Monday, 4 March 2013

7A. The PTSD Epidemic (Part 1 of 3)

You have no doubt heard about workplace stress, and I won’t deny that it occurs. Nevertheless, if you are going through a nervous breakdown, for any reason, then you will most likely find that the normal pressures of work you once took for granted – the boss who keeps insisting you adhere to deadlines, the clients who keep ringing you up, the workmate who keeps tapping his fingers, the promotion you just missed out on – have become just too much for you. In other words, you should be able to convince yourself that the workplace is the cause, rather than merely the occasion, of your breakdown.
Of course, when it comes to claiming for worker’s compensation, a few things would stand in your way. There would be contemporaneous records of both your symptoms, and the sequence of events at work. Comcare could insist on using their own psychiatrist, and they would make their decision merely on the basis of balance of probabilities.
But suppose you based your claim on something that happened 20, 30, even 40 of more years ago, and you yourself are the only source of information. Suppose, too, that if the initial psychiatric report were not favourable, you go to another doctor, and then another, perhaps changing your story, or the focus of it, every time. Suppose too, that when you had finally got your case watertight, they had to believe you.
This is not fanciful. This is exactly what staff at the Department of Veterans’ Affairs face every day. For the last twenty years, the country has been in the grip of an epidemic of PTSD: post traumatic stress disorder, and the fundamental reason is money.
Nor am I alone in that opinion. Once in my travels I discovered that one of my companions was a psychiatrist practising in Northern Ireland – at the height of The Troubles, mind you – so I asked her if she had many PTSD cases.
“Quite a few,” she replied, “particularly from the security forces. They don’t represent an overwhelming section of my practice, but a significant part.”
“And are you able to cure them?” I asked.
“Yes,” she said, “but it takes time. The major problem is getting them away from the danger. Many of them have a quite realistic fear of being killed.”
“Well,” I said, “I work for the Department of Veterans’ Affairs in Australia, and most of our veterans claim that PTSD is incurable.”
At this point she went ballistic. “Well, what do you expect!” she exclaimed. “You’re paying them to be sick. You’re offering a prize, and wondering why the runners run. You keep baiting the hook and wonder why the fish keep biting. I refuse to have anything to do with compensation claims. Treatment must be completely divorced from compensation.”
In another vein, I could mention the visit of a group of South Korean officials who came to study the department’s computer system. “I suppose you have many PTSD claims,” my manager commented.
“We don’t recognize the condition,” they replied. Why not? During the 1950s their nation saw contending armies march twice down the whole length of the country. The capital, and innumerable towns were destroyed. Millions of internal refugees were driven into one small corner of the land. Hundreds of thousands were killed. As far as they were concerned, PTSD was the norm for everybody of that generation.

However, before we go into detail about the Australian experience, one issue should be made clear. Recently, The Bulletin, in particular, had been running articles, unaccompanied by any factual case history, about poor, broken warriors, psychiatricly traumatised by recent wars, being hung out to dry by the cold hearted Department of Veterans’ Affairs. So let me say here and now: this is ludicrous. The law is extremely generous. If anybody has been anywhere near the front lines, and has any sort of mental disorder then, except in a few very unusual circumstances, it will be nearly impossible to deny him a pension. This chapter has nothing to do with such people.
In any conflict, only about ten percent of the military are actual combat troops. Of course, it does not follow that the other 90 percent were not exposed to danger – even extreme danger – and hardship at times. You wouldn’t want to be a quartermaster during the retreat from Greece, let alone the fall of Singapore. But there were tens of thousands in the latter stages of the Second World War, when the enemy was in retreat, who served in bases well behind enemy lines, providing support for those in the front line, but never so much as suffered an air raid. In Korea, Malaya, and Vietnam, too, many others never left the base except to drive to secure villages or outposts, and the enemy ambush they worried about never eventuated. Yet Veterans’ Affairs is swamped with claims by the likes of these. Indeed, those who really were in the front line have commented that most of the claimants were rear echelon troops. And, inexplicably, many of them are successful.
