Follow-up on PTSD and The Pentagon

I’d like to subtitle this post “Waiting for Martians,” for reasons that I hope will become clear as we go along.

The Army Times yesterday posted an article about the Pentagon’s decision to withhold the Purple Heart from soldiers who are inflicted with Post-Traumatic Stress Disorder.

The article notes that about 20% of the soldiers in Iraq meet the criteria for PTSD.  The article cites Department of Veterans Affairs findings that nearly 76,000 soldiers were given a provisional diagnosis of Post-Traumatic Stress Disorder between 2003 and 2007.  Obviously, this is a prevalent problem for our soldiers.

The article repeats the Pentagon’s reasons for disqualifying PTSD as an injury meriting the Purple Heart.

To further explain the Pentagon’s decision, the article quotes Charles Figley, professor of disaster mental health at Tulane University.  Figley is quoted as saying “There’s no blood test…no neurological map that clearly identifies” PTSD.

That’s true enough. But Figley goes on to say that PTSD is:

“an anxiety disorder, and all anxiety disorders are extraordinarily subjective. They’re difficult to treat through medication for precisely that reason.” However, “ongoing research could someday lead to a blood test…for the disorder…Figley said.”

Now I must admit that I am lost in this tangled trail of thought.  Let’s pull out the highlights of this argument.

“There’s no blood test…”
“All anxiety disorders are extraordinarily subjective…”
Anxiety disorders are “difficult to treat” because they are “extraordinarily subjective.”
Some day there may be a blood test to diagnose PTSD and anxiety disorder.
And a Pentagon spokesperson added “predictable and quantifiable physiologic injuries associated with specific psychological injuries is less robust now than it may be in the future”

I take this to mean that PTSD is difficult to diagnose by standardized tests like a blood screening or a CAT scan or an MRI.

That point is granted. Like the disorders Major Depression, Schizophrenia, Bipolar and many more, diagnosis is made largely by evaluation of a patient’s reports of their symptoms and levels of functioning. There are no lab tests to confirm the diagnosis of these conditions.

But here comes the point where I become confused. “Anxiety disorders are extraordinarily subjective” which makes them “difficult to treat.”  But someday there may be blood tests to verify the diagnosis.  And at some point in the future we may be able to specify the physical injury behind the disorder.

Only three interpretations of these statements come to me.

I am going to assume this first possible interpretation is not what they meant. They could be saying that since there is no external lab test to confirm the diagnosis, then there is no way to tell if the soldier is lying about his/her injury.  The Purple Heart could then be mistakenly awarded to persons malingering and conjuring up the illness.  So, 20% of the returning soldiers from the current wars could be faking the illness and not deserving of the Purple Heart.

I also assume that this second possible interpretation is false.  They could be saying that since there is no objective lab test for PTSD, then it may not be a real “illness” at all.  That would also imply that nearly all psychiatric disorders are not true illnesses or disorders.

The last intepretation that I can come up with is that unless there is proof of physical injury (in this case damage to the organ of the brain), then the assumption is that there is no injury.

So, for a soldier suffering from PTSD, there would have to be physical, independently verifiable proof of physical injury.

Allow me to make an aside for a moment.  One of the most intelligent persons I have ever met is a neurologist.  Several years ago, he allowed me to follow him around on his morning hospital rounds for a year or so as a volunteer.  I was and remain fascinated by the brain and neurology and he was kind enough to share his time and knowledge.  One day I asked him a fairly detailed question about the neurological pathways and neurotransmitters involved in a particular task and the set of related emotions.  His candid answer to me was: “Mike, we are going to have to wait for Martians to land and have them explain the brain to us in that kind of detail.  So far, we humans haven’t been smart enough.”

Back to the point at hand: objective physical trauma to verify the diagnosis of PTSD.  PTSD is not traumatic brain injury, it is not a closed head injury, it is not a lesion in the frontal or any other lobe.  It is not something that you can identify in a brain scan, picture or even by autopsy. Post-traumatic stress disorder is a psychiatric disorder whose specific mechanisms are unknown to us at this time. Never mind figuring out a way to distinguish those mechanisms in a fashion that would be suitable for a blood test. Like it or not, there is no way to send off a blood sample or a biopsy specimen and confirm the diagnosis.

That certainly does not imply that the psychiatric disorders are not true illnesses.  It does say that we simply do not have a complete understanding of the brain at this point in time.

May I suggest that if Professor Charles Figley and the Pentagon are, in earnest, waiting for the “neurological map that clearly identifies (PTSD)”, then perhaps they are waiting for the martians to land as well.

In the meantime, it seems cruel to me to deny the Purple Heart to soldiers who are suffering from PTSD as a result of their service to their country.

Why deprive them of such recognition simply because our science has not advanced sufficiently to provide absolute diagnostic confirmation?

4 responses on “Follow-up on PTSD and The Pentagon

  1. Paul Maurice Martin

    It occurs to me that maybe the major obstacle is just pragmatic. That is, I would think that for the most part, a dx of PTSD would be hard to connect to one specific heroic action…

    Although since your quotes don’t have them presenting this as the reason, maybe I’m reading too much sense into it?

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    Pretty impressive article. I just stumbled upon your blog and wanted to say that I have really enjoyed reading your opinions. Any way I’ll be subscribing to your feed and I hope you post again soon.

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