Meeting Military

Mental Health

Needs in the 21st

Century and

Beyond: A Critical Analysis of the Effects of

Dualism, Disparity and Scientific

Bias

Mark Russell, Ph.D., CDR, MSC, USN

2008 EMDRIA Conference, Phoenix,

Arizona (9/14/08)

Standard Disclaimer

The opinions and views expressed here

are those of the presenter and should

not be considered the policy, opinion,

or position of the United States Navy or

Department of Defense (DoD)

Medical Dualism and Mental Health

Disparity within Military Medicine

―I‘m not a fan of the facts. Facts change, but my opinion will never change, no matter what the facts are.‖

How Far Have We Progressed?

Before 20th century- ‘culture of trauma‘-―The idea that a soldier of previously sound mind could be so emotionally disturbed by combat that he could no longer function was not entertained; that he might suffer long-term psychological consequences of battle was also dismissed‖ (Jones and Wessely, 2007; p. 165)

―It is important to remember that most psychiatric casualties are soldiers who… unconsciously seek a medical exit from combat‖

Current U.S. Army ‗Textbook of Military

Medicine: War Psychiatry‘ (Jones, 1995)

‗Lessons Learned and Unlearned‘ or

Lessons Never Learned?

• WWII U.S. Army psychiatrists Appel and Beebe (1946)

concluded, ―Every man had a breaking point and neuropsychiatric casualties should be viewed as inevitable as gunshot and shrapnel wound in warfare.‖

• In reality-military historian Edgar Jones (2006), ―past experience suggests that [post-combat disorders] have the capacity to catch both military planners and doctors by surprise‖ (p. 533).

Mind-Body Dichotomy: Dualism

• 18th Century-‗Cartesian

Dualism,‘ emerges as

dominant European

philosophy

• Mind and body seen as

fundamentally unique and

separate

• Physical health and illness

viewed as the only authentic

focus of medical science

Mental Health Disparity

• Gross inequality between physical and

mental healthcare

• Unequal value, prioritization, status

and resources afforded to mental

healthcare science, practice, patients

and providers

The Take Away:

Five Critical Unlearned Lessons

1. That the actual prevalence of post war disorders is

historically grossly under-estimated by not

accounting for the full-spectrum of psychophysical

reactions, rampant stigma and barriers to care.

2. That every human being is vulnerable to acute and

chronic breakdown due primarily to cumulative

effects of war and/or traumatic stress regardless of

predisposition or resiliency factors.

3. That the psychophysical wounds of war are

fundamentally similar, authentic and morally

indistinguishable from war‘s tangible injuries.

The Take Away:

Five Critical Unlearned Lessons (cont.)

4. That the current antiquated dualistic healthcare paradigm, policy and practices results in harmful mental health neglect, stigma and disparity perpetuating cyclical crises and unjust trauma-pension wars.

5. That 21st century medicine must adopt an integrated (holistic) healthcare paradigm, policies and practices with full mental health parity in order to prevent future broken promises and failure to meet the mental health needs of war veterans and their families.

Reasons for Cyclical Failures in Meeting

Wartime Mental Health Needs

Military Occupational Hazards

Natural Disasters Humanitarian Relief

• 2008 Myanmar -

earthquake

• 2005 Indonesian -

Tsunami

• 2005 Hurricane Katrina

Training Exercises & Peace-Keeping

• •

Sexual Assaults

• 2008 DoD Sexual Harassment & Assault Report for FY07

• 2,688 cases

• 60% alleged rape

• 72% active-duty rape victims

International Terrorism

•1982-Beirut, Marine Barracks

•1996-Saudi Arabia, Khobar Towers

•2000-Yemen, USS Cole

•2001-Washington DC, Pentagon

Combat Operations

• 40 wars or conflicts any given

year

• 1% world population are

refugees

• GWOT: 1.6 million U.S.

service personnel deployed

• KIA: 4,683 WIA: 32,799

Suicide: 179

• 303,000 PTSD/depression

(20%)

Prisoners of War (POW)

• Lifetime prevalence of

PTSD = 70% (current

rates 20-40%)

• Lost 35% body weight

poorest recovery

It‘s Not All Negative: Positive Combat/Operational Stress

Positive Combat Stress Behaviors

• Unit cohesion: Loyalty to shipmates and leaders. Identification with unit traditions.

• Sense of eliteness

• Sense of mission

• Alertness/Vigilance

• Exceptional strength and endurance

• Increased tolerance to hardship and pain

• Sense of purpose

• Increased faith

• Heroic acts: Courage and self-sacrifice

Carpe Diem?

• The DoD, by far, is in best position to be a

leader in the World on scientific advancement

in:

• Understanding

• Assessment

• Prevention (resilience) and

• Treatment of traumatic stress

• We have yet to seize the opportunity!---WHY?

THE PROMISE

• ―Making appropriate and timely counseling available to our men and women is essential to mitigating longer term effects.‖

• ―The Military Health System is committed to doing everything possible to help our service members remain healthy, including providing access to high-quality mental health services.‖ William Winkenwerder, M.D.,

Assistant Secretary of Defense for Health Affairs (July, 2004)

Unprecedented Mental Health

Initiatives in DoD: A Story That Deserves Telling

Post-Deployment Health Screenings

Abundant Web-base Resources

Plethora of Information Available to

Service Members And Their Families

Access to Alternative Counseling Resources

Deployment Services

The Untold Story of

Mental Health Care

in DoD

Narrated by:

Mark Russell, Ph.D., CDR, MSC, USN

Multinational Medical Conference, Yokosuka,

Japan (9/20/06)

―The Perfect Storm‖

• Storm One: High Mental Health Demand

• Storm Two: Lack Of Access To Quality

Mental Health Care

• Storm Three: Strong Undercurrent of

Dualism, Neglect and Mental Health

Disparity

High Mental Health Demand

The First Storm

Reported Mental Health Problems Among Army & Marine Personnel

After Iraq Deployment*

15.2% 14.7%17.5%

15.7%18.0%

19.9%

27.9% 29.2%

0%

5%

10%

15%

20%

25%

30%

35%

Army Study Group Marine Study Group

DepressionAnxietyPTSDAny of These

Based On 2003-2004 Data!

Source: Hoge, et al, “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers

to Care,” New England Journal of Medicine, v. 351, no.1, July 1, 2004, pp. 13-22.

OEF/OIF Spectrum of Medical

Diagnoses in VA (n = 144,424)

Musculoskeletal 40%

Mental disorders 32%

Digestive System 30%

Ill Defined Symptoms 30%

Nervous system 28%

Respiratory 17%

Injury/Poisoning 16%

VHA Office of Public Health and Environmental Hazards, February 14, 2006

Time Period Neuropsychiatric (NP) Conditions *Medically-Unexplained Symptoms (MUS)

Crimean War

(1854-1856)

Melancholia; Insanity; Mania; Inebriation Epilepsy; Rheumatism; Irritable heart

U.S. Civil War

(1861-1865)

Insanity; Melancholia; Mania; Nostalgia

Monomania; Inebriation; Nervous Prostration;

Inflammation of Brain; Malingering

Rheumatism; Mental Aches; Dropsy;

Functional constipation; Neuralgia;

Irritable Heart; Epilepsy; Sunstroke; Chronic Diarrhoeas

Boer War

(1899-1902)

Insanity; Melancholia; Mania; Nervous Debility;

Neurasthenia; Psychosis; Inebriation; Nervous Shock

Debility; Rheumatism; Disordered Action of the Heart

(DAH); Sunstroke

Russo-Japanese

War (1904-1905)

Insanity; Hysteria; Hypochondria

Traumatic Neurosis; Nervous Exhaustion; War Neurosis

Brain Disease; Epilepsy; Brain/Spinal Cord Disease;

Peripheral Nervous System/paralysis

WWI

(1914-1918)

Insanity; Mental Defect; Psychosis; Manic-Depression;

Psychoneurosis; Shell shock; Neurasthenia; Traumatic

Neurosis; Alcoholism; Drug Addiciton; Constitutional

Psychopathy; Nervous Ilness; Nervous Disease;

Melancholia; War Hysteria; War Neurosis; Gas Hysteria;

Functional Nervous Disorder; Anxiety Neurosis;

Exhaustion Neurosis; Hypochondriasis; Psychasthenia;

Malingering

Disordered Action of the Heart (DAH)

Effort Syndrome; Rheumatism; Epilepsy; Vascular Disease of

the Heart (VDH); Cardiac Neurosis; Neurocirculatory

Asthenia; Endocrinopathies; Soldier’s Heart; Evacuation

Syndrome; Concussion Syndrome; Enuresis’ Neuralgia;

Paralysis without specified cuase; Defective speech;

WWII

(1939-1945)

