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PTSD: TO BE OR NOT TO BE?

Jan 10

G’day all!!! Be alert that Mr. Paulson and his minions are about to offer you a watered down version of the DSRRP (this week) that he hopes you will mindlessly choose over something that will truly represent you, the worker (i.e. The Mounted Police Professional Association of Canada). With regard to Mr. Paulson’s offer and what you already have, riddle me this, what’s the difference between shit and feces? You got it!!!! Time to start thinking for yourself!!!!

Be warned that this piece will take one more kick at the can regarding the validity of a diagnosis of ”PTSD”. This has been requested by your foreign counterparts, that are mostly unionized with much more power in terms of their relationship with management than you . I shall provide my reading of the literature and a brief Reference Section. I am not criticizing any diagnosis or health care professional you may have. I simply wish to inform; to present the entire picture and perhaps empower some of you. You’ll likely recognize “bits and pieces” from previous articles; I include them here only to provide continuity. I think it’s worth pulling it all together, as it is important to re-examine our ideas about how we humans respond to trauma. At the present both the media and the general public seem ready to play the “PTSD” card at every and any opportunity. Can it really be so? Is it really that simple?

The best that can be said for “PTSD” is only that it is one of many possible outcomes following exposure to an event outside our usual experience, and involving some threat to life and/or limb; another, for example, is “PTG”(Posttraumatic Growth). Hear much about “PTG”? I wonder why? To suggest that posttraumatic stress, as a disorder, is nearly inevitable following a traumatic stimulus may be creating a mental/emotional condition out of the normal distress associated with the rare or infrequent witnessing/experiencing of horrific events or abuse. Moreover the formal diagnosis of “PTSD” implies a failure of homeostatic mechanisms involved in stress recovery that has not been demonstrated empirically.

Several decades ago Robins and Guze suggested five areas that could be used to validate a psychiatric diagnosis:

* a clinical description including precipitating events and stability over time.

* biological, hormonal, radiological, quantitative evidence.

*distinct boundaries between the disorder’s characteristics and those of other psychiatric conditions.

* family or genetic statistical evidence shared between patients in the diagnostic category.

* treatment relevance and success related to precise diagnosis.

Schizophrenia, Major Depressive Disorder, and Substance-Related and Addictive Disorders are examples of mental disorders that have considerable legitimacy through the “Robins/Guze” process. “PTSD” has not achieved this kind of validity. As pointed out by Rosen (2007) the disorder’s “core assumptions” and hypothesized mechanisms, lack compelling or consistent empirical support.

Riddle me this!! An exposure to horrific/abusive events is sure to be psychologically devastating and will most certainly lead to a posttraumatic stress disorder, and undeniably put one at great risk for suicide. True or False? Answer: False! There is little doubt that exposure to a life threatening event can be upsetting; and is almost universally followed by an acute (usually anxious) response. However an accumulation of research over several decades is showing that human beings are more resilient than many of us think they are. (Do you really think that your ancestors, pre-historically, didn’t survive equal, or more horrific experiences than what you have experienced?). That is to say, the majority of us have the (genetic?) ability to “bounce back” from stressful, oppressive, and even traumatic events more quickly than the media and the general public have been lead to believe. One researcher from our reference section stated, “A fundamental starting point in the immediate aftermath of trauma is to expect normal recovery.” Another highly respected psychological investigator, in our references section, analyzed extant data on the neuroscience of resilience and came to these conclusions:

* humans are naturally resilient organisms and this is the norm rather than the exception.

* although temporarily upsetting, trauma and loss do not cause permanent damage in 90% of individuals.

* about 10% are less resilient and will not “bounce back” quickly-these will benefit from professional help.

* human resilience is a complex and still poorly understood combination of genetics, life experience, and coping style.

* there is some thought that people can be trained to be more resilient.

* coping styles are highly personal and incorporate a wide range of effective strategies that mental health professionals have deemed sometimes not healthy; including denial, bias, repression, laughing and “black humour”. These strategies have since been termed by some as “coping ugly”. People may not respond the way psychologists/psychiatrists think they should……but it works for them. Interfering with these natural coping mechanisms and telling people how they “should” be reacting may do more harm than good.

In the words of one respected author, “Sometimes the worst does happen, but our innate capacity to bounce back means that most of the time things will turn out alright”.

As I have previously suggested on this blog, extant research calls the diagnosis of “PTSD” into question. The diagnostic formulation is questionable at best and invalid at worst. I’ve previously outlined how in 1980 the DSM-III included “PTSD” under pressure from anti-war psychiatrists, psychologists, and social workers. The (anti-war) mental health professionals of the day argued that traumatic memories re-emerged in a more virulent form as (a form of) “PTSD”. The American Psychiatric Association began to generally diagnose using military diagnostic criteria. The DSM-IV presented a complex decision making process requiring much human judgement. The ensuing criticism precipitated several key changes; whereas there had been 11 of them in a revised DSM-III (1987), there were 15 changes in the DSM-IV (1994). Contemporarily there have been up to 200 combinations of symptoms through which “PTSD” can be diagnosed. A “PTSD” profile can “overlap” (or be confused with) several common mental conditions including mood disorders, anxiety disorders, and substance-related addictive disorders. In 1995 a major survey reported 88% of females and 79% of males diagnosed with “PTSD” had at least one co-morbid diagnosis. The most common was Major Depressive Disorder; it was found in approximately 50% of “PTSD” patients.

