The PTSD Trap

Scientific American has a knock-out article that questions whether the diagnosis of post-traumatic stress disorder is a coherent psychological concept or whether it is actually making the situation worse for soldiers with post-combat mental health problems.

As we’ve noted before, PTSD is a controversial diagnosis for two major reasons. The first is that it is not clear that the diagnosis describes anything different from other forms of anxiety and depression, except for that fact that it is related to a specific traumatic incident.

The second is that the diagnosis was largely introduced after pressure from veterans’ lobbying groups after the Vietnam war. In fact, PTSD was originally called ‘post-Vietnam syndrome’ and there are concerns that while it was politically expedient at the time, the concept doesn’t lead to good mental health care.

In fact, combat stress reactions have taken various forms through the years of which PTSD is the latest reincarnation.

The SciAm article tackles research in the US military suggesting that the syndrome is over-diagnosed and that the treatment plan is counter-productive and actually encourages people to remain disabled.

But one of the most interesting things about the article is that it tackles the one of the core features of the diagnosis – that the anxiety symptoms are directly tied to a specific traumatic event.

Many people who are diagnosed with PTSD turn out not to have been traumatised by the event they later attribute the trauma to, or may not have even been traumatised at all.

J. Alexander Bodkin, a psychiatrist at Harvard’s McLean Hospital, screened 90 clinically depressed patients separately for PTSD symptoms and for trauma, then compared the results. First he and a colleague used a standardized screening interview to assess symptoms. Then two other PTSD diagnosticians, ignorant of the symptom reports, used another standard interview to see which patients had ever experienced trauma fitting DSM-IV criteria.

If PTSD arose from trauma, the patients with PTSD symptoms should have histories of trauma, and those with trauma should show more PTSD. It was not so. Although the symptom screens rated 70 of the 90 patients positive for PTSD, the trauma screens found only 54 who had suffered trauma: the diagnosed PTSD “cases” outnumbered those who had experienced traumatic events. Things got worse when Bodkin compared the diagnoses one on one. If PTSD required trauma, then the 54 trauma-exposed patients should account for most of the 70 PTSD-positive patients. But the PTSD-symptomatic patients were equally distributed among the trauma-positive and the trauma-negative groups. The PTSD rate had zero relation to the trauma rate. It was, Bodkin observed, “a scientifically unacceptable situation.”

This does not necessarily mean the people are lying, but may simply be attributing true symptoms to an unlikely source.

It’s a wonderfully thought-provoking article that’s sure to ruffle a few feathers.

The writer, David Dobbs, has also put a load of background material and links to the relevant studies on his blog, so you can get a more in-depth perspective if it sparks your interest in the area.

Link to article ‘Soldiers’ Stress: What Doctors Get Wrong about PTSD’.
Link to David Dobb’s background material for the article.

8 Comments

  1. Posted March 16, 2009 at 9:46 pm | Permalink

    I am not an expert on PTSD but somehow I always wondered why each war has his own kind of PTSD e.g Gulf War and how will the Iraq war PTSD look like. Excellent blogpost, thanks,
    Dr Shock

  2. Posted March 17, 2009 at 12:57 am | Permalink

    It sounds to me like the army is looking for an out for the psychological effects of warfare. This isn’t new. It was done during the first World War and the second as well, when soldiers messed up (to use a non-technical word) by their experience were criticized as malingerers and sent back. Supposedly we are more enlightened today. Whether you call it ptsd, and whether the dx of ptsd is precise or not, people who experience a lot of death and violence suffer from it afterward. This is documented, for example, by the journalist and cartoonist Bill Maudlin during WWII, in his book Up Front in which he describes the same kind of effects as soldiers after Viet Nam. This surprised me in reading it, because that was a “good” war. It shouldn’t have: death, suffering, violence, fear of death, the shock of friends dying all around you, never knowing when it will be you to die or lose limbs or faculties has an impact and the after-effects of going through it are difficult. He described symptoms that would be among those listed for ptsd even though at the time it wasn’t associated with any dx. He was pleading with Americans to accept these soldiers’ symptoms and help them adjust back to civilian life.

