Life During Wartime: Can Mental Illness Be a Rational Response?

By Vaughan Bell | November 10, 2011 10:42 pm

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Charles Figley was a US Marine who signed up for service in the Vietnam War to “accelerate my progression toward being considered a man.” But after his tour of duty he ended up as veteran protesting against the war, stunned by the psychological impact on himself and his fellow soldiers.

He began to investigate the symptoms of his fellow veterans and, along with other anti-war psychologists and psychiatrists, proposed a disorder called “post-Vietnam syndrome” where veterans carried emotions of the war with them despite being safely back on US soil. In fact, various forms of combat stress had been recorded during previous wars, from “disordered action of the heart” diagnosed in the Boer Wars to the dramatic symptoms of shell shock and war neurosis from the First World War.

The concept caught on and appeared, in a demilitarised form, as “post-traumatic stress disorder,” a mental illness where an earlier trauma causes the person to have a sense of current threat characterised by flashbacks, intrusive thoughts, avoidance of reminders, and anxiety.

And here lies the paradox. Researchers have noted that “PTSD is classified as an anxiety disorder. Within cognitive models, anxiety is a result of appraisals relating to impending threat. However, PTSD is a disorder in which the problem is a memory for an event that has already happened.” After all, if you feel threatened with good reason, almost by definition, this isn’t a mental illness.

So if someone remains in danger after a life-threatening incident, does the concept of “post-traumatic stress disorder” even make sense?

As the diagnosis relies largely on totalling up symptoms in a checklist-like fashion, it is possible to diagnose someone with the condition in almost any circumstance. But no one knew whether treating it in people who are still in grave danger would be any use.

Until now that is.

In Southern Thailand, 3,000 people have been killed since 2004 by anti-government extremists who regularly target schools, health workers and other civilians. Victims of past incidents run a real risk of being involved in further attacks. A feeling of impending danger would, by any standards, be considered reasonable.

Psychologist Richard Bryant has been working with a group of Thai colleagues to see whether it is possible to successfully treat PTSD in a group of terrorism survivors who remain at high risk of further attacks.

The treatment of choice is a form of psychological intervention called “cognitive behavioural therapy” or CBT where a survivor and a mental health professional work together to modify the assumptions and behaviours that maintain the sense of disabling fear.

Bryant and his team recruited a group of patients with terrorism-related PTSD and treated half with standard medical management and half with a modified form of cognitive behavioural therapy to take into account the high level of ongoing risk.

Rather than looking at how certain reactions and thought patterns encouraged fearful responses to a largely safe environment, as they would with someone well out of harm’s way, they focused on developing skills to evaluate the likely risk of being harmed and how to recognise the benefits of accepting a level of risk in order to allow day-to-day functioning. For example, going to the market to buy food despite the possibility of attack.

Despite the seeming contradiction of diagnosing and treating PTSD in a high risk environment, the therapy had a clear and positive impact. Patients treated with the risk-aware cognitive therapy were more likely to be able to return to normal level of functioning and prevent the fear from incapacitating them.

We could say, from the results of this study, that the clinical concept of PTSD is useful even when a threat remains, but this raises the challenging issue of whether it is ethical to treat someone to enable them to put themselves in further danger—however carefully they can evaluate the risks.

Part of the definition of a mental illness involves drawing a line between what is considered within the range of normal emotion and behaviour and what is considered to be pathological. The application of PTSD to people who remain in constant danger blurs that line and raises the question of how much the definition of mental disorder depends its context to make sense.

 

Vaughan Bell is a clinical and research psychologist based at the Institute of Psychiatry, King’s College London and currently working in Colombia. He’s also working on a book about hallucinations due to be out in 2013.

CATEGORIZED UNDER: Mind & Brain, Top Posts
  • http://littlewinery.blogspot.com Tim Beauchamp

    Interesting. Then, by extension, could this treatment be provided prophylacticly in advance of trauma as a way of inoculating someone for PTSD? That type of treatment could reduce the future problems of service personal and civilian populations in war zones.

  • Pingback: The Crux of PTSD under threat of terrorism « Mind Hacks

  • LLM

    As a person who has been mentally ill for about 60 years and has been diagnosed with “incurable PTSD” I’ll say that in many cases what seems like behavior “outside the norm” is, by definition, a judgement dependent on environment: that is..what’s the “norm?”

    What we call PTSD can be seen as a survival strategy and selected-for mechanism that allows an individual to avoid dangerous situations, predators, plants and environments. Imprinted early, this avoidance is a lifelong adaptation of the individual.

    Unfortunately, in humans, certain types of ongoing early abuse or other traumatic environments cause permanent changes in the brain that no amount of therapy or drugs can change. Luckily for humans, adult onset PTSD is subject to change. Should it be changed? That decision belongs to the individual.

  • Pingback: quotes out of context | clusterflock

  • http://www.wired.com/wiredscience/neuronculture David Dobbs

    Very nicely done.

  • http://www.badastronomy.com John

    There was only one catch and that was Catch-22, which specified that a concern for one’s safety in the face of dangers that were real and immediate was the process of a rational mind. Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn’t, but if he were sane he had to fly them. If he flew them he was crazy and didn’t have to; but if he didn’t want to he was sane and had to. Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle.

    – Catch 22 (1961) by Joseph Heller.

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