DSM V Shadow Team Strikes Back at Psychiatric Establishment on PTSD

Mar 24 2009

DSM V Shadow Team Strikes Back at Psychiatric Establishment on PTSD

Since the establishment of the DSM V Shadow Team to track the proceedings of the DSM committee in response to their paranoid decision to keep all of their meetings a secret and not allow anyone to keep notes or talk to the press, we have been quietly reviewing psychiatric nosology and contemplating the architecture of psychiatry. The ongoings of the “mainstream” DSM committee were chronicled in an article in this month’s Time magazine (remember when you used to read that? So do I) called “Redefining Crazy: Researcher Revise the DSM-V” where it made the point that psychiatrists were spending more time arguing than coming to consensus (Hey Dr Hyman, I thought you weren’t supposed to talk to the press? I am gonna have to tattle on you to David).

However several recent articles by journalists who seem to have granted themselves honorary degrees in psychiatry and who quote whatever ridiculous opinion from psychiatrists that happens to cross their desk as if it is, well, worth quoting, have prompted us to speak out.

First off, the New York Times wrote an exceedingly lame editorial regarding the decision of the Department of Defense to not award the Purple Heart (the medal received by soldiers who are wounded in combat) for combat-related posttraumatic stress disorder (PTSD). Here is their lame comment:

PTSD can be difficult to diagnose, with symptoms that can arise later in life, far from the battlefield and are not necessarily linked to any specific actions of an enemy. So the Pentagon contends that it has no choice but to exclude its sufferers from the Purple Heart, given to those whose injuries result from direct and intentional action by the enemy…

The military is, in fact, moving forward merely by mentioning PTSD and the Purple Heart in the same breath. Imagine Gen. George Patton, who so notoriously slapped a quivering enlisted man, learning that his beloved Army was even considering giving medals to those whose combat tours left them mentally shattered.

Frankly I found this letter to be patently offensive, ill informed and incorrect. First off, General Patton was an idiot, and should not be celebrated for physically abusing soldiers. Secondly, PTSD is very much related to combat exposure, is not difficult to diagnose, and is not delayed in onset. The NYT morons go on to opine that “Purple Heart may not be the answer — not until, perhaps, advances in brain science bring full objectivity to the diagnosis of mental injury.” And exactly what “brain science” is that? The same morons who publicized dubious science such as the search for the neural correlates of morality or trumpeted a drug that would preserve marital fidelity are now turning those brain scanners against the recognization that war is hell and can be associated with life long mental wounds?

Next on the journalist role call is an article in Scientific American (”Soldier’s Stress: What Doctors Get Wrong About PTSD“) by David Dobbs. An example of one of his (highlighted) retarded statements is “misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.” Since when does the VA want chronic disability? If anything they are invested in reducing their costs. And who is he to say who is “misdiagnosed”? Not everyone develops PTSD, but for those who do, it is real, believe me, and it doesn’t matter what some pointy headed professors (or journalists) who are seeking attention with provocative statements say.

Dobbs taps into an underbelly of academic psychiatry that looks for approval from others by trying to look like they buck the trend about trauma and PTSD, with the basic message that PTSD is an overblown diagnosis created by a bunch of cry babies. Most of these “detractors” he quotes were authors of articles in a moronic special issue of the Journal of Anxiety Disorders in 2007 on PTSD. These authors purport to be offering important and controversial papers that will undermine the diagnosis of PTSD but instead they just send up a bunch of hot air balloons. Simon Wessely, a psychiatrist from the Institute of Psychiatry in London, writes a convoluted “historical” piece that seems to imply that we should pay attention to the role of secondary gain (e.g. getting disability benefits) in the development of PTSD. Big deal, some people want disability payments, does that mean PTSD is a bullshit diagnosis? I don’t think so. It would have been more interesting if Simon had written a piece telling us about who was the mystery woman at his institute involved in the Sex and Seroquel scandal who said that she needed to be punished by the head of the Seroquel Study Team for reading a paper about Risperdal.

Next in the Journal we have Richard McNally, who gets a lot of mileage out of pointing to his study showing that people who think they were abducted by aliens have psychophysiological responses that look like PTSD as evidence that PTSD is a bs diagnosis (if those aliens did that to my rectum I think I would have PTSD too, wouldn’t you)? He makes the point that if you tightened the criteria for PTSD that there would be fewer veterans classified as having PTSD (based on an article that revised the estimate downward from 14% to 9%). So what? As we pointed out in a letter to Science in 2007 that still would mean 236,000 Vietnam veterans with PTSD 30 years later.