Psychosis; Psychoneurosis; Alcoholism; Character-

Behavior Disorder; Disorder of Intelligence; Lacking

Moral Fiber; Battle Neurosis; Hysteria; Nervous

Exhaustion; War Neurosis; Reactive Neurosis; Old

Sergeant’s Syndrome; Mental Weakness; Fear Neurosis;

Immaturity Reaction; Wartime Neurosis; Malingering

Non-ucler Dyspepsia; Epilepsy; Heart Disease; Contusion

Injuries; Disordered Nervous System; Rheumatism; Cardiac

Neurosis; Enuresis; MUS of gastrointestinal, cardiovascular

and musculoskeletal systems; peptic ulcer; hypertension;

allergic disorders; dermatological conditions; Migraine;

Neurological defects

Lack Of Access To Quality

Mental Health Care

The Second Storm

Rapid Attrition of DoD Mental Health

Providers: The Silent Crisis In Navy

Psychology

0

20

40

60

80

100

120

140

8/1/2006

Billets

Filled

Deploy

• 135 Total Billets

• 80 Filled (59%)

• 12 Training

• 68 Deployable

• 10 on Carriers

• 5 RAD/retirement

request per month

Lack Of Adequate Training To

Respond To Mental Health Needs

Problems With Access to Quality

Mental Health Care (DVA/DoD, 2004)

• ―Psychotherapies should be provided by practitioners who have been trained in the particular method of treatment, whenever possible [Expert Consensus] (pg 9

summary).‖

2003-2005 – DoD Mental Health Training

Needs Survey (Russell & Silver, 2006)

• 133 MH providers in DoD surveyed

• 90% reported they have received no training or supervision per VA/DoD CPG on any of the best treatments of PTSD

• No systemic training (internship/residencies) on management or treatment of traumatic stressors

• What if these were dentists or surgeons?

LACK OF MENTAL HEALTH

PARITY

The Third Storm

Inside The Third Storm

Entrenched Medical Dualism:

Mental Health Disparity, Stigma and

Neglect

The ‗Untold Story‘

Name One Medical Innovation by DoD

Medical Research and Practice?• Importance of sanitation in field medicine – U.S. Civil War

• Infection control – Army Major Walter Reed proves cause of yellow fever led to eradication – Spanish-American War

• Use of x-ray machine, plastic surgery, tetanus antitoxin – WWI

• Blood transfusions – WWI

• Blood plasma – WWII

• Helicopter medevac, MASH, - Korea

• Damage control surgery, use of gortex to keep wounds open

• Army designed tourniquet – used w/ one hand

• Bandage made compressed shells of shrimp – fuses to red blood cells

• State of the art centers for burn, amputees, prosthetics, pain

• 93% survival rate in OIF/OEF!!!

Disparity: Increasing Survival Rate of

Physically Injured Soldiers

• WWII: 23% of injured combatants died

• Vietnam: 17% of injured combatants died

• Iraq/Afghanistan: 9% of injured combatants die

Gawande A. Casualties of War—Military Care for the Wounded from Iraq and Afghanistan. NEJM 351(24): 2471-2475.

Name One Major Mental Health

Innovation by DoD?

• ……………………………………….???

• None!

• Despite frontline psychiatry since 1917

CAPT Bill Nash, MC, USN

Combat/Operational Stress Control Coordinator

Headquarters, Marine Corps

Combat Stress Injuries:

Challenges for the 21st Century

Let Today Be That

Day

(CAPT W. Nash, 2/6/07)

When Did We Decide That Combat Stress and PTSD Are NOT

Primarily a “Sickness of Will”?

Evidence of Dualism, Neglect and

Disparity of Mental Health Care in DoD?

• Inadequate training of healthcare providers on post

deployment MH issues

• Grossly insufficient staffing levels of MH providers

• Lack of MH treatment training and monitoring

• Significant disparity (chronic neglect) in research

• Lack of regional research treatment centers for

traumatic stress reactions until November 2007

• MHAT-IV recommendation, ―publish a policy that ensures Soldiers/Marines are able to access mental health during the duty day‖ (OSG, 2007; p. 33).

Further Evidence of Dualism and Disparity

• Non-medical MH providers (psychologist, social workers, and chaplains) - provide majority of psychotherapy

• Disparity in promotion of non-medical MH providers

• Glass ceiling for non-medical MH providers

• Inexplicable discrepancy in monetary compensation between medical and non-medical MH providers

• Maximum specialty bonus is $2,000 annual (10 yrs of less) or $5,000 (10 or more yrs)

• Medical specialty pays include Dermatology $18,000; Pediatrics $12,000; Family Practice $13,000; and Psychiatry $15,000.

• No MH retention incentives offered until 2008

Direct Effects of Dualism and Disparity:Entrenched Stigma

63%

59%

55%

51%

50%

45%

41%

38%

25%

22%

18%

65%

0% 10% 20% 30% 40% 50% 60% 70%

Perceived as Weak

Unit Leadership Might Treat Differently

Unit Members Might Lose Confidence in Me

Difficulty Getting Time Off for Treatment

Leaders Would Blame Me for Problem

Would Harm My Career

Difficult to Schedule Appointment

Too Embarrassing

Don't Trust Mental Health Professionals

Mental Health Care Doesn't Work

Don't Know Where to Get Help

Don't Have Adequate Transportation

Source: Hoge, et al, “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers

to Care,” New England Journal of Medicine, v. 351, no.1, July 1, 2004, pp. 13-22.

Stigma of mental health problems

remains

Military Organizational Structural

Support for Dualism and DisparitySURGEON GENERAL

MEDICAL CORPS

DENTAL CORPS

CHAPLAIN CORPS

SUPPLY CORPS

MEDICAL SERVICE CORPS

LEGAL CORPS

ADMINISTRATIVE

CLINICAL

MENTAL HEALTH CORPS

Reporting Failures of 21st Century Military

Mental Health Care: What‘s the Difference?

• January 2004 (Russell)

• Critical shortage of MH clinicians

• High MH staff attrition

• Poor MH training (i.e., 90% untrained on EBT-PTSD)

• Restricted access to quality MH treatment

• Insufficient clinical research

• Inadequate general training on MH issues

• Need for anti-stigma campaign

• Establish state of art regional research and treatment center

• Eliminate root causes of dualistic healthcare and mental health disparity

• June 2007 (DoD Task Force)

• Critical shortage of MH clinicians

• High MH staff attrition

• Poor MH training (i.e., 90% untrained on EBT-PTSD)

• Restricted access to quality MH treatment

• Insufficient clinical research

• Inadequate general training on MH issues

• Need for anti-stigma campaign

• Establish state of art regional research and treatment center

Screaming Into The Storm

• After 2003 OEF/OIF deployment, extensive efforts made to utilize military complaint resolution system to prevent the current MH crisis including:

• 27 - Memoranda, point papers, data-driven reports sent to over 50 military/civilian leaders:

– (2003-06) found 90% of 133 DoD MH staff not trained to tx PTSD per VA/DoD CPG

• 15 -Approved media appearances; 6 -professional publications; 16 - professional presentations; and 9 -awards received

• 2- Formal IG complaints (Dec 05/Jan 06)

• 1 - Appearance w/ DoD MH Task Force (Oct 06)

21st Century Military Medicine:Dualistic & Disparity or Holistic & Parity?

• DUALISTIC VIEWS

• Mental health & illness as fundamentally unique and separate from physical

• Emphasizes predispositions and weakness as causal

• Questions authenticity

• Perpetuates stigma

• Under-values mental health science and treatment

• Justifies disparity in priority, resources and compensation

• Ensures cost ineffective fragmented healthcare

• HOLISTIC VIEWS

• Mental health & illness as inseparable and interdependent from physical

• Emphasizes toxic war stress as primarily causal

• Authenticity equal to physical

• Reduces stigma

• Parity in priority, value and resources toward mental health science and treatment

• Ensures cost effective integrated healthcare

Why Are Critical Lessons Unlearned?

Fleet Hospital Eight (2003)

―Very impressive work, however…unfortunately, it will all be forgotten at the end of the war until someone else rediscovers it!‖ RADM Diaz, MC, USN

EMDR Treatment for OIF-related

ASD/PTSD (Russell, 2006)

EM D R Treatm ent For C om bat R elated Stress

0

5

10

15

20

25

30

35

40

45

50

Patient 1 31 5

Patient 2 38 15

Patient 3 42 8

Patient 4 44 10

Pre IES Post IES

U.S. Medicine (2004)

‗PTSD Prevention, Care Techniques Debated‘

• "PTSD is often a treatment resistant problem. It is better to prevent it altogether than to treat it, said Cdr. Jack Pierce, MC, USN, clinical program staff officer for Marine Corps Medical Matters. ―

• ―The report also said there is no evidence that eye movement desensitization and reprocessing (EMDR) as an early mental health intervention following disasters so should not be considered a treatment of choice.‖ (COL Ritchie)

• "The new elements related to eye movements are not central to the effectiveness of the treatment." (R. Ursano, USUHS)‖

Psychological Consequences of War and

Violent Conflict

What is War?