  3. Posted March 17, 2009 at 1:19 am | Permalink

    I disagree that the military (which is far more than just the Army) is looking for an ‘out’. The question must be asked and answered as to why the returning soldiers from the different wars have different symptoms.
    It’s not completely unreasonable to think that the unwelcoming atmosphere at home that many Vietnam vets faced, coupled with possible drug abuse while deployed and upon returning home had something to do with the severity of some of the reactions.
    Nor is it out of the question that a few of the vets merely lied, some about having even been there.
    Frankly, the worst episodes, those nearing ‘epidemic’ levels follow “unpopular” wars, do they not? And this question should be asked also: why is not everyone effected by the traumatic events of war? Unless the definition of PTSD is watered down and spread very thin, most soldiers don’t experience it.

  4. Posted March 17, 2009 at 2:00 am | Permalink

    I agree with Lilian Nattel: this makes me think of the time when doctors were paid to demonstrate that smoking is not bad for you. I am no specialist, but I live in a neighborhood of retired soldiers and I doubt the science behind this paper: I have seen French soldiers from Indochine decades ago do the exact same things our soldiers do here when they come back from Irak. For instance, if there is no danger and you enter a room softly, they would throw themselves on the ground and roll away: it is very different from being “depressed”. The periods of silence followed by anger are also specific, together with a certain amount of dysfunctional aggression and deeply embedded paranoia. The defining event has no diagnostic meaning, as many soldiers would say anything rather than tell you what really happened, which typically takes them ten to twenty years to do.

  5. insanity
    Posted March 17, 2009 at 2:01 am | Permalink

    Dr. Shock and Miss Nattel,
    Very nice, but hopelessly flawed logic. Both of you are aware, I am quite sure, that being a homosexual was considered pathological and there was no such thing in the bible of psychiatry, DMS, as PMS, until great political pressure was placed on the APA and the writers of the DSM series in the 1970s. If you both accuse the Army of something improper, Dr.Shock being less direct, then following the type of logic that both you have presented above could very easily fit both groups of persons, homosexuals and females suffering from PMS, who, unless you are very young, recall the tremendous political pressure exerted by both groups on the APA and politicians to make these changes. The thing about assuming is that assumptions tend to apply to other groups and areas of society that might not be politically correct or you might not feel comfortable with thinking about. Do you think we will see such a blog that hints that being gay is a disease and that PMS is not a disease. You are aware that about 5 minutes is the maximum a person can hold his or her breath. As a result, neither should do so as it will never happen. My Point. Political and economic pressure have long significantly affected decisions by the APA, just as giant drug companies are doing in the writing of DSM-5, due out soon. How many psychiatrists and doctors on this panel to write DSM-5 have worked for or received grants from drug companies.
    23 out of 30 is about the number. But as we know from the two of you only the Army as ever used improper tactics to affect DSM decisions. I deal in facts, not assumptions, childish anecdotes, and politically correct motives. Just the Facts, Ma’am.

  6. Posted March 17, 2009 at 2:08 am | Permalink

    I am an expert in trauma and depression and do not have believe that PTSD is an outdated diagnosis. In fact, in my experience many of the returning soldiers are inaccurately misdiagnosed with disorders other than PTSD.

  7. Jules
    Posted March 18, 2009 at 11:25 pm | Permalink

    Hello All, I too am a professional working with PTSD among other other mental health dx. There are of course several issues at hand in understanding illogical research outcomes, and unfortunately there is not sufficient space to go into each one properly. Notwithstanding the fact that big pharma and public opinion are great influencers of medical culture (thank you ‘insanity’), one of the more simple and direct issues that relates to complex feedback from research is the ‘concretising’ or petrification of spectrum like issues. PTSD is a classic broad spectrum issue, the spectrum ranging from highly complex and severe symptoms ALL THE WAY through to more mild and hidden phenomena. It is a medical culture (not medicine in general) and a very human tendency to want to categorise PTSD as a very particular discrete thing (and its better for drug and insurance companies too), when it is much more clinically realistic to consider PTSD in terms of a spectrum of severity. Included in this spectrum thinking must go the idea of “what a trauma is” does it need to be “sudden and overwhelming” well perhaps it could be broader as it seems from careful clinical observation. I suspect that the issue with this research may have more to do with narrow definitions rather than false symptoms.