We come in peas to help Shadow Team solve mystey of psychiatric diagnosis.

Last time I saw Richard he broke his glasses down the middle during a lecture he was giving and had to hold up one half to read his slides, which he called his “monacle”, which together with his spirited presentation made him look like a mad professor, indeed.

Next we have Paul McHugh, MD, the evil troll who used to second as chairman of psychiatry at Johns Hopkins School of Medicine in Baltimore. Last time I saw him lecture was whining about one of his “case reports” of a woman claiming childhood sexual abuse ”how could that woman have been sexually abused by her father? That family was one of the most prominent families in Baltimore!” as if that made any frigging difference. They write:

PTSD, as presently diagnosed, described, and treated, has failed to improve on what had been standard teaching. It has redefined and overextended the reach of a long-recognized natural human reaction of fear, anxiety, and conditioned emotional reactions to shocks and traumas.

In other words, nothing like the old days, when guys killed Japs and enjoyed it, and gals got raped and if they didn’t stop sniveling you could just give them a good wack to help them get over it.

PTSD doesn't exist cuz I said so. So shut up and sit down.

Robert Spitzer wrote an editorial in this special issue which promised a radical revision, but instead merely recommended requiring that the person be personally exposed to the traumatic event, and dropped a few of the symptom criteria like irritability that were not specific to PTSD. Another editorial was written by the sociologist Allan Young and the epidemiologist Naomi Breslau. Last time I saw Allan he was reading a paper about the Yale Neurosciences PTSD program as an object for study by sociologists with the basic thesis that PTSD is a “social construct”. Frankly when I see a sociologist who studies mental health my instinct is to run in the opposite direction as quickly as I can. For what it’s worth here is the abstract of their paper. Let me know if you can understood it; I sure as hell couldn’t:

As represented in the DSMs, the PTSD syndrome coheres through cause and effect relations among diagnostic features. Research practices routinely ignore this essential characteristic, by atomizing the diagnostic features, especially the role of memory. The failure to confront this contradiction explains the failure of research to fully engage the pathological process that justifies the PTSD diagnostic classification. Several papers in this collection direct readers’ attention to this fundamental problem. We are pessimistic that their insight will lead to positive results.

They don’t sound very optimistic. Does that mean they are not resilient and are vulnerable to PTSD? Don’t worry guys if you get sick I’ll make sure that you do not go on disability and become chronic charges of the government.

What these guys are saying is that PTSD is “not reliable, not accepted” often made up to get victims’ compensation and compare that to “accepted” diagnoses like major depression and bipolar. What’s more their cronies on the mainstream DSM wants to drop Dissociative Disorders as diagnoses all together, for no better reason than because they, well, want to. Well I’ve got news for you guys just because drug companies made billions off of the pedalling of depression (and not PTSD) doesn’t make that disorder somehow more “real”. And the suffering of patients with PTSD and Dissociative Disorders for that matter is very real, thank you very much.

Bye now.

Tags: David Dobbs, diagnosis, DSM, DSM Shadow Team, mental health, Paul McHugh, psychiatrists, Psychiatry, PTSD, Purple Heart, Richard McNally, Robert Spitzer, Time magazine

Filed in DSM Shadow Team, Healthcare Politics, PTSD, Psychiatry | Doug Bremner

41 Comments

By Gianna, March 24, 2009 @ 10:58 am

Brilliant work Doug,
I found myself getting upset about all the people in power who are so clueless and truly unfeeling and calloused about the nature of trauma and human suffering.

How is it they can be so out of touch with that aspect of being human? I am forever puzzled by this.
By Gina Pera, March 24, 2009 @ 11:05 am

HUZZAH! You have absolutely nailed all the angles, Dr. B. — succinctly and cleverly. I read in awe.

In case you haven’t noticed, there is quite a trend afoot in academia, where poseurs desperate to establish their intellectual and ethical bona fides call every modern diagnosis (social anxiety disorder, PTSD, ADHD, etc.) a “social construct” — almost always invented by Big Pharma and promoted by craven researchers and physicians.

It’s pitiful (and a bit frightening to those who have children in college) how, in seeking to demonstrate to a faretheewell that they are their own critical thinkers, they are simply being anti-psychiatric, unthinking, uneducated lemmings. And discompassionate lemmings at that.

