When discussing an issue as complex as psychological injury, opinion and belief can distract from knowledge”1
McKenzie’s2 paper is thought-provoking and raises several perennial issues for the assessment of Post Traumatic Stress Disorder (PTSD). McKenzie appears to be making several points. Firstly, that there is an increasing prevalence of PTSD in ADF personnel, with this increase seemingly accounted for by poor diagnoses and overestimation of the condition. Secondly, that this increase is attributable to poor diagnosis by naïve civilian psychologists and psychiatrists, or to malingering, fraud, or character flaws on the part of patients, spurred on by secondary gain. Thirdly, he intimates that treatment reinforces symptoms. Fourthly, he presents a picture of a helpless ADF medical system that cannot manage these issues; with deteriorating morale for the ADF as a result. Finally, he states the need for comprehensive, holistic assessments with a medical tribunal to make a diagnosis. These issues will be addressed one at a time.
The prevalence of PTSD in ADF personnel
While McKenzie claims that there has been a “recent disproportionate increase”, and “an increasing number of presentations” for PTSD in the ADF, and that the prevalence of PTSD in the ADF is overestimated, there are no figures to support these claims, no speculation on what the actual rate should be, and no recognition of the complexity of the issues.
McKenzie’s claim that more than 20% of Navy personnel from the 1991 Gulf War are on pensions for mental health disabilities is without reference. The 2003 Gulf War Veterans’ Health Study3 reports that just over 20% of participants (mostly Navy) had scores on screening instruments indicating possible mental health disorders, this is not the same as being diagnosed with a disorder and then having a claim accepted and pension allocated. Firstly, screening measures such as the PCL-C only rate three of the six criterion clusters required for diagnosis. Secondly, in the 2003 Gulf War study the prevalence in a control group (those in the military but who did not serve in the Gulf War) was 14%, suggesting that general military service may have contributed to over half the prevalence of possible PTSD. Hence there may be errors in assuming that screening equals diagnosis and accepted claims.
To highlight difficulties in obtaining a clear picture of PTSD, screening of a large sample of RAN personnel returning from the Middle East4 suggests possible PTSD in less than 2% of the sample (in-line with community rates and lower than for at-risk groups). However, more than 18% of survivors of the fire in HMAS Westralia (and possibly up to 25%) reported symptoms of PTSD5. These contrasting figures suggest that in general, RAN personnel cope well with operational deployment, but that for some specific sub-groups there may be spikes in rates of disorder. To focus only on specific groups (or a small number of specific cases) without looking more broadly, may distort the impression of rates of PTSD across the population. Whether there is actually a disproportionate increase in mental disorders is not supported by any data and ignores the long history of mental health disorders in the military. At the later stages of World War I, one-seventh of all discharges from the British Army were for mental disorders and 20% of soldiers on Britain’s pension list suffered from a psychiatric casualty6. During World War II, the number of US servicemen sent home as psychiatric casualties exceeded the number physically wounded and was twice the number of those killed in battle7. Further, over one-quarter of US medical discharges from the Korean War were for psychiatric reasons8 and combat stress casualties accounted for nearly one-third of casualties of Israeli soldiers in the Yom Kippur war9. Of an elite unit of the British Army that served in the Falklands, over 20% who were still in service five years later were diagnosed with PTSD with nearly the same number experiencing many of the symptoms; and only one in four not reporting any symptoms of PTSD10. Peacekeeping can also result in elevated rates of PTSD, with 15% of Canadian peacekeepers in Yugoslavia developing PTSD11, and around 10% of US personnel in Somalia developed PTSD12,13. Clearly, PTSD and psychological disorders resulting from military service is not a sudden or new phenomenon. Nor are controversies concerning the quality of diagnoses of PTSD and fears of over-diagnosis. Similar concerns were raised in 1995; however, at the time, it was considered that if anything, PTSD was actually under-diagnosed, rather than overdiagnosed14.
Poor Diagnosis
McKenzie’s concern about naïve diagnostic practice in PTSD may be valid, but fails to recognise the complexity of the issue. The reliance on subjective measures and self-report is not unique to PTSD – but common to most mental health issues. It would be appealing to have definitive blood tests for everything; but they simply don’t exist – we have to do the best we can with what we have. What complicates the assessment of PTSD is its assumption of sole attribution of the condition to a specific event and not the individual, raising its perception to that of an ‘honourable’ or compensable mental health condition when compared to other conditions such as depressive or personality disorders.
