The Evil Hours (25 page)

Invited to the APA's annual convention in Toronto the next year, Shatan, Lifton, Haley, and Jack Smith came armed.
After presenting their paper and a series of detailed tables, Spitzer called a meeting of the Reactive Disorders Subcommittee, including the VVAW cohort, a researcher from the University of Iowa, and a respected family therapist from Syracuse. After hearing their arguments, Spitzer finally relented, though he made it clear that the new DSM entry would not be called “post-catastrophic stress disorder,” as Shatan and Lifton wanted. When the committee finally released its findings to the APA a few months later, it recommended a new diagnosis, which deemphasized the distinction between manmade and natural disasters and made no reference to Vietnam, but otherwise was almost exactly as Shatan had dictated it to Spitzer.
It was called “post-traumatic stress disorder.”

It would take another two years before the APA published the official version of DSM-III (which had more than tripled in length over the previous edition), but as word got out and preliminary drafts began circulating, a smattering of VA hospitals across the country began diagnosing veterans with PTSD. Shatan would later complain that the diagnosis had been depoliticized, but the publication of the early drafts was a victory that could scarcely have been imagined almost a decade prior when the first rap groups had met.
Ironically, much of what ended up in the DSM's entry for PTSD was simply a clinical elaboration of the work that Abraham Kardiner had outlined forty years before.

 

III. The Culture of Trauma

 

The post-1980 history of trauma has, to a certain extent, been a continuation of the methodology championed by Robert Spitzer in the early 1970s.
As Matthew Friedman, executive director of the VA's National Center for PTSD, explained in a 1988 interview, most of the early pioneers of the PTSD diagnosis perceived it as a “psychological disorder, rather than a biological disorder.”
According to Friedman, the first director of the National Center for PTSD, a seven-campus system created in 1989, his job was to bring PTSD into the psychiatric mainstream, which by the 1980s had become increasingly focused on the biological characteristics of mental illness.
Accordingly, the global research agenda for PTSD, heavily influenced by the budget priorities and interests of the U.S. Veterans Administration and the Department of Defense, has tended to favor exploring the neurological and biological foundations of PTSD rather than the psychoanalytic, cultural, and cross-cultural aspects of the condition. The narrative of trauma has become less about politics and inner psychic conflict and more about stress hormones and the chemical dance of synapses. These stark budget realities have also resulted in a tendency to study the struggles of the individual American military veteran and to apply the results to the global population.

In 1983, as the nation continued to struggle with a number of painful issues related to Vietnam (including the legacy of Agent Orange, a toxic defoliant used extensively by the U.S. military in Southeast Asia), Congress ordered the VA to conduct a comprehensive study to assess the war's impact on veterans. Covering more than one thousand male subjects, the seminal National Vietnam Veterans Readjustment Study found that 15.4 percent of Vietnam veterans had diagnosable PTSD at the time of the study and that 31 percent had suffered from it over the course of their lives.
The first study of its kind, the NVVRS helped to create a statistical foundation for the modern study of trauma and is still widely used as an epidemiological benchmark.

However, as with all things Vietnam, the NVVRS remains controversial, its numbers and meaning open to more or less continuous reevaluation in the same way that the Warren Report on the assassination of President Kennedy remains open. In 2006, a Columbia University epidemiologist reworked the data in the study and concluded that the lifetime PTSD rate for Vietnam veterans was closer to 18 percent.
A subsequent reexamination by a Harvard psychologist, who had served as a field interviewer for the original study, found that the NVVRS overstated the PTSD rates by nearly 300 percent, arguing that many of the veterans included in the study were “generally functioning pretty well.”
To hear the debates about the study (which was covered extensively in
Scientific American
) is to get a visceral sense of how elusive our knowledge of trauma is and how subjective the art of psychiatric diagnosis remains despite all the advances of modern neuroscience. And there is, in these statistical debates, something that goes beyond the numbers, something that goes beyond the particulars of what was, until very recently, America's longest war.

