The social construction of the war neuroses

My paper today concerns the social construction of war neuroses. It describes how persons who returned from wars with emotional difficulties have been diagnosed and treated according to the beliefs of the medical profession of the day. At the end of it, I will ask you to consider if our disabled veterans are being well served by derivative American psychiatric models.

Society’s concerns have always motivated the creation of new illnesses. Nostalgia was originally an illness category used to medicalise the problems of homesick soldiers.

In the American civil war, men were invalided out by left-sided chest pain, called ‘da Costa’s syndrome’. This pain was a copy of angina which is felt in the middle of the chest. Psychosomatic and somatoform symptoms were formerly known as hysteria. These are great imitators and often occur in epidemics.

In World War I diagnoses, symptoms and attribution theories changed again, with shell shock being most prevalent and Disordered Action of the Heart, DAH following closely.

Shell shock was believed to be the effect of shock waves from exploding shells which people believed damaged the brain and body, even when no direct hit had been taken.

By 1916, the link between shell shock and concussion had been broken. About one third of cases had developed symptoms suddenly in close proximity to an explosion. Another third were men going to their billets or trenches who heard distant shells. The last third were men with identical symptoms which had developed before they even reached the battle field. They had no knowledge of the traumatic events that were supposed to have caused their disorder. In some of these cases, doctors were able to give diagnoses of shell shock to men who had never left England.

Symptoms of anxiety and emotional distress

A proportion of people have always collapsed down under stress. This is not new. ‘Nervous breakdown’ was originally conceptualised as a breakdown between the brain and the functions of the body that it controlled.

Then, as now, traumatised soldiers returned from wars and sat staring at walls, growling irritably at anyone who made demands on them. They had bad dreams and physical symptoms that their doctors could neither explain nor relieve.

They got depressed, depleted, exhausted, developed obsessions and compulsions, went into themselves or insane. They became breathless, weak-kneed muzzy-headed and complained of any symptom you could imagine..

Or, at least that was the case before posttraumatic stress disorder was invented. Now everyone, military and civilian, breaks down in the identical, but prescribed, way.

How do doctors diagnose

You can conceptualise each symptom is a star in the sky and the doctor as the person who identifies the constellations and defines them as diseases and disorders by asking leading questions and examining for physical signs.

If the main problem is worry, doctors call it is anxiety, if sadness, depression, if inexplicable symptoms are located in the body, it is somatization or psychosomatic. If fatigue is prominent we call it neuraesthenia. If irrationality is prominent we suspect insanity, psychosis.

People do not change but in different cultures and in the same country at different times, an illness is expressed through a patient’s unique experience and history and diagnosed in a way that his culture permits and understands.

The medical profession has been successful in putting the label ‘illness’ on many disapproved types of behaviour. By defining a person as sick, the physician protects that person from social judgements such as lazy, habitually drunk, degenerate, criminal, cowardly or irresponsible. The label ‘illness’ carries with it the implication that the behaviours are properly, even successfully, managed by physicians as physicians show themselves to be willing to manage or deal with such problematic issues. The jurisdiction of medicine legitimates the claim that the ‘proper’ management of many forms of deviance is ‘treatment’ in the hands of a skilled and responsible profession. As a consequence, the established responsibilities of medicine extend far more widely than its demonstrated capacity to cure.

Freud made his name in the wider community by developing a talking cure for the war neuroses. His ideas were eagerly adopted by the various governments of the time. Freud’s treatments were never evaluated so we will never know if people treated by Freudian techniques did any better, health-wise, than those who were left alone, to rest and recover according to their own devices.

His concepts are dubious now, but his language, repression, traumatic memory and resistance still permeate the discourse and underpin the current remedies.

Gulf War Syndrome

Before I come to post traumatic stress disorder, I’d like to jump ahead and only mention Gulf War syndrome suffered in those servicemen who were within range of the oil well fires of Kuwait. Those who came back sick believe they were affected by unrecognised toxins or alternately, poisoned by medical injections. Gulf war syndrome and its attendant beliefs however, is confined by those who speak and read English and it remains unrecognised by other nationals who were also on ships nearby.

Vietnam and its inhuman conditions initially disgorged debilitated, preoccupied with their inability to get well and with clusters of cancer and abortions in their wives. These were attributed by the returned servicemen to Agent Orange, more particularly to its deliberate contaminant dioxin which everyone knew had the capacity to poison and cause cancer.

This issue was never put to test. Monsanto settled one big class action then successfully fought off the admission of further claims to court. This debate never reached closure.

Confusion reigned as information from the United States government about where Agent Orange had or had not been used, or indeed where the war had or had not been fought, was not trusted.

The dioxin issue was stalled because of the lack of availability of money to do proper epidemiological studies on widely scattered individuals and the because of poor military records about where dioxin was sprayed.

