Guest Editorial
Troubles in Traumatology
Richard J McNally, PhD 1
(Can J Psychiatry 2005;50:815–816)
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No area within psychiatry has expanded as much as traumatology—the study of the causes and treatment of posttraumatic stress disorder (PTSD). Despite its phenomenal growth, traumatology has been wracked with controversy (1,2). From the beginning, critics of the PTSD diagnosis wondered whether its advocates had discovered a disease entity in nature or whether they had cobbled together a cluster of symptoms shared with other syndromes and then traced its etiology to the unpopular war in Vietnam (3). Was PTSD discovered by clinical scientists or created by them?
Several years later, the National Vietnam Veterans Readjustment (NVVRS) study reported that 30.9% of all men who had served in that war—cooks and clerks as well as infantrymen— had developed PTSD and that another 22.5% had developed partial, subclinical PTSD (4, p 63). That over one-half of all who served developed at least the subclinical form of the disease should have been surprising, especially because only 15% of those who served in Vietnam were in combat units (5, p 209). The NVVRS suggested a hidden epidemic of untreated PTSD among Vietnam veterans, and funds poured into Department of Veterans Affairs (DVA) hospitals to cope with the problem. However, few seemed to notice that the NVVRS reported that twice as many men developed PTSD as were assigned to combat units. The mystery behind the discrepancy in numbers of those with the disease and of those in combat remains unsolved today.
Meanwhile, beginning in the 1980s, the notion that many adults harboured repressed (or dissociated) memories of their childhood sexual abuse (CSA) began to spread. Although architects of the PTSD diagnosis emphasized that traumatic events were remembered all too well, other traumatologists argued that the mind can protect itself by banishing horrific memories from awareness. Therapists began interpreting diverse symptoms as signs of inaccessible memories of trauma and began to use hypnosis and other methods to unlock and detoxify the supposed dissociated memories that were silently poisoning the mental health of victims. The movement to help survivors recall these allegedly repressed memories resulted in the worst catastrophe to befall the mental health field since the lobotomy era.
Therapy designed to recovered alleged repressed memories of trauma was based on misunderstandings of how memory works. The 2 articles in this issue were written to help counteract these misunderstandings. The first covers a multitude of errors that continue to plague the literature on trauma (6). Clinical theorists endorsing the concept of traumatic dissociative amnesia often misunderstand the very studies they cite in support of this alleged phenomenon. They often misinterpret diverse memory impairments as if they indicated an inability to remember the trauma itself.
The second article reviews evidence that people can come to believe they experienced emotionally intense events that never happened (7). It refutes the claims that people can only develop false memories of trivial events devoid of emotional significance and that memories of trauma are invariably accurate. This article is cowritten by Elizabeth F Loftus, one of the great figures in the history of psychology—a recent empirical study ranked her 58th in a list of the 99 most eminent psychologists of the 20th century (8).
Like a tsunami that has yet to strike shore, the impact of the most serious controversy in traumatology has yet to be felt. It concerns the validity of self-reported trauma exposure in American war veterans receiving service-connected disability payments for PTSD. Burkett and Whitley’s award-winning book Stolen Valor: How the Vietnam Generation Was Robbed of its Heroes and its History (9) alerted the field to the possibility that many individuals diagnosed with PTSD may never have been exposed to trauma in the first place. Mainstream traumatologists, however, have either ignored Stolen Valor or privately maligned the authors’ motives without substantively rebutting Burkett and Whitley’s critique of the field.
In fact, subsequent work has vindicated Burkett and Whitley. In a landmark study, Frueh and colleagues consulted archival data for 100 patients assessed at a DVA hospital who reported having been exposed to PTSD-inducing trauma in Vietnam (10). Only 41% of them had any evidence of combat exposure in their military personnel files. Although 94% had been diagnosed with PTSD, some were never in Vietnam or never in the military at all. Others had served in Vietnam as clerks or cooks but had described having suffered battlefield trauma.
An investigation recently completed by the Office of the Inspector General (OIG) of the DVA revealed that 25.1% of 2100 randomly chosen patients receiving service-connected disability had no convincing evidence in their clinical files of having been exposed to any traumatic events (11). The rate of these apparent false-positive cases of PTSD varied from a low of 11% in Maine to a high of 40.7% in Oregon. Because the report did not indicate how many had been involved in research studies, it is unclear how seriously the scientific database has been infected with false positives. However, in a recent neuroimaging study on combat-related PTSD, the researchers found that 53% of the combat-related PTSD subjects had no evidence of documented exposure to combat (12).
The OIG uncovered other bizarre facts. For example, the modal PTSD case got worse over time, despite treatment in the DVA hospital, until the service-connected disability rating reached 100%. At that point, mental health visits plummeted by 82%; for many patients, they ceased altogether once the maximum financial compensation had been achieved.
Why has traumatology lurched from one controversy to another? Why has PTSD, unlike the other anxiety disorders, been so often embroiled in serious controversy? One possibility is that concern for the plight of victims has led clinical researchers to suspend their scientific skepticism. To question those reporting exposure to childhood sexual abuse or those who served their country during wartime seems offensive and morally repugnant. As scientists, however, traumatologists are committed to discovering and publishing the truth, and pursuing the truth about trauma is ultimately best form of victim advocacy.
Funding and Support
Preparation of this manuscript was supported by grant MH 61268 from the National Institute of Mental Health, Bethesda, Maryland.
Acknowledgement
I thank BG Burkett for his comments on this editorial.
References
1. McNally RJ. Remembering trauma. Cambridge (MA): Belknap Press, Harvard University Press; 2003.
2. Rosen GM, editor. Posttraumatic stress disorder: Issues and controversies. Chichester (UK): Wiley; 2004.
3. Young A. The harmony of illusions: Inventing post-traumatic stress disorder. Princeton (NJ): Princeton University Press; 1995.
4. Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, and others. Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans Readjustment Study. New York (NY): Brunner-Mazel; 1990.
5. Dean ET Jr. Shook over hell: post-traumatic stress, Vietnam, and the Civil War. Cambridge (MA): Harvard University Press; 1997.
6. McNally RJ. Debunking myths about trauma and memory. Can J Psychiatry 2005;50:817–22.
7. Laney C, Loftus EF. Traumatic memories are not necessarily accurate memories. Can J Psychiatry 2005;50:823–8.
8. Haggbloom SJ, Warnick R, Warnick JE, Jones VK, Yarbrough GL, Russell TM, and others. The 100 most eminent psychologists in the 20th century. Rev Gen Psychol 2002;6:139–52.
9. Burkett BG, Whitley, G. Stolen valor: How the Vietnam generation was robbed of its heroes and its history. Dallas (TX): Verity Press; 1998.
10. Frueh BC, Elhai JD, Grubaugh AL, Monnier J, Kashdan TB, Sauvageot JA, and others. Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder. Br J Psychiatry 2005;186:467–2.
11. Department of Veterans Affairs Office of Inspector General. Review of state variances in VA disability compensation payments (Report 05-00765-137. 2005 May 19). Availabale: www.va.gov/foia/err/standard/requests/ig.html. Accessed 2005 Oct 7.
12. Kimbrell T, Leulf C, Cardwell D, Komoroski RA, Freeman TW. Relationship of in vivo medial temporal lobe magnetic resonance spectroscopy to documented combat exposure in veterans with chronic PTSD. Psychiatry Res Neuroimaging. Forthcoming.
Author
1. Professor, Department of Psychology, Harvard University, Cambridge, Massachusetts.
e-mail: rjm@wjh.harvard.edu
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