Same with some journalists, including a former NYTimes reporter’s hatchet job on conditions such as ADHD in the book Our Daily Meds.

They all hide their sloppy, sensationalist thinking behind Big Pharma’s misdeeds in recent years, conflating slimy marketing practices with “made up” diagnoses.

Your post should be required reading for, well, for everyone.

thank you!!!
By Sara, March 24, 2009 @ 4:36 pm

Personally I think Dobbs’ emphasis is on the fact soldiers are getting the “wrong treatment,” and that they are “misdiagnosed” in the sense that the wrong remedy is being applied to the problem. And then the wrong treatment, i.e. cocktails of psych drugs, leads to chronic disability. The point about a PTSD diagnosis in this day and age is not so much that it’s a bogus diagnosis but that most of the treatments thrown at it are bogus and likely to make the condition worse, not better. At some point in time you no longer know whether the poor vet is suffering from the original trauma or iatrogenesis from cocktails that only made him (or her) worse.
By David Dobbs, March 24, 2009 @ 10:25 pm

This is David Dobbs, the author of the article Dr. Bremner discusses in his post above.

I should say right off that I’ve long admired the more measured critiques that Dr. Bremner has offered about the pharmaceutical industry’s exploitation of the neurochemical model of depression. My regard for this work made his ~~critique of~~ attack on my article all the more disappointing.

I’m not disappointed because Bremner disagreed with my article. I’ve received several critiques of “The Post-Traumatic Stress Syndrome,” both privately and in blogs and public letters, that disagreed sharply with my argument. I’m disappointed because while these other critiques have ranged from thoughtful and considered to and savage and threatening, none has been so self-indulgently insubstantial. The others offered genuine arguments or genuine reactions. Bremner offers snark.

It would give me pleasure to merely insult Dr. Bremner back, but I think it more helpful for the discussion to actually address his points — a good term for them, as he seemed more interested in scoring rhetorical points than in actually dealing with the conceptual, diagnostic, and epidemiological issues raised in the article. To wit, with Bremner’s points — all of them that came even close to substance — quoted:

Bremner says

An example of one of [Dobbs's] (highlighted) retarded statements is “misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.” Since when does the VA want chronic disability?

I never said the VA wants chronic disability. Neither the institution nor its clinicians want chronic disability in their patients, and its extremely hard-working clinicians are trying hard to successfully treat PTSD. But they’re handicapped by a disability system that works against them, but which the VA administration apparently accepts because it’s politically expensive to speak of changing it.

Bremner then offers that

Not everyone develops PTSD, but for those who do, it is real, believe me, and it doesn’t matter what some pointy headed professors (or journalists) who are seeking attention with provocative statements say.

I’m won’t comment on Bremner lamenting about attention-seekers; that’s too easy. The real problem here is the statement that “for those who do [develop PTSD], it is real.” This is an argument? It’s a circle. It’s like saying those who get sunburn really have sunburn. I’m not saying that people who have PTSD don’t have PTSD. I’m saying that some people who are suffering other problems are mistakenly diagnosed with PTSD — with the result that some people we SAY have PTSD don’t actually have it. It’s absurd to hear a doctor argue this can’t be so. Millions are diagnosed with PTSD, which is terribly easy to confuse with depression, and every diagnosis is correct? We’re talking scale here. Bremner wants you to think we’re talking exists versus not-exists.

Dobbs taps into an underbelly of academic psychiatry that looks for approval from others by trying to look like they buck the trend about trauma and PTSD, with the basic message that PTSD is an overblown diagnosis created by a bunch of cry babies.

More insults substituting for arguments. And where’d we get “cry babies”? If you read the critiques, you’ll find that “PTSD is really cry babies” is not the argument being offered. The argument being offered is that we are mistaking other forms of genuine distress for PTSD. To speak of cry babies is to infantalize the entire debate.

Next up, Bremner chastises psychiatrist and researcher Simon Wessely for suggesting that

we should pay attention to the role of secondary gain (e.g. getting disability benefits) in the development of PTSD. Big deal, some people want disability payments, does that mean PTSD is a bullshit diagnosis? I don’t think so.

