The Technology of Diagnosis
THIS CHAPTER describes a series of diagnostic sessions conducted during 1986 and 1987 at a Veterans Administration psychiatric facility, the National Center for the Treatment of Post-Traumatic Stress Disorder (a pseudonym), specializing in the diagnosis and treatment of war-related PTSD. The center's origins and operations are described in some detail in chapter 6.
The veterans who come to be diagnosed at the center are drawn from two main sources. Approximately two-thirds of the men are referred from other VA psychiatric units, usually alcohol and drug abuse inpatient units, acute psychiatry inpatient units, and mental hygiene outpatient units. About a third of the veterans are self-referred. These men usually arrive with the encouragement and advice of other veterans—often men who have been previously diagnosed and treated at the center—and are sometimes familiar with PTSD diagnosis through self-help literature, such as The Vietnam Vet Survival Guide (Kubey et al. 1986: 100–116), Post-Traumatic Stress Disorder—V.A. Disability Claims and Military Review (Lepore 1986), and The Veteran's Self-Help Guide on Stress Disorder (a pamphlet published by the Veterans Education Project, a veterans' advocacy group).
Diagnosis at the center is based on several sources of information. (1) Most of these veterans have previous psychiatric diagnoses, made at other VA units. Their VA psychiatric records are reviewed at the center, and their therapists and case workers are contacted if necessary. The previous diagnoses tend to be read as assessments of the severity and chronicity of the patient's psychiatric problems rather than as classifications that need to be taken at face value. (2) Veterans are given a structured interview that asks for information about preservice history (including family life, social life, school performance), military history (including exposure to combat stressors), postservice history (including marital history, employment history, current income, disability payments or claims), and medical and psychiatric history (including past and current drug and alcohol use). (3) Diagnostic information is collected by a standardized diagnostic protocol, keyed to the DSM-III and (after 1987) DSM-III-R criteria for PTSD. (4) Observations are made concerning each man's current status, based on his appearance, behavior (including posture, facial expression, body movements, speech, ability to interact with the interviewer), appropriateness of emo-