At issue in the NVVRS is nothing less than the creation myth of PTSD itself, the widely accepted narrative of a war that was so obscene and so damaging to the psyche that it forced society to finally sit up and acknowledge trauma as a part of the human condition. Much like the Civil War in the nineteenth century, the Vietnam War opened up rifts in American society that remain unhealed. We visit and revisit these old wounds in somewhat the same way that individual sufferers of PTSD revisit their old wounds. Going to Iraq and seeing an American war fought in the first person taught me many things, one of which is that Vietnam and the divisions it created will probably always be with us. Vietnam and its aftermath opened up a number of new avenues of intellectual, political, and cultural experience, avenues we are still mapping today. In 2000, Robert McNamara, the divisive secretary of defense under President Johnson, published his second reconsideration of the war, titled
Argument Without End
, an appellation that seems to describe the debate about the psychological aftereffects of the Vietnam War as well.

Beyond the recent emphasis within psychiatry on biology, there is a larger social interest in saying that PTSD is primarily a brain event dominated by internal chemical processes. If an underlying biological basis for PTSD were discovered, if it could be described, as depression is so often described today, as “a chemical imbalance in the brain,” then the stigma associated with it could be virtually eliminated. Further, if a “cure” for post-traumatic stress can be found, then society as a whole won't have to bother with trying to deal with the events that cause trauma, which have deep roots in social justice issues. More often than not, it is the powerless and the disenfranchised who are traumatized, and as Arthur Egendorf liked to point out, any honest attempt to deal with the problem of PTSD must begin with a commitment to reduce the sources of trauma that are under human control: war, genocide, torture, and rape.
Robert Lifton, echoing this sentiment, said, “There are always moral questions, which are inseparable from political questions that are at issue. I think some psychologists may make the mistake of imagining that it's all a technical matter.”
A number of the original leaders of the VVAW, in fact, worried about this very thing, that post-traumatic stress would in essence become viewed as a manageable medical condition, like lupus or arthritis, an outcome that would encourage governments to wage wars and commit torture and genocide.

An influential 1995 article in the
American Journal of Psychiatry
, by Rachel Yehuda and Alexander McFarlane, seemed to address this tension, arguing that a conflict has arisen between “those who wish to normalize the status of victims and those who wish to define and characterize PTSD as a psychiatric illness. The future of the traumatic stress field depends upon an acknowledgment of the competing agendas and paradigms that have emerged in the last 15 years since the inception of the diagnosis, a clarification of theoretical inconsistencies that have arisen, and a reformulation of the next generation of conceptual issues.”
Perhaps unsurprisingly, the authors, after acknowledging the work of Lifton, Shatan, and company, come down on the side of privileging hardnosed science over other forms of inquiry into post-traumatic stress, concluding that “now that PTSD's place in psychiatric nosology is safely established, it is the scientific process that must provide the organizing philosophy for the field.”

This renewed focus on the hard stuff of brain science is not without its drawbacks. Chief among them is the lack of emphasis placed on the highly subjective experiences of survivors, experiences that are difficult to listen to and do not easily lend themselves to scientific measurement. And because it is instigated by an external agent, PTSD is, almost by definition, less of a “brain event” than schizophrenia or manic depression or virtually any other mental illness.
Yet to look at the field of trauma research today, one gets a clear sense that brain-imaging technologies are not seen as useful instruments in a larger toolkit but as actual windows into the mind of the survivor. It is not uncommon to hear researchers today voicing the hope that such technologies will be able to “prove,” once and for all, the existence of PTSD. We live in an era where the hard sciences are valued far and above other academic disciplines and where the humanities are frequently treated as luxury pursuits. This has resulted in a clinical culture, especially within psychiatry, that tends to treat neuroscience as the only rubric for understanding human experience, a clinical culture that applies the language of chemistry to describe patients' suffering, as in “titrating” a patient's emotional response to “prolonged exposure” therapy, as if a person suffering from a mental health disorder can be balanced like a chemical equation.