War affects different people in different ways. Some of my clients had been seconded to the R.A.F., and the air war over Germany. These brave men were required to fly 30 sorties, knowing that they had one chance in 25 of being shot down every time. Their death rate was the highest of any units of the Western allies, higher even than the prisoners of the Japanese. Understandably, many of the survivors had psychiatric difficulties - but it is amazing how many didn’t.
Then there was Mr B, a naval gunner. The war took him to the Mediterranean, where he manned the guns against the Luftwaffe, while bombs splashed seemingly at arm’s length from the ship. A couple of years later, he was in the Leyte Gulf, manning the guns against the kamikazes. Of course, he told a psychiatrist, he was scared while the battle was on. But what he couldn’t understand was why many of his shipmates were shivering and shaking hours, sometimes days, after the action was over. It didn’t make sense, in his opinion; the danger was past.
On the other hand, let us consider Mr M. Admittedly, he was only 17 when his ship went to Vietnam, to escort the troops destined to do the fighting. Vung Tau harbour is so shallow that troop ships had to anchor off shore, while men and supplies were ferried on small boats. The day before they arrived, he was told his duty would be to operate a radio ashore, next to the disembarkation pier. This would be no storming the beaches at Normandy, but an orderly transfer of soldiers at one of the safest harbours in Asia. But, when given a pistol, he was so nervous, his hand shook so much he could barely aim it. The next day, on the shore, his nerves were so bad, his stuttering made his radio communication incoherent. He has been a nervous wreck ever since.

The Nature of Mental Illness
To put everything in perspective, it is necessary to consider the incidence of mental illness in the general community. In medicine a distinction is made between the point prevalence – the percentage of people currently afflicted – and the lifetime prevalence, or the percentage who will be afflicted at some stage of their lives. The former will always be less than the latter, to take into account those who have not yet got the disease, and those who have got better. For generalised anxiety disorder, the point prevalence is approximately 3%, and the lifetime prevalence 5%. For dysthymia (chronic depression) the figures are 3% and 6% respectively. For specific phobias they are 4% – 8.8% and 7% - 11%, depending on the means of assessment. Further conditions can be added to the list as required. It has often been claimed – I don’t know on what authority – that a third of us will require psychiatric treatment at some stage, and I include myself in that category. In any case, it is clear that the scope of the problem is vast, and one must assume that a lot of those who went to war would have fallen victim to one of these disorders in any case.
Many, perhaps most, of the commonest mental disorders have their onset in early adulthood which, of course, also happens to be the age men go to war. Mr M would probably have fitted into that category. He appears to have been a naturally timid soul who should never have enlisted. A similar conclusion might be reached in the case of a Korean War veteran I interviewed. During the war, his duty was organise the transfer of supplies from ship to truck to the front. Yes, the base was bombed at one stage, but that wasn’t what bothered him. What caused his nerves, and the churning of his stomach, was the sheer pressure of the deadlines. After the war, he ran his own trucking company. Whenever accounts came due at the end of each month, he again got a nervous churning in the stomach. It is not difficult to see that he had a naturally anxious temperament, and that the war had nothing to do with it. But if he consulted the right psychiatrist, there is a good chance his claim would succeed.
Alcoholism is also such a pervasive evil in our society, that one can hardly expect that veterans would be exempt. But military service is also frequently the occasion when a man is introduced to the custom of social drinking. Indeed, in many cases, he was too young to drink before he enlisted. So did the war cause his alcoholism, or did it just provide the opportunity?

Veterans, like civilians, present with a wide variety of psychiatric disorders, but the ones most likely to be accepted as war-caused are, in order, PTSD, alcoholism, and generalised anxiety disorder. The first is a reaction to extreme experiences, such as combat, rape, or other physical assault. The second is something we are all familiar with. The third is more a personality quirk: a long term tendency to be anxious about anything and everything. But to understand the situation in Veterans’ Affairs, it is necessary to understand a bit about the nature of mental disorders.