Reports of birth defects, sickness and early death continued to emerge from Vietnam where the population had no choice but to live with dioxin contamination of their food chain.

Just last week a Government level joint inquiry was announced, between the United States and Viet Nam to inquire further into the effects on the health of the Vietnamese population exposed to Agent Orange.

The origins of POSTTRAUMATIC STRESS DISORDER

In 1973, psychiatrist Robert Lifton interviewed a very frightened veteran who had seen, but not participated in, the My Lai massacre. He had been told that he would be killed if he ever told anyone about it. because of the secrecy that had surrounded this, it was widey assumed that My Lai was a tip of an iceberg of similar rampages. Lifton railed against military psychiatry for claiming to be effective in containing the war neuroses and for returning troubled, or sick, soldiers to the field.

Lifton spearheaded a loose body of veterans and clinicians who lobbied the American Government describing, in turn, post Vietnam syndrome, post combat disorder and later, catastrophic stress disorder.

The symptoms of all these soldiers could be accounted for by existing diagnoses. This full range of problems did not easily lend itself to a system to distributing money to veterans.

A legitimating category was needed to accommodate an essential element, causation by war service.

The veterans lobbied the American Psychiatric Association to identify a uniform diagnosis, so that persons who were able to attract or conform with that diagnosis could get special access to more resources and, hopefully, to cures.

During the Viet Nam war and by the early '70s, drug abuse was rampant. After the soldiers came home, mental breakdowns began. Researching psychiatrists investigated large numbers of non-coping ex servicemen.

By 1980, the American Psychiatric Association mindful of the political sensitivity of Vietnam issues admitted the first of several versions of posttraumatic stress disorder. I am displaying the third version, from DSM IV.

The stressor, criterion A, the allegedly causal entity, had to be outside the range of normal human experience. This criterion was tightened up in later editions.

An epidemic of posttraumatic stress disorder followed. PTSD covered a huge collection of symptoms accommodating the manifestations of anxiety, depression and drug- or alcohol-dependence.

Creating categories

All the American Psychiatric Association diagnoses are the products of committees of interested parties, vested interests.

The Diagnostic and Statistical Manual of the American Psychiatric Association, usually known as the DSM is a catalogue of mental and behavioural disorders of interest to psychiatrists and defined by their symptoms and context. Each new version is appended by its edition number, I, II, III, IV, IVR. Its major use is to allow mental health professionals to communicate in shorthand, jargon words with insurers and other third party payers.

Each version increases the number of mental disorders available for categorising experience and behaviour until we now see Road Rage, which is losing your temper in a car or Intermittent Explosive Disorder which some people cannot tell from being bad tempered.

Twenty-four percent of the general population can be diagnosed according to this manual as having a mental or behavioural disorder.

This is called social construction of illness. People feel bad, mad, sad, worried angry, and upset. Their mental diagnoses are created by their answers to questions their doctors ask them, and are categorised according to the DSM.

The American Psychiatric Association makes sixty million dollars a year from selling the Manual so the mode is expansionist. The handbook represents psychiatry’s grab for power and therapeutic jurisdiction. The medicalisation of life’s vicissitudes is good for business.

Enthusiastic vested interests talk of cases which have not yet been recognised, which remain undiagnosed and, so, untreated..

The book contains warnings to the effect that its contents are not generated by scientific processes, but by committees. Diagnoses, with few exceptions, infer neither mechanism nor causation. The book specifically states that these categories are not suitable for use in legal proceedings. Yet the DSM sits at the right hand of every barrister and judge when their cases involve mental health issues.

This inventory is not a scrap of use in treatment. Clinical trials of known as well as new antidepressants fail miserably when DSM criteria for major depression are used for qualifying entry of a patient into a drug trial. As DSM’s category of ‘major depression’ can include unhappiness, grief and mourning, one would not expect it to respond reliably to pills. To demonstrate that antidepressants are an improvement on placebo, you need to use research criteria, which are the criteria for biological depression, not simply depressed mod or common human unhappiness. But the drug companies have us, and our patients, all well trained to expect a magic cure.

The classification of posttraumatic stress disorder in DSM III was a victory for the veterans and their supporters because it meant free treatment and compensation. The act of psychiatrising a grab-bag of symptoms, representing the suffering of thousands of men and women (mainly nurses), was more political than medical.

Without the intense lobbying of both the American Psychiatric Association and, later, Congress, posttraumatic stress disorder would not have been created at all and the veterans would have had no specialised help free of charge.

Treatment of posttraumatic stress disorder

This agglomeration of many levels of disorder under a single umbrella meant that some veterans would pay a price in treatment programs ill-suited to their needs.

In l986 the American government asked a veteran’s hospital to devise a treatment for posttraumatic stress disorder, so it could be taught and standardised.