There is no doubt that suitably motivated and/or coached individuals could fake PTSD and obtain a diagnosis, and the potential impact of coaching described by McKenzie is of concern. The difficulty in accurately diagnosing PTSD and discovering faking or malingering within a medical system (as opposed to forensic settings) is clearly recognised15-18. However, in response to concerns about malingering in PTSD19, it has been noted that “bad clinical practice does not negate the validity or relevance of a particular disorder”1; that “if clinicians misapply the construct of PTSD, this is not a problem with a disorder, but rather, with clinical practice”1; and that just because malingering or suggestibility exists, the suffering of genuine victims should not be trivialised20. Further, to automatically hold suspect those with PTSD of malingering risks ‘malingerophobia’– where apprehensions about malingering adversely bias clinical assessment21, or lead to the negative and marginalising attitudes toward survivors of the First World War:
“Men with war neuroses would have to struggle against the scepticism of the military, confusion in medical circles, and the perceived link between mental illness and moral weakness – even degeneracy, made by the wider society”22.
There is an inherent difference between an essentially therapeutic approach, with its focus on a trusting relationship between therapist and patient, and an essentially forensic or medico-legal approach, with its focus on scepticism of self-report, the need for corroboration and the need for proof. While the latter is required to fully address McKenzie’s concerns, the reality is that it is mostly busy general practitioners and therapists, rather than lawyers or forensic psychologists or pathologists, who are asked to assess and manage patients in the ADF. The Australian Guidelines (for the Treatment of Acute Stress disorder and post traumatic stress disorder18 note that: “regardless of the context, the practitioner must maintain a balance between providing empathic support to a distressed person while obtaining reliable and objective information”. This sound advice leads towards decisions made on the best possible information (which still may not be 100% accurate), rather than slipping into a biased attitude toward people seeking help being either genuine or malingering (or deserving of help versus not deserving of help). McKenzie seemingly attributes the disproportionate increase in mental disorders to poor clinical practice, malingering or fraud in reporting by patients, or reduced levels of resilience. However, he does not report anything that rules out an actual increase in PTSD due to legitimate reasons, or to any other potential sources of attribution, such as changes in societal attitudes towards the military or their actions, issues related to ethical or moral considerations in modern war, conditions of service, management or leadership styles, etc. To not even consider these is to overly simplify a very complex and emotional issue; especially as in World War II group factors such as unit cohesion and morale were considered more valid predictors of psychiatric breakdown than individual factors23,24 and in the Israeli Defence Force, leadership is considered to plays a crucial role in recovery and mental health of personnel25. McKenzie’s concern regarding the use of civilian psychologists and psychiatrists to diagnose and treat is valid and worthy of attention, given that:
“psychiatrists who have not been sufficiently schooled in the goals and methods of military psychiatry have been noted in previous wars to fail to understand the competing sides of the soldier’s struggle to overcome his fear, to overly emphasise with the soldier’s self-protective side, and to over-diagnose psychiatric disturbance”26.
Further, the Australian Guidelines18 note that the military context can result in differences between military members and the general community, with regard to pre-disposing vulnerabilities, the type and frequency of exposure to trauma, along with different symptom presentations and issues for assessment. Therefore, there is significant benefit to military mental health professionals having a good understanding of the military context and how it impacts on disorders such as PTSD.
McKenzie’s assertion that the Navy has higher than expected prevalence of mental health disorders than the other services is consistent with the relatively low levels of uniform full-time clinical psychologists and psychiatrists in the Navy, compared to the Army. Further, the report of increased use of mental health early intervention halving the number of battlefield evacuees in North Africa in World War II27 should lead McKenzie to offer the obvious solution of calling for more uniformed Navy psychiatrists and clinical psychologists to address this apparent bias in mental health casualties in the Navy. However, he has not; and this is a glaring and surprising omission, given his strong opinion on the problems in the Navy.
Treatment reinforces symptoms.
