The making of PTSD

Sociologist and Vietnam War combat veteran Wilbur Scott describes how post-traumatic stress disorder came to be an official psychiatric disorder listed in the America Psychiatric Association’s “Diagnostic and Statistical Manual,” third edition (DSM-III), published in 1980.

A faculty member at the U.S. Air Force Academy, Scott notes this story is important for two reasons.

First, it raises the question of “what constitutes the normal experience and response of soldiers to warfare.” What psychiatrists once considered abnormal behavior would come to be viewed as a normal response to combat. That is, to be traumatized by combat was a normal human reaction to an abnormal situation: the horrors of war.

Second, the story illustrates “the politics of diagnosis and disease.” The making of PTSD is a clear example of how medical scientists and their allies successfully advanced a psychiatric diagnosis as both an accurate description of reality and a discovery of a condition (PTSD) that was real but previously unknown.

Published in 1968, the DSM-II omitted “gross stress reaction” (which appeared in the DSM-I published in 1952), a disorder produced as a consequence of serving in combat. Scott argues that a likely explanation for dropping gross stress reaction was that individuals revising the DSM-II had no direct experience in World War II and/or the Korean War. Also, respected psychiatrists serving in Vietnam were of the opinion that existing disorders in the DSM-I covered the range of emotional problems experienced by soldiers fighting in Southeast Asia.

In 1967 a small group of Vietnam War veterans gathered in New York City to protest a war they considered unjust. Taking the name Vietnam Veterans Against the War (VVAW) they urged fellow veterans to help end the conflict and bring their “brothers” home. The VVAW would play a key role in placing PTSD in the DSM-III.

Scott notes that as the war unfolded many Veterans Administration physicians believed that veterans who were agitated by their wartime experience suffered from some neurosis or psychosis whose origin “lay outside the realm of combat” – that is, a pre-existing condition. Not all psychiatrists shared this perspective. Upon reading of the My Lai Massacre in Vietnam (1969) where U.S. Army soldiers killed between 347 and 504 unarmed civilians, psychiatrist Robert Lifton (who served as a military psychiatrist during the Korean War and was a staunch opponent of the Vietnam War) testified before a Senate subcommittee on the psychological impact of combat on soldiers. Lifton stated the same psychological processes (psychic numbing and dehumanization of the enemy) that allowed soldiers to kill on the battlefield also allowed them to commit war-related atrocities. Lifton was highly critical of military psychiatrists. He believed these physicians were primarily advocates of the military’s interests rather then the welfare of their soldier-patients.

In April 1971, a young African-American man, Dwight Johnson, was killed while attempting to rob a liquor store. Two-and-a-half years prior to his death, Johnson had received the Congressional Medal of Honor for combat heroism. Psychiatrist Chiam Shatan, who opposed the Vietnam War, was “deeply moved” by the Dwight Johnson incident. Shatan was concerned about the absence of a war trauma diagnosis in the DSM-II. In a professional paper he wrote of a “post-Vietnam syndrome” (later changed to the broader “post-catastrophic stress disorder”) that typically occurred nine to 30 months after returning from Vietnam, the time frame of Johnson’s crime and death. Shatan described a syndrome he called “delayed massive trauma” characterized by guilt, rage, psychic numbing and alienation.

Robert Lifton and Chiam Shatan became participants in VVAW “rap groups.” The two psychiatrists, along with VVAW members and others, constructed the biographies of more than 700 Vietnam veterans, WWII concentration camp victims, rape victims and others. Based on these findings Lifton, Shatan and VVAW member Jack Smith attempted to convince a three-member APA committee that some form of trauma-induced disorder should be included in the forthcoming DSM-III.

Scott argues that proponents of what became PTSD prevailed “because a core group of psychiatrists and veterans worked consciously and deliberately for years to put it there.” They succeeded because they were better organized, were more politically active and had more lucky breaks during the fight for inclusion than their opponents. The importance of PTSD in the DSM-III cannot be overemphasized as this disorder was now legitimated by the APA. With this new perspective, Scott states, emphasis shifted from the particular details of a troubled solider’s background and psyche “to the nature of war itself.” In formulating their diagnosis, mental health practitioners would now take seriously “the patient’s combat experience.” For some veterans, PTSD was likely confounded by other issues such as alcohol abuse and related problems.

The creation and inclusion of PTSD in the DSM continues to be a matter of contention. British psychiatrist Simon Wessely asks if PTSD “is a valid psychiatric entity found across time and culture, representing a predictable but abnormal response to trauma? Or is it a Western, culture-bound syndrome, created to heal America’s guilt over the Vietnam War?” Psychiatrist Paul McHugh (formerly of Johns Hopkins University) has been one of the harshest critics of PTSD. For McHugh, “a natural alliance grew up between patients and doctors to rectify the existence of the disorder: patients received the privileges of the sick, while doctors received steady employment when, with the end of the conflict in South East Asia, hospital beds were emptying?”

Critics also question the efficacy of the PTSD diagnosis. Has it been successful? How many veterans has it helped, and at what cost to taxpayers? According to McHugh, the “inventive construction” of chronic PTSD served as a justification for “service-related psychiatric centers” devoted to treating veterans whether or not they were getting better. McHugh’s reading of the evidence is that overall, troubled individuals were not improving.

While the appropriate response to soldiers’ psychological, war-induced trauma is open to debate, the reality that combat veterans experience trauma is beyond question and was hardly the “inventive construction” of the VVAW and sympathetic psychiatrists. A 1946 study concluded that after 35 days of sustained combat, 98 percent of World War II soldiers experienced some adverse psychiatric symptoms. Of the 2 percent who did not succumb to battlefield stress, most were characterized as “aggressive psychopathic personalities” who were this way before entering the military.

Richard Gabriel, author of “No More Heroes: Madness and Psychiatry in War” (1987), states that in every 20th-century war in which American troops fought, the chances of becoming a psychiatric casualty were greater than the chances of being killed by enemy fire. In World War II, just under 406,000 American military personnel were killed while almost 1.4 million suffered psychiatric symptoms severe enough to debilitate them for some period.

George J. Bryjak lives in Bloomingdale, retired after 24 years of teaching sociology at the University of San Diego. He served in Okinawa and Vietnam with the First Marine Air Wing. A list of sources for this series on PTSD will appear with the third and final part Tuesday.