• Carl von Clausewitz ‗On War‘ (1790)

• ―War is the act of force to compel our enemy to do our will….a continuation of political intercourse.‖

Current Armed Conflicts (42)

War Stress Injuries

• Why high prevalence of post war disorder in 20th century?

• (1) Prevention of escape behavior (desertions)

• (2) Greater exposure to unpredictable, inescapable, uncontrollable threats 24/7

• (3) Greater lethality of weapons to inflict physical and psychological injury

• (4) Psychological conditioning to overcome universal resistance to killing

The ‗Universal Human Phobia‘:

Psychological Resistance to Killing

A Brief History of

Warfare Evolution

Firearms

Body Armor

Logistics: Transportation

Armored Warfare

Fortification

Artillery

Air Warfare

Sea Warfare

Psychological Warfare

400 BC 200 BC 1000 12001100100 BC300 BC 14001300 16001500 18001700 20001900

20

50

100

500

1000

5000

10K

10M

1000K

500K

100K

Hand-to-Hand Weapons

18th Century 12-pounder

17th Century 12-pounder

16th Century 12-pounderFlintlock

Minie Rifle

155mm Long Tom

WW2 tank

French 75mm

Fighter-bombers

The Trend in Lethality

Quantifying Theoretical Lethality• If one assumes that lethality is the inherent capability of a

given weapon to kill personnel or make material ineffective in one hour, where capability includes range, rate of fire, accuracy, radius of effects, and battlefield mobility, then quantitative measures can be computed to compare dissimilar weapons

Weapon Killing Capacity

Sword 20

Javelin 18

Simple bow 20

Longbow 34

Crossbow 32

Arquebus 10

16th C. 12-pounder cannon 43

17th C. matchlock musket 19

17th Century 12-pounder cannon 229

18th Century flintlock musket 47

18th Century 12-pounder cannon 3,970

Weapon Killing Capacity

Minie rifle, muzzle-loading 154

Late 19th Century breech-loading rifle229

Sprinfield Model 1903 rifle (magazine) 778

WW1 machine gun 12,730

French 75mm gun 340,000

WW1 fighter-bomber 229,200

WW2 machine gun 17,980

US 155mm M2 "Long Tom" gun 533,000

WW2 medium tank 2,203,000

WW2 fighter-bomber 3,037,900

Two Types of Tactical Swarming

“Massed Swarm”(Eurasian horse archers)

“Dispersed Swarm”(Somali Militia)

Example of Dispersed Swarming –

Mogadishu, 1993Command and Control:

• Burning tires

• Runners

• Cell phones

• Megaphones

• Smoke from crash sites

• Sound of firefights

Elusiveness based on:

• Urban terrain

• Noncombatants

• Home turf

• Roadblocks, narrow alleys

equalized mobility

What You May See

Combat Exposure for OIF SoldiersHoge et al. (2004)

Event Army (%) USMC (%)

Attacked/Ambushed 89 95

Being shot at/receiving fire 93/86 97/92

Shooting at enemy 77 87

Killing enemy combatant(s) 48 65

Handling human remains 50 57

Seeing injured

women/children

69 83

Seeing dead/injured

Americans

65 75

Killing non-combatant(s) 14 28

Being wounded 14 9

Intensity of Combat Exposure and

Post War Disorder Prevalence

What You May Hear

A Few of the Many Stressors of

Operational Deployment

PHYSICAL• Heat • Dehydration • Illness

• Cold • Sleep deprivation • Injury

MENTAL• Alternating between hyper-focused & bored

• Insufficient information• Value conflicts

EMOTION

AL

• Fear (of failure) • Hatred of the enemy

• Loss of friends • Guilt and shame

SOCIAL• Being away from loved ones and friends

• Loss of personal space • Isolation

SPIRITUAL• Life doesn‟t make sense like it used to

• Loss of faith • Loss of purpose

Operational Stressors

War-Zone Anticipation Stressors

What You May Smell

Profile of Hostile Forces

Human Stress Response

Clinical Management

Mark Russell, Ph.D.

Physiological Response to Stress

Chronic stress & Acute stress

Pituitary Gland, Hypothalamus and Amygdala

Adrenal glands= Secrete hormones

Epinephrine Cortisol Glucocorticoids

Heart = beats faster

Arteries = widen

Stomach = digestion stops

Lungs = faster / shallow

Muscles = tense

Normal Combat Reaction (Menninger, 1948)

• 50% - pounding heart

• 45% - sinking stomach

• 30% - cold sweats

• 25% - nausea

• 25% - shaking/tremors

• 25% -muscle stiffness

• 20% - vomiting

• 20% - general weakness

• 10% - involuntary bowel

• 6% - involuntary urination

General Adaptation Syndrome (GAS)

• Stage 1: Alarm Phase

―fight, flight or freeze‖

response

• Stage 2: Adaptation or

Resistance phase

• Stage 3: Exhaustion or

breakdown phase

Variable impact of stress on immune system(Adapted from Robert Sapolsky in Merson, 2001)

Cumulative Effects of Stress and Health

Adaptive Coping vs. Stress Injury

Injured by stress

– May feel like you’ve “lost it”

– Often more abrupt change

– Don’t feel like yourself any more

– You lose control

Bent by stress

– May feel irritable or anxious

– A gradual change

– You still feel like yourself

– You remain in control

Stress injuries can heal

Brief History of War Stress Injuries

The ‗Zeitgeist‘

• German expression

meaning "the spirit of

the age", literally

translated as "time

(Zeit) spirit (Geist)"

• prevailing intellectual

and cultural climate of

an era (Wikipedia,

2008)

Connecting Treatment to Etiology

• Beliefs about the causes of an ailment greatly influence

how we attempt to treat it.

• Consider how you would treat a ‗mental‘ impairment we

believe is caused by:

– Inherent weakness of character and/or constitution

– Lack of will power or moral fiber

– Suggestibility (i.e., from indulgent, self-oriented psychiatric

‗culture of trauma‘)

– Simulation or secondary gain (i.e., escape duty, pensions)

– Inadequate training and resiliency skills

– Legitimate psychophysical injury from physical environment

(i.e., cumulative effects of war or combat stress)

Managing Post War Disorders: Effects of Mind-Body and Etiological Views

• DUALISTIC VIEWS

• Mental health & illness as fundamentally unique and separate from physical

• Emphasizes predispositions and weakness as causal

• Questions authenticity

• Perpetuates stigma

• Under-values mental health science and treatment

• Justifies disparity in priority, resources and compensation

• Ensures cost ineffective fragmented healthcare

• HOLISTIC VIEWS

• Mental health & illness as inseparable and interdependent from physical

• Emphasizes toxic war stress as primarily causal

• Authenticity equal to physical

• Reduces stigma

• Parity in priority, value and resources toward mental health science and treatment

• Ensures cost effective integrated healthcare

Common Myths Underlying

Dualistic Predisposed War Hysteria

• Myth 1: Pre-20th century chronic post war disorder was rare (culture of trauma)

• Myth 2: Non-combatant breakdown is proof of predisposed war hysteria

• Myth 3: The vast majority (90%) of acute breakdown recover

• Myth 4: Resiliency is overwhelming (90%) normative response to war-thus chronic post war disorder is generally proof of predisposition

Debunking Myth 1: Historical Evidence of

War Stress Injuries prior to 20th Century

Evidence of 18th Century War Stress

Injuries and Etiology• 460-350 B.C. Hippocrates - Greek

physician, ‗father of Western medicine‘

• Rejected supernaturalism

• Holistic concept of mental illness (melancholia, hysteria, mania, phrenitis, inebriety)

• Etiology attributed to brain pathology and life style factors

• 129-200 A.D. Galen - prominent Roman physician extended Hippocratic materialistic etiology of mental illness

• 460-350 B.C. Hippocrates “Whenever people of the mountains or plains or prairies were sent to another country, a terrible perturbation always followed them” (McCann, 1941)

Evidence of 18th Century Post War

Disorder: ‗Nostalgia‘• 1678 –Swiss physician Johannes Hofer

described ‗Nostalgia‘ or pathological homesickness - as first identified post war disorder

• ―Men of all temperaments, weak and strong, are more or less susceptible‖ (Hofer, 1678)

• 1678- Holistic etiology -―Nostalgia is due essentially to a disordered imagination, whereby the part of the brain chiefly affected is that in which the images are located‖ (Hofer, 1678)

• 1774 – Jasper reported 1,000 of Scottish English, Laplander, Celts, French, & Austrian soldiers dying of the ‗homesickness disease‘

Evidence of 19th Century Post War

Disorders: Crimean War (1854-1856)

• 1854-1856- 2,561 Russian soldiers admitted at one military hospital for ‗nervous exhaustion‘ disorders

• 1859-Russian Military Medical Academy-established to train Russian military psychiatrists and research post war disorders

• 1863-Royal Victoria Hospital in Netley, England created for functional heart disorders

• 1867-Maclean studied 5,500 Crimean War veterans with ‗irritable heart‘

Etiologic Views in Pre-1945 Russian Army

• History of Russian military and psychiatry closely intertwined (Wanke, 2005).

