The Politics of PTSD
How a Diagnosis Battled Its Way into the DSM
by Mary Sykes Wylie
In retrospect, it seems bizarre that hundreds of thousands of veterans, all suffering from similar, dramatic symptoms, could be largely ignored by the Veterans Administration (VA) and psychiatry in general. But before the 1970s, almost no mental health authorities--military or civilian--imagined, much less expected and prepared for, traumatic reactions to war to emerge years after the conflict ended. There was yet no official traumatic stress diagnosis, and the VA assumed that any psychiatric problem occurring more than one year after discharge couldn't be related to military service.
During the Korean War, for the first time, clinicians provided frontline treatment for psychiatric breakdowns, returning the soldiers to battle as soon as possible afterward. Because this approach had worked so well--only 6 percent of Korean War evacuations were for psychiatric reasons, compared with World War II, when 23 percent were--the military was prepared to use the same approach in Vietnam. Only, nobody sought help. In fact, during Vietnam, there were proportionately far fewer reported cases of trauma on the actual battlefield than there'd been in previous wars. The primary reason seems to have been that soldiers had one-year rotations and knew that if they could just hold themselves together for 12 months--often with a little help from their friends, marijuana and heroin--they'd be free.
But after they returned stateside full of relief and happy to be alive, many of them--up to 50 percent according to the National Vietnam Veterans Readjustment Survey of 1988--began breaking down, months or even years later. Why? In spite of its time-limited nature for any individual vet, this war was in many ways even more stressful than others in the nation's history. First, troops were deployed individually, not in cohesive units, which undermined a sense of social support and increased their feelings of personal isolation and alienation. Second, troops were younger and less mature; Vietnam was often referred to as a "teenage war." Third, all wars are nasty, but this one had the special kind of nastiness that goes with a brutal guerilla war. There was an air of murderous futility about what soldiers were expected to do, and little experience of victory or accomplishment. A unit would take a hill one day, suffering massive casualties, only to have to take it again the next day.
And the Vietnamese didn't appreciate being "saved" and "liberated"; it was often impossible to tell friend from foe. As one vet said, "We are the unwilling, working for the unqualified, to do the unnecessary, for the ungrateful."
And the coup de grace: when they got home--deposited in the States maybe 36 hours after seeing a buddy's head shot off--they were unloved, unwanted, unappreciated, and often regarded as a kind of embarrassment. The U.S. had just lost its first war, and by the time it was over, a huge number of people thought the whole thing had just been a terrible mistake and wanted to forget about it. They also wanted to forget about the vets--the ones most visibly associated with the debacle, who kept reminding America that the war wasn't really over. Even veterans organizations were prejudiced against Vietnam vets, sometimes closing their doors to them.
Also, many PTSD symptoms didn't show up as the pitiful twitches and tremblings and motor paralysis that had afflicted the shell-shocked or combat-fatigued soldiers of earlier wars. The symptoms Vietnam vets experienced often appeared far more aggressive and less sympathetic. As public support for the war declined, so did the public perception of veterans, who were often undeservedly portrayed as drunk, drug-addled, brawling, wife-beating, unemployable, whacked-out guys. So it was easy for people to think, as one Vietnam vet wrote, "The Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people."
Whatever the VA's official position, however, by the early '70s, there were vast, underground rumblings about something going round the country--some strange, debilitating constellation of symptoms that seemed to be afflicting tens of thousands of returning Vietnam veterans. Trauma specialist Charles Figley, whose 1978 book, Stress Disorders Among Vietnam Veterans, was the first to address the problem, remembers when he became aware of this nameless phenomenon. A Vietnam vet himself and antiwar advocate, he recalls circulating among other vets at the massive 1971 peace rally in Washington, D.C., and listening to men talk about their nightmares, their violent rages and irrational fears, their alcoholism and drug addiction, their difficulty holding onto jobs. It was this experience, he says, that convinced him to go back to school and study psychology to find out what was happening to so many of his fellow soldiers.