Again Bremner builds and whacks a straw man. Wessely is arguing not that “PTSD is a bullshit diagnosis” but that the VA’s perverse disability incentives (as described in my article), might in some cases shape patient and clinician behavior. It’s odd that Bremner, having written extensively on how money, gifts, and other incentives have influenced psychiatrist’s prescription practices, should argue that financial incentives never sway patient nor clinician behavior.

Next up: DB tries to convince his readers that Richard McNally’s best evidence for PTSD’s diagnosis is drawn from a study of the psychology of alien abductions:

[McNally] gets a lot of mileage out of pointing to his study showing that people who think they were abducted by aliens have psychophysiological responses that look like PTSD as evidence that PTSD is a bs diagnosis (if those aliens did that to my rectum I think I would have PTSD too, wouldn’t you)?

Readers who examine McNally’s most comprehensive critique of PTSD [pdf download] will find that of its 17 pages, one sentence — noting that people who believe they’ve been abducted have false memories — alludes to that phenomenon. No matter; Bremner highlights this — this weirdest thing he can find — so he can make a rectum joke.

The rest is little better.

I do agree with Bremner on one point: He is right to complain that the DSM-V process is closed, secretive, and quite possibly dominated by a status quo perspective. But why is he claiming in his post title, and implying elsewhere within it, that he is “Striking Back at [the] Psychiatric Establishment on PTSD”? He’s not attacking the psychiatric establishment here; he’s striking at the very people (and one person who wrote about them) who are questioning the PTSD psychiatric establishment. Bremner compains he’s locked out of the DSM-V’s PTSD group. So are McNally and virtually all his fellow PTSD skeptics. Yet Bremner doesn’t mention this, and it certainly doesn’t seem to bother him. It just bothers him that he wasn’t invited.

This is pretty deep irony. Well, no it’s actually pretty shallow — shallow, really, that Bremner, who has railed so effectively about the pharmaceutical industry’s overextension of a paradigm based on increasingly tenuous evidence, should greet so cynically and glibly an evidence-based argument that something roughly similar — and I am not equating the PTSD establishment with pharma here, but merely noting one paralle dynamic– might be happening in his own field. The two fields differ in many ways. But in both, evidence is growing that a shaky model of mental disorder is being overapplied.

Bremner rails constantly about that dynamic in the treatment of depression. Yet when it comes to his own field, he acts as if such a thing is beyond imagining.
By Doug Bremner, March 24, 2009 @ 10:43 pm

First of all I would like to thank David Dobbs for replying to my post. I subcribe to his feed and think he is a fine journalist. I should state that I am a VA psychiatrist seeing returning Iraq vets and not authorized to speak for them and in fact not authorized to speak at all, so writing this I am at risk as it were. About disability this is an age old argument and to argue that individuals would not want a pay check for their disability related to combat this is absurd, but this does not negate the posibility that they have a combat related mental disorder. As for PTSD I would say that the trauma response results in multiple outcomes so the so called specificity argument related to PTSD is absurd. And I do hold to my argument that academics can be getting benefit points from certain governmental and special interest groups that bolster their so called contrarian positions on the topic of combat stress.
By David Dobbs, March 24, 2009 @ 11:44 pm

THanks for the response, Doug. I recognize your constraints as a VA psychiatrist in discussing the disability structure. To clarify my own position on the point you raise, howeveer: I agree wholeheartedly that the possibility that some vets might find disability income as a conscious or unconscious draw to a PTSD diagnosis does not negate the possibility that they have a combat-related mental disorder. But it might increase the chances that disorder would be diagnosed as PTSD rather than something else that might be more accurate — and, as my article spells out in a bit more detail, the structure of the PTSD disability benefits, which end fairly promptly when the pt gets better, discourages healing. The mix of response is muddy. But the countertherapeutic structure of the PTSD disability benefits makes a PTSD Dx both more attractive initially — but in many cases less constructive in the longer term. Fixing the disability structure in the way outlined in my article — so that benefits continued in full for a time after return to work and then tapered off — would actively encourage healing while still providing support for vets still on the mend.

Thanks,

David Dobbs
http://neuronculture.com
By BOB FIDDAMAN, March 25, 2009 @ 2:27 am

My son is about to embark on a career with the British Armed Forces. He will witness things beyond his comprehension and upon his return from tour will be a different man to what he is today.

Will he be offered a pill to block out his mental images? Probably.

Will he take that pill? Probably not.

I loved your term Doug ‘combat related mental disorder’ [CRMD] – You should patent it because it will no doubt be used by pharma.

