Saturday, December 31, 2005

Thanks for the link ...

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.


Trish said...

I find it astonishing what Freuh said as quoted on Helen's blog:

"Frueh, a professor of public psychiatry at the Medical University of South Carolina. "My concern about the policies is that they create perverse incentives to stay ill. It is very tough to get better when you are trying to demonstrate how ill you are."

Frueh's quote makes no sense to me. Admitting that PTSD is an actuality does not keep a person ill. Why would a young guy want to identify as ill if they weren't actually ill? That makes no sense to me. He's acting like those suffering are completely at the mercy of suggestion.

I agree that the prevelance of PTSD should not be used as either a rallying cry for the anti-war movement, nor should the rates of PTSD be down-played to support the pro-war groups, either.

What does concern me in addition to the mental anguish that is suffered by the soldiers is the incredibly high incidence of head injuries and the number of young men who have lost limbs in this war. I hope that no expense is spared in caring for them. We owe them that at the very least.

Michael said...

Dr. Freuh's first complaint is that the patient's are told they will have an illness which can not be treated. Psychiatry's responsibility is to treat the illness. South Carolina's position to date is that the illness can't be treated; but, if we don't say so, patient's won't be ill. It is good to get going with treatment, to try, if need be, various strategies, to know them; so that disability can be minimized.

Diagnosis involves 'being confronted... with.. death.' The case I wanted to publish involved someone who did not go to VN but was 'confronted by death.' It's hard to discuss w/o a publication.