The Politics of PTSD

Recent news articles have reported that nearly 216,000 veterans diagnosed with PTSD – post-traumatic stress disorder – receive benefits from the Veterans Administration (VA). Most of these veterans are from the Vietnam period, and many, including myself, were granted their disability ratings only during the last decade. Since 1999, the VA’s PTSD benefit payments have jumped 150 percent, from $1.7 to $4.3 billion annually. Clearly, since the disorder’s recognition in 1980 by the American Psychiatric Association (APA), PTSD – with its long, silent history under other names, from soldier’s heart to combat neurosis – has finally become a cost of war to be reckoned with.

Now, with reports that the percentages, if not the absolute numbers, of returning Iraq and Afghanistan war veterans suffering from PTSD may exceed that of their Vietnam-era counterparts, VA budgetary outlays for care and treatment of this malady are likely to skyrocket even further.

Naturally, the merits of a given veteran’s case for PTSD care and treatment should be judged on the best scientific evidence and screening methodologies available. It is the need based on science that should dictate the size of the VA’s budget to accommodate veterans traumatized by war, and not the size of the budget that shapes or manipulates diagnostic criteria to reduce the PTSD population among returning war veterans.

Concern has mounted in recent months among veterans and their advocates that it is money, and not science, that may set the VA’s PTSD-related mental health agenda in the years ahead. Not only could this revised agenda have a potentially disastrous impact on the well-being and readjustment of today’s returning veterans, but it has already caused considerable anxiety among veterans who have been rated with PTSD in recent years and who fear their benefits may be unjustly curtailed. Apparently, the VA’s ill-conceived plan to review the cases of thousands of veterans compensated for PTSD since the mid-1990s has been scuttled, owing to negative political fallout in Congress. But now the VA seems bent on pursuing its plan to limit future PTSD cases through a new strategy that will pit one prestigious scientific body against another, and which even Congress may have less influence to monitor or challenge.

The VA has contracted with the Institute of Medicine, a component of the National Academy of Sciences, to conduct a sweeping reexamination, not only of all medical and scientific literature on PTSD to date, but on issues related to PTSD’s "treatment, prognosis, and compensation." Such an initiative, given how much remains to be learned about PTSD, may be timely as long as objective science holds sway over politically motivated cost-cutting. At the same time, the VA initiative threatens to second guess, and potentially delegitimize, the long-standing authority of the American Psychiatric Association, under whose aegis PTSD research and treatment has been studied and advanced for more than a quarter century.

Anyone familiar with PTSD as researcher, clinician, or long-term client, is well aware of the competing hypotheses around the exact nature of the disorder, not to mention the rival claims of relative efficacy for one therapeutic method versus another in the treatment of PTSD’s persistent and aggressive symptomatology. Psychiatrist and noted author Robert Jay Lifton, a pioneer in the early efforts to gain recognition for a condition initially observed in Vietnam veterans as post-Vietnam syndrome and later defined systematically by the APA as PTSD, has long recognized the powers of human resilience among some individuals to survive horrifying episodes of war-related trauma. That’s the good news. Where such individual hardiness is not present, though, many are not so fortunate, and the psychic damage incurred by such victims can lead to social dysfunction, social pathology, or even suicide.

Most veterans I know who are rated with PTSD, including myself, will tell you that after living with this condition, often for decades, their symptoms never go away, but that with self-vigilance, proper care, and the support of loved ones and friends, their symptoms can be managed and kept at bay. Given this well-documented collective experience, the most troubling aspect of the VA-mandated Institute of Medicine’s PTSD review is not just the hidden assumption that something is wrong with the existing PTSD science or benefit-adjudication criteria, but the introduction within the policy debate of an expectation that combat trauma can be prevented. Concepts like "survivability" and "resilience" offer hope of coping mechanisms to returning veterans who undergo disturbing changes of behavior because of their wartime experiences. The idea that an individual’s response to trauma in warfare can be "prevented" prior to or immediately following the traumatic event seems suspiciously convenient for those who would bend science to a conservative vision of social policy. Ironically, in this scenario, support for the troops in the field does not translate into support for veterans at home.

In July 2000, I had occasion to interview Daniel King, Ph.D., head of the Behavioral Science Division of the VA’s National Center for PTSD. Dr. King is a quantitative psychologist. He and his team performed statistical analysis on data furnished by clinicians working with PTSD clients throughout the VA system. One unexpected finding King had begun to notice around the time we were talking was a quantum leap in cases of "late-onset" PTSD. These were veterans, in their fifties like me, who were entering the VA system for the first time in the mid to late 1990s.

In fact, the VA’s own surveys show that, of the vast majority of Vietnam veterans known to suffer from PTSD, less than one-fourth have ever benefited from VA-related services. Under the circumstances, it seems as if the increased burden in compensation payments that the VA is experiencing should have come as no surprise. Prior to its official recognition, moreover, PTSD was frequently referred to as "delayed stress," while the prefix "post" in the current usage would seem to suggest, logically at least, that the syndrome’s appearance can’t be tied to a fixed timeline.

In my own experience, PTSD is an insidious disease, one that I went to great lengths to deny in my own life for decades. Denial, in fact, was my biggest enemy, in the sense that I failed to grasp for years that PTSD, perhaps all mental illness, has a life of its own and is not subject to conscious regulation like the normal ups and downs most people experience. When I realized that PTSD often controlled me, and not the other way around, I was able to finally confront my condition and learn how to better cope with and manage my symptoms. Without the safety net provided by the VA, that would not have been possible.

Reprinted from the Bangor Daily News.