Before a condition can be determined to be war-caused, a diagnosis is required, and the SoPs require that it adhere to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), published by the American Psychiatric Association. As such, it reflects a particular American viewpoint – to be more precise, the viewpoint of the 200-odd psychiatrists who control the APA.
There is one small problem: the DSM-IV was never intended as a diagnostic tool. It was intended for research. If you want to research, for example, the causes of agoraphobia or the treatment of obsessive compulsive disorder, then it is useful if everyone agree on what is being discussed. But every realistic psychiatrist will admit a degree of artificiality in the diagnoses. Physical diseases are discrete. You can have osteoarthrosis in one knee, but not the other. You can have tuberculosis, but not asthma. But the mind is not so compartmentalised; everything is related to everything else. The diagnoses thus bear some resemblance to vegetation maps. It is useful to look at a map and see that one area is said to be covered with wet sclerophyll forest, and another with dry sclerophyll woodland, but anybody who expected to see as clear a demarcation on the ground as on the map would be setting himself up for disappointment. Similarly, placing a circle around a set of symptoms which tend to go together and calling it a diagnosis has some practical value, but overlapping symptoms and incomplete diagnoses are going to be commonplace. Nevertheless, experience shows that if psychiatrists are allowed to be sloppy in their diagnoses, a lot of highly questionable situations will result.
An appendix to DSM-IV covers “culture-bound syndromes” ie disorders which are found only in certain cultures. Most appear to be variations on more familiar themes, but some can be bizarre. Such is koro, included in the Chinese Classification of Mental Disorders, and which causes males of east and south Asia to go into a panic about their penises receding into their bodies. It was also suggested that anorexia nervosa and multiple personality disorder are culture-bound syndromes of the West, being rare or non-existent elsewhere. The former, certainly, appears to be of recent origin.
This illustrates something which most people would find counterintuitive: manifestations of mental illnesses are, to a certain extent, influenced by society’s expectations. It is from society that we learn, not only how to behave under given circumstances, but also the conditions we can expect to put up with, the ones we can expect to be beyond our powers to cope, and how we are expected to react when we cannot cope. A minor example of this is the fainting fit, or “fit of the vapours” which 18th and 19th century ladies were expected to exhibit when distressed, and which allowed them to unconsciously escape from difficult situations. There is no point in developing a private neurosis, Freud is alleged to have said, if there is a public neurosis available.
Readers are no doubt aware of physical diseases, such as diabetes and Parkinson’s disease, caused by chemical imbalances in the body. The same thing applies to the mind, because impulses are passed between cells in the brain by chemicals called neurotransmitters, and when they are out of balance, the victim’s emotions and thought patterns go awry. Indeed, mood-altering drugs, such as the opiates, and even caffeine, have their effect by means of their close resemblance to certain brain chemicals. Schizophrenia may even be the flip side of Parkinson’s disease. Whereas Parkinson’s disease is caused by a lack of the chemical dopamine, the drugs which control schizophrenia block the effects of dopamine. (Yes, I know this is an oversimplification.)
Likewise, such disorders as bipolar disorder, in which the victim alternates between a manic and a depressive phase, probably result from the imbalance of other neurotransmitters. Depression, in particular, has been linked to low levels of a chemical known as serotonin. These problems appear to be constitutional in origin, but serotonin can be knocked out of you by events. Everybody knows that a severe setback, such as bereavement, or the loss of a job, can trigger a bout of depression. But one thing we know about such reactive depression is that, after a while, you snap out of it. If depression lasts for years, the odds are it is not due to an external event. Nevertheless, many sufferers have had it accepted as war-caused.