McKenzie infers that some treatment programs reinforce a victim mentality and therefore impair recovery from PTSD. He also expresses seeming surprise that one particular therapy technique (Albert Ellis’ ‘catastrophe scale’) is not in common use. Treatment that reinforces a victim mentality may reflect poor treatment which should be considered an aberration rather than the norm. However, it could also simply reflect the complexity of psychotherapy for PTSD. The early stages of therapy involve building rapport and trust, and then gradually confronting traumatic memories. In establishing a therapeutic relationship, a therapist would generally allow a client to describe their experience without critique and with validation, which, if therapy was terminated at that stage, would appear as if the therapist was endorsing the client’s initial presentation. A further challenge is that therapy for PTSD involves clients repeatedly confronting their traumatic memories with sufficient intensity to evoke the human fear response, and to then review the meaning they make of their memories. However, two of the hallmark symptoms of PTSD are distress associated with reminders of the event and avoidance of reminders of the event. This makes therapy potentially distressing to clients with PTSD, with a tendency for avoidance that needs to be overcome. Despite the best intention of both clients and therapists, PTSD therapy may be terminated prematurely if clients feel unable to tolerate the distress for therapy (for any of a range of possible reasons), resulting in little therapeutic gains.
With regard to the use Ellis’ catastrophe scale, this particular technique is just one of a wide range of similar techniques used for cognitive restructuring in Cognitive Behaviour Therapy (CBT) and that most can have positive effect. Further, CBT techniques are used widely in therapy, and CBT is one of only two psychological treatments for PTSD recommended in the Australian Guidelines18.
A helpless medical system
McKenzie seems to infer that members are just given diagnoses from civilian psychologists and psychiatrists in isolation from medical officers. However, this should not be the case. At all times, a member’s medical employment classification and their management for PTSD should be the responsibility of medical officers. Further, the ADF medical employment classification review boards should serve the purpose of the tribunals recommended by McKenzie. Far from diagnoses being made in isolation from medical officers, MEC reviews are instigated by and are the responsibility of medical officers who can accept or reject the opinions of civilian psychologists and psychiatrists, or who can seek second opinions, perhaps with a forensic psychiatrist for difficult cases or even noting doubts about diagnoses. If there are problems with how this process works in practice, it shouldn’t necessarily be viewed as problems with disorders, diagnoses, patients, or other health professions.
McKenzie’s argument does not appear to recognise the existence of guidelines and policies for PTSD; giving the impression that there are no standards for assessment. In 2007 the Australian Centre for Posttraumatic Mental Heath published guidelines for the treatment of adults with PTSD and Acute Stress Disorder18. These guidelines, endorsed by the NHRMC, the RANZCP and the APS, recommend a comprehensive assessment process (and not just a quick checklist). McKenzie states that screening scores indicate that successive generations of Australians are becoming less able to tolerate the demands of war-like deployments. While McKenzie provides no evidence to support this, it is a possibility. Further, he draws the conclusion that “ADF morale is likely to deteriorate in the long term and resilient personnel become disillusioned if PTSD becomes the primary focus of the ADF Mental Health Strategy”. However, if the assessment of PTSD is as poorly undertaken with a significant adverse impacts on the whole ADF as McKenzie suggests, and/or if there is a disproportionate increase in one particular disorder, then making a priority of increasing resources to address those problems is highly appropriate. PTSD is certainly not the only health or mental health area in the ADF requiring attention. Given the problems with PTSD that McKenzie cites, and the need to increase the number of uniformed mental health professionals available (particularly in the Navy) to improve diagnostic skills and clinical practice, to run forensic investigations and/or oversight medical tribunals whilst also improving resilience, simply will not happen without considerable resources and focus of attention.
Despite our best hopes, conditions such as PTSD are complicated and heavily emotionally laden – they are not new or faddish, and are a long-recognised and unfortunate feature of military service. If there were simple answers, we would have heard them by now. To try to reduce or simplify an issue as complex as PTSD is to either undervalue or overvalue the experiences of patients and to provide them with a less than optimal service. We owe those in the military an evidence-based and genuinely holistic understanding of PTSD.
