al. (2004) reported that 18% of soldiers newly redeployed from Iraq have PTSD - a rate that is alarmingly high, it is likely that this rate will decrease over time. Studies suggest that in the face of severe military service demands, including combat, most men and women do remarkably well across the lifespan. [...]

For those soldiers who don't recover, the most troubling aspect of military-related PTSD is its chronic course. There is evidence that once veterans develop military-related PTSD their symptoms remain chronic across the lifespan and are resistant to treatments that have been shown to work with other forms of chronic PTSD. Thus, it is vitally important to provide early intervention to reduce the risk of chronic impairment in veterans.
Unfortunately, the prejudice and derisive attitudes of Wente and her American counterparts stand in the way of these servicemembers getting the early intervention they need.

Claim 3: PTSD is just like normal worries and stresses, an sufficiently "resilient" people get over their worries and stresses without help.

Conservatives never seem to get tired of belittling severe traumas by pointing out their superficial similarities to minor traumas. (Remember the "fraternity hazing" analogies about Abu Ghraib?) There is no excuse for this kind of unconscionable dishonesty. It's as if Wente were to dismiss and minimize the consequences of blindness based on the argument that sometimes everyone has to strain their eyes to see in dim light. Even if you're heartless enough to doubt the testimony of people with PTSD, the altered neurochemistry is undeniable.

None of this information is hard to find, even without the resources of one of Canada's largest newspapers. The entire first page of Google hits for "Satel PTSD" are either articles by Satel (Wente's only "scientific" source), or articles debunking her claims about overinflated PTSD diagnoses. Wente really had to work hard to avoid evidence that Satel is not credible. Either she's so incompetent that she can't manage a Google search, or she has a serious agenda. We vote for the latter.

Interestingly, this column isn't the first time Wente has written about PTSD in the Canadian military. Back in May of 2005, the Globe and Mail published a different column of hers that could have been the current column's more inflammatory cousin. The arguments were identical, although the tone was even more openly derisive: there are so many cases of PTSD these days that they must all be faking it, many of those cases sound absurd on paper (especially when the paper is the Globe and Mail and the columnist describing the cases is Margaret Wente), isn't it obvious that they're all just in it for the cold hard cash. Her closing line was even "But resilence is out of fashion. Besides, it won't get you a cheque." One underresearched, ideology-laden column might be a passing fancy, but two certainly smacks of an agenda, or even an obsession. We can't help but wonder what might drive Wente to write what amounts to the same column twice--could it be that she didn't manage to convince anyone a year ago, so she decided to tone down the rhetoric and recycle her original words once the casualties in Afghanistan had started mounting and the polls had started indicating a dip in support for the mission?

Although Wente is quick to declare that doubting the validity of PTSD is "unfashionable," in fact, with her commentary, she joins a whole framework of American conservatives with close ties to the Bush Administration, who are currently engaged in an effort to discredit the entire concept of PTSD - particularly the notions that it is common and frequently disabling.

Why do so many conservatives in both countries want to deny the reality of PTSD? On the American side, many are motivated by a reflexive disapproval of federal spending, and a corresponding desire to decrease spending on psychiatric treatment and disability benefits for servicemembers and veterans. Others fear that honesty about the prevalence of PTSD will hurt the war effort:
Dr. Susan Mather, a former top VA official who retired in January as its chief public health officer [says that] "They already have a recruitment problem...the parents of these youth, if they think their children will come back from the military experience changed forever - which they undoubtedly will be; not only changed but disabled by the experience, mentally as well as physically - they are going to be a lot less anxious to have these kids join up. And there’s a feeling that if this gets too much publicity and appears to be too widespread, it will hurt recruitment."
But neither of those pragmatic reasons explains the fervor of their attacks on PTSD-disabled vets, or the contempt that drips from Wente's words as she writes about young soldiers in trouble. It seems that there are deeper ideological factors at work. Generally speaking, any argument that individuals may be helpless to escape their life circumstances is threatening to the conservative ideology of personal responsibility. Social psychology research demonstrates that conservatives are more likely to hold the implicit worldview that bad things don't happen to good people, or, conversely, that the troubles people suffer are generally deserved. Finally, conservative discomfort with PTSD is also motivated by the perceived need for aggressive support of the war effort. It's as if they believe that negative effects of war must never be acknowledged, or the case for military action will collapse. In Canada, this is currently being expressed as denial that Canadians are even engaged in war in Afghanistan - the preferred conservative terminology is "peacemaking." (Hello, Orwell!) Clearly, that case collapses if large numbers of Canadian troops engaged in such a mild, inoffensive activity are found to be suffering from major psychiatric trauma as a result.

But the hysterical denial of war's negative effects is most common among conservatives who are far removed from the actual work of combat. Lieutenant Colonel Dave Grossman, a retired Army Ranger and a professor at West Point, paints a very different picture:
It is essential to acknowledge that good ends have been and will continue to be accomplished through combat. Many democracies owe their very existence to successful combat. Few individuals will deny the need for combat against Nazi Germany and Imperial Japan in World War II. And around the world the price of civilization is paid every day by military units on peacekeeping operations and domestic police forces who are forced to engage in close combat. There have been and will continue to be times and places where combat is unavoidable, but when a society requires its police and armed forces to participate in combat it is essential to fully comprehend the magnitude of the inevitable psychological toll.
Exactly so. If you believe that war is sometimes necessary, then it is your special obligation to be aware of the human cost of what you are asking your soldiers to do, and to mitigate the damage - with early treatment, when possible, and a supportive safety net for those who don't respond to treatment - to the greatest possible extent. More and more, the military recognizes that. Why don't the conservative hawks?