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Post-traumatic stress: Have they got it all

wrong?

by Jane Feinmann - The Times, London, October 29, 2003

Opinions vary on post-traumatic stress

ONE OF THE less obvious consequences of the September 11 attack was the establishment of post-traumatic stress disorder (PTSD) as a suitable case for treatment. Up to 75 per cent of the population in some parts of New York were reported to be suffering long-term psychological symptoms — mostly flashbacks, nightmares and intrusive thoughts. About 9,000 counsellors were involved in a programme that was seen as essential to prevent long-term mental health problems. But did it work, or make things worse?

New evidence suggests that the science underpinning PTSD, first recognised as a psychiatric diagnosis in 1980, is shaky. Identification of the disorder followed the discovery that up to half of veterans of the Vietnam War were suffering “significant stress reaction symptoms”. Yet researchers soon found that memories of the events that had apparently triggered these symptoms were “highly inconsistent” and that treatment rarely brought improvement. Then it was found that only 15 per cent of Vietnam soldiers were in direct combat units and at potential risk of PTSD,. This figure is just one third of the veterans diagnosed with PTSD and in receipt of the $2 billion payments made annually to those with the problem.

This diagnosis is “one of the biggest blunders of 20th-century psychiatry”, says Dr Loren Pankratz, professor of psychiatry at Oregon Health Sciences University. In a new book, Malingering and Illness Deception (edited by Peter Halligan, Christopher Bass and David Oakley, OUP, £35), he says that therapies aimed at treating the problem “do not cure PTSD, they teach it”, creating victims by “reinforcing the idea that one’s behaviour is attributable to events in instances where that is not true”. The disorder, he says, affects only a tiny minority of people who are already mentally frail, suggesting that these pre-event factors contribute more to serious distress disorders than the “toxic event”.

In Britain, attitudes to PTSD vary. On one hand there is widespread belief that even events such as car crashes and muggings can cause the disorder, and that police, firefighters and doctors are also vulnerable. Medics are more sceptical. A study of UK combat soldiers in the Gulf War by a team at King’s College Hospital has reported that 1 per cent suffered PTSD symptoms. And the Ministry of Defence’s view is that while deep distress is a normal response to war, talking to one ’s peers is more helpful than counselling — and long-term mental health problems are rare. A year ago, in line with British medical consensus, the MoD banned CISD (critical incident stress debriefing), a technique still widely seen in the US as a routine intervention for disaster victims.

“At the end of the Falklands, it was clear that troops who came back by ship and had time to relax and talk through experiences with their peers were far less likely to suffer problems than troops who flew home and went straight back to barracks,” says Surgeon Lieutenant-Commander Neil Greenberg, a psychiatrist with the MoD. “It’s a finding we’ve built.”

The new initiatives are now being tested. Greenberg is part of a research team at King’s College studying the impact of trauma on UK personnel in Iraq. However, some psychiatrists are concerned that PTSD as a diagnosis may be abandoned here. “Accepting psychic trauma requires acknowledgement of our own vulnerability to trauma and victimisation,” says Gillian Mezey, a forensic psychiatrist at St George’s Hospital Medical School, southwest London. “Dismissing PTSD as a diagnosis denies the suffering of people exposed to severe and life-threatening trauma.”


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