Post-traumatic stress disorder – in response to McKenzie’s holistic view
By Stephen Rayner In Commentary Issue Volume 18 No. 4 Doi No https://doi-ds.org/doilink/11.2021-12922198/JMVH Vol 18 No 4
When discussing an issue as complex as psychological injury, opinion and belief can distract from knowledge”1
McKenzie’s2 paper is thought-provoking and raises several perennial issues for the assessment of Post Traumatic Stress Disorder (PTSD). McKenzie appears to be making several points. Firstly, that there is an increasing prevalence of PTSD in ADF personnel, with this increase seemingly accounted for by poor diagnoses and overestimation of the condition. Secondly, that this increase is attributable to poor diagnosis by naïve civilian psychologists and psychiatrists, or to malingering, fraud, or character flaws on the part of patients, spurred on by secondary gain. Thirdly, he intimates that treatment reinforces symptoms. Fourthly, he presents a picture of a helpless ADF medical system that cannot manage these issues; with deteriorating morale for the ADF as a result. Finally, he states the need for comprehensive, holistic assessments with a medical tribunal to make a diagnosis. These issues will be addressed one at a time.
The prevalence of PTSD in ADF personnel
While McKenzie claims that there has been a “recent disproportionate increase”, and “an increasing number of presentations” for PTSD in the ADF, and that the prevalence of PTSD in the ADF is overestimated, there are no figures to support these claims, no speculation on what the actual rate should be, and no recognition of the complexity of the issues.
McKenzie’s claim that more than 20% of Navy personnel from the 1991 Gulf War are on pensions for mental health disabilities is without reference. The 2003 Gulf War Veterans’ Health Study3 reports that just over 20% of participants (mostly Navy) had scores on screening instruments indicating possible mental health disorders, this is not the same as being diagnosed with a disorder and then having a claim accepted and pension allocated. Firstly, screening measures such as the PCL-C only rate three of the six criterion clusters required for diagnosis. Secondly, in the 2003 Gulf War study the prevalence in a control group (those in the military but who did not serve in the Gulf War) was 14%, suggesting that general military service may have contributed to over half the prevalence of possible PTSD. Hence there may be errors in assuming that screening equals diagnosis and accepted claims.
To highlight difficulties in obtaining a clear picture of PTSD, screening of a large sample of RAN personnel returning from the Middle East4 suggests possible PTSD in less than 2% of the sample (in-line with community rates and lower than for at-risk groups). However, more than 18% of survivors of the fire in HMAS Westralia (and possibly up to 25%) reported symptoms of PTSD5. These contrasting figures suggest that in general, RAN personnel cope well with operational deployment, but that for some specific sub-groups there may be spikes in rates of disorder. To focus only on specific groups (or a small number of specific cases) without looking more broadly, may distort the impression of rates of PTSD across the population. Whether there is actually a disproportionate increase in mental disorders is not supported by any data and ignores the long history of mental health disorders in the military. At the later stages of World War I, one-seventh of all discharges from the British Army were for mental disorders and 20% of soldiers on Britain’s pension list suffered from a psychiatric casualty6. During World War II, the number of US servicemen sent home as psychiatric casualties exceeded the number physically wounded and was twice the number of those killed in battle7. Further, over one-quarter of US medical discharges from the Korean War were for psychiatric reasons8 and combat stress casualties accounted for nearly one-third of casualties of Israeli soldiers in the Yom Kippur war9. Of an elite unit of the British Army that served in the Falklands, over 20% who were still in service five years later were diagnosed with PTSD with nearly the same number experiencing many of the symptoms; and only one in four not reporting any symptoms of PTSD10. Peacekeeping can also result in elevated rates of PTSD, with 15% of Canadian peacekeepers in Yugoslavia developing PTSD11, and around 10% of US personnel in Somalia developed PTSD12,13. Clearly, PTSD and psychological disorders resulting from military service is not a sudden or new phenomenon. Nor are controversies concerning the quality of diagnoses of PTSD and fears of over-diagnosis. Similar concerns were raised in 1995; however, at the time, it was considered that if anything, PTSD was actually under-diagnosed, rather than overdiagnosed14.
