It is sadly not unusual, in connection to soldiers and marines returning from Iraq and Afghanistan who have sought psychiatric help for PTSD, to hear news reports alleging substandard VA in-patient or out-patient facilities or staffing, lack of after-discharge follow up, seemingly cruel denial of disability benefits, or when begrudgingly given, their lack of adequacy.
The effect of this is reinforced by television shows intended for entertainment, which feature a plot where a crime is committed by a combat veteran said to be suffering from PTSD, usually involving him in killing his wife, kids, or co-workers, and/or often himself. The denouement depends on whether or not the screenwriters wish to find the VA, the Department of Defense, or some other prominent and presumably greedy or crooked corporation or political figure guilty of the crime, rather than the veteran himself, who was portrayed to the viewer, at least, as truly ill with PTSD despite what the bureaucracy said about his not needing services, or their lack of adequacy or quality.
In both our news or our entertainment, then, we are likely getting saturated with depressing news about returning veterans and PTSD, and it is not surprising that many of us feel someone has to be blamed for this mess. Given that it is the VA that is charged most directly with dealing with the physical and mental health needs of veterans, it would appear to those who are outraged that they must therefore be the most responsible for denying each and every undoubtedly deserving veteran their rights to treatment and compensation for their having developed PTSD while in combat for our country.
But what if there were actual many serious questions about the validity of the official description and diagnosis of PTSD in successive editions of the DSM (the Diagnostic and Statistical Manual) , the bible, as it were, for psychiatrist, psychologists, and social workers? Could that explain a part of the problem?
What does the accumulated evidence suggest are the rates of developing PTSD among the soldiers and marines as a whole? When an exhaustive analyses of case records are done retrospectively, do the experts report that the VA has under-diagnosed or over-diagnosed PTSD?
What war-time circumstances make it seem more likely that a person has PTSD than not? Is every one who is the military at the time of war equally likely to develop PTSD?
And are there any cases of persons faking PTSD to either collect disability payments? What would make anyone think that this was even likely?
Some answers to these questions are emerging, and while they are not entirely consistent with one another, they should give one pause before automatically blaming the health care professional at the VA (and it would behoove VA hospital librarians to be aware of some of the following articles).
Is There An Even-Handed Study, Published in a Serious, Peer-Reviewed Journal, About What is Wrong with the way the VA handles PTSD patients?
Probably the best example of a thoughtful and thorough-going critique can be found in a piece by Frueh et al. in the American Journal of Public Health. They present a series of findings about the VA that are at once seemingly pro-and-anti veterans claims with respect to PTSD. On the responsive side, they report “The number of veterans receiving VA disability payments for PTSD increased 79.%%, whereas those receiving payments for other disabilities increased only 12.2%. On the slow-to-get-it-right-side: “In 2006, the VA took an average of 657 days for appeals resolution of disability claims.” Two core problems seem to be blamed more than others: There is vast inconsistency between the rates of returning veterans beings diagnosed with PTSD by hospital and by region, because of the way DSM is applied. They suggest that this is because the DSM description of the illness and guidelines for diagnosis are not based on generally agreed upon scientific evidence, and this is because an adversarial culture is almost unavoidably fostered in psychiatric treatment at the VA, because about 95% of the veterans seeking diagnosis and treatment of any mental disorder are filing a disability claim for PTSD at the same time. These veterans have zero financial interest in NOT being diagnosed with PTSD, and tend to view any diagnosis by the mental health professional that is handling their case that is not PTSD as hostile to their rights. This does not mean that all these patients are filing for PTSD benefits only for the money, or that they do not have PTSD. It does mean that some of them could be out as much as $36,000 a year in cash and many related health benefits ( an annual income that sadly, many under-educated or under-skilled veterans might have trouble making even without a qualifying PTSD diagnosis).
Is There a Consensus Based on Solid Scientific Evidence that the Current Standards for Diagnosis of PTSD Are Reliable?