• 1706- Peter the Great established a clinic in Vyborg to care for mentally exhausted soldiers.

• 1761- specialized psychiatric hospitals were established by Catherine the Great providing humane treatment for mentally ill Russian veterans.

• Materialistic etiological concepts embraced by Russian Medicine, led by Ivan Pavlov-mental and emotional reactions as physiologically inseparable from the nervous system or brain.

• Etiology-war stress injuries are predictable and primarily caused by pathogenic (toxic) environmental war stress effects on the nervous system

Women Pioneers in Treatment

of Post War Disorders

• 1856-Flourence Nightingale –Humane treatment of Crimean War veterans suffering post war disorder

• 1848-Dorothea Dix –Mental Hygiene Movement. In 1852, the U.S. Congress established The Government Hospital for Insane in Washington D.C., to provide ―the most humane care and enlightened curative treatments for the insane of the Army and Navy.‖ Appointed Chief Nurse, Union Army

Evidence of 19th Century Post War Disorders:

American Civil War (1861-1865)

Conflict Country Casualty Rates NP/MUS

Admissions

Pensions

U.S. Civil War

(1861-1865)

Union

(2,213,363)

Confederate

(1,050,000)

KIA: 140,414

WIA: 281,881

Death by disease:

224,097

Deserters:

200,000

KIA: 74,524

WIA: Unknown

Death by disease:

164,000

Deserters:

100,000

Acute Rheumatism

(145,000)

Chronic Rheumatic

(109,000)

Mental Aches

(50,000)

Nostalgia (5,200)

Functional

constipation

(150,000)

Irritable Heart

(10,636)

Dropsy (2,224)

Insanity (1,231)

WIA/injuries

(117,947)

Chronic diarrhea

(55,125)

Diseases of Heart

(25,994)

Rheumatism (40,790)

Neuralgia (2,144)

Epilepsy (1,512)

Disease of

brain/insanity

(1,098)

Nervous prostration

(5,320)

Etiologic Views of War Stress Injuries:

American Union Army (1861-1865)Union Army Surgeon General William A. Hammond adopted a holistic, ‗mind-body unitary theory‘ of war stress injuries

1862- Established the ‗U.S. Army Hospital for Diseases of the Nervous System‘ in Philadelphia (known as Turner Lane) dedicated to the research and treatment of ‗nervous disorders‘

Viewed ‗nervous disorders‘ as legitimate, morally indistinguishable from war wounds.

S. Weir Mitchell developed the ‗resting cure‘, a precursor to frontline psychiatric intervention.

1864 Jacob Da Costa‘s published first study of treating 200 soldier‘s with ‗irritable heart.‘

1883 Hammond - "The brain is the chief organ from which the force called the mind is evolved, and, so far as the present treatise is concerned, may be regarded as the only one…either in health or disease‖ (p. 9) adding ―The connection between the mind and brain is not doubted at the present day, although the character of the relation is still the subject of controversy ―(p. 10).

History of the ‗Trauma and Pension Wars‘

• ―Trauma‖ Greek - physical wound began to be applied to ‗psychical‘ injuries suffered by victims of railway accidents in North America and Europe in the 1860-70s.

• 1889 -1 of 117 train workers killed and 1 of 12 injured in accidents

• 1864 - British physician John Ericksenclassified first holistic, post traumatic stress condition – ‗Railway Spine‘

• ―It must be obvious that in no ordinary accident can the shock be so great as in those that occur in Railways. The rapidity of the movement, the momentum of the persons injured, the suddenness of its arrest, the helplessness of the sufferers, and the natural perturbation of the mind that must disturb the bravest, are all circumstances that of necessity greatly increase the severity resulting to the nervous system‖ (Ericksen, 1864)

Traumatic Neurasthenia

• 1869 -American physicianGeorge Beard- coined the term „neurasthenia‟

• Holistic condition caused by depleted „nerve force‟ from adapting to modern urbanized society or traumatic events

• Quickly adopted in Europe

• Mitchell‟s „resting cure‟ was treatment of choice

Hysteria: 3,000 Year Mystery

Traumatic Hysteria: Holistic Paradigm of

Predisposed Post-Traumatic Disorder

• 1870‘s- Jean M. Charcot keenly interested in ‗male hysteria‘ at Salpetreiere Hospital in Paris, France.

• Using ‗auto-suggestion‘ or hypnosis including veterans from the Franco-Prussian War (1870-1871)

• Intense affect combines with individual predispositions, a process he labeled ‗diathese‘ to produce, holistic ‗hysterie traumatique‘ (traumatic hysteria).

• Subsequently, Pierre Janet and Sigmund Freud extended Charcot‘s predisposition theory of traumatic hysteria by emphasizing early life experiences over the direct environmental effects of traumatic events

Traumatic Neuroses:

Traumatic Events as Causal• 1888-Prominent German neurologist

Hermann Oppenheim, Director of the Neuropsychiatric Clinic at the Charite

• Disagreed with ‗predisposed traumatic hysteria‘ - controversial lecture published in 1889 introducing ―Die Traumatischen Neurosen‖ (The holistic, Traumatic Neuroses), attributing primary causation to brain injury from traumatic stress

• ―The abnormal excitability of the cardiac nervous system is an almost constant symptom of traumatic neurosis‖

Initial Resolution of the Mind-Body Debate:

Holistic Post Traumatic Stress Disorder

• 1864 -British Legislative Act of made railway companies liable for ‗railway spine‘ injuries (Glynn, 1910) subsumed under the broader category of ‗traumatic neuroses‘and extended to other work-related accidents (‗accident neurosis‘)

• 1880-British Employers Act

• 1897-British Workmen‘s Compensation

• 1889 -German Imperial Insurance Office Act followed British legal precedent granting ‗traumatic neuroses‘ the status of ‗actionable conditions‘ by extending the 1884 Accident Insurance Law (Brunner, 2003).

The Growing Trauma-Pension

Debate

• 1910 – Thomas Glynn‘s seminal forensic review of post traumatic disorders.

• ―Traumatic neurasthenia (traumatic neurosis) has come to be recognized by lawyers as indicative of a definite disorder produced by accident and on the other hand, the term hysteria to the unprofessional, is suggestive of malingering‖ (p. 1333)

• ‗Pension Neurosis‘ (Rentenneurose)

Evidence of Early 20th Century Post War

Disorder : The Boer War (1899-1902)• 1900 - British Army surgeon

Morgan Finucane reported symptoms in soldiers ―akin to nervous shock or those observed after railway accidents‖

• Sample of 6,276 war pensions

• 15% (964) diagnosed with post war disorder

• Debility (392) – 20,767

• Functional Rheumatism (272) –24,460

• Disordered Action of Heart (DAH; 199) – 3,631

• Psychosis (27)

• Sunstroke MUS (21) - (Jones & Wessley, 2005)

Evidence of Early 20th Century Post War

Disorder: Russo-Japanese War (1904-1905)

• 24% (2,309) of all Moscow military hospital admissions diagnosed- ‗nervous exhaustion‘

• 12,753 Russian NP admits to Central Harbin hospital

• Unprecedented - Russian military hospital Central Harbin diagnosed at least 2,000 cases of ‗traumatic neurosis‘ directly attributed to war stress (Wanke, 2005)

The Rise of Dualism and Hysteria

• 1911-Robert Gaupp- hysterics ―lacked a firm mechanism of inhibition seen in particular women, effeminate men, children, the uneducated, and those outside Western Europe who were more likely to lose self-control and react to stimuli by ‗fleeing into‘ hysterical symptoms‖

• (Cited in Lerner, 2003; p. 38).

• 1905-Joseph Babinski replaced Charcot and holistic traumatic hysteria with dualistic predisposed hysteria as ―the sum total of the symptoms that can be called forth by suggestion and dispelled by counter suggestion‖ such as psychotherapy (Cited in Marlowe,

2000; p, 21).