Beginning in the mid-'70s, vets all over the country became very active, forming hundreds of rap groups to talk about their war experiences and coalescing into large, politically powerful, organizations to struggle for financial, social, and medical recognition of their problems. Many of the psychiatrists and psychologists who treated these vets and led rap groups were Vietnam veterans themselves, and they became forceful allies in the drive to get better care from the VA. Finally, in 1979, Congress officially mandated the VA to provide a network of counseling centers for Vietnam vets, to treat their "readjustment problems," including the as-yet-named PTSD. Even so, VA hospitals didn't begin to provide treatment aimed at trauma until the early '80s, after PTSD was included in the DSM-III (the third edition of theÂ Diagnostic and Statistical Manual of Mental Disorders ).
By the late 1970s, it had become obvious to many therapists that the old diagnostic system had fatal flaws. DSM-II seemed to have been written for a world in which serious trauma virtually never occurred. If somebody did perchance experience what DSM-II called "overwhelming environmental stress" (details never specified), it was assumed that, once the stress had been eliminated, recovery would occur in short order without any special help. If recovery didn't speedily happen, "another mental disorder is indicated"--suggesting that the failure to get better lay in the patient's own inherent psychological weakness or vulnerability, and had nothing to do with the trauma.
While the veterans were struggling for recognition on one front, another campaign was being waged--which included some of the same people--on another, to get traumatic stress back into the DSM. In 1974, psychiatrist Chaim Shatan, who was in the vanguard of the fight for better mental health care for veterans, heard about a New Jersey public defender representing a Vietnam vet accused of committing violence against property--an action for which the vet claimed amnesia. The public defender tried to get his client declared not guilty based on traumatic war neurosis, but the judge rejected the defense, saying there was no such diagnosis.
Shatan told the public defender to contact Robert Spitzer, head of the task force that he knew was then beginning preparations for the new DSM-III, assuming that there'd be such a diagnosis in the upcoming manual. But Shatan and other veteran advocates were shocked to hear that Spitzer had no plans to include any diagnosis for war neurosis in the new edition.
So Shatan contacted other psychiatrists who'd studied the psychological impact of war and genocide--including Robert Lifton, author of a book about Hiroshima victims and later a book about Vietnam, as well as psychiatrists William Niederland and Henry Krystal, researchers studying Holocaust and concentration-camp survivors--to mobilize support to their cause. Eventually, they helped form the Vietnam Veterans Working Group, comprising vets, psychiatrists, mental health organizations, academics, antiwar activists, church groups, and the like to lobby the American Psychiatric Association on behalf of a PTSD diagnosis.
Meanwhile, Charles Figley, who'd founded the Consortium on Veteran Studies at Purdue University and had led several symposia on vets at psychological conferences, published Stress Disorders Among Vietnam Veterans, which also became ammunition in the effort. Eventually, Spitzer agreed to form a committee to study PTSD, and, in 1980, PTSD was finally included in DSM-III.
For the first time, an official DSM diagnosis assumed a psychological disorder was caused not by inner dynamics or neurotic predisposition, but by outer events that happened to the person. In fact, without the trauma, there's no diagnosis. And the trauma itself had to be something truly big and bad. DSM-III distinguished--as DSM-II hadn't--between life's ordinary vicissitudes that might generate a psychological "adjustment reaction" and traumatic events that would most likely overwhelm someone, like natural disasters, rape or assault, bombing, torture, death camps, military combat, plane crashes, and so on. The events had to be "outside the range of normal human experience," represent a threat to life and limb, and be experienced by the victim with intense feelings of fear, helplessness, and horror.
The diagnosis was as much a political victory as a shift in the terrain of mental health. For the first time, political advocacy and social consciousness overtly contributed to the creation of an official diagnostic category for a psychiatric illness, taking into specific account the recent man-made horrors of world history--war, torture, genocide. This was also the same DSM that, in another highly politicized process, removed homosexuality from the list of mental disorders. So it wasn't surprising that some critics maintained--and still contend--that both the inclusion of PTSD and the exclusion of homosexuality owed more to politics than science.
--Mary Sykes Wylie