Bob Herbert, in today’s NY Times, writes: “I couldn’t have been less surprised to read last week that an American G.I. had been charged with gunning down five of his fellow service members in Iraq.”

He goes on to say that “Recent attempts by the military to deal with some of the most egregious aspects of its deployment policies have amounted to much too little, much too late. The RAND study found that approximately 300,000 men and women who had served in Iraq and Afghanistan were already suffering from P.T.S.D. or major depression. That’s nearly one in every five returning veterans.”

His conclusion is that “We’re brutally and cold-bloodedly sacrificing the psychological well-being of these men and women, which should be a scandal.”

That is a scathing review of the current treatment of America’s service personnel.

On the other hand, Scientific American ran a lengthy article, Soldiers’ Stress: What Doctors Get Wrong about PTSD. The ‘key concept’ of this author’s position is that “The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.”

The author, David Dobbs, writes in his blog, Neuron Culture that:
“We are likely overdiagnosing PTSD in veterans by some 300 to 400%….the arcane disability system at the VA so discourages recovery that those receiving VA treatment — which is roughly similar to treatments that cure 2/3 of civilian patients — show no treatment effect at all. They’re no more likely to get better than are vets with PTSD not getting treatment.”

If the system is so broken and resistant, then one would assume that persons or groups, for their own benefit, maintain the current system instead of adopting a better alternative.

I suppose that it is possible that some in the VA benefit from the current model and would resist change to whatever might be a more effective model.

However, Dobbs finds that the country as a whole is invested in maintaining what he calls an “arcane disability system.”

Dobbs asserts that “war… might not be as scarring as we like to think it is….American culture seems to have a deep investment in the the picture of war as irredeemably toxic, and in its experience as incurably damaging.”

The structure of Dobbs argument runs similar to (but not as far as) Thomas Szasz or those in the anti-psychiatry movement. According to Wikipedia, Szasz finds that “people with mental illness have a “fake disease,” and these “scientific categories” are in fact used for power controls. Schizophrenia is “the sacred symbol of psychiatry” and, according to Szasz, is not really an illness. To be a true disease, the entity must somehow be capable of being approached, measured, or tested in scientific fashion.”

Hence there is a lot of emphasis on refining the criteria for PTSD and being able to objectively identify and measure the disorder in the brain. As Dobbs writes: “To make the diagnosis of PTSD more rigorous, some have suggested that blood chemistry, brain imaging or other tests might be able to detect physiological signatures of the disorder.”

And there is some progress being made in that arena. For instance, Medical News Today reported on recent research using functional magnetic resonance imaging scans (fMRI) that “found marked differences between the two groups in an area of the brain governing the sense of self. When the soldiers were shown the combat photos, this area, found in the medial prefrontal cortex, lit up remarkably in the PTSD group, but very little in the non-PTSD group.”

To give him his due, Dobbs does not find PTSD to be a “fake” disease. He concludes his blog entry with: “PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified, replicated, and finally perhaps become the thing itself — a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis.”

We have now gone from Herbert’s moral outrage at the lack of proper care and concern for veterans to Dobbs’ view that PTSD cases are 300-400% overly diagnosed and then for a quick stroll through metapsychiatric and cultural analysis.

Let’s return to the subject that is of real interest here: those who suffer from the psychological distress called PTSD.

The Canadian Journal of Psychiatry published a piece by Brunet, Akerib and Birmes titled: “Don’t Throw Out the Baby With the Bath Water” in 2007. The authors argue that:
“If we consider the evolution in the field of trauma research, there are at least 2 major tendencies: on the one hand, the criteria for diagnosing PTSD have become stricter, while, on the other hand, our ability to detect and correctly assess trauma exposure and PTSD has improved, thereby leading to the identification of new, previously undiagnosed cases. The net result of these 2 tendencies is a remarkably stable rate of PTSD in the epidemiologic surveys of the last decade.”

There are, then, real persons with PTSD, whether due to rape in the US or witnessing battle in Afghanistan, suffering from real emotional pain and cognitive limitations. We should get to the heart of the matter and figure out the best means of treating the illness and the best way to finance that treatment. Let’s not get side-tracked by fMRI results and whether or not America has a guilty conscience and so has made war out to be a scarring experience.

As Brunet, Akerib and Birmes write:
“the public debate and increased awareness about the hidden human and financial costs of traumatogenic events such as warfare, rape, and child abuse—to name just a few—must continue for the good of society.”