• War hysteria became a disease of the ‗will‘

The Rise of Dualism and Hysteria

• 1886 – Bernhard published sexual crimes survey of 36,176 German girl

• 1893 –Breuer & Freud‘s ‗Studies of Hysteria‘ adopt Janet‘s tenet of dissociation from trauma

• 1896 – Freud cited sexual trauma as cause for hysteria in ‗Aetiology of Neurosis‘

• 1896 – ‗Aetiology of Hysteria‘ Freud adopted dualistic concept of hysteria emphasizing repressed impulses and secondary gain vs. traumatic events as causal

• Psychoanalytic views became predominant during WWI and WWII

1864-1905: The Reign of Holistic

Paradigm of Post Traumatic Disorders

• Major difference between post traumatic classifications was

degree that predisposition was emphasized.

• Significant overlap of diverse psychophysical symptoms

• „Traumatic hysteria‟ as described by Charcot, Janet and

Freud initially- generally adopted holistic view of

symptoms and suffering along with „traumatic neurosis‟

and „traumatic neurasthenia.‟

• Both „traumatic neurosis‟ and „neurasthenia‟ classifications

included sub-group of holistic predisposed traumatic

hysteria

Kay (1912) analyzed war-stress impact from 1886 to 1908 for the British

Army finding significant associations between increased rates of post war

disorders and duration of war stress ―the amount of the increase is proportional to the duration of campaign‖ (Kay, 1912; p. 153)

Intensity of combat exposure ―The conditions of modern warfare calling large numbers of men into action, the tremendous endurance, physical and mental required, and the widely destructive effect of modern artillery fire‖

(Cited in Jones & Wessely, 2005; p. 13)

Forewarning military leaders about the toxic effects of 20th century

warfare ―we shall have to deal with a larger percentage of mental disease the hitherto‖ (Cited in Jones & Wessely, 2005; p. 13)

Conversely, WWI German Army psychiatrist Robert Gaupp predicted

―only a small percentage succumbs and takes flight into sickness‖ (Cited in

Lerner, 2003; p. 40)

1912: Framing the Mind-Body Dichotomy

and “Trauma-Pension‟ Debate

The First World War (WWI: 1914-1918)

Extending the Trauma-Pension, Mind-Body

Debate to Post War Disorders• December 1914, widespread post war disorders appeared even in seasoned

Allied and German military officers and enlisted leaders, including an estimated 10% of British officers and 4% of enlisted personnel

• 1914 Berlin Society of Psychiatry and Nervous Illness meeting, Oppenheimconcluded ―The war has taught us and will continue to teach us (1) that just as before there are traumatic neuroses; (2) that they are not always covered by the concept of hysteria; and (3) that they are really the product of trauma and not goal-oriented, well cultivated pseudo illness ―

• Gaupp, a staunch advocate of dualistic predisposed hysteria stated ―the most important duty of the neurologist and psychiatrist is to protect the Reich from proliferations of mental invalids and war pension recipients‖

• Alfred Hoch (1915) levied charges against insurance doctors awarding war pensions as responsible for epidemic of nervous weakness, ―The individuals are in fact sick, but they would be well, strangely enough, if the law did not exist‖

Difficulties Estimating Actual Prevalence of Post War Disorders

• American Civil War- estimated 300,000 deserters between Union and Confederate armies

• 3,080 WWI British soldiers sentenced to death for cowardice, desertion or malingering with an estimated 300 executed.

• American Army psychiatrists in Korea-as incidence rates of frost bite rose number of NP casualties decreased (self-inflicted wounds)

• 42 of 75 (56%) Korean War vets on orthopedic wards reported NP symptoms via impromptu psychiatric interview

• 2003, a Navy Fleet Hospital screened 1,341 (97%) OEF/OIF medically evacuees finding 377 (30%) with ASD, PTSD, or depression

• Widely-varying, non-standardized diagnostic labels

• Military policy to avoid psychiatric labeling

• Blurring between diagnosing organic versus functional somatic syndromes (i.e., cardiovascular defect vs. soldier‘s heart)

• Unbridled stigma and disparity exemplified by battlefield executions for inability to continue the fight, public ridicule (i.e., ‗psycho,‘ ‗lacking moral fiber‘ -2,989 RAF) and imprisonment (e.g., 900 Union Army courts-martial).

Time Period Neuropsychiatric (NP) Conditions *Medically-Unexplained Symptoms (MUS)

Crimean War

(1854-1856)

Melancholia; Insanity; Mania; Inebriation Epilepsy; Rheumatism; Irritable heart

U.S. Civil War

(1861-1865)

Insanity; Melancholia; Mania; Nostalgia

Monomania; Inebriation; Nervous Prostration;

Inflammation of Brain; Malingering

Rheumatism; Mental Aches; Dropsy;

Functional constipation; Neuralgia;

Irritable Heart; Epilepsy; Sunstroke; Chronic Diarrhoeas

Boer War

(1899-1902)

Insanity; Melancholia; Mania; Nervous Debility;

Neurasthenia; Psychosis; Inebriation; Nervous Shock

Debility; Rheumatism; Disordered Action of the Heart

(DAH); Sunstroke

Russo-Japanese

War (1904-1905)

Insanity; Hysteria; Hypochondria

Traumatic Neurosis; Nervous Exhaustion; War Neurosis

Brain Disease; Epilepsy; Brain/Spinal Cord Disease;

Peripheral Nervous System/paralysis

WWI

(1914-1918)

Insanity; Mental Defect; Psychosis; Manic-Depression;

Psychoneurosis; Shell shock; Neurasthenia; Traumatic

Neurosis; Alcoholism; Drug Addiciton; Constitutional

Psychopathy; Nervous Ilness; Nervous Disease;

Melancholia; War Hysteria; War Neurosis; Gas Hysteria;

Functional Nervous Disorder; Anxiety Neurosis;

Exhaustion Neurosis; Hypochondriasis; Psychasthenia;

Malingering

Disordered Action of the Heart (DAH)

Effort Syndrome; Rheumatism; Epilepsy; Vascular Disease of

the Heart (VDH); Cardiac Neurosis; Neurocirculatory

Asthenia; Endocrinopathies; Soldier’s Heart; Evacuation

Syndrome; Concussion Syndrome; Enuresis’ Neuralgia;

Paralysis without specified cuase; Defective speech;

WWII

(1939-1945)

Psychosis; Psychoneurosis; Alcoholism; Character-

Behavior Disorder; Disorder of Intelligence; Lacking

Moral Fiber; Battle Neurosis; Hysteria; Nervous

Exhaustion; War Neurosis; Reactive Neurosis; Old

Sergeant’s Syndrome; Mental Weakness; Fear Neurosis;

Immaturity Reaction; Wartime Neurosis; Malingering

Non-ucler Dyspepsia; Epilepsy; Heart Disease; Contusion

Injuries; Disordered Nervous System; Rheumatism; Cardiac

Neurosis; Enuresis; MUS of gastrointestinal, cardiovascular

and musculoskeletal systems; peptic ulcer; hypertension;

allergic disorders; dermatological conditions; Migraine;

Neurological defects

Shell Shock and Demise of Holistic

Paradigms1915- British psychologistCharles S. Myers published case studies of ―shell shocked‖ soldiers suffering diverse psychophysical sxs

Holistic etiology - ―an invisibly fine molecular commotion in the brain‖ (TBI-today)

-1916 - Germany‘s artillery barrage at Verdun -100,000 shells an hour

- 1916 -Allies‘ 1,500,000 shells during 5-mo. ‗Battle of the Somme‘ resulting 6,000 ‗shell shock‘ cases per month

• French ‗la confusion mentale de la guerre,‘ German ‗kriegsneurose‘

• Public media and

increased prevalence

caused outrage

amongst war planners

WWI

(1914-1918)

German

(11,000,000)

British

(8,904,467)

American

(4,355,000)

Russian

(12,000,000)

Total Nervous disease: (613,047)

-Nervous illness; Rheumatism

-Cardiac neuroses

Shell shock (80,000); DAH (41,699)

Gas hysteria-80 of 96 (83.3%) gas casualties sampled

Total NP: 200,000 –(1929)

-DAH (42,948),Effort syndrome (35,000)

-VDH (21,706)

-Rheumatism (28,983)

-Functional Nervous (11,443)

-Epilepsy (6,388)

-Shell shock (18,596)

-Neurasthenia (55,469); Insanity (12,000 in 1930)

Total NP: 69,394

-Psychoneurosis (11,443)

-Shell shock (63)

-Neurocirculatory asthenia (1,737)

-Nervous diseases and injuries (6,916)

-Epilepsy (6,388)

-Endocrinopathies (4,805)

-Psychosis/mental disease (7,910)

-Inebriety (alcohol/drugs) (3,878)

-Mental Defect (21,858)

-Constitutional psychopathy (6,196)

Total: 102,566

-Nervous illness (81,154)

The 1916 Medico-Scientific Political Coup:

