||Dear Readers: Dr. Frank Ochberg wrote this article for journalists and it relates depression to PTSD. Some of our cities have been hit recently with natural disasters. Living in New Orleans right now, is like a war zone -and so are the lives of many trauma survivors, no matter where they live. That being the case I feel that this article has many interesting points for all of us. Joyce, Director, Gift From Within
The Emotional Impact of Reporting War at Home
By Dr. Frank Ochberg
War is the ultimate disaster and despite its glorification in myth and metaphor, we all know that witnesses of mass carnage are affected and changed. The war reporter is a professional witness, trained to see and hear and smell the event, to find "human interest," to absorb images of destruction and survival and portray them in words and pictures. Ordinary citizens flee war zones. Journalists move toward them. Some fly thousands of miles to get to the fighting; others, reporting conflicts in their own countries, head toward violence that may be very close to their own homes and families. To be both citizen and journalist of a nation at war is to endure intense, prolonged, intimate exposure to cruelty and loss.
Recently we have learned that a sample of war reporters suffer rates of PTSD "comparable to those of combat veterans" (Erica Goode, NYTimes 9/17/02, detailing the Feinstein study). This does not mean that the foreign correspondent who flies from conflict to conflict and continent to continent, as did Feinstein's 140 subjects, are psychiatric cripples. Far from it. They are a resilient, motivated, capable group. But they do have a significant number of symptoms that impair quality of life. Overcoming denial of this fact is healthy. And there is evidence that the culture of denial is changing for the better. Large news organizations such as the BBC, Reuters, CNN, and the New York Times are training reporters for hazardous duty and are recognizing the need to include training about PTSD and related conditions. The Dart Center website includes many examples of interaction among traumatic stress experts and media professionals who are at risk for traumatic stress.
Unexpected exposure to horror and terror has emotional consequences, no matter where the traumatic event occurs. That is, we react with a rush of adrenalin and our brains record and sort images with nerve cells bathed in a common chemical soup. There is a fundamental neurochemistry of traumatic stress. Depending upon our genetic makeup, some of us will have inescapable echoes of the "trauma imprint." We will have flashbacks and nightmares and other related emotional changes consistent with PTSD. Some of us will not have this pattern, but will have profound feelings including sorrow and anger. Some of us will be relatively unmoved -detached, even numb. The "first responder" to trauma, whether a firefighter, a medic, a police officer, a soldier, or a war reporter, can be expected to have emotional consequences, although some are more likely than others to suffer painful symptoms from these biological changes. Anyone in the business of reporting trauma should recognize and understand PTSD. PTSD is a common medical consequence of exposure to unexpected, haunting events.
But what about the reporter who lives in the war zone? Is it different to cover the conflict that rages in your country, that kills your relatives, that destroys your economy? Of course it is. PTSD is not the best model for understanding psychiatric consequences to reporting war at home. The best model is biological depression. This requires some explanation.
PTSD is (1) being haunted by a traumatic memory; (2) feeling emotionally numb and avoidant; (3) having anxiety that interferes with sleep, concentration and calm. Depression is being sad, not feeling pleasure, becoming hopeless, helpless, worthless, and having a selective lethargy: you can climb a flight of stairs, but you can't do the tasks you feel you were put on Earth to do. Or you can do them but with enormous effort.
PTSD affects brain pathways that are associated with memory and anxiety. A traumatic memory is created when parts of the brain that use adrenalin (or its close relatives) as "transmitter" become overactive. Not everybody's brain is wired the same way. Among high functioning, well adapted people, some are more likely than others to create traumatic memories when exposed to traumatic events. Once created, a traumatic memory has a life of its own, bursting into awareness when we do not want it to. Sometimes a trauma memory lies dormant for decades, then becomes a problem after life circumstances have changed. Trauma memories tend to cause fear rather than demoralization. But, depending upon the memory, it can arouse guilt, shame, fear, crushing sadness or rage. Regardless of the type of emotion, the significant feature of traumatic memory is the fact that this memory has the ability to spring forth, to come out of context, to disrupt work and play and confidence. PTSD means, among other things, contending with trauma memory.
Depression, as understood by psychiatrists, is very different. Biological depression is a flaw in the brain's "mood thermostat." It is normal to feel sorrow when life is sad. It is normal to grieve and to be overwhelmed with a profound sense of loss after an intimate tragedy--the death of a loved one, for example. But it is biologically, medically abnormal to lose the capacity to regain emotional equilibrium after experiencing sadness or grief.
When I was a psychiatric resident 35 years ago we were taught to separate depression into two categories: endogenous (from within, or biological) and exogenous (from without, or due to life events). We treated the two differently, assuming that exogenous depression required tranquilizers rather than antidepressants. In a way, we thought of it more like PTSD, although PTSD was, as yet, undefined. Now we know differently. When people feel hopeless, helpless and worthless; when they lose the will and energy to work; when their depression lasts two weeks without remission -- it means the "mood thermostat" is blown. It means that neurotransmission in mood-regulating pathways is depleted, just as insulin is depleted in diabetes. You can get biological depression from repeated exposure to depressing life events -- and from traumatic stress.
Living in a war zone is frightening -- hence war-related PTSD. Living in a war zone is depressing -- hence war-related depression. My personal experience meeting and caring for journalists who lived in war zones convinces me that depression is more of an issue than PTSD, although both may coexist. Reporters from Southeastern Europe and from South Africa described and displayed a loss of elan, a weight within, a secret burden that held them down. They spoke about this with reluctance. For some reason, we may be destigmatizing PTSD without destigmatizing depression. We need to understand and destigmatize both.
Depression is relatively easy to treat. In fact, over 70% of persons with biological depression respond to a combination of medication and psychotherapy. This does not alleviate the sadness and grief that are appropriate and proportional to profound loss. But it does restore the ability to experience pleasure and to recover after sorrow.
There is good reason to be depressed (in the common, layman's sense of the word) living through, for example, the hell of life in the former Yugoslavia. But there is no reason to avoid the diagnosis and the treatment for depression (in the medical sense of the word) when the diagnosis applies. War causes PTSD and it causes depression. These are medical conditions. When your country is your beat, and your country has suffered outrageously, you deserve treatment as well as respect.
Frank Ochberg is a psychiatrist and the former Associate Director of the National Institute of Mental Health and a member of the team that wrote the medical definition for Post Traumatic Stress Disorder. He was the editor of America's first PSTD treatment text. Dr. Ochberg is the Founder of Gift From Within.