In January 1994, as a newly minted 54-year-old psychiatry resident at the Salem Virginia Veterans Administration Medical Center, I met a 72-year-old veteran of the United States Army. He was brought in by his family, his son and a daughter as I recall, because he had become totally withdrawn and isolated after his wife had died several months earlier. He barricaded himself in his rural Virginia farmhouse and threatened anyone, including his children, who came on his property. Fearfully, his children called law enforcement to help bring him safely to the VA, the first contact with the VA since he left the United States Army in late 1945.
His children described his life of social isolation which was managed by his wife who protected him, managing virtually all his contacts and his activities of daily living. He was a part-time farmer and some-time saw-mill worker who never had friends and avoided contact with neighbors and even his family of origin. He always carried a firearm. His children never heard him speak of his experiences during his service in the Army. They only knew he had been in France and Germany in 1944.
This veteran was initially treated for Major Depression with psychotic features primarily manifest as paranoid delusions. He was unkempt, malnourished, hyper-vigilant, made no eye contact and initially was virtually mute. But slowly, within the tightly structured and secure enclosure of the locked psychiatry unit, helped by the patient and supportive staff, and perhaps assisted somewhat by the effect of psychotropic medication, he began to trust and finally talk about his life and his military experience. He was in the area of the Ardennes in December 1944, caught up in the German blitzkrieg, part of the Battle of the Bulge. He was a gunner on a tank and was the only surviving member of his crew after an attack that set the tank on fire. He was trapped under the burning tank which was subsequently surrounded by German infantry. He does not know how long he was unable to move, afraid to breathe or cough, sure he was either going to die or was already dead and was in some sort of hell. It may have been a day or two, maybe longer, before he was found by American soldiers. He was not evacuated then, despite his burns, as the unit was on the way to relieve Bastogne. He told me in 1994 he knew then, in 1944, he was not and would never be the same person again.
This veteran was eventually discharged to the care of his family with a diagnosis of Major Depression. There was some lively debate about the diagnosis of PTSD with my arguments for the diagnosis of PTSD being dismissed by the more senior staff, no in terms of age. The minds of the military, the VA and Congress were still uncertain about the diagnosis of a disorder called PTSD in Vietnam veterans. The idea of PTSD from WW II was not, ever, in serious consideration. After all, it was only 50 years from the Battle of the Bulge. It seemed there was just not enough time for the scientific community, the military and political establishment to accept the reality of a disorder that has been part of humankind since the very first time man picked up a weapon in anger.
Evolution of PTSD as a Diagnosis
Progress has been glacial, to say the least. However, there may be some light within the scientific community. Writing in an editorial in JAMA Psychiatry, July 22 2015, Charles w. Hoge, MD, provides some perspective to this Sisyphean struggle:
“In 1979, the US Congress directed the Veterans Administration to establish Readjustment Counseling Centers (Vet Centers)….By 1980 consensus was reached on the first definition for posttraumatic stress disorder (PTSD). However, scientific and political debate raged as to whether PTSD was a legitimate disorder and Vietnam service a legitimate cause; members of Congress called for the closure of Vet Centers.” [View article online.]
However, Congress did fund the National Vietnam Veterans Readjustment Study (NVVRS). While squabbling continued over the definition of PTSD, in 1988 the NVVRS researchers “concluded that 30% of Vietnam veterans met PTSD criteria during their lifetime and 15% still had PTSD.” This data did not seem to impress the powers that be, and with changes in the DSM of the American Psychological Association in 1994 the above figures were changed to 19 and 9 percent. Perhaps this revision was more palatable to those authorities who still did not believe PTSD to be a real entity.
The lessons of Vietnam-associated mental health problems were largely ignored when the military began operations in Iraq and Afghanistan, the first sustained ground combat undertaken by the United States since the war in Vietnam. In a paper written by Dr. Charles Hogue, et al. in 2004 in the New England Journal of Medicine (351:13-22), “Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care,” raised the alarm (my word) about the inevitable mental health outcomes of these conflicts. At that time Dr. Hogue stated: “Little of the existing research is useful in guiding policy with regard to how best to promote access to and delivery of mental health care to members of the armed services.” Despite this paper documenting the relationship of combat experiences to the incidence of PTSD, the concept of PTSD being a real disorder continued to be debated and largely dismissed.
In October 2010 Dr. Hamid R. Tavakoli, MD, of the Department of Psychiatry, Naval Medical Center, Portsmouth, VA published an article in Psychiatric Annals (40:10) with the following conclusion:
“Posttraumatic stress should be regarded as normal human response and emotions of adjustment. When the course of readjustment is complicated, it should be differentiated from comorbid psychiatric conditions, such as major depressive disorders, generalized anxiety disorders and behavioral problems (e.g. substance dependence), because each has an established and specific treatment program of its own. Moreover, patients and society will be better served by removing disability compensation for PTSD…”
In a particularly scurrilous diatribe unfit for inclusion in a scientific journal, Dr. Tavakoli makes a statement that PTSD is the product of mixing politics and medicine. “The development of PTSD is a case of such a mixture. Triesman and McHugh state that ‘PTSD is an example of how cultural attitudes and power politics came to dominate the profession’s assumptions about meaning, memory and mind.’ Add sociocultural and political factors and we have the formula: Vietnam war + antiwar psychiatrists + distressed America veterans = PTSD (a special condition, caused by wartime experiences, leading to a range of emotional illnesses that last for years, or decades, entirely because of ‘traumatic memories’ that disrupt all of psychological life.)”
This, I am embarrassed to say, from an established and published military psychiatrist. However, this is the same line of thinking and some of the same words used by a recently retired Vice Chief of Staff of the Army (not a medical person) as he describes his self-anointed expertise on PTSD. The true scientific data on PTSD as a psychologically traumatic injury to the brain, which will drive a stake into the heart of Dr. Tavakoli’s presentation, will follow in future posts to this blog.
At the present time we are left with the incontrovertible data published in JAMA Psychiatry on line July 22, 2015: Course of Posttraumatic Stress Disorder 40 Years After the Vietnam War: Findings From the National Vietnam Veterans Longitudinal Study (NVVLS), Charles Mamar, MD, et al. As noted by Dr. Hoge, “The most important NVVLS finding is confirmation of the chronic and debilitating course of war-related PTSD.” This study found lifetime warzone prevalence of 17.0% in male veterans (15.2 in females) and current prevalence to be 4.5% (6.1% in females)…These figures likely do not reflect the full disease burden owing to psychometric concerns…and because nearly a quarter of the cohort died in the interim between the NVVRS and NVVLS (PTSD is strongly associated with mortality).” These numbers are even more significant when the numbers of Vietnam veterans with subthreshold PTSD are considered.
The following statement sums up where we are in the care of our soldiers and veterans now: “Thus, despite unprecedented efforts to encourage earlier treatment access for Iraq and Afghanistan veterans, their need for services will undoubtedly grow over time.” At this time it is clear the military and the VA are not willing and are not capable of offering the level of care our servicemen and women have earned and deserve. It seems it is not possible to be proactive, rather, remaining merely reactive, to the winds of our political minions.