Treating the trauma of war – fairly

In relabeling cases of PTSD as 'personality disorder,' the US military avoids paying for treatment.

The high incidence of post-traumatic stress disorder (PTSD) among soldiers returning from Iraq is one of the many "inconvenient truths" of this war. Inconvenient largely because it is costly: The most effective and humane means of treating PTSD are time-intensive and long-term.

The military, however, has changed the terms and given many thousands of enlisted men and women a new diagnosis: "personality disorder." While the government would be obliged to care for veterans suffering from combat-related trauma, a personality disorder – defined as an ingrained, maladaptive way of orienting oneself to the world – predates a soldier's tour of duty (read: preexisting condition). This absolves Uncle Sam of any responsibility for the person's mental suffering.

The new diagnostic label sends the message: This suffering is your fault, not a result of the war. On one level, it's hard not to see this as another example of the government falling short on its care for Iraq war veterans. Yet there's another, more insidious, bit of sophistry at work. The implication is that a healthy person would be resistant to the psychological pressures of war. Someone who succumbs to the flashbacks, panic, and anger that haunt many former soldiers must have something inherently wrong with him. It's the psychological side of warrior macho: If you're tough, you can take it. Of course, we know this is not true. Wars forever change the lives of those who fight them and can leave deep scars.

Now is not the first time that psychiatric diagnoses of returning soldiers have been altered apparently for reasons of political expedience. During World War I, countries in Europe were overwhelmed with men coming home complaining of paralysis, confusion, insomnia, and other unexplained symptoms. The disorder came to be known as "shell shock" – a term the British War Office banned in 1917 because it asserted a direct connection between the war and the problem, which meant those suffering were eligible for treatment.

German psychiatrists debated whether such mental problems were the result of "trauma" (from the Greek for "wound") or "hysteria" (from the Greek for "womb," referring to a neurotic state associated with women). Over time the medical establishment favored "hysteria," which put the blame on the individual's failure to adapt rather than on the intolerable nature of modern warfare. In fact, it was thought that the camaraderie and rigor of battle would help strengthen those with "weak" mental constitutions and motivate potential malingerers. (A great scholarly book on the topic is "Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890-1930" by Paul Lerner.)

In Germany and Austria, the goal shifted from easing a man's pain to rendering him fit to go back to battle, often through the use of strong electric current. (Sigmund Freud was an expert witness at a trial for a prominent psychiatrist accused of overly cruel electric treatments.)

The switch in terms from trauma to hysteria (during World War I) or PTSD to personality disorder (today) is far from trivial. Rather, the new labels allow the government and society at large to do two things: 1) attribute symptoms after serving to individual psycho-pathology; and 2) disown the problem of the former soldiers' suffering. We needn't question the system that sends young people to war – merely the stability of those who bear the emotional brunt of battle.

Politicians have a vested interest in sidestepping the high price soldiers pay for their service. But we know better, and at the very least owe them appropriate medical and psychological care and the acknowledgment of their wounds.

Better screening at the enlistment and training stages is needed, both to forestall retroactive diagnoses and to identify soldiers with personality disorders that could interfere with their duties. (This debate has arisen after recruitment standards have been lowered with regard to mental health and criminal records to fill quotas.)

Better preparation prior to deployment would also help. The National Guard has seen higher rates of PTSD than the Marines. This may suggest that the more extensive training specific to combat received by marines helps them tolerate potentially traumatic situations.

Another important development would be a cultural shift within the military that both recognizes and destigmatizes the need for psychiatric care. This way soldiers and veterans would not be afraid to seek help in a timely manner – or be punished for having psychological complaints.

Finally, we as a nation need to recognize that our actions have consequences for those who assert them – and to remind our leaders before there's any commitment of troops.

Judith D. Schwartz is writing a novel set in Freud's Vienna.

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