Regarding the disability issue, one has to look beyond physical disabilities [loss of limb, shrapnel wounds etc]. Would a soldier be deemed ‘disabled’ if his brain was not functioning correctly? Would the chemical imbalance theory be used as supporting evidence to prescribe a soldier a re-uptake inhibitor?

Interestingly, President Bush had one of the most high powered jobs in the world. This job must have attracted stress. Bush has always been the target of comedians. I just wonder if Bush has ever been prescribed a powerful SSRi..and even if he was… would he have taken it knowing what he surely does about them?

Thing is… would any of us trust a world leader who was taking an SSRi?

I’ve gone off the track a little here, I know.

Great post Doug. Food for thought.

Fid
By anon, March 25, 2009 @ 3:42 am

Sophia Frangou works at the IOP, doesn’t she?
By Hmmm, March 25, 2009 @ 9:00 am

Yes, she is an academic psychiatrist who until a few years ago was married to Tonmoy Sharma, who lost his license due to research ethics violations, but the seroquel emails were signed by a research nurse, so the mystery woman IOP investigator remains… a mystery, I guess
By Alison, March 25, 2009 @ 6:49 pm

Thank you for this. They want to get rid of dissociative disorders in my opinion because there is no magic and expensive pill for them and because they actually require real therapy from a well trained professional. No profit in that.
By Doug Bremner, March 25, 2009 @ 10:17 pm

yeah absolutely. I have said this before but I think this is an excellent example of pharma influence on DSM and should be highlighted in future posts.
By Marian, March 26, 2009 @ 10:47 am

Alison is spot on here. Another aspect, that my “paranoid” scheme of things simply can’t ignore: there’s lately come up evidence that particularly psychiatry’s holy cow, so-called “schizophrenia”, very well may be caused by trauma. Well, this has primarily been discussed in Britain, but what if more and more Americans get ideas like this one into their heads?! No good. For Big Pharma, and for our culture in general. Recognizing PTSD as real and valid, means recognizing that certain mechanisms in our culture, that are regarded “normal”, are in fact traumatizing.

You’re on to something in that regard, when you say: “In other words, nothing like the old days, when guys killed Japs and enjoyed it, and gals got raped and if they didn’t stop sniveling you could just give them a good wack to help them get over it.”

Personally, I take it to the level of describing our whole culture, modern western civilisation, as thoroughly dysfunctional, abusive, and, yeah, traumatizing. With rape and war being just the tip of the dysfunctionality-iceberg.

As we all know, abusers do whatever it takes to protect themselves. And the most crucial thing to do for an abuser in order to protect him-/herself, is to silence the abused. So, let’s do whatever it takes to undermine the idea, that trauma could be the source of any mental distress at all, let’s discredit the diagnosis of PTSD. Preferably in favor of diagnoses like “bipolar”, “depression”, “schizophrenia”, etc. Those are the diagnoses, that do silence the abused.

IMO, PTSD – in an extended version, including late onset – is the only valid psych diagnosis. But maybe I, too, just needed a good wack to get over it. And a lifetime supply of, uhm, let’s say Seroquel, to shut me up for good – apropos of chronic disability. Too bad, I didn’t buy it.
By Gina Pera, April 18, 2009 @ 1:34 pm

“Dobbs taps into an underbelly of academic psychiatry that looks for approval from others by trying to look like they buck the trend about trauma and PTSD, with the basic message that PTSD is an overblown diagnosis created by a bunch of cry babies.”
——-
I’ve noticed this same phenomenon with regards to ADHD — underbelly academics (including liberal arts’ historians and the like) who seek to make a name for themselves by pandering to the public’s and their colleagues’ cognitive dissonance about the reality of this condition. Yes, all you need are behavioral interventions to help a person listen better, stop the noise in their brains, and everything else. Any person with ADHD whose suffered the worst that therapy can hand out will tell you how helpful that was.
By Gina Pera, April 18, 2009 @ 1:45 pm

Dobbs wrote: “I’m saying that some people who are suffering other problems are mistakenly diagnosed with PTSD — with the result that some people we SAY have PTSD don’t actually have it. It’s absurd to hear a doctor argue this can’t be so. Millions are diagnosed with PTSD, which is terribly easy to confuse with depression, and every diagnosis is correct? We’re talking scale here. Bremner wants you to think we’re talking exists versus not-exists.”
—-
I just read your article, Mr. Dobbs. And it looks like you did a painstaking job of presenting the complexity of this issue.

