from Iraq Now. The most clinically useful biological finding in PTSD is that, in contrast to Major Depression, (the 'stress hormone') cortisol levels are low. Aerni at al. in the American Journal of Psychiatry summer 2004 discuss how low cortisol lends to consolidation of traumatic memories and that 10 mg a day of Cortef for a month may be helpful in halting this. Sometimes, especial early in the course of disease if it is to have a quick effect, lithium has been dramatic in its effect. Lithium use is not in current algorithms though, was first reported on by Bessel van der Kolk in 1983. For diagnosis, using the CAPS, the "clinician ..PTSD scale," in an appropriate way drops you past the patients irritabiity defenses, an aspect of PTSD = personality disorder diagnostically. PTSD is like panic in that if there is suspicion and you deny it you may be more likely to have it.
I like reductio ad absurdum arguments. In such an argument you take a hypothesis and draw it's logically consequences to something absurd, or known to be false, thus disproving the original hypothesis. Something of an example can be made here of the argument that PTSD is a false construct. You may see below in my description of the uses of trauma By general Giap in his war strategy against the US that a soldier involved in hand to hand combat, eventually surviving by stabbing the north Vietnamese in the belly while holding the man's rifle, getting blood all over his hands in the man's death. 20 years later, the sargeant spends years trying to wash the blood off his hands by rubbing them as in Shakespeare's Macbeth. I submit that it is logical that in the pregunpowder days, war would have much more often involved combat with hand held piercing instruments and late intrusive memories of the combat would have involved such incidents. By incorporating such a psychic struggle, memory in a scene in Macbeth, Shakespeare shows that he knew of such in the human condition. He also associated it with a sense of guilt, one potential diagnostic criteria in the PTSD diagnosis. Allow me to say that it is absurd to think that Shakespeare included such a report based on the litigiousness and pseudoscience of American law or payments by VA.
A cautionary note too about 'Stolen Valor.' One of my patients spent a tour as a liaison office for the Air Force but with the Army in Laos. We didn't have a big contingent there. By treaty negotiated by Harriman for JFK, that the north said later convinced them we weren't serious about South VN, neither we nor the north were in Laos, not that that affected there presence there a whit. People next to him in small planes were shot on take-off. When he came back to (?) Arizona to get his next assignment, the clerk there started off by saying, "Well I see you haven't had a foreign assignment in a while..." I haven't read it though.
Something I have read that I note more than others is that the professor disputing the relevance or incidence of PTSD if from the University of South Carolina Medical School. It has a history of nihilism with regards to PTSD. I quoted a paper from there in my publication in Military Medicine in 1991, p 100-101.
I thought there nihilistic view of our medication strategies in PTSD was appropriate. Recently this institution had several articles published in the British Journal of Psychiatry supporting the quote in Dr. Helen. The editor of the journal opined that PTSD was maybe not a real diagnosis like schizophrenia or Major Depression. Part of the discussion was about having the diagnosis and not having been in the war theater. I sent in a case report supporting this possibility. This was turned down as I am sure they turn down a lot of prospective articles. Lisa Oliver, delightful lady and English name, who deals with these things conveyed to me 'that the readership wouldn't have sufficient interest.' The politics of PTSD does not just involve it's advocates.
Saturday, December 31, 2005
Wednesday, December 28, 2005
Note to a Reader
I tend of late to follow developments in blogs in the links left and may comment there. I'd be interested in any reaction you have to those blogs and may see your comments there or let me know in comments here. I'm mulling over a new blog on America's war guilt, something I began to develop in the post immediately below. This would be based on Robert Fliess's book and has been outlined in an earlier post on 'Cindy Sheehan.' In WWII, by personal account reported to me, we fired on, and sank, drifting Japanese evacuees of warships marked with the Red Cross in the Coral Sea. Yes we also shot down our own fighter aircraft when, in clear celebration of recent victory but against regulations, it dropped down to below deck level in flight parallel to one of our ships. A different age and time, a different psychological mind set.
Robert McNamara, defense sec'y for Kennedy and up until late Johnson, served 20 years earlier on Curtis LeMay's staff and did bomb damage assessment work on the bombing of Japanese cites. We were in a different situation in VN, and I think to Mr. McNamara's credit and ours we acted differently. McNamara also acted from a sense of regret over our actions against the Japanese of which he had been a part. In terms of limiting our air targets in North VN, the possibility of restraint went to far, allowing escape for important supply depot transshipment points, I haven't researched if on McNamara's watch, and body count was a metric with ethically dangerous implications. But underlying, our honorable conduct in a tradition of ancient Greece exposed your soldiers, Marines, naval patrol boat personnel, SEALs, aviators to death, casualty, and PTSD. Dulles and Eisenhower may have comitted us and there should have been a 58 election pursuant to the Geneva accords, I see this as a hinge point in our foreign policy, to see if this was truly fated but clearly a democratic VN could have eventually returned the emperor to power or turned to Ho Chi Minh. We were not in a war for national survival and did not act like it. That does not mean we can not be. It is ironic that from VN we have an ignoble feeling for military action while the Pacific War left us care free.