Poor Diagnosis
McKenzie’s concern about naïve diagnostic practice in PTSD may be valid, but fails to recognise the complexity of the issue. The reliance on subjective measures and self-report is not unique to PTSD – but common to most mental health issues. It would be appealing to have definitive blood tests for everything; but they simply don’t exist – we have to do the best we can with what we have. What complicates the assessment of PTSD is its assumption of sole attribution of the condition to a specific event and not the individual, raising its perception to that of an ‘honourable’ or compensable mental health condition when compared to other conditions such as depressive or personality disorders.
There is no doubt that suitably motivated and/or coached individuals could fake PTSD and obtain a diagnosis, and the potential impact of coaching described by McKenzie is of concern. The difficulty in accurately diagnosing PTSD and discovering faking or malingering within a medical system (as opposed to forensic settings) is clearly recognised15-18. However, in response to concerns about malingering in PTSD19, it has been noted that “bad clinical practice does not negate the validity or relevance of a particular disorder”1; that “if clinicians misapply the construct of PTSD, this is not a problem with a disorder, but rather, with clinical practice”1; and that just because malingering or suggestibility exists, the suffering of genuine victims should not be trivialised20. Further, to automatically hold suspect those with PTSD of malingering risks ‘malingerophobia’– where apprehensions about malingering adversely bias clinical assessment21, or lead to the negative and marginalising attitudes toward survivors of the First World War:
“Men with war neuroses would have to struggle against the scepticism of the military, confusion in medical circles, and the perceived link between mental illness and moral weakness – even degeneracy, made by the wider society”22.
There is an inherent difference between an essentially therapeutic approach, with its focus on a trusting relationship between therapist and patient, and an essentially forensic or medico-legal approach, with its focus on scepticism of self-report, the need for corroboration and the need for proof. While the latter is required to fully address McKenzie’s concerns, the reality is that it is mostly busy general practitioners and therapists, rather than lawyers or forensic psychologists or pathologists, who are asked to assess and manage patients in the ADF. The Australian Guidelines (for the Treatment of Acute Stress disorder and post traumatic stress disorder18 note that: “regardless of the context, the practitioner must maintain a balance between providing empathic support to a distressed person while obtaining reliable and objective information”. This sound advice leads towards decisions made on the best possible information (which still may not be 100% accurate), rather than slipping into a biased attitude toward people seeking help being either genuine or malingering (or deserving of help versus not deserving of help). McKenzie seemingly attributes the disproportionate increase in mental disorders to poor clinical practice, malingering or fraud in reporting by patients, or reduced levels of resilience. However, he does not report anything that rules out an actual increase in PTSD due to legitimate reasons, or to any other potential sources of attribution, such as changes in societal attitudes towards the military or their actions, issues related to ethical or moral considerations in modern war, conditions of service, management or leadership styles, etc. To not even consider these is to overly simplify a very complex and emotional issue; especially as in World War II group factors such as unit cohesion and morale were considered more valid predictors of psychiatric breakdown than individual factors23,24 and in the Israeli Defence Force, leadership is considered to plays a crucial role in recovery and mental health of personnel25. McKenzie’s concern regarding the use of civilian psychologists and psychiatrists to diagnose and treat is valid and worthy of attention, given that:
“psychiatrists who have not been sufficiently schooled in the goals and methods of military psychiatry have been noted in previous wars to fail to understand the competing sides of the soldier’s struggle to overcome his fear, to overly emphasise with the soldier’s self-protective side, and to over-diagnose psychiatric disturbance”26.
Further, the Australian Guidelines18 note that the military context can result in differences between military members and the general community, with regard to pre-disposing vulnerabilities, the type and frequency of exposure to trauma, along with different symptom presentations and issues for assessment. Therefore, there is significant benefit to military mental health professionals having a good understanding of the military context and how it impacts on disorders such as PTSD.
McKenzie’s assertion that the Navy has higher than expected prevalence of mental health disorders than the other services is consistent with the relatively low levels of uniform full-time clinical psychologists and psychiatrists in the Navy, compared to the Army. Further, the report of increased use of mental health early intervention halving the number of battlefield evacuees in North Africa in World War II27 should lead McKenzie to offer the obvious solution of calling for more uniformed Navy psychiatrists and clinical psychologists to address this apparent bias in mental health casualties in the Navy. However, he has not; and this is a glaring and surprising omission, given his strong opinion on the problems in the Navy.