What I didn’t see — perhaps because there just wasn’t room for it — is the fact that the soldiers recruited for this latest war effort might have had an unusually high incidence of ADHD going in. Some research indicates this population is more vulnerable to developing PTSD. And if that underlying disorder is never detected or treated, chronic disability could surely ensue.

Whether ADHD rates in the military are higher than during the Viet Nam era, who can say; but then as now, the people who were most likely to to have limited options elsewhere were those who weren’t “college material,” and no doubt often due to undetected/untreated neurocognitive disorders.

This is a complicated story, and I credit you for trying to cover it. And yes, it’s too bad that George Bush wasn’t medicated; we might have avoided this morass if he (and Cheney) had been.
By Marian, April 18, 2009 @ 2:40 pm

Gina Pera: “What I didn’t see — perhaps because there just wasn’t room for it — is the fact that the soldiers recruited for this latest war effort might have had an unusually high incidence of ADHD going in. Some research indicates this population is more vulnerable to developing PTSD. And if that underlying disorder is never detected or treated, chronic disability could surely ensue.”

Seems to me to beputting the carriage before the horse, as the majority of people dx’ed with “ADHD” (I’m one of those “underbelly academics”, yup) in fact are trauma-victims. Like the Norwegian 8-year-old, I learned about recently, who eventually, after continuous battering, got beaten to death by his stepfather in 2005. While no one reacted, because the 8-year-old had an “ADHD”-label, that explained his bruises and injuries in the eyes of everybody, who noticed them. Let’s protect society, and blame the individual (’s biology)!
By Andy Morgan, April 23, 2009 @ 10:22 am

Doug, you and I both know from our work at the National Center for PTSD that although PTSD is a genuine mental health condtion, there are multiple factors at play that motivate people to claim (and be diagnosed with) the disorder. The fact is that we have a profession of arms (not a draft) and there is terrific reason to have a healthy debate about whether our tax dollars will pay for and support people who elected to work in a profession that puts them at increased risk for illness. finally with respect to Allan Young (who is a terrific historian of medicine) I’d recommend you read his book and get up to speed on how social processes shape (and reshape) the things we call illness. this does not mean people do not genuinely suffer; it simply means the the boxes and labels we come up with change over time and, in each timeframe, we tend to view them as “correct”. Although I might share your frustration about some things that occur in this field, I do not share your view that referring to others in such derogatory language is necessary. reasonable minds can (and do) differ in our field. We both know that there was great resistance to our finding that memories for traumatic events change and are not indelible; however these findings have been replicated by over 5 separate research groups; I recall some advocacy oriented members of ISTSS wanting me to remove myself from the membership for having testified about these data. I do value empiricism and think we benefit from it. Rich MacNally did folks a terrific service in analyzing the NVRSS data. noone disputes his technique or his findings. His opponents, like you in this blog, resort to making fun of him personally. I dislike that style and think that is beneath you to do that.
Andy
By Doug Bremner, April 23, 2009 @ 10:39 am

OMG! Andy Morgan! I feel like I am back at West Haven being *scolded* by my chief resident again! Yes I did get Alan’s book but only got part way through it. And as for Richard: 1) you spelled his name wrong, and; 2) last I checked he didn’t seem to be shy of controversy so he can probably fend for himself. BTW stay tuned for more Shadow Team updates.
By Alison, April 23, 2009 @ 10:40 am

Andy Morgan:
If we followed your logic, workmen’s compensation would not be available to people who work in high risk for injury jobs either and we would be pretty much out of luck finding anyone to work in construction, oil rigs, many manufacturing and other blue collar jobs, not professions. Do you really want to say that people who join the army are “choosing” to risk PTSD knowingly or are you saying you don’t believe we need an army which is an entirely different political question?
By Andy Morgan, April 23, 2009 @ 8:37 pm

Doug, it is not a scolding so keep the countertransference in check.
It is a peer recommendation that you consider being polite when referring to colleagues. Rich didn’t mind me turning him from an irishman into a scot by adding an “a” to his name. My point is that his work is solid and we both know our field is full of folks who are more into advocacy than science. If you prefer to engage in personal attacks rather than a genuine debate about data that is your choice.
By Andy Morgan, April 23, 2009 @ 9:10 pm

