combat writing badge C O M B A T
the Literary Expression of Battlefield Touchstones
ISSN 1542-1546 Volume 03 Number 04 Fall ©Oct 2005

An Expert Analysis of PTSD

As a calculated effort first designed to discredit our efforts in Vietnam, and to denigrate those who serve in the military as well, American print and popular media have overwhelmingly and consistently described veterans returning from conflict as being drug abusers, mentally unstable, and essentially unfit for reintegration into society. Now, Iraq vets are being described as having similarly high levels of mental disorder, and the cycle of misinformation is again being repeated.

The general theme at the moment is that up to thirty percent of Vietnam veterans suffered from mental disorders, and that returning Iraq veterans will suffer similar stress rates. It is interesting that almost nothing is said about veterans of the extremely successful operations in Afghanistan, with some suspecting that this is exactly because they have enjoyed such success in that operation. With the Iraq veterans, however, isolated incidents, such as a recent Massachusetts veteran becoming angry with rowdy partygoers, receive nationwide exposure, when factual investigation shows that such occurrences happen no more frequently than among the population at large, to include newspaper employees themselves. Such incidents are then widely publicized along with figures suggesting the thirty percent mental illness rate, and now a sixty percent rate of brain injury as well, in order to prove the case that returning vets are, indeed, mentally ill.

The reality, however, is quite different, and shows a surprising pattern of resilience that most people demonstrate, rather than victimization and mental illness after stress. The official publication of the American Psychological Association, the American Psychologist, has now reached a startling conclusion concerning all who undergo severe trauma: an astounding eighty-five percent of people actually show surprising and significant resilience, even when confronted with severe stress; stress which is similar in severity to combat. The higher thirty- and sixty percent figures of mental illness seem to result basically from three types of market forces which promote and publicize the higher figure.

First of all, there is what is known as a dumbing down of the definition of psychiatric disorder.

The author of the long-awaited National Comorbidity Study, a report which astoundingly asserted that a quarter of all adults in the United States – twenty-six percent – qualify as mentally ill, has now admitted that many people with mild and limited depressions grossly inflated this figure due to the low threshold required to be diagnosed as mentally ill. He used moving from one town to another as an example which would trigger symptoms severe enough to meet study criteria for illness. A similar phenomenon often happens to veterans when they endorse items on routine questionnaires, such as "Do you have repeated memories of a stressful military experience?", "Do you become upset when something reminds you of a stressful military experience?", et cetera. Some may endorse such an item if they recall being stressed by their drill instructor or by being six thousand miles away from home, stresses everyone routinely endures, but now, voilà!, they have earned a diagnosis of Post Traumatic Stress Disorder.

Secondly, higher figures, such as these, result at least partly from aggressive diagnostic efforts that are often financially driven by those who benefit. Aggressive screening and internet websites, which advise vets on how to file for disability benefits and coach on the symptoms of PTSD, for example, can easily raise such diagnostic rates.

And thirdly, rates are artificially inflated as a result of just such fraud and dissimulation. As just reported in the British Journal of Psychiatry by Burkett and his colleagues, when records were vetted at a typical Veterans Affairs (VA/USDVA) PTSD clinic, only forty-one percent of the total sample had objective evidence of actual combat exposure. An astounding fifty-nine percent of these treatment-seeking Veterans Affairs patients were shown to have misrepresented their combat involvement in Vietnam, so much so that a massive review of disability cases is now being undertaken by the VA/USDVA.

In addition, with all the publicity about PTSD, it turns out that, of those veterans who, without question, and who absolutely suffered the worst trauma imaginable, through not just a single tour of duty, but through four or five, and up to seven years of the war, such as the surviving Vietnam Prisoners of War (POW), not a single veteran survivor of the Vietnamese prison camps currently receives any disability pension as a result of psychiatric disability.