The most recent review to date (June 2008) by Rosen & Lilienfield in Clinical Psychology Review suggests that “virtually all core assumptions and hypothesized mechanisms [through which PTSD is said to develop in the patient] lack compelling or consistent support.” They strongly recommend a thoroughgoing revision of the PTSD section in the next version of the DSM. This view is in part by shared by Elhai et al in the Journal of Clinical Psychiatry who feel that some of the criteria are not particularly distinctive, particularly “PTSD’s overlapping anxiety and mood disorder”. But they go on to suggest that in the current climate, any revision is unlikely to reduce the prevalence of diagnoses, nor will it likely “address questions raised about the diagnosis’ construct validity.” There is an entire issue (v.21, number 2, 2007) of the Journal of Anxiety Disorders focused on “Saving PTSD from itself in DSM-V” that is required reading for anyone who feels that the portrayal of PTSD as expressed in DSM-IV is still credible under close scientific scrutiny.
At What Rates do Veterans of Actual Combat Develop Disabling or Significantly Impairing PTSD?
There is a long-running debate between Dohrenwend et al and probably the best known PTSD practitioner and researcher in the country, RJ McNally of Harvard University’s Psychology Department, about the degree to which the largest database concerning the mental health of returning soldiers and marines, the NVVRS, or National Vietnam Veterans Readjustment Study, under-reports, reports at about the right level, or over-reports PTSD. Dohrenwend et al revised the rate of credible findings from an original estimate of 15.2% down to 9.1%, which McNally suggests would be actually down to 5.4% if it were based more strictly on having the PTSD actually render the veteran unable, or significantly impaired in his ability, to make a living and conduct his personal and family life. The story is arguably best reported in a commentary by Kilpatrick in the Journal of Traumatic Stress , which also includes a defense by the co-principal investigators of their original assessment.
Can Racial and Ethnic Differences in the Development of PTSD Among Combat Veterans Be Explained?
Dohrenwend et al. report in the Journal of Traumatic Stress that their analyses of records from the NVVRS, or National Vietnam Veterans Readjustment Study, shows that “Compared with [MW]Majority White [meaning non-Hispanic White], the Black elevation is explained by Black’s greater exposure [to actual combat] ; the [HW] Hispanic elevation, by Hispanics’ greater exposure [to actual combat], younger age, less education, and lower Armed Forces Qualification Test Scores [a test of general knowledge and aptitude for learning new skills]. The PTSD elevation in Hispanic versus Blacks is accounted for mainly by Hispanics’ younger age.” Basically, the younger the soldier or marine is, the less educated he or she is, the less advanced military training or experience he or she has, the lower the level of command and responsibility he or she has, and most importantly of all: the more actual combat they experience and close at hand casualties they witness, the likely it is that they develop PTSD. although even if all these conditions are met, only a small fraction actually do develop it.
Where Can I find a Readable & Highly Cited Overview of Controversies Surrounding PTSD to Get Started?
While it is somewhat dated (2003), this blogger can recommend, the paper by McNally in the Annual Review of Psychology 54: 229-252, entitled “Progress and Controversy in the Study of Posttraumatic Stress Disorder.” At the time of this blog this article has already been cited 96 times in other journals of behavioral medicine and clinical psychology. Among the rather sobering findings reported is the high rate at which veterans who had seen no combat whatsoever filed claims for PTSD, and indeed of the number of persons, including prominent public figures and actors, who were not even veterans at all, claiming to have suffered effects.
In Closing, A Cautionary Note on Dismissing PTSD Out of Hand
Not even the worse critics of the current means of diagnosing PTSD, or of its current treatment or of the process by which some claims of disability or compensation are granted or denied, argue that this is a factitious disorder in all cases. There is a growing body of evidence of late that there are some biological correlates in terms of brain imaging, human biochemical measurements, and a credible finding that those with mild brain trauma (conccusions mostly) seem to be at greater risk.
