Health Leader, Combat Stress: 2003

STORY BY

David Theis

Is there a more stressful place on earth than a battlefield?
Probably not. Though we all live lives of greater or lesser stress at any given moment, only in battle do others have the right to kill us.

It’s not surprising, then, that stress was first recognized as a medical problem during World War I, when soldiers diagnosed with a malady popularly referred to as “shell shock” were sent away to psychiatric hospitals for complicated treatments that often made the problem only worse.

With new wars, the nomenclature changed. Some soldiers in World War II suffered from “combat” or “battle fatigue,” and also tended to be removed from the battlefield and treated remotely at a hospital, often never to return.

Viet Nam veterans helped mainstream the idea that horrific events can resurface years later and be experienced post-traumatically through a collection of equally horrific symptoms. The term post-traumatic stress “syndrome” crept into the vocabulary, labeling the latent reaction to previous trauma.

“Combat stress” is the current jargon, and greater therapeutic successes are being realized by treating the soldier immediately with support, therapy and/or medication right near the front lines. Experts believe that keeping the soldiers with their units and returning them as soon as possible may reduce what has come to be recognized as post-traumatic stress disorder (PTSD).

Post-Traumatic Stress Over-Diagnosis?

But one doesn’t have to be entrenched in the combat zone to find “shell-shock” or PTSD symptoms. These victims of stress have typically suffered unnerving events such as car wrecks, abduction, terrorism, accidental near-deaths or violent assaults.

But, according to Dr. Dan Creson, professor of psychiatry at the University of Texas Medical School at Houston, diagnoses of PTSD have become too frequent.

Creson says, “People see as much PTSD as they’re inclined to see,” and explains that the criteria for this diagnosis are “subjective. There’s no reliable test.”

Creson uses his personal history to illustrate his point. He served in Vietnam, and has stories that “I don’t like to tell” about his experiences there as a physician. “I have colleagues that call that PTSD, but, if people have emotional reactions to emotional situations, how’s that a disorder?”

For Creson, a “full-blown” case of PTSD is “unmistakable.” It includes “nightmares, flashbacks, anxiety, depression.” Not a simple reluctance to relive a painful situation.

According to Creson, there is a danger in over-diagnosing PTSD. There is “substantial data [indicating] that pathologizing PTSD symptoms tends to increase long-term problems.” He explains, “Once you’re labeled [as ‘sick’] it becomes self-perpetuating.”

Creson began to develop his opinions about PTSD during his tour of Vietnam, and after active duty when he served in the navy reserves. He treated many people with PTSD. “They were pretty messed up,” he allows, but adds, “Did it [their condition] have to be permanent? No.”

Creson, who also holds a PhD in anthropology, is a firm believer in “human resiliency. After all, we did survive running around the savannah, hunting for our food.”

He finds that people with actual field experience are less likely to “medicalize” stress symptoms. He has served as a humanitarian consultant in battle zones all around the world: Kosovo, West Africa, Afghanistan. Doctors working on the ground at such “complex emergencies tend to think people can cope with and handle amazing amounts of stress without having their lives totally compromised.”

In contrast, Creson says that academics “tend to see it [PTSD] around every corner.”

But Creson doesn’t deny that PTSD exists. Treatment for such cases is based on work done rehabilitating torture victims. In such cases, he recommends “validating and normalizing their feelings.” In other words, helping the people understand that their feelings “are real and significant,” but that their “feelings are not diseases.”

But he doesn’t recommend pushing people to re-experience their pain, in an attempt to desensitize them. Instead he directs sufferers to start thinking about the future: “You’ve got all this stuff to do tomorrow. How are you going to go about it?”

He also recommends encouraging people to take psychological, social, and physical risks. “People will withdraw after traumatic experiences,” he says. “You have to fight that.”

Finally, he suggests getting people back into their routines as soon as possible.

These techniques are the very ones used in combat zones, so getting people back into their routines can mean sending them back into battle.

Researchers are working on new treatments for PTSD. Some therapists recommend behavioral interventions while others additionally prescribe medications such as sleep-aids and anti-depressants. One new technique is called “narrative therapy,” in which “people develop their own stories and you help them change them.”

But none of these treatments is the silver bullet. “To be honest, we’re still struggling to find the best way to treat people without creating long-terms morbidities.” But Creson finds grounds for optimism in the sheer volume of research being done.

“Sooner or later we’ll get some reproducible rationality,” he says.

UPDATED: 4-10-2003

David Theis

Post-Traumatic Stress Over-Diagnosis?

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