This daily activities of this hospital were observed and recorded by a medical anthropologist Allan Young and written up in a book called ‘The Harmony of Illusions: Inventing Post-traumatic Stress Disorder’ and I will be quoting this source.

Briefly, veterans were treated as in or out-patients. They qualified for in-patient treatment if they did not have too many so-called ‘characterological’ problems, these being with drugs, criminality or personality disorders.

The underlying philosophy of the program was that the uncovering of their traumatic memories, bringing them to the surface, would result in a cure.

They were expected to do this with the help of therapists in group and individual sessions; they were to abstain from illicit mood-changing drugs but antidepressants and tranquillisers were readily available.

Veterans were paid full pensions, that is they were deemed TPI while they were in hospital.

If they could get their previous diagnoses, usually alcoholism drug abuse, personality disorder, brain damage and schizophrenia, reversed and, if they could leave the clinic with a diagnosis of Post-traumatic Stress Disorder, then they could get up to $60,000 in back pay.

I stress these men were ex servicemen and nobody would suggest they were not sick. They were sick in the same way as members of the non service population were sick;

It was arguable and highly contested that proportionately, more of them were sick than were sick in their matched control group who had stayed at home. This was not enough. These Veterans needed a good reason for being sick, preferably one that originated in their service so sickness could be attributed to it.

Many could not remember having seen any bodies or being distressed during their tour of duty. Some had spent the war in a cannabis haze, some had not seen a battlefield but they knew of others who had been killed.

This is where the discarded Freudian concepts of repression and traumatic memory came in. If the serviceman could not remember the trauma that had caused his symptoms, it was because he had repressed both the traumatic event and the feelings associated with it. He had to recall those feelings to be cured and compensated.

It did not surprise anybody that within days or weeks of this treatment, their memories of war experiences started to emerge, vivid and clear.

As traumatic memories emerged, the men became more disturbed and needed medication and more attention.

There were two further problems with this treatment program.

first, no one ever asked for recourse to the Army historians, in the face of constant accusations by some veterans that others were just making it all up. Co-patients suggested that some were fabricating their experiences were silenced. If medical and therapy staff expressed that idea, they were warned, then dismissed. This scepticism was given a Freudian name, ‘resistance’ and it was treated as an attitude that had to be overcome.

The second problem was that the expensive and elaborate treatment regime was never evaluated. When it eventually did come under scrutiny, no therapy which involved recalling traumas made it into any list of evidence-based effective remedies.

The patients were constantly saying that they did not want to talk about their experiences or their feelings, and they would get angry about what was going on. They did not like the treatment nor the stirring up of old wounds. People who have experienced atrocities want to forget and get on with their lives, but these people were told that they had to dredge it up. Before this remedy was invented, encouraging individuals to stew in their distress was generally considered detrimental to recovery and it was generally recognised that therapies which concentrated on the past did not help much for the individual’s future.

Furthermore, the public wasn't interested in remembering an often shameful war and they didn't want reminders from the veterans.

Reliability

Diagnoses have ratings of varying levels of validity and reliability. A fair validity diagnosis is schizophrenia, in that those people who have voice hallucinations are very likely to have delusions and disordered thoughts.

Posttraumatic stress disorder was a diagnosis with poor validity. When it was first put together, the committee recognised that there was only a very small correlation between the criteria. That is, if a returned serviceman had experienced catastrophic trauma, he had only an 8% chance of experiencing a significant number of the other listed symptoms.

The symptom lists were soon being circulated by various Veteran Associations. Films about veterans were written by script writers with the Manual beside them.

The availability of the DSM made instant experts of anyone who could ask leading questions, and these included lawyers and other veterans. The DSM provided and created diagnoses for those who could fill out forms which contained the right questions.

After the symptoms have been identified in a veterans discussion, or by a report writer in the lead up to a forensic examination, the symptoms list became very familiar to the reporting subject.

The diagnosis is written in American psychobabble, not ordinary language. This unique jargon made the phenomenon of learnt symptomatology very easy to identify.

It was not long before a significant, then a massive number of claimants in veterans as well as every other jurisdiction were able to attend their medical examiners and recite some or ll of the following

I’ve got flashbacks, I have intrusive recollections, I’m hyperalert and I have a startle response. I am detached and alienated and I have rages. I lost it and hit my wife because I had a flashback while were arguing at the kitchen table. I avoid watching television in case a war scene comes on.

Psychic numbing was harder to pronounce.

These veterans had not read the fine print to find out how to describe in detail what they felt. Nor were they familiar with the natural responses to the events that they were describing. Few were able to report what they did to put an end to their intrusive recollections, so they nursed them and concentrated on them. Stories abounded about the veterans who were concerned that they had not yet finished their survivor quilt, as one of the circulating symptom lists contained a spelling error for ‘survivor guilt’ which is one of the smaller criteria..