References & Other Suggested Readings
Axelrod BN. 2006. Interpreting symptoms in military personnel after combat.
Browne T et al. 2007. Explanations for the increase in mental health problems in UK reserve forces who served in Iraq. British Journal of Psychiatry 190 (6): 484-489.
Coyne JC & Thompson R. 2007. Posttraumatic stress syndromes: Useful or negative heuristics? Journal of Anxiety Disorders 21 (2): 223-229.
Dorhenwend BP et al. The psychological risks of Vietnam for US veterans: A revisit with new data and methods.
Dohrenwend BP et al. 2007. PTSD and Vietnam veterans – A Response.
Dohrenwend BP et al. 2007. Continuing controversy over the psychological risks of Vietnam for US veterans. Journal of Traumatic Stress 20 (4): 449-465.
Dohrenwend BP et al. 2008. WAX-related posttraumatic stress disorder in Black, Hispanic and majority white Vietnam veterans: The roles of exposure and vulnerability. Journal of Traumatic Stress 21 (2): 199-208.
Elhai JD et al. 2007. Varying cautionary instructions, monetary incentives, and comorbid diagnostic training in malingered psychopathology research. Journal of Personality Assessment 88 (3): 328-237.
Frueh BC et al. 2005. Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorders. British Journal of Psychiatry 186: 467-472.
Frueh BC et al. 2007. US Department of Veterans Affairs disability policies for posttraumatic stress disorder: Administrative trends and implications for treatment, rehabilitation, and research. American Journal of Public Health 97 (12): 2143-2145.
Frueh BC et al. 2008. VA disability and posttraumatic morbidity: Frueh et al. respond. American Journal of Public Health 98 (5): 775-776.
Hall, Ryan C.W & Hall, Richard C.W. 2006. Malingering of PTSD: Forensic and diagnostic considerations, characteristics of malingerers and clinical presentations. General Hospital Psychiatry 28 (6): 525-535.
Hall, Ryan C. & Hall, Richard C. 2007. Detection of malingered PTSD. An overview of clinical, psychometric, and physiological assessment: Where do we stand? Journal of Forensic Sciences 52 (3): 717-725.
Hoge CW et al. 2006. Post-traumatic stress disorder in UK and US forces deployed to Iraq.
Hoge CW et al. 2008. Mild traumatic brain injury in US soldiers returning home from Iraq. New England Journal of Medicine 358 (5): 453-463.
Hoge CW et al. 2007. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry 164 (1): 150-153.
Hotopf M et al. 2006. The health of UK military personnel who deployed to the 2003 Iraq war: A cohort study.
Hotopf M et al. 2006. Post-traumatic stress disorder in UK and US forces deployed to Iraq: Authors reply.
Howard MD. 2007. Escaping the pain: Examining the use of sexually compulsive behavior to avoid the traumatic memories of combat. Sexual Addiction and Compulsivity 14 (2): 77-94.
Jelicic M & Merckelbach H. 2004. Traumatic stress, brain changes, and memory: A critical note. Journal of Nervous and Mental Diseases 192 (2): 548-553.
Jones R. 2006. Interpreting symptoms in military personnel after combat.
Kasai K et al. 2008. Evidence for acquired pregenual anterior cingulated gray matter loss from a twin study of combat-related posttraumatic stress disorder. Biological Psychiatry 63 (6): 539-541.
Kashdan TB et al. 2007. Anhedonia, emotional numbing and symptom overreporting in male veterans with PTSD. Personality and Individual Differences 43 (4): 725-735.
Kilpatrick DG 2007. PTSD and Vietnam veterans.
Kilpatrick G. 2007. Confounding the critics: The Dohrenwend and colleagues reexamination of the National Vietnam Veteran Readjustment Study. Journal of Traumatic Stress 20 (4): 487-493.
Knoll J & Resnick PJ. 2006. The detection of malingered post-traumatic stress disorder. Psychiatric Clinics of North America 29 (3): 629-end of article.