End of Holistic Post War Disorder Paradigm

• September 1916- Munich War Congress of the German Association for Psychiatry and Neurological Association

• Medical history by replacing holistic post traumatic disorder paradigm with dualistic, predisposed war hysteria and end trauma-pension debate

• 1916 - German military outlawed holistic ‗traumatic neurosis‘ (i.e., shell shock), adopted aggressive frontline measures to end ‗hysteria‘ and cowardice

• 1916-British Army Council replaced ‗shell shock‘ with ‗Not Yet Diagnosed Nervous‘ (NYDN)-adopted aggressive frontline psychiatry and policies to end hysteria, cowardice and malingering

• 1917- American Expeditionary Forces entered WWI-avoiding holistic diagnoses. Salmon (1917) implements frontline ‗PIE‘ similar to French & British to ‗conserve the fighting force‘

Post-WWI Mental Health Crisis (P. Bailey; The New York Times; September 14, 1919)

Post-WWI Mental Health Crisis

Published: June 2, 1922

Post-WWI Mental Health Crisis

Published: September 9, 1923

Published: May 26, 1929

Post-WWI Mental Health Crisis Published:

June 30, 1935

The Trauma-Pension and Mind-Body

Wars from 1916 to 1943• After WWI, every major military power conducted investigations

into causes of the ‗dishonorable‘ epidemic of war hysteria with moral outrage of paying pensions to large masses of un-deserving vets.

• Urgent mission was to ensure there would never be a repeat of the universally condemnable ‗war hysteria‘ in future wars

The Enemy Within: Eliminating Dualistic War Hysteria and the ‗Culture of Trauma‘

• 1926, the German National Pension Court and Imperial Insurance Office reversed its 1889 decision-officially rejecting traumatic neurosis as actionable.

• 1939 Nazi Germany flatly outlawed post war disorders as a run up to WWII under the potential punishment of death

• War stress injuries universally viewed as illegitimate ‗dualistic predisposed hysterical‘ conditions ineligible for compensation as ‗imaginative‘ illness (Brunner, 2003).

• Japanese military government mandated destruction of all military mental health records (Matsumura, 2005).

The Enemy Within: Eliminating Dualistic War Hysteria and the ‗Culture of Trauma‘

• 1920- British War Office Committee of Enquiry - established due to socio-political concerns from veterans over treatment and compensation (Leese, 2002).

• The Commission attributed blame for war hysteric masses as result of poor recruit screening of inherently predisposed or defective personnel, low unit morale and training, cowardice and malingering-greatly exacerbated by psychiatric labels like ‗shell shock‘ that inadvertently provided honorable grounds to escape duty

• By 1939-Britain kept only six military psychiatrists on the payroll.

• 1942 British Prime Minister, Winston Churchill, ―I am sure it would be sensible to restrict as much as possible the work of these gentlemen (Army psychiatrists), who are capable of doing an immense amount of harm with what may very easily degenerate into charlatanry. The tightest hand should be kept over them, and they should not be allowed to quarter themselves in large numbers upon the fighting services at the public expense‖ (Cited in Jones & Wessely, 2005; p. 116).

Eliminating Dualistic

Predisposed War Hysteria

and Culture of Trauma

• 1927-Efforts to disband military mental health services began were completed by 1937 as reflected in the revised 685-paged U.S. Army‘s ―Handbook for the Medical Soldier‖ containing only a single page dedicated to treating war stress and a handful of military psychiatry advisors on the payroll (Wanke, 2005).

• 1941-Harry Sullivan appointed as U.S. Army psychiatric consultant to the Selective Service

• 1941 - Orr reported the objectives of NP screenings was to disqualify the obviously ‗psychopathic‘ or psychiatrically unfit then ―eliminate further: (1) those men with more subtle personality disorders missed by previous examiners; (2) men whose present personality makeup suggests that they may break under the special stresses and strains of camp life; and even beyond these, (3) men who may be expected to develop some type of neuropsychiatric disorder at any time during the next eleven years ―

• 1941 to 1943 rejected 1,680,000 ‗predisposed hysterics‘ or remotely defective inductees.

• However over 1,103,000 Army and 150,000 Navy/Marine Corps NP casualties resulting in 504,000 (72%) supposedly non-defective Army and 100,000 (67%) Navy/Marine Corps personnel psychiatrically discharged

• 248 veterans previously disqualified followed-up one year after induction with 209 (84%) still on active duty; 32 discharged (2 accepting officer commissions) and 5 killed in action

• 1943-Chief of Staff, General George C. Marshall – abandoned the failed social-experiment which empirically disproved the predominant paradigm of dualistic, predisposed war hysteria.

Published: May 21, 1942

World War II (1939-1945)

• 1939 – U.S. Army disbanded psychiatry units – emphasis screening out the mentally and intellectual deficient recruits prone to crack

• 1,680,000 registrants classified as ―unfit‖ due mental disease or educational deficiency

• 1943 – Capt Phil Hanson ―rediscovered‖ PIE returned rate of 70%

– Guadalcanal: 1MARDIV had 40% of casualties disabled by combat stress

– Okinawa: 1:2 disabled by combat stress

Paradigmatic Compromise for Dualistic

Predisposed Post War Disorders• 1943- Western paradigm emerged re-interpreting ‗acute‘

symptoms and ‗acute‘ post - war disorder as predictable, ‗universal‘ and holistic-but short-lived human stress reactions

• Consequently, since WWII- Western militaries emphasize non-pathological terms for acute stress breakdown, ‗battle or combat fatigue,‘ ‗flier‘s fatigue,‘ ‗battle or combat exhaustion,‘‘ ‗operational fatigue,‘ ‗combat-stress reaction‘ and contemporary ‗combat and operational stress reaction,‘

• De-pathologizing ‗acute‘ stress reactions and temporary breakdown by avoiding psychiatric labeling and military separation unless combatants did not recover

• 1958 Beebe & Appel. ―One of our cultural myths has been that only weaklings break down psychologically (and that) strong men with the will to do so can keep going indefinitely‖ (p. 164)

• **However- chronic war stress injury was viewed as evidence of dualistic predisposed war hysteria and/or secondary gain

Maintaining Dualistic War Hysteria

Paradigm in ‗Chronic‘ Post War Disorder• 1946 – ‗Infamous slap‘ of ‗battle fatigued‘ soldier by

General George C. Patton, USA, Palermo, Italy

• 2003 British High Court, MoD‘s experts testified, ―psychiatric thinking for most of the 20th century was of the view that the determinants of prolonged psychiatric disorder are established in early life, either by genetic or developmental processes‖ and that ―breakdown would be short lived. If this was not the case then the cause was not really the war at all, but a person‘s predisposition and personality‖(McGregor et al., 2006; p. 22).

• ―Before the 1970‘s, anyone who suffered long-term effects after a frightening event was considered constitutionally predisposed to mental illness or subject to a repressed childhood trauma; in either case, responsibility lay with the individual‖(Jones and Wessley, 2007)

Conflict Country Casualty Rates NP/MUS Rates Per

1,000

NP/MUS Admissions

WWII

(1939-1945)

German

(17,900,000)

American

(16,112,566)

British

(5,986,000)

Russian

(22,000,000)

Japanese

(9,100,000)

KIA: 3,500,000

WIA: 5,000,000

KIA: 291,557

WIA: 671,846

(1:19- NP:WIA)

KIA: 326,000

WIA: 277,077

KIA: 1,297,954

WIA: 1,166,615

KIA: 1,300,000

WIA: 4,000,000

20-30 per 1,000 NP only

60-70 per 1,000

(Southwest Pacific

theater)

38.3 per 1,000

(European theater)

-43.5 per 1,000 (Army

only)

British 2nd Army

(200 per 1,000) during

Normandy

NP only: 6-10 per 1,000

(1:38; NP:WIA)

Total: 472,250 ‘war neurotic’

-3-5% of all hospital admissions

were NP only

Total: 1,253,067 – NP only

Army: 1,103,067 –NP only

Navy/Marine Corps: 150,000-NP

only-34% of total admits

Total: 409,887 NP only

-Dyspepsia-largest single cause of

medical invalidity 1939-40; 17%

all medical discharges in May

1942

- ‘Lacking morale fiber’ (2,989) in

R.A.F.

Total: 1,007,585 NP

(26.6% NP of all hospital

admissions)

Total: 10, 454 NP

Published: August 6, 1944

Post-WWII Mental Health Crisis

Post-WII Mental Health Crisis

Published: July 12, 1944

Post-WWII Mental Health Crisis

Published: February 15, 1946

Post-WWII Mental Health Crisis (H. Rusk; The New York Times; November, 16, 1947)

Overview of Mind-Body Dualism

and the ‗Trauma-Pension Wars‘• 1952-DSM-I. Post-WWII research

on stress reactions led to the diagnostic formulation of ‗gross stress reaction‘ in the first DSM (APA, 1952).