A variant of the PTSD theme was sparked by a preliminary report by the Army News Service which suggested that among one hundred five severe neck and head casualties assessed between June and October of 2003, doctors discovered about two-thirds, or sixty-seven percent, to have brain injuries. This figure was immediately picked up by other news services, with inferences that life-saving Kevlar armor was contributing to undiagnosed brain injuries which would often show up later in life, be poorly identified or treated by the military or the VA, and which would cause disastrous results for the veterans and their families. This more than sixty percent figure was readily bandied about by the media.

As one of the Army's senior brain injury specialists for years, I was particularly interested in these assertions and found them implausible. Reviewing the situation personally with Dr. French, the current neuropsychologist assigned to this unit, I determined that the figures came from a very small, highly specialized unit to which only those injured with the very highest risk for brain trauma were admitted. As of March 2005, out of the estimated half million troops who have served in Iraq and Afghanistan, about four hundred eighty troops had been determined to have a diagnosable brain injury, about half of those actually admitted to the unit. This seems to be the genesis for the more than sixty percent brain injury figure trumpeted by the press. Nonetheless, 480 out of 500,000 troops still translates to an incidence rate of 0.00096%. Additional study by Dr. French indicated that part of the good news of this study was that about half of these four hundred eighty injured troops, or about two hundred forty, actually had milder concussions, which were in point of fact expected to resolve within two to three months. And finally, some such brain injuries are always the unfortunate result of rather mundane accidents, such as motor vehicle collisions, that could happen anywhere, not just in combat, but these figures were not available. Such analyses, of course, are not reported by the media.

In summary, stress may take its toll, but stress does not control the lives of most veterans. It is only a minority, the consensus now being that this figure is about fifteen percent, who develop problems related to their experiences for which they genuinely need help — probably about the same as the general population. It is the resilience, not the exaggerated and overly trumpeted reports of mental disturbance, which is to be noted and celebrated among our veterans.

Over the recent years, there has been a concerted effort to raise public consciousness about the mental health of veterans, and to insure that all of our veterans receive the treatments that they need and deserve. Accurate screening, destigmatization of disorders, and providing prompt attention to those who need it is all desirable. But we should not define mental illness down, overestimate the normal adversities of life, or denigrate the service of our veterans by underestimating their courage and resilience.

Accurate estimates of problems and a genuine recognition of resilience will honor those who serve, as well as preserve our medical resources, so that they will be available to those who really need them, and not dissipated recklessly, that we might better follow Lincoln's admonition to "bind up the nation's wounds; to care for him who shall have borne the battle, and for his widow, and his orphan."

The model of PTSD presented at the 2004 Texas Psychological Association conference in San Antonio by B.G. Burkett and C.A. Hopewell has been validated by a recent VA/USDVA Office of the Inspector General report.

The model shows that the diagnosis of PTSD:

  • carries several major conceptual flaws;
  • is greatly over-diagnosed;
  • has been driven largely by a culture of victimization and an anti-American ideology, rather than by science;
  • this political ideology has resulted in considerable primary and secondary gain for therapists, who have established an institution that profits from generating disability claimants by creating an industry of victimization and a culture of therapism;
  • that the behavioral correlates of symptom expression and disability are easily and comprehensively affected by operant and classical conditioning paradigms, which reinforce and maintain the disorder by both primary and secondary reinforcement.

One implicit conclusion is that Hopewell's model of PTSD as a cascade of physiological and cognitive/affective/behavioral variables, with the critical variable being an identification and assumption of the role of victimization, due to the attribution of external events, is a more viable model rather than most of the current models of PTSD.

Dr. Sally Satel has presented equally viable suggestions for better management of the PTSD crisis, which is not a crisis of PTSD, but rather a crisis of our creation of this often faux disability. I would recommend her book One Nation Under Therapy. This, combined with Dr. Levant's comprehensive work on resilience with APA, and the integration of psychology as a primary care modality to help people be resilient, rather than to create more disability, is the direction in which to go.

by C. Alan Hopewell
... who is a psychologist and psychopharmacologist, a former Army officer now slated for reactivation, a past-president of the Texas Psychological Association, and is the 1990 recipient of the Outstanding Clinical Neuropsychologist award. He has published extensively in professional journals.

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