  8. umswati
    Posted March 19, 2009 at 6:16 pm | Permalink

    I think there is some truth in all of this, but the problem is not with traumatic stress syndrome as a concept but with the paradigm of diagnosis.
    I guess the start of your commentary says is all, because of course diagnosis is not a psychological concept, it is an agreement by panel of a cluster of symptoms with an artificial, usually non-empirially derived threshold for being a case or non-case.
    In this respect PTSD is no different to any other diagnosis, and as such is prone to all the usual failings, including poor inter-rater reliability, high rates of co-morbidity and poor specificity and sensitivity. You only need to look at diagnosing schizophrenia to see the same problems. And these problems extend from the clinician to the so-called structured assessment instruments which you mention in the commentary, and which appear to undermine the concept of PTSD.
    Indeed it has always been empirically false to even separate depression and anxiety, so commonly do they co-occur. So it’s no suprise that 60% or more of people with a diagnosis of PTSD also meet criteria for depressive disorder. Added to this that depression without PTSD is probably the most common non-resilient outcome from trauma, and one can see why there are concerns about lack of coherence to the diagnosis. PTSD is indeed a social construction, but no more than any other diagnosis. Role on symptom-based formulations!
    In addition, it seems to me even the most revered of experts seem to miss another fundamental of the PTSD diagnosis, Criterion E, clinically significant impairment. Having symptoms of PTSD is not the same as having PTSD. Immediately following a significant trauma, almost everyone will have symptoms of PTSD. For most people they lessen as time passes. One can have “symptoms of PTSD” such as nightmares in the context of all kinds of other disorders. The work of Chris Brewin, Ann Hackmann and others has shown us how distressing intrusive imagery crosses disorders. Scott and Stradling published a paper called “PTSD without the trauma” showing how someone can fulfill all the criteria for PTSD without a putative life threat having occured. And someone can live for years with all kinds of “symptoms”, but if their lives aren’t affected to the extent that they are impaired in a number of domains, such as work, relationships etc, then they don’t qualify for the diagnosis of PTSD.
    Unfortunately all too little attention is given to this criteria and its correct assessment, as clinicians rush to assess the symptom-based criteria and then assume the person is therefore impaired. This is what McNally seems to be complaining about with the adjusting soldiers.
    At the same time if someone is in distress to the extent their functioning is significantly impaired, their life falling apart, then it would be somewhat inhumane to state that because they only have 2 , not 3 Criterion B avoidance symptoms at clinical threshold, then they don’t require/deserve treatment. What if their only avoidance symptom was “avoiding anything outside my room!”. If anything, the impairment criteria should be listed as A, not E, because this is the fundamental reason someone might need the help of a professional.
    Finally I took some exception the the comment by McNally that accurate reliable diagnosis is essential for making sure someone gets the correct treatment, giving the example of offering prolonged exposure to those with PTSD, but cognitive restructuring to those with depression. Any psychologist worth his salt would disagree with this. Treating someone with PTSD almost always also involves tackling their thoughts about the event and its consequences, which are often inaccurate, maladaptive or “frozen in time and requiring update” (cf Ehlers and Clark). At the same time Brewin and Wheatley have shown how imagery-based treatments can be effective for people with depression, and Jeff Young describes similar approaches with people with personality disorders. Again this goes back to the whole medical model of diagnosis directly suggesting treatment, which unfortunately falls apart when you are talking about people’s thoughts and feelings. We should be matching the treatment technique to the individual and their specific presentation, not to whether they tick this box or that. The sooner we dump diagnosis altogether the quicker we can dispense with these arguments.


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