• 1968-DSM-II, ‗transient situational disturbance‘ was adopted with a similar conceptualization of the holistic pathogenic effects of overwhelming stress (APA, 1968).

• 1980-DSM-III-‘PTSD‘ first diagnosis since 1864 ‗traumatic neuroses‘ attributing etiology to traumatic stressors vs. predisposed hysteria

Korean War (1950-1955)

―The Forgotten War‖

• 55,000 veterans died in Korea

• No major studies on Korean War veterans

• DoD provided frontline MH and triage system

• Estimated 30% of U.S. troops have full or partial PTSD, high incidence of substance abuse

• Least likely to utilize VA health services

Post-Korean War Mental Health Crisis

Work Centers Proposed for 'Goldbrickers'

By Nate Haseltine Staff Reporter

The Washington Post and Times Herald (1954-1959); Dec 1,

1954; ProQuest

Common Myths Underlying

Dualistic Predisposed War Hysteria

• Myth 1: Pre-20th century chronic post war disorder was rare (culture of trauma)

• Myth 2: Non-combatant breakdown is proof of predisposed war hysteria

• Myth 3: The vast majority (90%) of acute breakdown recover

• Myth 4: Resiliency is overwhelming (90%) normative response to war-thus chronic post war disorder is generally proof of predisposition

The PTSD Debate Enters the Trauma-

Pension Wars: Vietnam War (1964-1975)• 1988- Congressionally

Mandated National Vietnam Veterans Readjustment Study (NVVRS)

• Lifetime prevalence PTSD = 30% (1.7 million vets)

• 15.2% males (450,000) and 8.5% females (610), have current PTSD.

• 30% of WIA have current PTSD

• 50-60% co-morbidity

• 38% divorced within 6-

months

• 40% homeless men; 15%

unemployed

• Mortality - 65% more

likely suicide; 48% MVA

Post-Vietnam War Mental Health Crisis

Panel Says Delayed Fear Grips VetsBy Stuart Auerbach Washington Post Staff Writer

The Washington Post, Times Herald (1959-1973); May 3, 1972;

ProQuest

Debunking Myth 2:

Empirical Evidence of Stress and Health• General William C. Menninger, Office of Surgeon General, U.S. Army

(1947)- ―except for … a …[small]… group of psychologically and scientifically minded physicians, it has required …a second World War to acquaint the people with the actuality of psychosomatics‖ (p. 93).

• Seyle and Fortier (1950) ―The nervous system is particularly sensitive to the effects of systemic stress‖

• ―combat intensity is the greatest battlefield predictor of stress reactions. In general as the number of physical casualties rise, so will the numbers of CSRs‖ (Helmus & Glenn, 2005; p.32),

• Recent meta-analyses of 50 brain imaging studies on PTSD revealing structural abnormalities in multiple frontal-limbic brain areas associated with PTSD (Karl, Schaefer, Malta, Dorfel, Rohleder & Werner, 2006).

• Empirical review of 11 neuroimaging psychotherapy studies on mood and anxiety disorders, including PTSD-indicates significant changes in brain function coinciding with symptom reports following successful treatment (Frewen, Dozois & Lanius, in press).

OPERATION DESERT STORM

(1991)

-Post-deployment status: Few days

after return to CONUS, PTSD rate was

3.2% (males); 9.6% (females)

-18-months Post-deployment: PTSD

rate increased 9.4% (males); 19.8%

(females)

- Handling human remains – PTSD

rates of 48% current; 65% lifetime

-Congressional Gulf War Studies

-1998 PL 105-277 Persian Gulf War

Veterans Act

-1998 PL 105-368 Veterans Programs

Enhancement Act

Gulf War Syndrome Theories

Congressional Gulf War Studies on

Health Effects of War Stress

• ―In response to deployment-related stress, physiologic changes occur in the body, may persist for a long time after deployment has ended, and may result in symptoms and disorders that appear soon after exposure to the stressor or become evident only years later.‖ (IOM, 2008; p. 66).

Congressional Gulf War Studies:

Chronic Health Effects of War

• ―Activation of the stress response ensures survival in the short term, but is maladaptive when its activation persists as a result of chronic, severe, or repeated stress‖ (IOM, 2008; p. 59).

• ―Chronic stress can lead to adverse health outcomes that affect multiple body systems such as the CNS, endocrine, immune, gastrointestinal and cardiovascular systems.‖ (IOM, 2008; p. 59)

Common Myths Underlying

Dualistic Predisposed War Hysteria

• Myth 1: Pre-20th century chronic post war disorder was rare (culture of trauma)

• Myth 2: Non-combatant breakdown is proof of predisposed war hysteria

• Myth 3: The vast majority (90%) of acute breakdown recover

• Myth 4: Resiliency is overwhelming (90%) normative response to war-thus chronic post war disorder is generally proof of predisposition

Debunking Myth 3: Recovery after Acute

Breakdown is Normative• Reviews of efficacy of frontline psychiatry- 78-85% of troops not

restored to full-duty (Jones & Wessely, 2003)

• 1944- ‗Restricted‘ report of restoration rate between 16-32% (Sandiford,

1944a)

• 1944- ‗Secret‘ classified study reports 43% relapse (Sandiford, 1944b)

• 1943 -‗Restricted‘ report, ―of patients returned to duty, how many go back to combat? We have no figures with which to answer the question, but can make a fairly good estimate—it is less than 2.0 per cent!‖ (Grinker & Spiegel, 1943).

• 1943 -―over 70% can be rehabilitated for selective non-combatant service, in quiet sectors‖ (Grinker & Spiegel, 1943)

• 2003- British High Court upheld the MoD‘s defense ruling ―Given this relative absence of reliable evidence as to their therapeutic effect there was a further question mark over whether or not it was even ethical to implement the principles of forward psychiatry at all‖ (McGregor et al., 2006; p. 25).

Common Myths Underlying

Dualistic Predisposed War Hysteria

• Myth 1: Pre-20th century chronic post war

disorder was rare (culture of trauma)

• Myth 2: Non-combatant breakdown is proof

of predisposed war hysteria

• Myth 3: The vast majority (90%) of acute

breakdown recover

• Myth 4: Resiliency is overwhelming (90%)

normative response to war-thus chronic post

war disorder is often proof of predisposition

Predispositions and Risk Factors in

General and Mental Health• 2003 MoD PTSD Case-

‖psychiatric thinking for most of the 20th century was the view that the determinants of prolonged psychiatric disorder are established in early life.‖

• ―Breakdown would be short-lived. If this was not the case then the cause was not really the war at all, but a person‘s predisposition and personality‖ (McGregor et al., 2006; p. 22)

• ―What is most important to reiterate is that the causes of health and disease are generally viewed as a product of the interplay or interaction between biological, psychological and socio-cultural factors. This is true for all health and illness, including mental health.‖ (American Surgeon General, DHHS, 1999)

‗Old Sergeant‘s Syndrome‘

Old Sergeant‘s Syndrome

• 1949 -Sobel studied 100 seasoned noncommissioned officers ‗old‘ in combat experience identified with ―old sergeant syndrome,‖ or ―Guadalcanal twitch‖ a constellation of chronic psychophysical symptoms in well-motivated, combat-tested, invaluable soldiers and leaders

• ―For these men were among the best and most effective of the trained and disciplined combat infantry soldiers‖ (Sobel, 1949, p. 137)

• 2nd Lieutenant Audie Murphy (1924-1971), depicted in the 1949 movie, ‗To Hell and Back‘, is the American military‘s most highly decorated WWII soldier receiving 33 awards for bravery including the Medal of Honor, after fighting in 9 major European campaigns, and being WIA three times- suffered publicly from severe ‗battle fatigue,‘ insomnia and depression symptoms consistent with PTSD (http://www.audiemurphy.com).

• ‗Flier‘s fatigue‘ ‗operational fatigue‘ was vividly illustrated in the 1949 movie ‗Twelve O‘ Clock High‘ with fewer than 25% completing a full tour of duty (Chermol, 1985).

