Academic journal article Policy Review

PTSD's Diagnostic Trap

Academic journal article Policy Review

PTSD's Diagnostic Trap

Article excerpt

MILITARY HISTORY IS rich with tales of warriors who return from battle with the horrors of war still raging in their heads. One of the earliest examples was enshrined by Herodotus, who wrote of an Athenian warrior struck blind "without blow of sword or dart" when a soldier standing next to him was killed. The classic term--"shell shock"--dates to World War I; "battle fatigue," "combat exhaustion," and "war stress" were used in World War II.

Modern psychiatry calls these invisible wounds post-traumatic stress disorder (PTSD). And along with this diagnosis, which became widely known in the wake of the Vietnam War, has come a new sensitivity--among the public, the military, and mental health professionals--to the causes and consequences of being afflicted. The Department of Veterans Affairs is particularly attuned to the psychic welfare of the men and women who are returning from Operation Iraqi Freedom and Operation Enduring Freedom. Last July, retired Army General Eric K. Shinseki, secretary of Veterans Affairs, unveiled new procedures that make it easier for veterans who believe they are disabled by wartime stress to file benefit claims and receive compensation. "[Psychological] wounds," Shinseki declared, "can be as debilitating as any physical battlefield trauma."

This is true. But gauging mental injury in the wake of war is not as straightforward as assessing, say, a lost limb or other physical damage. For example, at what point do we say that normal, if painful, readjustment difficulties have become so troubling as to qualify as a mental illness? How can clinicians predict which patients will recover when a veteran's odds of recovery depend so greatly on nonmedical factors, including his own expectations for recovery; social support available to him; and the intimate meaning he makes of his distress? Inevitably, successful caregiving will turn on a clear understanding of post-traumatic stress disorder.

One of the most important and paradoxical lessons to emerge from these insights is that lowering the threshold for receipt of disability benefits is not always in the best interest of the veteran and his family. Without question, some veterans will remain so irretrievably damaged by their war experience that they cannot participate in the competitive workplace. These men and women clearly deserve the roughly $2,300 monthly tax-free benefit (given for "total," or 100 percent, disability) and other resources the Veterans Administration offers. But what if disability entitlements actually work to the detriment of other patients by keeping them from meaningful work and by creating an incentive for them to embrace institutional dependence? And what if the system, well-intentioned though it surely is, does not adequately protect young veterans from a premature verdict of invalidism? Acknowledging and studying these effects of compensation can be politically delicate, yet doing do is essential to devising reentry programs of care for the nation's invisibly wounded warriors.

What is PTSD?

THE MOST RECENT edition of the Diagnostic and Statistical Manual (DSM IV) of the American Psychiatric Association defines PTSD according to symptoms; their duration; and the nature of the "trauma" or event. Symptoms fall into three categories: re-experiencing (e.g., relentless nightmares; unbidden waking images; flashbacks); hyperarousal (e.g., enhanced startle, anxiety, sleeplessness); and phobias (e.g., fear of driving after having been in a crash). These must persist for at least 30 days and impair function to some degree. Overwhelming calamity--or "stressor," as psychiatrists call it--of any kind, such as a natural disaster, rape, accident, or assault, can lead to PTSD.

Notably, not everyone who confronts horrific circumstances develops PTSD. Among the survivors of the Oklahoma City bombing, for example, 34 percent developed PTSD, according to a study by psychiatric epidemiologist Carol North. …

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