Tuesday, June 18, 2013

PTSD: it's not what you think it is

I really don't know what PTSD is.  Nor do I know what is PTSD.  I know the definition, what the DSM says, but that definition seems way too small to me, inadequately capturing the full human experience.  Most of the "symptoms" described in the DSM are either expectable adaptive response to dangerous conditions and/or conditioned emotional responses.*   The DSM's purpose is to define a disorder, but I can find no basis for distinguishing a normal response to horrific events from a "disorder."  How much is "too" much of a response, too big an effect?  Who's to say?  If I imagine a mother seeing her dearly beloved child hit by a car, how long "should" it be before any thought, any reminder of her child will not bring up the image in her mind and a flood of tears?  Years later, when she comes across a toy in the attic, might she not break down in sobs again?  If so, does that mean she's suffering from a disorder?

I recently read a review of the book Wave by Sonali Deraniyagala. The book describes her experiences subsequent to loosing both her parents, her husband, and her two children to the Indonesian tsunami. She, as she said, "lost my world."  When I thought about that, I thought she was exactly right.  Doesn't our world, the world we really live in, consist of the web of primary relationships in our lives?  That's the meaningful world, the world that concerns us.  My connection to everything else is much more tenuous and abstract.  What's the right response to loosing a world?  She tried to kill herself several times, drank as much alcohol as she could get, did nothing "productive" for years.  Any inclination I have to judge her response, call it too much, "pathology," is instantly tempered by my own knowledge that in her situation, I have no confidence at all that I would do anything in any way substantially different.  I know I certainly couldn't guarantee it even though I see my writing this blog as demonstrating some level of resiliency.  The only way I can imagine one makes such a judgement is to perform some sort of disconnect from one's own fears and knowledge about one's self.

Categorizing a person's response to combat or other horrific life events in terms of a set of "abnormal" symptoms is insane.  It seems to me to resemble nothing so much as whistling in the dark.  We are all faced daily, by the possibility of tragedy, horror, and loss.  Each time we get in a car, or our loved ones do, some part of us is more or less aware of our vulnerability.  Do you track your loved ones' flights?  As a parent, are you a little anxious when your children, even though adults, embark on a long drive?  The reality of sudden, "unexpected" death is all around us.  We all need, and find, ways of dealing with the fear of sudden, catastrophic loss, this reality stirs.  One way of lessening our fear is, I believe, to say to ourselves: "Those people who are still suffering?  They're different, got a disorder."  Implied is "I wouldn't be like them."  Really?  Are you sure?

I think it is arrogant on our parts to imagine we can define what is a normal or abnormal response to what is essentially a personal existential crisis.  What will a soldier decide to do about all she/he has seen and done?  They have seen how the animal drive to survive obliterates all man-made ethics, laws, morals.  They have seen human beings, who they may well have believed to be made in the image of God, engage in wanton butchery.  They may have done the same and tasted a blood-lust in them which, being so foreign to our conception of ourselves, they cannot/will not acknowledge.  They have experienced our essential, undeniable vulnerability and meat-like existence; that a little blob of metal can reduce to non-existence, obliterating everything.  They know that we, too, live in a dog eat dog world.

They have seen that which everyone has told them were inviolate, first principles of our social order betrayed like so much dust. Things like duty, honor, trust, loyalty, decency, basic humanity. They may have done things that violated there most deeply held and cherished values and believe there is no real possibility of redemption or forgiveness.  These are some of the real issues combat veterans struggle with and then they come back to a world that refuses to know much of this.  A society that, all too often, makes them either cardboard heroes, demonic "baby killers," or passive victims of a malevolent government and, at best, offers them a disorder as a way of understanding all they are going through.

So since I have no idea what the "proper" or normal response to all this is or should be, I can't imagine defining some responses as a disorder and others not.  I don't know what is PTSD: what response is a disorder, abnormal, too much, "pathology."  So because I don't know what is PTSD, I don't know what PTSD is and neither, I believe, do you.

But even more importantly, what does it matter?  Are only the diagnosed entitled to help, care, concern, understanding, compassion?  Only those with a disorder should be held deserving?  Given the potential damage that the diagnosis of PTSD can do, as I have detailed in this blog, insisting on the absurd administrative requirement of a diagnosis before help is offered is nearly criminal.  EVERY combat veteran should have easily available opportunities to seek assistance on his or her own terms without the necessity of agreeing to be defined as having a disorder.  When we designed the program at Walter Reed we explicitly defined it as available to any combat vet "having difficulty re-adjusting to life in the US" with no mention of PTSD.  I refused to do a CAPS ** on prospective program candidates, believing to do so would increase the likelihood of them seeing themselves as "having" a disorder, rather than struggling to come to terms with their combat experience.  It was only because we stood "outside" of the normal military mental health system that we were able to do this and that reality was no small part, I believe, of what made our program effective.

So let's admit we don't know what PTSD is.  Let's admit we don't know how a person "should" cope with things we can barely imagine.  Let's stop the focus on "symptoms" and symptom relief.  Instead, let us, as individuals, therapist, and society, embrace the whole, struggling person in humble commitment to travel alongside.  I think it will improve the assistance we offer.  And probably us too.

* In the June 3, 2013 New Yorker article "In the Crosshairs" Jonathan Shay defines combat PTSD as "the persistence into civilian life, after danger, of the valid adaptations you made to stay alive when other people were trying to kill you."

** Clinician Administered PTSD Scale: the so called "gold standard" for PTSD diagnosis.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."