This surge in biological thinking has, in the minds of some, reached the point of absurdity. As one senior VA clinician with the National Center for PTSD joked with me recently, “So tell me about the war, so I can better work on your hippocampal transplant.” As William Normand, a practicing psychoanalyst in New York, said succinctly, “Psychiatry has gone from being brainless to being mindless.” Oliver Sacks, the popular author and neurologist, put it this way: “All of us have our own, distinctive mental worlds, our own inner journeyings and landscapes, and these, for most of us, require no clear neurological ‘correlate.'”
In 1979, at the dawn of contemporary neuroscience, Nobel laureate Eric Kandel argued a similar point, saying that all academic disciplines require “antidisciplines” in order to advance human knowledge: “The hard-nosed propositions of neurobiology, although scientifically more satisfying, have considerably less existential meaning than do the soft-nosed propositions of psychiatry.”
The human mind is perhaps nature's most complex creation, and no single academic discipline, however promising, should be relied upon to explain it in its totality.

Around the time that Yehuda and McFarlane's article was published, there was an increasing recognition of what some observers have called the coming of the “Age of Prozac,” an age dominated by both a biological materialism and a growing faith in modern pharmaceuticals and their ability to solve a growing number of personal problems, many of which hadn't previously been considered mental illnesses. In his bestselling book
Listening to Prozac
, psychiatrist Peter Kramer described a number of his patients who under the influence of the drug “were not so much cured of illness as transformed.”
Based on his experience with such transformations, Kramer began referring to Prozac as a “cosmetic pharmaceutical,” a term that neatly described the driving force behind a new mental health culture in the United States, a trend that increasingly sees patients as consumers and seeks ways to serve their needs. This new orientation has had an impressive effect on psychiatry. Between 1987, the year Prozac was introduced, and 2007, the number of Americans diagnosed with a mental disorder increased by almost 250 percent.

Modern trauma psychiatry has been influenced by this sea change in American attitudes toward mental illness, and not long after Prozac's debut, doctors who had heard about the extraordinary results their colleagues were getting with depressives began prescribing ­SSRIs (Selective Serotonin Reuptake Inhibitors, the class of drugs that Prozac belongs to) to PTSD patients. This type of prescription is sometimes referred to as happening on an “off-label” basis, and this happened in the case of SSRIs because the drugs have few known side effects and it seemed likely that they might work, reducing the emotional numbing symptoms associated with PTSD. Zoloft, an SSRI fielded in 1991, is now the most prescribed drug for PTSD and was the first medication to receive FDA approval for such treatment.

This accidental discovery, of a drug associated with a particular mental illness being effective with another disorder, is, it turns out, typical of modern pharmaceutical research, where the major drugmakers today will admit that they have no biological “targets” to shoot for in developing new drugs.
This lack of a scientific basis for using SSRIs to treat PTSD confused more than a few practitioners, and in 2007, after the VA asked it to, the prestigious Institute of Medicine investigated the situation and found that “for all drug classes reviewed, the evidence is inadequate to determine efficacy in the treatment of PTSD.”
In other words, regarding the use of drugs to treat PTSD, the jury is still out.

Despite these huge gaps in scientific knowledge, public faith in the idea that biology is destiny continues to grow. Along with the dramatic growth and popularity of “cosmetic pharmaceuticals” like Prozac has come a dramatic lowering of the threshold for what people define as mental illness and an increasing popularity of the PTSD concept in the culture at large. As one Oxford University psychiatrist put it recently, “Society has rejected the stiff upper lip.”
In 1992, the World Health Organization included a slightly modified version of PTSD in its International Classification of Diseases compendium, one of the most widely used diagnostic tools in the world, a step that virtually guaranteed that post-traumatic stress would see global acceptance. As an institutionalized form of compassion and a concept by which victims of violence can connect, PTSD has proved to be a formidable concept indeed. One Manchester, New Hampshire, physician and lawyer argued mid-decade that “post-traumatic stress disorder is
the
mental illness of the nineties.” Adding, “With the number of cases of PTSD being diagnosed today, it can almost be called a growth industry.”