A case can be made that such conditions are the only true mental “illnesses”, and that everything else is a social or personal problem dressed up in medical terminology. This is certainly the case with personality disorders, which might be simplistically defined as an inappropriate attitude to life and other people. The advent of the SoPs has made such conditions almost impossible to accept, but it wasn’t always the case. Dr Whiting (Be In It, Mate!) marvelled at pensions being granted for something labelled “inadequate personality”, which he interpreted as meaning “bit of a no hoper”. (I was told it was a code word for alcoholism. In one case I know for a fact it meant “bone lazy”.) I shall never forget one fellow who, somehow or other, got obsessive personality accepted as defence caused. He was no doubt pleased with the pension, but was outraged by the diagnosis, and immediately sent to the VRB, and his local Member of Parliament, a fourteen page letter, with fourteen pages of attachments, to prove that he was not obsessed.
A great variety of personality disorders are listed in DSM-IV, some apparently well-established, and some designated for further study and comment. A victim (if that’s the right word) of histrionic personality disorder always wants to be the centre of attention, while someone with a narcissistic personality is, to use the vernacular, full of himself. In contrast, avoidant personality disorder implies painful shyness. Someone with paranoid personality disorder thinks the world is against him. If he has depressive personality disorder he is a chronic pessimist. If a person resists doing anything anybody else wants him to do, he has a negativistic personality disorder. Antisocial personality disorder (psychopathy) refers to someone who has no conscience, or respect for others. Often this is preceded by conduct disorder, which is a label given to children who are really, really bad.
As you can see, there tends to be an overlap between the mental disorder label and what would commonly be regarded as moral defects though, to be fair, the editors of DSM-IV do stress that people are still responsible for their own actions. Nevertheless, there does appear to be a certain arbitrariness about what makes the list. Sexual sadism is included, but rape is not. Childhood gender identity disorder is still included, but the condition it often develops into, adult homosexuality, was removed from DSM-IV in 1977 after a major political campaign, and in defiance of mainstream psychiatric opinion, not to mention common sense. Thirty years later a move was made to discuss the removal of all the paraphilias (perversions), but this time they ran into a snag. A long series of child molestation scandals had recently alerted the public, and when word got out that the APA was about to declare pedophilia normal, the political counter-campaign proved too strong. Incidents like this tend to tarnish the APA’s claims of objectivity.

Diagnostic Problems
In between the chemical imbalance disorders and the personality disorders lie those conditions which are essentially, a failure of the mind’s coping mechanism – with the proviso, of course, that some events are so severe that very few people could be expected to cope with them. This is where PTSD comes in. It is not a new disorder; it used to go by such names as shell shock and combat fatigue, but it was only after the Vietnam War that it received its current format, which is shown in the table on the top of this blog labelled, PTSD Criteria. I would suggest you keep it open while you read the following.
Taken at its face value, the syndrome is easy to understand. This is what happens when a person’s coping skills are completely overwhelmed. The victim cannot get the traumatic event out of his mind. It comes back to haunt his dreams and his waking thoughts. Any reminder makes him feel like he is back there again. Consequently, he seeks diligently to avoid anything which reminds him of it. He is irritable, he cannot sleep. He jumps at shadows, because responding with lightning reflexes was once the only thing which kept him alive. Not surprisingly, full blown PTSD is not difficult to diagnose.
Unfortunately, things are never as simple as that where money is concerned. When the PTSD epidemic first made its presence felt, psychiatrists tended to be rather rough and ready in diagnosing it. When the SoPs arrived in 1994, and the department insisted on the DSM-IV criteria being used, it did not result in more considered diagnoses. Rather, it meant that psychiatrists became more imaginative in artificially forcing their patients’ symptoms into the mould of PTSD. Let us examine them one by one.