Robert McNamara, defense sec'y for Kennedy and up until late Johnson, served 20 years earlier on Curtis LeMay's staff and did bomb damage assessment work on the bombing of Japanese cites. We were in a different situation in VN, and I think to Mr. McNamara's credit and ours we acted differently. McNamara also acted from a sense of regret over our actions against the Japanese of which he had been a part. In terms of limiting our air targets in North VN, the possibility of restraint went to far, allowing escape for important supply depot transshipment points, I haven't researched if on McNamara's watch, and body count was a metric with ethically dangerous implications. But underlying, our honorable conduct in a tradition of ancient Greece exposed your soldiers, Marines, naval patrol boat personnel, SEALs, aviators to death, casualty, and PTSD. Dulles and Eisenhower may have comitted us and there should have been a 58 election pursuant to the Geneva accords, I see this as a hinge point in our foreign policy, to see if this was truly fated but clearly a democratic VN could have eventually returned the emperor to power or turned to Ho Chi Minh. We were not in a war for national survival and did not act like it. That does not mean we can not be. It is ironic that from VN we have an ignoble feeling for military action while the Pacific War left us care free.
Monday, December 05, 2005
May America not fall victim in Iraq to General Giap's trauma inflicted in VN
Instapundit has looked at the phenomenon of lagging support for Bush and the Iraq War. A part of the answer I think is found in the following. The ancient Chinese warrior Sun Tzu taught his men to "know your enemy" before going into battle. For if "you know your enemy and know yourself," he wrote, "you need not fear the result of a hundred battles." But, Sun Tzu warned, "If you know yourself but not the enemy, for every victory gained you will also suffer a defeat" (quoting Sun Tzu after I am reminded of the centrality of his doctrine by Thuan Q. Vu, M.D. of Bedford, Texas, the quote from Oliver North).
General Giap, the commander in chief of North Vietnamese communist, military forces from the forties through 1973 when his assault on South VN was repulsed, used this lesson it seemed to me from my vantage point as a VA psychiatrist. During the Tet offensive part of the quadrangle of a trench line was overrun and one of the sergeants that I treated faced a large man running at him with a rifle in the trench at port arms, that is carried at a 45 degree angle. He recalled how to fight such an opponent from an exercise in basic training, grappled with him, holding the man's rifle, and attempted to stab him in the belly with his knife. The opposing soldier had a wide web belt and this was difficult. A struggle literally to the death ensued and the sergeant stabbed him in the belly and threw him out of the trench bleeding to death. The next morning, the battle over, our sergeant went to see his opponent, found a picture in his front shirt pocket of a woman and 2 children. He threw the man's rifle as far as he could in expressing his tension as in the beginning of 2001, A Space Odyssey. Years later he would spend days rubbing his hands, rubbing the blood off that he perceived there. Another soldier found himself having investigative talent in VN. After the Tet offensive, when 2 ton trucks carried our casualties out of Hue as Mariness marched in to retake it, though he guarded city gates, he was in a quiet place. Somewhat later during the rainy season he wondered why the ground near him was bubbling during the rain. A mass grave was discovered. The communists executed thousands of civilians they apparently had a list for when they overran the city and buried them in mass graves. He also found out that the communists put pictures of a woman and children in front pockets of North Vietnamese soldiers, particularly those raised in their orphanages who would be most fanatically loyal to the regime. If they were killed in battle, well you already know the story. At Tet, General Giap sadistically to his own forces threw them in all their fury against a foe in another weight class militarily, nearly annihilating his forces in the South but showing to America the potential of hatred. He did not leave all to this battle though in adapting himself to the dictum of Sun Tzu.
A soldier in illustrating to me that the Vietnamese did not control sadism by internal guilt in contrast to a Western position offered this example. The Vietnamese would beat a dog to tenderize the meat before killing the dog to eat it. Nor in VN was there a protected period for childhood. General Giap appeared to use these differences to affect Americans. A soldier was in his first day in country and walking in a city. Something in the distress of a mother and child on a bridge led him to hustle over to her. Another US soldier, happening there, ran to her first and threw the baby off the bridge. The baby exploded just before it hit the water. In another example a young boy was running toward a patrol boat. A sailor saw a bulge in his shirt and fired; the boy exploded being wrapped in explosives. The sailor, partially African American, perhaps better able than most of us to pick up the syncopated overtone in a presentation, said, "I'd like to talk to the commanders about the way they treated their children." For many Americans, it was not so easy to resolve the double bind of wanting to be tender to children and being affronted with their death and the implication of some responsibility. Such incidents I heard again and again. The way the communists induced guilt and psychological isolation in Americans was taken to an art form, and I am afraid you would tire of the gallery but interestingly and in seeming contradiction in such a hardened enemy, such seemed a priority military objective . Americans did commit, occasionally, war crimes and/or the appearance of them in defending themselves against their feelings of guilt or in the liberty of sadism both taught in the school above or in frightened isolation. This was just the icing on a devil's food cake prepared mostly by the North Vietnamese communists and as America ate it, particularly the public, it became nauseated. Even though President Johnson's choice for Commander in Chief VN, Creighton Abrahms, led his forces in new directions with the South Vietnamese
toward true liberty, Pavlov's American dog wanted none of it, just wanted, desperately, out of the bakery. Wanted nothing of the military. And thus we come to Iraq. In a detail left out of the riveting Street Without Joy, some at least of those French forces who fell shortly before Dien Bien Phu in the magnificent Ashau Valley and surrounding mountains, were not recovered by the French and were buried by their Vietnamese foes standing up in the ground on the mountain pass where they fell, facing France with a bright domed stone on the ground above their heads. Similalry, the ABC program This Week buries our dead facing toward America. May they rest in honor and in peace.