Treatment reinforces symptoms.
McKenzie infers that some treatment programs reinforce a victim mentality and therefore impair recovery from PTSD. He also expresses seeming surprise that one particular therapy technique (Albert Ellis’ ‘catastrophe scale’) is not in common use. Treatment that reinforces a victim mentality may reflect poor treatment which should be considered an aberration rather than the norm. However, it could also simply reflect the complexity of psychotherapy for PTSD. The early stages of therapy involve building rapport and trust, and then gradually confronting traumatic memories. In establishing a therapeutic relationship, a therapist would generally allow a client to describe their experience without critique and with validation, which, if therapy was terminated at that stage, would appear as if the therapist was endorsing the client’s initial presentation. A further challenge is that therapy for PTSD involves clients repeatedly confronting their traumatic memories with sufficient intensity to evoke the human fear response, and to then review the meaning they make of their memories. However, two of the hallmark symptoms of PTSD are distress associated with reminders of the event and avoidance of reminders of the event. This makes therapy potentially distressing to clients with PTSD, with a tendency for avoidance that needs to be overcome. Despite the best intention of both clients and therapists, PTSD therapy may be terminated prematurely if clients feel unable to tolerate the distress for therapy (for any of a range of possible reasons), resulting in little therapeutic gains.
With regard to the use Ellis’ catastrophe scale, this particular technique is just one of a wide range of similar techniques used for cognitive restructuring in Cognitive Behaviour Therapy (CBT) and that most can have positive effect. Further, CBT techniques are used widely in therapy, and CBT is one of only two psychological treatments for PTSD recommended in the Australian Guidelines18.
A helpless medical system
McKenzie seems to infer that members are just given diagnoses from civilian psychologists and psychiatrists in isolation from medical officers. However, this should not be the case. At all times, a member’s medical employment classification and their management for PTSD should be the responsibility of medical officers. Further, the ADF medical employment classification review boards should serve the purpose of the tribunals recommended by McKenzie. Far from diagnoses being made in isolation from medical officers, MEC reviews are instigated by and are the responsibility of medical officers who can accept or reject the opinions of civilian psychologists and psychiatrists, or who can seek second opinions, perhaps with a forensic psychiatrist for difficult cases or even noting doubts about diagnoses. If there are problems with how this process works in practice, it shouldn’t necessarily be viewed as problems with disorders, diagnoses, patients, or other health professions.
McKenzie’s argument does not appear to recognise the existence of guidelines and policies for PTSD; giving the impression that there are no standards for assessment. In 2007 the Australian Centre for Posttraumatic Mental Heath published guidelines for the treatment of adults with PTSD and Acute Stress Disorder18. These guidelines, endorsed by the NHRMC, the RANZCP and the APS, recommend a comprehensive assessment process (and not just a quick checklist). McKenzie states that screening scores indicate that successive generations of Australians are becoming less able to tolerate the demands of war-like deployments. While McKenzie provides no evidence to support this, it is a possibility. Further, he draws the conclusion that “ADF morale is likely to deteriorate in the long term and resilient personnel become disillusioned if PTSD becomes the primary focus of the ADF Mental Health Strategy”. However, if the assessment of PTSD is as poorly undertaken with a significant adverse impacts on the whole ADF as McKenzie suggests, and/or if there is a disproportionate increase in one particular disorder, then making a priority of increasing resources to address those problems is highly appropriate. PTSD is certainly not the only health or mental health area in the ADF requiring attention. Given the problems with PTSD that McKenzie cites, and the need to increase the number of uniformed mental health professionals available (particularly in the Navy) to improve diagnostic skills and clinical practice, to run forensic investigations and/or oversight medical tribunals whilst also improving resilience, simply will not happen without considerable resources and focus of attention.
Despite our best hopes, conditions such as PTSD are complicated and heavily emotionally laden – they are not new or faddish, and are a long-recognised and unfortunate feature of military service. If there were simple answers, we would have heard them by now. To try to reduce or simplify an issue as complex as PTSD is to either undervalue or overvalue the experiences of patients and to provide them with a less than optimal service. We owe those in the military an evidence-based and genuinely holistic understanding of PTSD.
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