Section B, re-experiencing, is probably the most characteristic feature of PTSD. Note, however, that only one item needs to be present, and some can be easily fudged. Distressing dreams are a good example. Frequently, the psychiatrist fails to ask the content of the dreams. Often it transpires that they bear no resemblance to anything which actually happened on service. The psychiatrist will then claim that they are symbolic of actual events – which may well be the case, but they also may be totally unrelated to any actual trauma. With a bit of imagination, any dream can be regarded as symbolic of anything. What about (1) recurrent and intrusive distressing recollections? Often this is not distinguished from ruminations. People tend to ruminate over negative life experiences when they are depressed. If a person is pursuing a pension related to the war, it is likely that thoughts about the conflict will start to dominate his consciousness. Not only that, but if you have ever had a dramatic experience, whether good or bad, the memory of it will jump into your head whenever you see something similar. However, many veterans – and quite a few psychiatrists – incorrectly call these “flashbacks”, thus fitting themselves into B(3), although a flashback, by definition, means that the person feels he is back in that situation again. B(4) and (5), along with C(1) and (2) are particularly instructive. The victim of PTSD will typically break into sweat or trembling, or display other signs of distress and arousal, when discussing the traumatizing event. Yet, I have lost count of how many times I have stood in the AAT and watched a man, on minimal or no medication, spend half an hour to an hour in the witness box, calm as a cucumber, while he describes the events that allegedly left him a nervous wreck. In most of such cases, his psychiatrist will then state that he satisfies B(4) and (5). (And yes, I have met people who really did have PTSD – and it showed.)
Let’s go to section C: avoidance. Only three items are required, but it will be noted that only the first three are directly referable to the alleged traumatic event. Numbers (4) to (7) could easily be the result of non-war-caused anxiety, depression, or simply alcoholism. Number (7) might even be a realistic assessment of the situation! Even (1) and (2) may have nothing to do with PTSD. Most of us will avoid thoughts, conversations, activities etc about negative experiences in our lives. Why rake over the past? Put it behind you! This is a normal reaction, not pathological. Likewise, a veteran may avoid marching on ANZAC day, or joining the R.S.L., because it brings back too many disturbing memories – or it may be because of the way he was treated when he came back from Vietnam, or because of personality clashes with the members of the local R.S.L, or because he dislikes their political stance, or because he is simply not interested. If he doesn’t watch war movies or read war stories, he might simply be joining a lot of non-veterans who regard them as a load of rubbish.
As for section D, these are simply anxiety-type symptoms, not necessarily specific to PTSD. Only two are required, and it is not difficult to list a couple – say (1),(2), or (3) – which even healthy people may experience.
To alleviate their suffering, the most common method victims of any significant psychiatric disorder use is to self-medicate with alcohol. The result is a short term relief, but the long term effect is to make the condition worse. Conversely, if excess alcohol is not taken then, over a period of decades, PTSD tends to get better. (I know it is an article of faith in many veterans’ organisations that PTSD is incurable, but I have seen enough case histories to the contrary to know better.) The result is, by the time a claim reaches Veterans’ Affairs, the condition is almost invariably complicated by alcoholism.
But even here, problems arise. How do we know that alcoholism is not the sole diagnosable condition? Alcoholism is known as the great imitator. Sections D, E, F, and at least half of C could quite easily be the side effects of alcoholism. Even when the veteran has really experienced a traumatic event, how do we know that it was the cause of his alcohol abuse or dependence? He may have simply followed the same route most civilian alcoholics do: by commencing as social drinkers and not knowing when to stop. In most cases, war service occurs at the same age as social drinking, but there have been a number of cases where the veteran’s own testimony reveals that he was an alcoholic before he went to war. Indeed, it may well have already drowned his coping skills, and made him more vulnerable to PTSD.
Most psychiatrists accept a patient’s own account of his drinking habits, but occasionally one of them double checks by requesting biochemical tests. Not infrequently, the tests reveal that he could not possibly have drunk so much for so long.
“There is a lot of exaggeration of alcohol consumption,” one psychiatrist said to me.
“Surely it is the reverse?” I said, and then added the comment made by a reformed alcoholic: “If a man says he had four drinks, it means he had fourteen.”
