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Simon Wessely, esteemed British psychiatrist and researcher, is now Sir Simon.
Last month, the Queen bestowed knighthood upon the 57-year-old King’s College professor for his pioneering work to improve mental health services in the British armed forces. (Beeb story here).
News of this glorious honor should promote the work of Sir Simon — who is both my friend and colleague — far and wide. Within the field of psychiatry, his studies on the history of combat-related post-traumatic stress disorder, its features and treatment should be mandatory reading.
Among his most powerful findings is the vast role that social and psychological contexts play in the manifestation of postwar distress. This holds great significance for how the military and clinicians think about the psychological casaulty of war, address the problem of suicide among veterans, and ease soldiers’ re-entry into civilian life.
I was reminded of Wessely’s subtle analyses when I read of a potential new treatment for PTSD called a stellate ganglion block. In brief, the stellate ganglion is a collection of nerve cells that form a knot-like structure next to the spine at the level of neck. The nerve fibers emanating from the ganglion, one on each side, are connected to the arm and upper trunk (and regulate sensation of pain, vasculature constriction and sweating) and to various parts of the brain, including the amygdala, which is thought to be associated with fearful and aggressive responses.
Blocking the stellate ganglion with a local anesthetic may suppress the so-called “fight or flight” reaction common to many people with PTSD. Early outcomes of this procedure are mixed but gauging its promise on a larger scale is ultimately an empirical matter for researchers, who are now seeking partipants at the Navy Medical Center in San Diego, here. And if it proves to be helpful, I, as a psychiatrist, would surely offer it to patients.
But what struck me about the ganglion blockade is that it targets only one dimension of PTSD: the physiological. Without question, symptoms of nervous system dysregulation –anxiety, phobias, hypervigilance, disrupted sleep — are common in PTSD. They are the signature symptoms as most contemporary psychiatrists understand the syndrome. But conceptualizing PTSD as a primarily neurological problem – that is, an innate fear reaction that does not abate when a person is no longer under threat — is one reason that treatments aimed at the biological underpinnings of the condition are woefully inadequate for many veterans.
There is a narrative component to post-war distress.
How veterans come to see themselves, their futures, their role in the family, and in the world, have a profound influence on readjustment. Damning self-appraisal mixed with alcohol probably lies behind many of the suicides in veterans. This anguish is more existential than it is psychiatric, although it is very important to recognize that the nature of post-war syndromes is not either/or. What’s more, these two general forms of pathology can exacerbate each other.
One of the best illustrations of the mental fog of war – the overwhelming feelings of social dislocation, guilt, or unremitting sorrow – are portrayed movingly in the New York Times‘ series of articles on veterans back from war. In a long 2009 article on suicides, Erica Goode wrote, here, of some veterans’ “obsession with failures, real or imagined.” One Army veteran Goode writes about was trailed by grief and guilt “combined with other stresses: financial troubles, disputes with his estranged wife over their young daughter, the absence of the tight group of friends who had helped him make it through 12 months of war.”
“`I have failed myself,’ he wrote in a note found later in his car. `I have let those around me down.’”
A recent account, here, of female veterans who had been sexually abused in the service emphasized the insult of betrayal of trust in their colleagues and the military. In a vet center in Long Beach, California, the article described how “the women formed an emotional battalion, squaring off against unseen enemies: fear, loneliness, distrust, anger and, most insidious of all, the hardened heart.”
For many veterans, the transition between military and civilian life is a critical juncture marked by acute feelings of flux and dislocation. A veteran’s odds of success in civilian life depend greatly on nonmedical factors, including his own expectations for recovery; social support available to him; and the intimate meaning he makes of his wartime hardships and sacrifice.
That is why mental-health professionals must pay attention to the everyday problems that beset many veterans during the readjustment period, including financial stress, marital discord, parenting strains, occupational needs. These can hasten the demoralization that combined with alcohol and hopelessness is a tinderbox prescription for suicide.
Returning from war is a major existential project. Imparting meaning to the wartime experience, reconfiguring personal identity, and reimagining one’s future take time. Biological therapies should of course be part of an armamentarium of care, but in so many cases, they won’t be enough.
Sally Satel is a psychiatrist, resident scholar at the American Enterprise Institute, and lecturer at Yale University School of Medicine. She is co-author of the forthcoming book, Brainwashed – The Seductive Appeal of Mindless Neuroscience.
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