Doing business with posttraumatic stress disorder

Experienced forensic examiners are embarrassed when they are confronted with a royal flush of symptoms presented in words not consistent with the speaker’s education. The ability to recite the list often did not correlate with the normal range of activities which comprised of the rest of the veteran’s life.

While some had never recovered from the war at all, others had been discharged in good mental and physical health, had enjoyed a marriage or three and had successful businesses or careers and had brought up a family.

Many had got sick with the symptoms of posttraumatic stress disorder when age, alcoholism, marriage breakdown or disease had caught up with them.

Veterans came in reciting the symptoms of posttraumatic stress disorder in the same order as the DSM.

They conflated flashbacks with normal remembering and real with falsely recovered memory

I knew that they recited a set of symptoms that would occur together, in nature, as infrequently as 12345678 would win lotto.

In my recent experience, a soldiers who had driven trucks in an area where an ambush had previously occurred suddenly recalled in group therapy how frightened he had been at the time. Another recalled a previously unrecognised closeness to three soldiers who had since suicided and distressed him. However he reported different names, different times and different modes of suicide in all the different reports that his quest for compensation had generated. One navy veteran recounted to me how the rivets of the HMS Sydney let in streams of water whenever depth charges where set off in port.

I found myself in a sceptical frame of mind so I often asked for recourse to army historians. I soon pleaded off assessing veterans. I found repatriation to be the most ideologically-driven jurisdiction I had worked in, even worse than NSW workers compensation.

I came to understand they came to believe that having served was the cause of their latter life problems.

What defines posttraumatic stress disorder is this apparent delay in reaction to trauma. It sets posttraumatic stress disorder apart from the cases of shell shock suffered in the First World War which disabled soldiers on the spot.

This counterfactual information did not deter the American diagnosticians. Rather than abandon their traumatic paradigm, they shored it up by inventing the concept of delayed Post-traumatic Stress Disorder. This ensured that compensation was paid.

Veterans were blaming events long past for a behaviour and experience manifesting in the present time.

As any layman with common sense will tell you, you feel at your worst in the days, weeks or months after a trauma, a loss or a bereavement, then you get better. You do not suddenly feel awful 20 years later, unless, of course, you learn something you did not know before.

The ability to believe the counter-intuitive view, counter to our own experiences, is referred to as the ‘trained incapacity of the expert.’

The time frame is wrong. We are being asked to reason backwards, from effect to cause. As there are always a myriad causes for any given effect. As the song says, ‘Fools give you reasons, wise men never try.

Cause and attribution are conflated and confused. Cause is a scientific concept, hard to prove. Attribution arises out of politics and preoccupations and masquerades as a medical diagnosis.

The medico-legal fix

Judicial Tribunals distributed benefits in accordance with how many of these symptoms claimants are able to recall and have documented for them.

Courts failed to differentiate reports that had been generated by honest clinical examinations from those generated by check lists and leading questions. Bad law encouraged bad medicine and vice verse.

My dilemma was that unless the veterans did that, learnt the symptoms with which they were forced to ‘do business’, the judges in various jurisdictions would claim that they did not meet the necessary criteria for posttraumatic stress disorder and they were not compensated.

"In other words, Alan Young pointed out, if you want your claim to be understood, you'd better use the language of posttraumatic stress disorder -- or other diagnoses -- coined by the DSM."

“Now the people whose problems had nothing to do with the war can claim posttraumatic stress disorder while those with genuine afflictions are not getting the attention they need. The real victims get lost in the middle of the mess."

Young believes that the application of posttraumatic stress disorder is open to all kinds of abuse, as much for the individual who falsely claims a memory of a traumatic event as for governments who will use the label to avoid dealing with the genuine physical suffering of returned soldiers.

It's ironic, says Young, that in 1980, Congress initially rejected the notion of posttraumatic stress disorder , fearing the can of worms it would open in terms of compensation. Now, the "veteran's administration welcomes posttraumatic stress disorder because it's easier to deal with than pursuing an investigation of the medical and environmental hazards to which the soldiers were exposed.

This analysis of the social construction of medical knowledge describes the roles played by society’s concerns, advocacy groups and moral entrepreneurs of health. it is ideologically-driven and It does not address fact finding or scientific concerns.

Posttraumatic stress disorder is one manifestation of the dominant paradigm of the late twentieth century. We now assume that emotional disturbances were caused by psychic traumas in childhood. Before that, we believed that they emotional problems were caused by bad parenting, by the mother. Like the genetic theories of Lysenko, causation by trauma often turns out to be a truth sustained by officialdom, supported by powerful institutions while not meeting any of the criteria for science.

No culture can progress on a basis of falsehood, as its repercussions cause wasteful misery and retard progress.

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