“Under normal circumstances, yes,” replied the doctor, “but not in veterans’ claims. Veterans’ Affairs is the only venue where claimants are rewarded for their heavy drinking.”
You will also note the reference in Table 7 to “delayed onset”. The existence of such a delay cannot be doubted. Although many a soldier was evacuated from the battlefield suffering from “shell shock”, quite a few bore themselves up well during the conflict itself, when their whole effort was concentrated on staying alive, and they had the support of their comrades, only to “decompensate”, to use the technical term, on the way home. You may well have seen that joke poster hung up at work, proclaiming: “As soon as the rush is over, I’m going to have a nervous breakdown.” Sometimes, it is not a joke.
Just the same, some suspicion must be raised when the onset is excessively delayed. Every other psychiatric SoP requires the onset to occur within a certain short period after the putative traumatic incident. PTSD has no such requirement. Years, even decades, may elapse, and the claim need not fail. One soldier was returning home during peacetime when he came across a terrible accident. The victim, in fact, died in his arms. No-one would dispute that this was traumatic. However, by the time PTSD was diagnosed, and he was unable to work, eight years had gone by, and there was no evidence that he had sought so much as a tranquilliser from his GP.
Remember: this was non-operational service. The standard of proof was balance of probabilities, the same which applies to you and me in worker’s compensation claims. You too could witness an horrific accident on your way home from work. You too could then return to work the next day, continue climbing the promotion ladder, seek no treatment whatsoever, and then, after eight years, find yourself such a nervous wreck that you can no longer work.
In the above case, he was sent to two separate psychiatrists, but he could not be shaken on the presentation of his symptoms. This brings us to the major problem with the diagnosis: we are not dealing with naïve subjects. The symptoms of PTSD are common knowledge. In the 1980s, so the story goes, psychiatrists were perplexed to hear veterans insert into their litany of symptoms, “And I’m knitting a survivor quilt.” It turns out that the handout sent to veterans’ organisations contained the typographical error, “survivor quilt” for “survivor guilt. [David Straton (1999). The Trouble with PTSD. Traumatologye 5:1, Article 4.
This eminently readable, and amusing, article deserves to be read in its entirety. It can be accessed here.]
Veterans have attended meetings held by ex-service advocates and been shocked to find they are being coached on the right things to say to get their claims accepted. One advocate boasted that he used to attend the psychiatric consultation with the claimant in order to “assist” him. In fact, he even boasted of writing Dr M’s reports for him. Of course, he may have been exaggerating, but having read Dr M’s reports, I am not at all sure.
Probably such bare faced lying afflicts only a minority of claims. But there are infinite gradations between outright malingering and complete, objective honesty. People can be self-deluded. They also have a tendency to act and feel the way society expects them to. As explained in the discussion on culture bound disorders, a public neurosis is available; they might as well take it.
Typically, a veteran’s first encounter with a psychiatrist is in relation to a pension claim. He has talked to someone in an ex-service organisation, and a helpful pensions officer explains to him that his problems are quite common. It’s called PTSD, and he really ought to put in a claim. The advocate then shows him the PTSD SoP, which includes the diagnostic criteria. His natural tendency will be to see himself in the list of symptoms, because he had been told he should, and it all makes sense anyway. At least a month or two will elapse between the claim and the consultation, and by then it is likely he has familiarised himself with the criteria. Unless he is brutally honest with himself, there will always be a temptation to exaggerate his own case to make it fit. In any case, a person going through a nervous breakdown is especially vulnerable to suggestion. If he is told that he should be having intrusive, distressing recollections of the event, then distressing recollections he will have. They will prey on his mind, and disturb his sleep, because he is now obsessed with the progress of his claim.
And if the psychiatrist fails to support him? He goes back to the advocate, who gets him to appeal to the VRB. At the same time, he suggests he ask his doctor to refer him to another psychiatrist – one recommended by the ex-service organisation, who can be relied upon to say the right thing.