General Giap, the commander in chief of North Vietnamese communist, military forces from the forties through 1973 when his assault on South VN was repulsed, used this lesson it seemed to me from my vantage point as a VA psychiatrist. During the Tet offensive part of the quadrangle of a trench line was overrun and one of the sergeants that I treated faced a large man running at him with a rifle in the trench at port arms, that is carried at a 45 degree angle. He recalled how to fight such an opponent from an exercise in basic training, grappled with him, holding the man's rifle, and attempted to stab him in the belly with his knife. The opposing soldier had a wide web belt and this was difficult. A struggle literally to the death ensued and the sergeant stabbed him in the belly and threw him out of the trench bleeding to death. The next morning, the battle over, our sergeant went to see his opponent, found a picture in his front shirt pocket of a woman and 2 children. He threw the man's rifle as far as he could in expressing his tension as in the beginning of 2001, A Space Odyssey. Years later he would spend days rubbing his hands, rubbing the blood off that he perceived there. Another soldier found himself having investigative talent in VN. After the Tet offensive, when 2 ton trucks carried our casualties out of Hue as Mariness marched in to retake it, though he guarded city gates, he was in a quiet place. Somewhat later during the rainy season he wondered why the ground near him was bubbling during the rain. A mass grave was discovered. The communists executed thousands of civilians they apparently had a list for when they overran the city and buried them in mass graves. He also found out that the communists put pictures of a woman and children in front pockets of North Vietnamese soldiers, particularly those raised in their orphanages who would be most fanatically loyal to the regime. If they were killed in battle, well you already know the story. At Tet, General Giap sadistically to his own forces threw them in all their fury against a foe in another weight class militarily, nearly annihilating his forces in the South but showing to America the potential of hatred. He did not leave all to this battle though in adapting himself to the dictum of Sun Tzu.
A soldier in illustrating to me that the Vietnamese did not control sadism by internal guilt in contrast to a Western position offered this example. The Vietnamese would beat a dog to tenderize the meat before killing the dog to eat it. Nor in VN was there a protected period for childhood. General Giap appeared to use these differences to affect Americans. A soldier was in his first day in country and walking in a city. Something in the distress of a mother and child on a bridge led him to hustle over to her. Another US soldier, happening there, ran to her first and threw the baby off the bridge. The baby exploded just before it hit the water. In another example a young boy was running toward a patrol boat. A sailor saw a bulge in his shirt and fired; the boy exploded being wrapped in explosives. The sailor, partially African American, perhaps better able than most of us to pick up the syncopated overtone in a presentation, said, "I'd like to talk to the commanders about the way they treated their children." For many Americans, it was not so easy to resolve the double bind of wanting to be tender to children and being affronted with their death and the implication of some responsibility. Such incidents I heard again and again. The way the communists induced guilt and psychological isolation in Americans was taken to an art form, and I am afraid you would tire of the gallery but interestingly and in seeming contradiction in such a hardened enemy, such seemed a priority military objective . Americans did commit, occasionally, war crimes and/or the appearance of them in defending themselves against their feelings of guilt or in the liberty of sadism both taught in the school above or in frightened isolation. This was just the icing on a devil's food cake prepared mostly by the North Vietnamese communists and as America ate it, particularly the public, it became nauseated. Even though President Johnson's choice for Commander in Chief VN, Creighton Abrahms, led his forces in new directions with the South Vietnamese
toward true liberty, Pavlov's American dog wanted none of it, just wanted, desperately, out of the bakery. Wanted nothing of the military. And thus we come to Iraq. In a detail left out of the riveting Street Without Joy, some at least of those French forces who fell shortly before Dien Bien Phu in the magnificent Ashau Valley and surrounding mountains, were not recovered by the French and were buried by their Vietnamese foes standing up in the ground on the mountain pass where they fell, facing France with a bright domed stone on the ground above their heads. Similalry, the ABC program This Week buries our dead facing toward America. May they rest in honor and in peace.