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 ...

The Mystery of Creativity

The other day, I picked up Silvia Nasar's "A Beautiful Mind," and instantly I was hooked.

The book chronicles the life and times of John Nash, the mathematical genius who lost decades of his life to schizophrenia.

"How could you," a colleague asked back in 1959, "believe that extraterrestrials are sending you messages?"

"Because," Nash replied, "the ideas that I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously."

In 2007, I had the occasion to hear Dr Nash speak at a convocation at the American Psychiatric Association's annual meeting. He held a densely-worded typescript up to his face and proceeded to read in an interminably relentless monotone. I would have made a beeline for the door, but you don't even think about such things in the presence of a Nobel Laureate.

Okay, I lie. I thought about it.

Then something he said made my ears perk up. "My recovery began," he related, or words to that effect, "when my reputation finally started catching up with the acclaim I felt I deserved."

Speaking of schizophrenia and creativity: At a different session at the same APA meeting, Nancy Andreasen MD, PhD of the University of Iowa pointed out that Newton was a wild and crazy guy who had a psychotic break at age forty, that Albert Einstein was an eccentric who had a son with schizophrenia, and that James Watson was a bit of a loose cannon who also had a son with schizophrenia.

Thus, the three most important discoveries of the modern scientific era, Dr Andreasen said, had something to do with schizophrenia. What are the odds of that?

In the 1970s, Dr Andreasen pursued the schizophrenia connection in a survey of the Iowa Writer’s Workshop. She expected to find a percentage of well-adjusted individuals with schizophrenia in their families, only to find herself "absolutely astounded" to discover instead that 80 percent of them had some form of mood disorder.

Confessed Dr Andreasen: "This is a great example of starting out with the wrong hypothesis and coming up with a completely different answer."

In her talk, Dr Andreasen discussed a study she is working on, involving scanning the brains of artists and scientists, including Nobel Laureates, as they perform simple tasks. She is expecting to find greater than usual activity in the association cortices in the brain, where unconscious processes play out.

Dr Nash's great creative work was done in his early-mid twenties, before his illness manifested in full. But the author of "A Brilliant Mind" gives us the impression that John Nash was always a case of schizophrenia waiting to happen. From Day One, he was an outsider. Even in a profession notorious for its oddballs and cranks, John Nash never quite fit in.

We tend to identify mental illness by severe episodes and breaks with reality. But there tends to be long lead-in periods, with clear warning signs. Psychiatrists refer to these under-the-radar symptoms as "prodromal" states. Maybe something will happen, maybe not.

So here is a man with no ordinary brain. Thoughts connect in startlingly original ways. On one hand, it produced a stunning piece of rationality - games theory - that was so novel that his contemporaries failed to fully grasp its significance. On the other, this same remarkable brain was responsible for equally astonishing irrationality, a tragedy that robbed its owner of three decades of his life.

How could this be? We are still learning ...

Check out my article on creativity.