Added to this is the fact that so many psychiatrists use what is known as the Davidson Interview. Why they even imagine it can be objective is a mystery to me, and a greater mystery why the Department encourages, and pays for it. Perhaps I should quote a couple of the questions, so that you can see for yourself:
B.1. Have you experiences painful images or memories of your experience which you couldn’t get out of your mind, even though you may have wanted to?
Have these been recurrent?
How often are you troubles by the memories?
B.2. I’d like to ask you about your dreams. Have you had repeated dreams of violence, death, or other themes related to your experiences?
And so on. It goes straight through the PTSD criteria in a cookbook fashion, asking nothing but the sort of leading questions which would never be allowed in a court of law. Any interviewee can see what the “right” answer is. Even a completely honest veteran is likely to be subconsciously influenced to give replies that will assist his case. It mentions no other symptoms except those of PTSD and, unlike some questionnaires, contains no trick questions to determine if the interviewee is lying or, less culpably, is prone to agree with whatever question is put to him.
Thus, by a combination of deliberate lying, suggestibility, the natural tendency to subconsciously advance one’s own interests, and the credulity of professionals, mental disorders tend to change over time to assimilate to the format of PTSD. Let us take a few examples:
  • J was a decorated war hero. “He was the bravest man in my unit,” his commanding officer said, “and I put him in the most dangerous of situations.” Some years after he returned from Vietnam, he had personal conflicts with his superiors, and suffered a breakdown. He cheerfully agreed with me that he had more trouble with his own hierarchy than with the enemy. As a result, schizophrenia was accepted as defence (not war) caused. In hindsight, this diagnosis appears dubious. It was more likely an isolated psychotic incident. In any case, the symptoms bore no resemblance to those of PTSD. It is also certain that, when he was examined some years later, he was psychiatricly normal. Yet, several years after that, he lodged a claim for PTSD and Dr M (remember Dr M?) supported him.
  • K also saw conflict in Vietnam, but by his own account, he had been an alcoholic for a long time prior to that date. Twenty years after the war, it all came to a head. A psychiatrist diagnosed alcoholism, along with a number of anxiety type symptoms but, despite sympathetic questioning, he was unable to detect any of the re-experiencing symptoms typical of PTSD. K was then sent to another psychiatrist, who did discover re-experiencing symptoms. Tellingly, the subject reported that they had been present only after he attended an army reunion. Moral of the story: have a nervous breakdown, talk to your friends about it, and they’ll give you a whole set of new symptoms.
  • After his return from peacekeeping in Somalia, H came down with a whole suite of bizarre symptoms, the chief of which were night terrors (which are not the same as nightmares). A battery of military psychiatrists examined him, but were unable to reach a diagnosis, except to discover that it was not PTSD. They had specifically questioned him about the characteristic symptoms of PTSD, and came up negative. Next thing we knew, he had turned up in another state, with a report from a tame psychiatrist, and this time the whole panoply of PTSD, and nothing but PTSD, was displayed.
Of course, in hindsight, one can agree that H’s condition, however misdiagnosed, was at least due to his eligible service. J’s and K’s probably were not, but one hardly be upset if men of their calibre receive a pension. The next case, however, does not fit so well with the others.
  • In 1978 an air force dental technician had a nervous breakdown. The Department decided it was due to overwork, and determined it to be defence caused. (This was before the change in standard of proof.) Twenty years later, he came back with a report from a tame psychiatrist, who diagnosed PTSD stemming from his service during the Indonesian Confrontation. Interestingly enough, the psychiatrist failed to mention any traumatic event which could have precipitated PTSD. The veteran then mentioned running into a bout of strong turbulence when flying, which he had strangely omitted to mention to the psychiatrist. The irony is, he was already receiving a pension for it under the label, anxiety state. Moral of the story: PTSD is the diagnosis everybody likes.
Continue to Part 2 of Chapter 7

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