PTSD’s Vexations

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Post-traumatic stress disorder has always been a controversial diagnosis, and so it was at last week’s annual gathering of the American Psychiatric Association.
They date back to when the term “PTSD” was first listed in the Diagnostic and Statistical Manual (DSM) in 1980, after the end of the Vietnam War. The diagnostic criteria have just changed, as discussed in my recent post.

Controversies on the issue surfaced at an overflow workshop that began with Harold Kudler, an esteemed PTSD researcher with the Department of Veterans Affairs.

Dr. Kudler emphasized that whatever the controversies about nomenclature in the new DSM-5, the care of the patient should be at the center. He’s planning on posting about that here on Battleland in the near future. Other issues bubbled up during the workshop:

Does “secondary PTSD” exist? Navy Lieutenant Jennifer Shippy explored the question of whether it could be caused: 1) by exposure to media; 2) in family members exposed to service members; and 3) in caretakers working with service members.

Navy Captain Kevin Moore looked at PTSD from the commander’s point of view. Commanders want to take care of their patients while maintaining good order and discipline.

Could other toxic insults, such as mefloquine (Lariam, an anti-malarial medication) toxicity have contributed to symptoms of PTSD for some Iraq and Afghanistan and other veterans? Physician-epidemiologist and former Army officer Remington Nevin added to that contentious discussion with some powerful evidence.

I emphasized the need to develop treatments that Soldiers and Marines are willing to access. Younger service members do not like conventional evidence-based treatments. Medications have side-effects, including sexual dysfunction. Psychotherapy involves talking about the trauma, which many battle-hardened veterans are loath to do, especially to a civilian who has not been downrange.

The newer alternative treatments — acupuncture, stellate ganglion block, yoga, trans cranial stimulation, omega fish oil, virtual therapy– are much better accepted by Soldiers and Marines. But there is not yet the scientific evidence to prove their worth.

Is the label “PTSD” even right? Retired Army general Peter Chiarelli, retired Navy captain Bill Nash, noted psychiatrist and PTSD expert Frank Ochberg and others suggest it be called Post-Traumatic Stress Injury. This would acknowledge that it is not a fault of the sufferer, but a wound due to combat. The thinking is that the relabeling would reduce the stigma associated with the word “disorder.”

Should service members with PTSD automatically receive a 50% disability, as is now the case? Many military and VA medical personnel are concerned that becomes an incentive for the patient to develop and/or retain symptoms, rather than get well, and perhaps lose their compensation.

Should service members with PTSD be eligible for the Purple Heart medal? Currently the diagnosis of PTSD is explicitly barred from the Purple Heart. The organization, “Honor for All”, has been advocating for a change to that requirement.

The audience responded with a flood of questions, comments and opinions:

— Can the symptoms of PTSD be undone? Is that what the nightmares are all about?

— What about “moral injury“?

— What impact does taking care of someone with PTSD have on the caregiver?

— If a caregiver learns of war crimes, what is he or she supposed to do?

The fog war envelopes the battlefield, as well as minds wounded there. No easy answers were forthcoming. But as a long-time Army psychiatrist, I was heartened by the eager crowd of psychiatrists in attendance. Their combined intelligence and fervor made clear that their primary goal is to take better care of the troops and veterans who need it.