Special Report

Ordering More Disorders

As it discovers new "disorders," the DSM guidebook for psychotherapists should dispose of Post-Traumatic Stress.

By 7.13.12

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In the early 19th century Samuel Butler wrote a quasi-utopian novel called Erewhon. It was startlingly prescient. Those who committed crimes were considered to be ill. Those who were ill were considered guilty of a crime. Society objected to facing the pains of others. In the following century Aldous Huxley expanded the same envelop in Brave New World. Joy was the order of the day; unhappiness was unacceptable self-indulgence. Depression, feelings of unworthiness, and similarly common strains were unnecessary, rendered so by pills Huxley called soma. (Sex was for fun exclusively and procreation was a crime; babies were made in the laboratory -- that's why God made petri dishes and test-tubes.)

Butler and Huxley would not be at all shocked by the current contretemps over what should go into the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the proximate cause being the proposed inclusion of bereavement as a disorder. The DSM is a guidebook for psychiatrists and psychologists, akin to the user's manual that comes with your appliances and vehicles, that standardizes the human psyche and renders it susceptible to tinkering along suggested lines. Equally important (well, maybe more so), it determines what tinkering will be covered by insurance. Ah ha!

Put baldly, the more tinkering is suggested in the DSM, the more money there is to be made by those who purport to plumb the human mind. ("And how did that make you feel, Shirley?") It surely is true that being listened to can be therapeutic. But if listening required professional attainments, bartenders would have to be board-certified.

According to a January 25 New York Times article addressing the issue, depression as defined by the current DSM does not include bereavement (i.e. what one feels when a loved one dies). The community is divided over whether it should. The dispute comes down to whether it is inappropriate to be unhappy when, say, your child dies. Some in the profession appear to feel this is "normal," while others feel that it is a pathology that should be treated, no doubt with a little help from Medicaid.

Feeling bad about a death is not the only potential DSM inclusion on the table. Other favorites are "binge eating disorder" (can "binge drinking" be far behind?), and "premenstrual dysphoric disorder" (what are comediennes to do when PMS "jokes" aren't funny anymore?). It is statistically verifiable that once a behavioral condition, however transitory, is labeled a "disorder" the number of people diagnosed with the "disorder" goes zooming up the charts. Suddenly tens of thousands of people who formerly were reduced to having to pull up their socks and get on with their lives can now lie back on the couch and indulge a "disorder" they didn't previously know they had. That is very gratifying for some personalities and very lucrative for the person who "diagnosed" their disorder.

If all this were restricted to low-lit rooms, couches, boxes of Kleenex, and someone murmuring "Hmmm, and did your uncle remove his hand when he realized you were uncomfortable?" it would all be relatively harmless quackery.

But it doesn't stop with the session on the couch. The pharmaceutical industry gets into the act as well. There are pills (soma?) to be popped, such as those, e.g. Paxil, Prozac, Zoloft, implicated in the suicides of people, chiefly those of a youthful age, being "treated" for various adolescent angsts. These episodes may match up with the high number of American soldiers committing suicide.

The unhappy (and largely unexamined) fact is that the military does not have a sufficient number of troops to fight the protracted wars now slowly grinding to an inconclusive halt (and so has to keep re-using the troops it has), and it does not have enough doctors to treat those who are dealing with the consequences. So, in order to get the stressed trooper back up on his or her feet and into the fight, out comes the pill bottle. The result, as I personally confronted during my brief tenure as Deputy Undersecretary of Defense for Wounded Warrior Care and Transition Policy, is soldiers too addled to assemble a simple sentence.

Which brings us to another revision to the DSM to be prayed for, this one not an addition but a deletion. The DSM currently characterizes Post-Traumatic Stress as a "Disorder." U.S. military medical personnel confronting a soldier's reaction to trauma, usually manifested as some greater or lesser degree of stress, commonly seize on the DSM definition in addressing the reaction. This produces one or a combination of the following results, sometimes depending on whether the soldier means to stay in the service or leave it:

The soldier who intends to make a career of the military is loath to have a "disorder" on his or her (inexpungible) military record. The military culture is one that penalizes anyone suspected of emotional weakness. The military is trying to change this, with little success. Commanders may urge people to report themselves if they are experiencing symptoms of stress, promising there will be no penalty, no stigma, attaching to those who ask for help. By and large, soldiers do not trust the leadership, at least on this point. Accordingly, soldiers who need help are likely to resist seeking it.

The soldier who intends to leave the military is equally reluctant for his or her medical record to have the pejorative term "disorder" permanently inscribed as they try to find employment in the civilian job market. For some professions, e.g. law enforcement, the associated stigma can be an absolute bar to employment.

Post-Traumatic Stress is a condition associated with warfare for as long wars have been fought. It is freighted with euphemisms that can be found in accounts of conflict going back to the Iliad, but there is little more understanding of how to manage it today than there was when Achilles slew Hector, despite mountains of monographs, studies, and theoretical therapies. The one conclusion that clearly can be drawn is that reaction to trauma differs from one person to the next and is not susceptible to the kind of standardization implied in the Diagnostic and Statistical Manual of Mental Disorders.

Whatever becomes of "bereavement" as an accouterment to depression in the next edition of the DSM, the term "Disorder" must be detached from Post-Traumatic Stress if our military personnel are to have a fair shot at surviving the consequences of their hard service to our nation. 

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About the Author

Noel Koch served for eleven months as Deputy Undersecretary of Defense for Wounded Warrior Care and Transition Policy in the Obama Administration.