More fundamental and rarely spoken of problems include misdiagnosis and malingering. With regard to the first, posttraumatic symptoms may not even be linked to trauma. Bodkin, for example, was able to demonstrate that among major depressives, both patients with and without trauma met the criteria for “PTSD” at identical rates, i.e. 73%.

With regard to malingering, the 1988 Viet Nam Readjustment Study revealed that of 31% of veterans with what had been diagnosed as full blown “PTSD”, only 15% had been assigned to combat units. It was noted that there was a correlation between subjective symptom severity and financial compensation; suggesting that secondary gain (not necessarily consciously undertaken) plays a role in a “PTSD” response. A study in 2000 showed a subject sample of veterans treated at VA outpatient programs with records that were highly consistent in their presentation of key words and subjective reporting. The question might be asked, is this an example of precise diagnostic criteria (which we have seen don’t exist) or the expectancies and/or elicitation techniques used by examiners.

Something similar was seen in the WWI reports of military personnel suffering with “soldiers heart”, “shell shock”, or “contusion”. These personnel presented with a symptom profile that included shaking, stuttering, limping, and several sensory signs e.g. deafness, mutism, and blindness. What is seen today in presumably the same disorder was not evidenced e.g. anger, numbness, anxiety, flashbacks, and profound sadness.

Interestingly Frueh and his colleagues discovered that the veterans subjective reports of military deployment often did not match their combat experience; for example, 32% of males attending VA outpatient “PTSD” programs related to combat exposure had no combat experience. Another investigator found that compensation seeking veterans were more likely to over-report or exaggerate “PTSD” symptoms. In 2005 the Inspector General’s Office associated with the VA announced the results of its’ investigation of Viet Nam veterans readjustment and included the finding that the veterans’ symptoms increased until maximum benefits were attained; following which an 82% drop in the use of VA mental health services occurred without any change in other medical services.

So in sum (and I am addressing our foreign visitors who made this request) it seems we could draw a few conclusions:

* it is difficult to distinguish between a “PTSD” symptom cluster and what could be seen as a normal human response to massive trauma.

* “PTSD”, MDD, GAD, and Substance-Related and Addictive Disorders diagnoses are difficult to separate; moreover, the symptoms used to define “PTSD” are not strongly correlated with trauma.

* the diagnosis of “PTSD” relies on unverified trauma and subjective reports of symptom profiles.

* financial compensation may be an important reinforcing factor; suggesting secondary gain.

So there it is. What do you think? What is your reaction? Please feel free to comment and always remember…..THERE IS NO FEAR!! COULD IT BE THAT WE ARE IN ERROR WHEN WE VIEW LIFE’S PROBLEMS AS UNJUST IMPOSITIONS RATHER THAN EITHER THE SIMPLE FACTS OF LIFE, OR OPPORTUNITIES TO GROW?

Dr. Mike Webster
Reg’d Psychologist
#0655

References

Baldwin, S.A. et al. A case study in critical psychopathology. The Scientific Review of Mental Health Practice (2007).

Scott, W. PTSD in DSM-III: A case of politics in diagnosis and disease. Social Problems. 1990: 37

Jones, E. A paradigm shift in the conceptualization of psychological trauma in the 20th Century. Journal of Anxiety Disorders (2007).

DSM-IV Source Book. Arlington VA. American Psychiatric Publishing Inc. (1994).

Kessler, R.C., Post Traumatic Stress Disorder in the National Co-Morbidity Survey. Archives of General Psychiatry, (1995).

Bodkin, J.A. Is PTSD caused by traumatic stress? Journal of Anxiety Disorders (2007).

Gold, S.A. Is life stress more traumatic than traumatic stress? Journal of Anxiety Disorders, (2005).

McNally, R.J. Can we solve the mysteries of the National Viet Nam Veterans Readjustment study: description, current status, and initial PTSD estimates. Research Publishing, Triangle Park, NC (1998).

Barglow, P. Is PTSD a valid psychiatric diagnosis? The Scientific review of Alternative Medicine (2006).

Frueh, B.C. Documented combat exposure of U.S. veterans seeking treatment for combat related PTSD. British Journal of Psychiatry, (2005).

Elhai, J.D. Health service use predictors among trauma survivors: A critical review. Psychological Services, (2005).

Department of Veterans Affairs Office of Inspector General. Report Number 05-00765-137. Washington DC, (2005).

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From → Other, PTSD, Resilience, Stress

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