Wednesday, May 26, 2010

PTSD - Since When Is An Event Supposed to Justify a Condition?

My good friend Willa Goodfellow (Prozac Monologues) has written an extremely thought-provoking blog piece on PTSD. She summarizes a 2004 article by neuropsychiatrist Nancy Andreasen of the University of Iowa. How we view the condition can be largely attributed to Dr Andreasen.

The phenomenon has been around since the beginning of time, but our understanding remains limited. During World War I, soldiers who experienced "shell shock" were shot as cowards. In World War II, soldiers who suffered "battle fatigue" were given "therapy" to return them to combat in one week. (The therapy, such as exposure to recorded artillery fire sounds, typically exacerbated their distress.) General Patton infamously slapped a bed-ridden soldier.

The postwar DSM-I of 1952 recognized "gross stress disorder," but this was removed from the DSM-II of 1968. The post-Vietnam War era set the scene for its comeback in the DSM-III of 1980. Dr Andreasen was charged with the task of looking into "post-Vietnam syndrome." As Willa describes it:

Given her experience with burn victims, Andreasen pressed for a more inclusive description of the illness. Post Traumatic Stress Disorder entered the new edition, described as a stress reaction to a catastrophic stressor that is outside the range of usual human experience.

Unlike all other mental illnesses, the first criterion for a PTSD diagnosis is an event rather than  a symptom. Another way of putting this is that the DSM mandates a valid reason for an individual's response. The DSM-IV of 1994 and this year's draft DSM-5 (due out in 2013) simply play around with the scope of the valid reason. The 1994 version widened the criterion to include events not necessarily outside the range of human experience (such as surviving an auto accident) while the DSM-5 would narrow it again.

Compare this to depression. Psychiatry does not require a valid reason for us to rate a diagnosis. To the contrary, a valid reason - such as bereavement - would rule out a diagnosis (unless the depression were to persist). In this context, depression would be a normal response to an abnormal situation. We are supposed to feel depressed when we lose someone close to us.

We often get clinically depressed for seemingly no reason at all. Since there is no logic to the depression, the thinking goes, we must be thinking and behaving irrationally. And if this significantly interferes with our daily life, we are presumed to have a mental illness. We elicit sympathy or opprobrium, as the case may be.

The same applies across the anxiety spectrum (with the notable exception of PTSD). We don't need a valid reason - such as an intruder entering through the window - to justify a panic attack. Being frightened of your own shadow will do just fine.

So, I'm wondering. What happens to the poor individual who suffers severe trauma for a stupid reason? Not from combat. Not from being exposed to an act of God or an unspeakable outrage. Something stupid, really stupid. Such as perhaps a close encounter with a circus clown. The trauma may be irrational, but then again so is all the rest of mental illness.

Is that person's distress any less?

Suppose two people rupture their ACL. Does the person who ruptured his ACL while playing basketball get treated while the other individual who ruptured hers playing with her dog get sent home? Isn't it the condition - rather than the precipitating event - we're supposed to be treating?

There are no easy answers here. But the questions, the questions ...


Willa Goodfellow said...

Absolutely, John. Thanks for the reference, and thanks for taking up this cause. David Conroy, author of "Out of the Nightmare," says that being suicidal is cause for PTSD. He gives the argument in "Why is it so hard to recover from being suicidal." -- There's a link to this website in the upper left corner of my blog. But my psychiatrist doesn't buy it, so neither does Social Security. What's at stake is who gets treated, and who doesn't.

One correction: Dr. Ronald Pies pointed out to me, when I also overlooked it, that the DSM V draft has eliminated the "bereavement exception." He and Sidney Zisook successfully lobbied for this change. His comments are at, my post from 2/18/10.

artist60164 said...

I am so glad I found you and your sites. Not only do you have first hand experience in "These Areas" you present with much humor so all of us Matzo Balls can still understand and feel special.


John McManamy said...

Hey, Willa. Absolutely. Psychiatry doesn't even address the trauma of surviving any psychiatric episode, suicidal or not. Think about it. You've been through absolute hell. Your brain has either flipped out or shut down. If it's severe depression, the survival rates are about the same as combat ("decimation" literally means one in ten). Then you're often dealing with wreckage equivalent to an Act of God. You're friendless, jobless, even maybe homeless. Plus a medical doctor has just said you're crazy and you have to deal with it the rest of your life.

Oh, and maybe your episode involved a run-in with the law and locked units and restraints.

I appreciate that in combat brave men and women experience things no one should ever have to experience, and I have spoken out very strongly about doing the right thing for our returning soldiers. I will be re-running my Memorial Day blog in a few days that has strong words about unrecognized PTSD in our returning soldiers.

But honoring our soldiers should never be an excuse for diminishing what our population has been through. We can recognize and treat both with compassion. Maybe we call both PTSD. Maybe we find different names. But we recognize the condition is universal and we get smart about dealing with it.

Re Pies and Zisook - I don't buy it. There is a case to be made for depression that is linked to a precipitating event (I did this in my People's DSM). This would include such things as relationship break-up, loss of job, toxic work or family situation, etc, as well as bereavement.

This would encourage clinicians to work with the patient in addressing the underlying issues instead of just throwing a pill at the problem. This is a throw-back to the DSM-I and II, "depressive reaction" to an event or interpersonal stress.

Interpersonal therapy deals with this. Learning how to deal effectively with your boss or in-laws etc takes a lot of stress out of your life - may even make life pleasant - which nips depression in the bud.

But psychiatrists are really stupid to this. I mean really really stupid. I don't have room here to cite examples. But it is encouraging that I learned about how stupid psychiatrists are from reform-minded psychiatrists. So things may be slowly changing.

In my opinion, Zisook and Pies have it half-right. And half-right is dangerous. If a bereavement diagnosis encourages clinicians to deal with the underlying grief issues, then all well and good. But I think it will blind a lot of clinicians to the fact that bereavement is usually perfectly normal. We NEED to be depressed in these situations, not numb to our psychic pain.

I have a funny feeling if the bereavement diagnosis becomes reality, then the really stupid psychiatrists will be encouraged to throw pills at the situation.

As I said, half-right is dangerous. We need to go back to the drawing board on this one.

John McManamy said...

Many thanks, Jeanne. Consider me a fellow "matzo ball" with peanut butter. :)

Lavinia said...

I may start calling myself the "chemical gal". So many labeled PTSD are actually brain injured or even exposed to chemicals and their entire health is disrupted. So there is a school of thought that this "label" replaced what Buddhism describes as "not knowning". If you can't see it on an xray you must have PTSD.

I can harp on this one a long time, but apparently I am now becoming a scientist in my 9th reincarnation. I am going to WDC next week to deal with new laws on chemicals. Europe one more time is years ahead of us.

John McManamy said...

Hey, Lavinia. Willa went into some of that in her blog, and it certainly applies across mental illness. Several years ago, at the American Psychiatric Association annual meeting, I attended a very sparsely attended session on toxins. The stuff that chemicals and molds and bad ventilation etc can do to our brains. Clearly, judging from the poor attendance, American psychiatry is light years behind on this.

Also, we're way behind on subtle brain injury. I received a very good education on this from someone who was hit by a truck. It took years before the docs finally figured out it was diffuse axonal injury. In her blog, Willa mentioned subtle physical brain trauma that may be a major contributing factor to PTSD.

Let us know what you find out.