A human condition: the PTSD diagnosis through the years
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Post-traumatic stress disorder, once viewed with skepticism in the aftermath of the Vietnam War, has evolved into a widely accepted condition, shedding light on the traumas that define human experience.
TPR’s Carson Frame spoke with Dr. Terence Keane, director of the National Center for PTSD-Behavioral Sciences Division, about that shift, beginning with the Vietnam Veterans Readjustment Study.
Keane: In 1983, there was a lot of skepticism about this new diagnosis and what it would mean for psychiatry, psychology and public policy in the country. Congress enacted legislation that mandated that the Department of Veterans Affairs would conduct an epidemiological study to presumably confirm or deny the extent to which PTSD as a disorder existed and whether it was related to combat in combat exposure. And the study was conducted over about a three and a half year period from start to finish. Then it was presented to Congress in 1988.
It demonstrated that PTSD was a coherent psychiatric diagnosis that occurred in great numbers for people who went to Vietnam and even greater numbers for those people who were exposed to high levels of combat. It also had a lot of information about women veterans. At the time, women were largely in health care and administrative roles. But they were sadly exposed to combat in a variety of ways. What makes a hospital safe in the war zone? Importantly too, the women were exposed to sexual harassment and even sexual assault and they were suffering.
Frame: It sounds as though this study really validated the PTSD diagnosis, as well as the experiences of veterans and clinicians.
Keane: You hit it out of the park with that. It is absolutely the case that it provided validation. This became a bona fide area of scientific inquiry within just a couple of years. It was important not just to veterans and public policymakers, but to the academic community: medicine, psychology, clinical psychology.
The climate and the landscape changed dramatically surrounding this disorder and its application … to civilians, community violence, domestic violence, industrial accidents, transportation accidents where people were experiencing life and death events. Usually between 15 and 25% of those people would go on to develop PTSD.
Frame: I noticed that you were part of a team that ultimately developed a PTSD scale. How important was it to be able to quantify symptoms and markers?
Keane: You're absolutely right to suggest that the measurement issues were critical to the development of the field. Because people then started to use our measures to study all kinds of other populations because they were generic measures that looked at PTSD with or without reference to combat stressors. So it's not just whether you have PTSD. It's whether you have PTSD and how much of it you have — how severe a case. So it's — I don't know if this makes sense — a dimensional or a continuous construct. Like some people have very little of it. Some people have none of it. Some people have a lot of it.
Frame: What do you recall about that period in the field, when we were suddenly looking at trauma in this whole different way?
Keane: Well, you know, it is funny that you should say that. Because I was astonished by it all! The original introduction to PTSD in the diagnostic manual said that traumatic events were rare, beyond the realm of usual human experience. Well, nothing could be further from the truth. There is actually a tremendous amount of trauma in our society.
Frame: Give me a sense of how clinicians have changed the way they think about outcomes for psychological trauma patients. Was there a shift from, ‘well, we can help patients manage this’ to ‘we can actually heal some of these symptoms or ameliorate them completely’?
Keane: Yes, I think that's exactly what has happened. Initially there was a sense that people were disabled, possibly permanently. But what we've learned over time is these interventions can be very successful in alleviating the diagnosis. Let's be clear. People still remember what happened. They still respond to what happened. But they can manage it successfully. They can live productive lives and contribute to their families and to their communities.
Frame: Just stepping back for a second and focusing specifically on military personnel and veterans, how would you say clinicians have changed their understanding of contributing factors to PTSD in that population? In terms of the cultural context, the reentry, deployment factors, etc.?
Keane: Very early on in the development of the field, there was a sense that these events happen to people and then those people develop PTSD. There's nothing further from the truth. There are many contextual factors. Some of them are personal, like genetics, personal background, emotionality, family structures, family experiences, things like education, socioeconomic status. All of these things contribute to who does and who doesn't go on to develop PTSD.
And, as I mentioned earlier, somewhere between 15 and 25% of people might develop this condition after exposure to traumatic events. There has to be a way to account for why 75 or 85% of people do not develop it. That's one of the key questions in all of psychopathology.
Frame: What are some of the things you see on the horizon when it comes to treating psychological trauma?
Keane: Well, I think the thing that has me most concerned right now is the application of psychedelic medications to the treatment of PTSD. And I think it represents a real distinct failure to come up with innovations. You know, I'm a little worried because people with PTSD often develop substance abuse problems. And so I think we have to go into this with great care. That's the challenge in front of us.