Current Paradigm of Post War Disorders in

21st Century Military Medicine

• 8/18/08: ―Of the 10 percent or so who have PTSD, most will recover with time, patience and love. Some will need more.‖ (S. Ward Casscells, M.D.;

ASD(HA), MHS.blog)

• 8/18/08: ―Services altering strategy on PTSD…that treats such ailments (PTSD) as temporary instead of lifelong problems‖ (Stars

& Stripes, 2008)

• 8/18/08: ―In the past, we thought if a Marine had PTSD, he was gone. Now it‘s more like breaking a leg.‖ (SGTMAJ Wilson, Personal and

Family Readiness Division, S&S, 2008)

DVA/DoD Public Health Model• Most war fighters/veterans will not develop a

mental illness but all war fighters/veterans and their families face important readjustment issues

• This population-based approach is less about making diagnoses than about helping individuals and families retain a healthy balance despite the stress of deployment

• Incorporates the Recovery Model and other principles of the President‘s New Freedom Commission on Mental Health

– There is a difference between having a problem and being disabled

PTSD and Current U.S. Army

‗Textbook of Military Medicine: War

Psychiatry‘

• ―Chronic PTSD symptoms develop in those with social and biological predispositions in whom the stressor is meaningful when social supports are inadequate‖ (Jones, 1995; p. 416).

• ―Other mechanisms such as positive reinforcement (secondary gain in Freud‘s model) seem more important in the chronic maintenance of symptoms‖ (Jones, 1995; p. 417).

Resistance to Scientific Change and EMDR:

A Case Study of Dualism and Disparity in the

Armed Services

Progression of Science and Prominence

• Scientific resistance to innovation or change is necessary has an adaptive function

• In psychology, prominence is relative to whichever theory is currently favored by the broader scientific and intellectual community as opposed to specific school‘s ability to document scientific truths(Tracy et al., 2005)

VA/DoD CPG and EMDR

• ―Overall, argument can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD‖ (pg. 5).

• ―Foa et al (1995) note that exposure therapy may not be appropriate for use with clients whose primary symptoms include guilt, anger, or shame‖ (pg. 4).

• ―EMDR may be more easily tolerated for patients who have difficulties engaging in prolonged exposure therapy‖ (pg. 2).

VA/DoD CPG and EMDR

• ―The possibility of obtaining significant clinical improvements in PTSD in a few sessions presents this (EMDR) treatment method as an attractive modality worthy of consideration‖(pg 1)

• ―EMDR processing is internal to the patient, who does not have to reveal the traumatic event‖ (pg 1).

• ―EMDR has been found to be as effective as other treatments in some studies and less effective than other treatments in some other studies‖ (pg 9 summary).

Domestic and International PTSD

Treatment Practice Guidelines:

EMDR as EBT-PTSD

• American Psychological Association, Division 12 (Chambless et al., 1998)

• International Association for Traumatic Stress Studies (Foa, Keane, & Friedman, 2000)

• United Kingdom Department of Health (2001)

• Israeli National Mental Health Council (Bleich, Kotler, Kutz, & Shalev, 2002)

• Northern Ireland Department of Health (2003)

• Dutch National Steering Committee for Mental Health Care (2003)

• French National Institute of Healthand Medical Research (2004)

• DVA/DoD (2004)

• American Psychiatric Association (APA, 2004)

• U.K.‘s National Institute for Clinical Excellence (NICE, 2005)

• International Cochrane Review (2007)

• International Studies of Traumatic Stress Society (2007)

Domestic and International PTSD

Treatment Practice Guidelines:

EMDR as non-EBT-PTSD

• VA commissioned

Institute of Medicine

(2007) review

Restricted Access to EMDR

Training in DoD

• Center for Deployment Psychology (2007)-mission train DoD interns/residents

• VA‟s National Center-PTSD-mission train DVA/DoD

• No EMDR training

• Army Medical Department (AMEDD)-offering limited EMDR training since 2008

DoD/VA Regional PTSDTraining Project(Russell, Silver, Rogers, & Darnell, 2007)

Dates of Training Location #MH providers trained

12-13 Jan 05 (part I) PACNORWEST region. Ft.

Lewis Army Base, WA

70 total: (DoD = 60; VA =

10)

28 Jan – 4 Feb (part I) NH Great Lakes, MI 10 total: (DoN)

8-10 Apr 05 (part I) NAS Brunswick, ME 8 total: (DoD)

19-20 Apr 05 (part I) NH Bremerton, WA 10 total: (DoN/DoA)

4-5 May 05 (part II) PACNORWEST Region, Ft.

Lewis Army Base, WA

62 total: (DoD = 57;

VA = 5)

9-10 May 05 (part I) NMCSD, San Diego 15 total: (DoN)

Aug 05 (part I & II) NH Camp Pendleton, CA 12 total: (DoN)

Sep 05 (part I & II) Ft. Hood, TX 70 total: (DoA)

Total of 10

Trainings

*257 total

participants

EMDR Treatment Outcome: Combat-PTSDMean # sessions = 4.3 (n = 48)

(Russell, Silver, Rogers, & Darnell, 2007)

8.5

2.2

1.2

6.8

0

1

2

3

4

5

6

7

8

9

Pre-tx Post-tx

SUDS

VoC

EMDR Treatment Outcome: Combat PTSDImpact of Events (IES) & Beck Depression

Inventory (BDI) (n = 48)(Russell, Silver, Rogers, & Darnell, 2007)

61

20 20

4.2

0

10

20

30

40

50

60

70

Pre-tx Post-tx

IES

BDI

Banning of EMDR Research in DoD(Russell & Friedberg, 2008)

EM D R Treatm ent For C om bat R elated Stress

0

5

10

15

20

25

30

35

40

45

50

Patient 1 31 5

Patient 2 38 15

Patient 3 42 8

Patient 4 44 10

Pre IES Post IES

• $300 million to study PTSD

and TBI (USA Today, 8/5/08)

• 2007-DoD‘s ‗Center of

Excellence for Psychological

Health and Traumatic Brain

Injury‘ in Arlington, VA

• 28 March 2008 key word

search of PILOTS PTSD

dbase:

• CT = 1096

• EMDR = 533

National PTSD Research

• A 28 March 2008 key word query of NIMH‘s PTSD Research dbase

• CT – 638

• CBT – 255

• Behavior Therapy – 641

• Question: ―The number of references to EMDR research in the NIMH‘s dbase is:‖

• (a) 2

• (b) 12

• (c) 50

• (d) 105

• Correct answer:

• (a)

RCT favorably comparing EMDR to Prozac and placebo (van der Kolk et al., 2007)

(Russell & Friedberg, 2008)

Mental Health Disparity in

Federal Research

Veteran‘s PTSD Research• A 28 March 2008 key word

query of VA‘s National

Center for PTSD Research

dbase:

• CT – 76

• BT – 30

• ET – 27

• Question: ―The number of

references to EMDR

research in the NC-

PTSD‘s dbase is:‖

• (a) 0

• (b) 9

• (c) 18

• (d) 27

• Correct answer:

• (b) – 9, but only 2 actual research articles found(Russell & Friedberg, 2008)

Military PTSD Research• A 28 March 2008 key

word query of DoD‘s

Deploy-Med Research

dbase:

• CT – 647

• CBT – 526

• ET – 368

• VRT – 111

• CPT - 61

• Question: ―The number of references to EMDR research in the DoD‘s dbase is:‖

• (a) 11

• (b) 50

• (c) 158

• (d) 305

• Correct answer:

• None of the above

• ‗0‘ EMDR research! (Russell & Friedberg, 2008)

Military PTSD Research (Russell & Friedberg, 2008)

• Which of the

following therapies

is NOT one of the

13 current DoD

PTSD treatment

trials?

• (a) Yoga

• (b) EMDR

• (c) Acupuncture

• (d) Bioenergy

• Answer:

• (b) EMDR

Restricted Access to EMDR Treatment• Tricare Management Activity (TMA)

• 5 Feb 2005. ―I request that TRICARE coverage for this rapidly emerging mainline therapy for PTSD be re-evaluated. I do not believe that increased cost would result, as patients who are candidates for EMDR are currently receiving traditional psychotherapy. In fact, if the rapidity of response is as it appears to be, costs would actually be reduced with shorter duration of therapy.‖ (BG Dunn)

• 30 Jul 2007. ―I believe that increased costs should not result, as patients who are candidates for EMDR are currently receiving traditional psychotherapy and EMDR actually has shorter therapy duration and better success. I strongly recommend that EMDR be a TRICARE covered psychotherapy service for all TRICARE beneficiaries.‖ (MAMC)

• 13 Aug 2008. ―Eye movement desensitization and reprocessing therapy (EMDR) is considered an unproven treatment and is not covered by TRICARE.‖ (OSD-HA/TMA)

Conclusions: Preventing the

Recycling of Trauma-Pension Wars

• Military medicine to take the lead and adopt a holistic, neuropsychiatric paradigm of post war disorders

• Top-down, aggressive public health campaign to eliminate dualism, MH neglect and disparity during times of war and peace

• Establish separate ‗Mental Health Corps‘ and eliminate disparity between providers

• Eliminate harmful scientific resistance and bias toward EMDR and any other future EBT

Carpe diem?

Slides: info@emdria.org

Contact Mark Russell: desensei01@aol.com