Alison, I’m not sure you’ve understood what I was saying. my comment about compensation was referring to the fact that, in the past, the social contract with Americans who were drafted in service was that the US Government would provide them health care and benefits for the rest of their lives. However, I am simply saying that there is room for a healthy debate as to whether or not folks who volunteer for certain professions are entitled to benefits that were available when the draft was in place. you may be reading far more into my comment than was intended. PTSD is currently a diagnosis for which retroactive compensation is available; the diagnosis is one that can be difficult to verify as there are no objective measures of the disorder. This means that there is significant room for false claims. although some people may believe medical fraud is harmless, I do not: it removes healthcare dollars from the patients who need them. the challenge for us in psychiatry is to develop more objective measures of the illnesses we assess. Although it may be more difficult, this is no different a standard than exists in the rest of medicine. Until we do we shouldn’t pretend that we know the specificity of our methods. Whether or not folks will enlist in the military without knowing for certain that they might claim disability income for events that occur during their time of service is a valid question but it does not answer the question as to how or in what manner citizens would like their tax derived disability income money used. The good news is that however citizens decide this issue, our military will be in good shape. First, the vast majority of soldiers exposed to traumatic events during war never develop combat related PTSD. Second, the findings from a large body of research about military Selection and Assessment indicates that thoughts about future disability and compensation payments are not the primary motivating factors as to why most individuals enlist during wartime.
By Alison, April 23, 2009 @ 9:36 pm

My late uncle was a 20 year army man. He served 2 tours in Vietnam setting up MASH kitchens, was exposed to Agent Orange, had major health problems for some time, never got compensation, never sought it and died in his late 70’s of prostate cancer, not likely caused by his war experiences. But if his medical problems after he left the army had killed him, do you think his widow should not have been compenstated or that he should not have been just because he was a volunteer and not drafted? I just don’t understand your spin on what our social contract is with people who take on dangerous and difficult jobs most folks don’t want. If they aren’t “forced” into the job, although of course in reality many are at least coerced by circumstances through lack of other opportunities for employment, poverty, lack of education, recruitment in high schools etc., then “we”, whoever “we” are, don’t owe them anything? And actually there is a shortage of folks willing to serve in the armed forces. I am not pro-war, but if we are going to send folks over to serve in our wars, and we are mostly in the U.S. sending the children and fathers and mothers of low income people, not the sons and daughters of the well-off, than yes, I do think we have a duty to them when they suffer injuries of whatever kind and I do not buy into this new version of the old discounting of the serious repercussions for many of serving in a war zone. Haven’t we done this war after war after war? Isn’t it time to stop? Just my opinion. Why start with PTSD in trying to be more objective in assessments in psychiatry? Why not start with childhood bipolar disorder or “social anxiety disorder” or these new and upcoming “shadow diagnoses” we have to look forward to?
Why is psychiatry so interested in taxpayers’ money and how it is spent all of a sudden? Look at how much was spent by Medicaid programs on no better atypical anti-psychotics. Sorry, I don’t think I misunderstood you, I think we just don’t agree.
By Gina Pera, April 23, 2009 @ 10:04 pm

This is an incredible statement, Andy:

The fact is that we have a profession of arms (not a draft) and there is terrific reason to have a healthy debate about whether our tax dollars will pay for and support people who elected to work in a profession that puts them at increased risk for illness.

—-
One could make the case that we, in fact, do NOT have an “all-volunteer” army. We largely have conscription-by-poverty-and-lack-of-other-options. And, in fact, many joining the military during the big sign-on bonus phase were psychiatrically vulnerable.
By Doug Bremner, April 24, 2009 @ 11:02 am

Andy, “countertransference”?? Last time I checked we were not in therapy together. But this is an annoying example of psychiatrists using therapy jargon terms when they are arguing with someone. As for being “polite” it is Richard who first made the joke about having a “monacle” when he broke his glasses in a very public lecture (I have 100 witnesses) and all I am doing is repeating what he said. Maybe what you are really uncomfortable about is my pushing back against those expressing their opinion that trauma/ptsd/amnesia/dissociation is bogus/exaggerated/over-compensated/doesn’t exist, and that usually without data. So it is like I did research/I am a professor, now here is my opinion about a issue related to clinical mental health (even though I never see patients).
By Andy Morgan, April 24, 2009 @ 5:44 pm

