The number of American soldiers with emotional symptoms and invisible wounds is anyone's guess--perhaps 500,000 or more. All too often, the soldiers have suffered multiple IED blasts, serious injuries, and exposure to toxins or undetected infections. (Remember Gulf War syndrome?) These are complex conditions that defy conventional research.
Boone points out that the posttraumatic stress disorder (PTSD) diagnosis "emerged as much from politics as from medicine"--it was a product of the activism of Vietnam veterans. But the interaction of politics and pathology is not unique to this syndrome, or any other medical or psychiatric condition. The state of "being sick" goes far beyond the physiology of the injury or pathogen afflicting the individual. Illness is a state of being of the whole mind and body.
Social and financial factors matter. Across the country, high rates of suicide, unemployment, and homelessness among veterans attest to the economic hardships they are encountering. Just focusing on causation, diagnosis, or the medical science is shortsighted. Getting veterans to work and improving the quality of their lives should be the priority goals. Programs for disability compensation and providing benefits for employment and education are fundamental to the treatment and prognosis of PTSD.
More resources are essential, but innovation and new thinking are vital--especially integrating clinical care, vocational rehabilitation, and educational support. It is time to undertake a comprehensive review in preparing for the postwar epidemic that has already begun.
Stephen N. Xenakis, M.D.
Brigadier General, U.S. Army (Ret.)
THE PREMISE OF KATHERINE N. Boone's article appears to be that PTSD is a normal reaction to combat (or other) stressful events. Although she acknowledges that most people exposed to such stressors do not meet diagnostic criteria for PTSD, she fails to understand that one can only exhibit PTSD if the symptoms cause "significant distress or functional incapacity." In PTSD, the intensity of distress and magnitude of functional incapacity are abnormal and clinically significant. They set people with PTSD significantly apart from others.
The PTSD classification was developed in response to a growing demand for clinical help by veterans (and survivors of rape, natural disasters, and other calamities) who were incapacitated and suffering greatly from their posttraumatic symptoms. The development of the diagnosis has led to evidence-based treatments such as cognitive behavioral therapies and medications. It has also opened the door to important scientific advances demonstrating that traumatic psychological events may produce profound and enduring alterations in behavior, interpersonal relationships, brain mechanisms, and functional capacity. A major area of current research is resilience: Why do some traumatized people develop PTSD, while others do not?
The fact that there have been changes in PTSD diagnostic criteria since 1980 is a sign of scientific and clinical progress, not, as Boone suggests, a weakness in the rationale for the diagnosis itself. Because the author has trivialized--and clearly does not understand--PTSD, this article does a great disservice to millions of people with PTSD. I hope that it will not discourage them from recognizing that they suffer from a disorder for which very effective treatments are available at Department of Veterans Affairs facilities and elsewhere.
Matthew J. Friedman
Executive Director, National Center for PTSD
U.S. Department of Veterans Affairs
Professor of Psychiatry and Pharmacology and Toxicology
Dartmouth Medical School