Lanius R. 2007. Complex adaptations to traumatic stress: From neurobiological to social and cultural aspects. American Journal of Psychiatry 164 (11): 1676-1683.
Linden M et al. 2007. Posttraumatic Embitterment Disorder: Definition, Evidence Diagnosis & Treatment. Hogrefe & Huber. 155pp.
Maren S & Chang CH. 2006. Recent fear is resistant to extinction. Proceedings of the National Academy of Sciences 103 (47): 18020-18025.
McNally RJ. 2003. Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology 54: 229-252.
McNally RJ. 2006. Cognitive abnormalities in post-traumatic sress disorder. Trends in Cognitive Sciences 10 (6): 271-277.
McNally RJ. 2007. Can we solve the mysteries of the National Vietnam Veterans Readjustment Study?. Journal of Anxiety Disorders 192-200.
McNally RJ. PTSD and Vietnam veterans – A Response.
McNally RJ. 2007. Revisiting Dorhrenwend et al.’s revisit of the National Vietnam Veterans Readjustment Study. Journal of Traumatic Stress 20 (4): 481-486.
McTeague LM, McNally RJ & Litz BT. 2004. Pre-war, war zone and post-war predictors of pisttraumatic stress in female Vietnam veteran health care providers. Military Psychology 16 (2): 99-114.
Milliken CS et al. 2007. Longitudinal assessment of metnal health problems among active and reserve component soldiers from the Iraq war. JAMA: Journal of the American Medical Association 298 (18): 2141-2148.
Murdoch M et al. 2006. The association between in-service sexual harassment and post-traumatic stress disorder among department of veterans affairs disability applicants. Military Medicine 171 (2): 166-173.
Nathan PE. 2005. Bringing home the psychological immediacy of the Iraqi battlefield. Pragmatic Case Studies in Psychotherapy 1 (2): 1-3.
Norman SB et al. 2007. Profiling posttraumatic functional impairment. Journal of Nervous and Mental Disease 195 (1): 48-53.
Pitman RK et al. 2006. Clarifying the origin of biological abnormalities in PTSD through the study of identical twins discordant for combat exposure. Annals of the New York Academy of Sciences 1071: 242-254.
Rasmusson AM, Vythilinga M & Morgan CA, 2003. The neuroendocrinology of posttraumatic stress disorder: new directions. CNS Spectrum 8 (9): 665-667.
Rosen GM. 2004. Litigation and reported rates of posttraumatic stress disorder. Personality and Individual Differences 36 (6): 1291-1294.
Rosen GM. 2006. DSM’s cautionary guidelines to rule out malingering can protect the PTSD data base. Journal of Anxiety Disorders 20 (4): 530-535.
Rosen GM & Frueh BC. 2007. Challenges to the PTSD construct and its database: The importance of scientific debate. Journal of Anxiety Disorders 21 (2): 161-163.
Rosen GM & Lilienfeld SO. 2008. Posttraumatic stress disorder: An empirical evaluation of core assumptions. Clinical Psychology Review 28 (5): 837-868.
Rosen GM & Taylor S. 2007. Pseudo-PTSD. Journal of Anxiety Disorders 21 (2): 201-210.
Schlenger WE et al. The psychological risks of Vietnam: The NVVRS perspective. Journal of Traumatic Stress 20 (4): 467-479.
Spitzer, RL et al. 2007. Saving PTSD from itself in DSM-V. Journal of Anxiety Disorders 21 (2): 233-241.
Wessely S. 2005. War stories: Invited commentary. British Journal of Psychiatry 186: 473-475.
Wheeler DP & Braggin M. 2007. Bringing it all back home: Social work and the challenge of returning veterans. Health and Social Work 32 (4): 297-300.
Zohar J et al. 2008. Post-traumatic stress disorder: Facts and fiction. Current Opinion in Psychiatry 21 (2): 74-77.
Tony Stankus [email protected] Life Sciences Librarian & Professor
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