Gina, it is a fact that we don’t force people to perform government service in the military. Although some people may, due to their circumstances feel they must enlist, this is not the same as conscription and it does not entail the same commitment that was expressed to servicemen and women who were drafted. I am simply saying that I support socialized medical care for those who the government drafted; I am not sure that this holds for people who elect to be government employees by voluntary enrollment. I am not sure why it is so incredible to you that I am suggesting that there is no inherent reason we should adhere to the current disability system. this seems to be a statement you disagree with. this is normal given the current need in the country to think about how, and in what manner health care and disability should be handled.
By Alison, April 24, 2009 @ 5:58 pm

We do actually force people to serve, have you never heard of “stop loss”? It is incredible that you are choosing to start rationing health care with our veterans actually.
By Andy Morgan, April 24, 2009 @ 6:16 pm

Doug, I am not uncomfortable with you pushing back with those you disagree with you; I initially wrote that I thought the name calling you engage in in your blog is beneath you; you appear to disagree with my sentiment and that is your choice; We both know that many of the claims in the trauma dissociation and amnesia field have been overblown and exaggerated. this is not to say that genuine cases do not exist; it is the reality of the situation that both genuine and overblown claims exist. that is part and parcel of an adversarial legal system and the status of diagnostic and clinical assessment methodologies in our field. Clinicians have a truth bias and a need to maintain a therapeutic relationship with their patients; This impairs their ability to detect fraudulent claims; indeed, as demonstrated in detecting deception research on this issue, impartial evaluators who are not in a treatment relationship are far better at detecting false claims. So, in the end clinicians believe the world they encounter represents the truth whereas non clinicians believe theirs is the more accurate view. Both have valid points of view. Neither, in my view, deserve to be subjected to name calling. This does nothing positive for our profession and contributes to the negative view held by the public that academics are those who engage in silly debates and name
calling because the stakes are so low…
By Gina Pera, April 24, 2009 @ 6:42 pm

Andy, I don’t pretend to know anything about these disability issues, esp. vis a vis the military.

I’m just pointing out that, if we’re honest with ourselves, it’s not an all-volunteer army. Some people are left with little other choice but to sign up; and given the hefty bonuses offered in recent years, the temptation was strong – the only way to help their families, wipe out their debts, etc..

If we did a better job of treating neurocognitive disorders in this country (instead of massively denying them), we’d have a lot fewer or these vulnerable people being recruited, and then the politicians would have to figure out how to solve problems in other ways.

That said, I do believe there are career soldiers who join the military because that’s where their gifts are. We’re lucky to have them, and we should treat them well, especially when half the country puts a lunatic into office who then sends them off to war. That is certainly out of their control.
By Lizzy, May 4, 2009 @ 8:32 am

Anyone who goes to war is not thinking clearly, even if their life circumstances lead to exploitation by those in power. To be traumatized by war is normal. PTSD is a sad thing, as is war.
By Lizzy, May 4, 2009 @ 8:38 am

In order for young men to get financial aid to attend college, they must sign an agreement that they will go to war.
By Lizzy, May 4, 2009 @ 8:40 am

Even if you’ve signed an agreement, don’t go to war.
By Alison, May 4, 2009 @ 11:22 am

I think these comments are classist and elitist, sorry but I do.
By Gary Morrison, May 30, 2009 @ 9:11 am

American Psychology is in crisis. This industry and its troubles have nothing to do with science or ethics. Psychology defends a statist view of history. The class structure they have worked to preserve and pretend not to recognize is in collapse. How effectively they have psychologized to conceal Americas chronic social, economic and political ills has been their secret trade value all along. They seem to have some budding awareness that this priveliged professional position in society is now in jepordy. Their science is among the last existing vestages of the Victorian tradidition and their rituals are part of the camp that goes with it. These people are living in a world that no longer exists. Who can blame them for attempting to reinvent themselves as a cult? They are running out of options. To loose the patronage of the pharmacuetical industry and HMO’s would be the end of the line for them and they know it. Whatever the outcome, 60,000 licensed practicioners can hardly avoid creating a scene when push finaly comes to shove.It stands to reason that the DSM V committe is not meeting in secret to do legitimate science. To better understand their perdiciment, consider that they are now being forced to contemplate their declining fortunes, which are not unlike those of a traveling circus at the dawn of the age of television. Psychology is the 59′ Buick of american social sciences, pure nostalgia.
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