Stressed Out Vets: Believing the worst about post-traumatic stress disorder.

The Weekly Standard, August 21, 2006

By Sally Satel

“DEAR DR. SATEL: You are an ideologically constipated coward.” So begins one of several dyspeptic communications I’ve received recently from Vietnam veterans and others.

What provoked their ire was a remark of mine quoted in the Washington Post on June 20. Under the headline “Iraq War May Add Stress for Past Vets; Trauma Disorder Claims at New High,” the article suggested that the current war is responsible for a surge in disability compensation among veterans’ ranks.

While I do agree that current news coverage may prompt anxiety, sleeplessness, and distressing memories among veterans who have led productive lives since leaving Vietnam, I told the Post I was “skeptical” that veterans who had functioned well for three decades would now be permanently incapacitated.

My sentiments are unpopular–you “right-wing, bloviating [expletive deleted] pseudo-psychiatrist,” wrote another reader on his blog–but my point is actually an encouraging one. That is, even if veterans are undone by news and footage of fighting in Iraq, few are likely to endure a subsequent lifetime of chronic anguish or dysfunction of the kind that requires long-term disability entitlement.

The technical term for such newly triggered incapacitation is “reactivated post-traumatic stress disorder,” or reactivated PTSD. The clinical literature describes veterans of World War I, World War II, and the Korean War who, after briefly showing signs of stress disorders in the immediate aftermath of service, led productive lives for decades before breaking down in their sixties or seventies.

Clinical experience with such patients suggests that they can improve with treatment. The same is true of Vietnam veterans. When a traumatic event in civilian life causes a reemergence of PTSD symptoms, their response to treatment has generally been good. “There is no question that reactivated PTSD has been successfully treated,” Matthew Friedman, a physician and the executive director of the National Center for PTSD, told me. “We know this from the patients’ trauma and treatment histories.”

And then there was the reaction to September 11. Veterans Administration medical centers in the New York area and even across the country had braced themselves for an influx of Vietnam and Persian Gulf veterans with reactivated PTSD. Yet re searchers from the Department of Veterans Affairs Connecticut Healthcare System at West Haven, writing in the American Journal of Psychiatry in 2003, found no increase in the use of inpatient or outpatient mental health services at VA centers among veterans with a diagnosis of PTSD or any other mental illness in New York City or elsewhere in the United States in the six months after September 11. Another research team at the Bronx VA Medical Center did detect a rise but could not establish that it was actually due to the attack on the World Trade Center.

In yet another analysis, the West Haven team reported in 2003 in Psychiatric Services that “VA patients with preexisting PTSD were, unexpectedly, less symptomatic at admission [to hospital] after September 11 than veterans admitted before September 11, and patients who had follow-up assessments after September 11 showed more improvement.”

What about after the Persian Gulf war? No data have been published regarding the pattern of compensation awards to Vietnam veterans in the wake of that conflict. It would be interesting to see the data, but unless they showed quite a large bump in claims, they would be hard to interpret, for a couple of reasons.

For one thing, the VA was increasing its funding of services and outreach to Vietnam veterans from 1988 into the early ’90s. In addition, evaluating claimants’ motivation years after their original trauma is rarely straightforward.

The VA is facing this very conundrum today. According to a May 2005 report from its inspector general, the department is now paying compensation for post-traumatic stress disorder to nearly twice as many veterans as it did just six years ago, at an annual cost of $4.3 billion. The vast majority of the recipients are Vietnam veterans in their 50s and 60s.

But how to distinguish between applicants who can be helped with short-term psychiatric care, those who are seeking a free ride, and those who truly merit the diagnosis of chronic post-traumatic stress disorder (reactivated or not) and thus should receive long-term care and payments of up to $2,300 a month for life?

Among the latter are applicants who have “never been right,” as their spouses often say, since their discharge from the military. They never regained their civilian footing and drifted further and further away from their families and communities. By the time they come to a veterans hospital for treatment, they are seen as having “malignant PTSD,” that is, severe symptoms of post-traumatic stress disorder complicated by drug and alcohol abuse and other mental problems like depression. They are notoriously challenging to treat.

Other veterans have significant life problems such as alcohol abuse, erratic employment, and domestic violence. But was traumatic ex posure in war the true cause? This is not always obvious, yet many VA mental health workers simply assume that whatever problem a veteran has is a product of his war experience.

Thus, to focus on the Iraq war as the primary reason for disability claims by Vietnam veterans is to miss a more complicated picture. More likely, other dynamics play a significant role in generating new claims of disability.

That picture comes into clearer focus when one asks, “Why now?” Today, the average Vietnam veteran is 60, which means any new compensation awards will coincide with the retirement years. Retirement itself, even for people with no latent store of wartime horrors, often leads to feelings of profound dislocation.

This is not surprising. After all, retirement can signify impending frailty and threats to one’s identity, which in our culture is largely defined by occupation. It may also denote a loss of purpose, foreclose an important social outlet, or dissolve comforting daily routines. Physical illness and the loss of a spouse may also hit hard at this phase of life.

The good news, though, is that when individuals encountering these difficulties seek care, clinicians report that they tend to do well and are able to find relief through new kinds of activity and revised perspectives on aging and other existential dilemmas.

Will the same hold true for veterans who suffered psychological trauma in wartime? Clinical experience with World War II and Korea veterans with reactivated symptoms–often brought on by retirement–strongly suggests that those who functioned well for the years between their military service and retirement will improve.

For others–those who led rockier lives and long attributed their drinking or concentration and sleep problems to job-related stress–the clinical challenge is greater, though not necessarily insurmountable. “Now sitting at home with ‘the wife,’ there’s not too much camouflage handy,” says Grant Devilly, trauma expert at Swinburne University in Australia, who has worked extensively with Korea and Vietnam veterans in his country.

How do these patients fare with treatment? “Quite well,” Devilly tells me. But, he emphasizes, there is a marked difference between his country’s mental health care system for veterans and ours. “We provide information on a healthier lifestyle, enhance beliefs and attitudes that the veteran can be an agent of change in his own life, and promote skills in linking and relating to family and others,” Devilly explains. “In the States,” he says, eschewing political correctness, “therapists tend to see vets as PTSD on legs.”

Devilly has a point. It is well established that the prognosis for PTSD patients is highly dependent on “post-event” factors, such as expectation of lasting impairment, marital discord, poor physical health, and financial stress. Clinicians in the United States have come to recognize the vast importance of ameliorating “post-event” factors, but change can be slow.

I have often wondered how many of our veterans are never given a full opportunity to recover. Unfortunately, some veterans’ advocates and old-guard clinicians remain too ready to see psychological distress as tantamount to incurable PTSD–hence, the quick reach for the disability claims form.

Another veteran who wrote me was offended. “My hope is that if I need to seek professional help in ‘coping’ with my past, I will be met with compassion, respect, and an open mind instead of cynicism.”

That is my hope, too. I am rarely cynical about patients’ capacities for renewal, but I worry that my correspondent might fall into the hands of those too ready to cast him as a psychiatric invalid.

Sally Satel is a psychiatrist and the coauthor, with Christina Hoff Sommers, of One Nation Under Therapy.