Veterans & PTSD: PTSD A Disease

Q: Dear Dr. Ochberg, I read a statement by you and found it very interesting. “I used to believe that PTSD was a normal reaction to a terribly abnormal situation. Now I consider the diagnosis a dis-order that warrants respect for its power and its biological reality.” Would you please differentiate what you used to think and what you now believe regarding diagnosis for PTSD. I hypothesize that to be a good grunt in the war zone, one must actively have PTSD. PTSD facilitates the model a soldier must emulate in combat. The counselor that I have seen for many years agrees with my hypothesis. Mostly, it is being acutely cognizant and hyper-vigilant. The Marines had given me the desire, power and authority to take human life and I was anxious to see how these things worked. My request was accommodated. Though very frightening, I performed as I had been trained and indoctrinated. Do I suffer from PTSD or do I suffer from conflict between my human nature and indoctrination programming that stuck and cannot be erased? Both civilian and military communities concur in opinion that I suffer PTSD.
A Vietnam Veteran

A: Dear Sir:

I used to think that PTSD was the medically normal reaction to extreme and traumatic stress. To have flashbacks and nightmares and all the rest were the brain and the mind’s natural and healthy way to register such a profound and disturbing experience. While terribly painful and disabling, the symptoms were proportional to the events, just as normal grief, lasting years and years, is the medically normal response to loss of a spouse or child. Normal is a word with many meanings, including statistically average, morally appropriate, and healthy as opposed to diseased. I was one who, at the outset, thought we should place PTSD in the part of the diagnostic manual that dealt with disorders rather than the “V-Code” section of non-disorders so that Blue Cross would pay, but I really did not consider PTSD a disease. Now I do.

It doesn’t mean I consider the condition stigmatized or dishonorable. Quite the contrary: I think PTSD earned on the battlefield deserves not only compensation, but honorable recognition. But thanks to brain imaging and advances in diagnosis and treatment, I believe PTSD causes damage to brain function, brain physiology and, at a very subtle level, brain anatomy. This damage is reversible. New pathways can form. Depleted neurotransmission can be corrected. Haunting memories will not be erased, but they can become part of the normal memory system rather than part of the traumatic memory system. The latter is the system that causes flashbacks and sudden, unbidden “re-experiencing.”

I find that the medical model, relying on this concept of a treatable injury to brain function, helps me help others. There are research psychiatrists who know more than I do about MRIs and the specific parts of brain anatomy implicated in PTSD. But I do believe that the PTSD brain has altered neurotransmission in areas that regulate the fear response, the range of pleasurable emotion, and the capacity for “autobiographical memory.” Autobiographical memory includes a language for extreme events and the ability to recall horror without evoking the horror so that it feels in the present rather than the past. I also believe that chronic PTSD (over several years) is near impossible to “cure.” It can be managed, more or less. It may be fruitless and disrespectful to ones sense of self to consider “cure.” When people with PTSD are able to help others, I believe a reasonable goal has been reached.