Shrinks (35 page)

In the article, Shatan wrote that Post-Vietnam Syndrome manifested itself fully after a veteran returned from Asia. The soldier would experience “growing apathy, cynicism, alienation, depression, mistrust and expectation of betrayal, as well as an inability to concentrate, insomnia, nightmares, restlessness, rootlessness, and impatience with almost any job or course of study.” Shatan identified a heavy moral component to veterans’ suffering, including guilt, revulsion, and self-punishment. Shatan emphasized that the most poignant feature of Post-Vietnam Syndrome was a veteran’s agonizing doubt about his ability to love others and to be loved.

Shatan’s new clinical syndrome immediately became fodder for the polarized politics over the Vietnam War. Supporters of the war denied that combat had any psychiatric effects on soldiers at all, while opponents of the war embraced Post-Vietnam Syndrome and insisted it would cripple the military and overwhelm hospitals, leading to a national medical crisis. Hawkish psychiatrists retorted that the
DSM-II
did not even recognize combat exhaustion; the Nixon administration began harassing Shatan and Lifton as antiwar activists, and the FBI monitored their mail. Dovish psychiatrists responded by wildly exaggerating the consequences of Post-Vietnam Syndrome and the potential for violence in its victims, a conviction that soon turned into a caricature of demented danger.

A 1975
Baltimore Sun
headline referred to returning Vietnam veterans as “Time Bombs.” Four months later, the prominent
New York Times
columnist Tom Wicker told the story of a Vietnam veteran who slept with a gun under his pillow and shot his wife during a nightmare: “This is only one example of the serious but largely unnoticed problem of Post-Vietnam Syndrome.”

The image of the Vietnam vet as a “trip-wire killer” was seized upon by Hollywood. In Martin Scorsese’s 1976 film
Taxi Driver
, Robert De Niro is unable to distinguish between the New York present and his Vietnam past, driving him to murder. In the 1978 film
Coming Home
, Bruce Dern plays a traumatized vet, unable to readjust after returning to the States, who threatens to kill his wife (Jane Fonda) and his wife’s new paramour, a paraplegic vet played by Jon Voight, before finally killing himself.

While the public came to believe that many returning veterans needed psychiatric care, most veterans found little solace in shrinks, who tried to goad their patients into finding the source of their anguish within themselves. The rap sessions, on the other hand, became a powerful source of comfort and healing. Hearing the experiences of other men who were going through the same thing helped vets to make sense of their own pain and suffering. The Veterans Administration eventually recognized the therapeutic benefits of the rap sessions and reached out to Shatan and Lifton to emulate their methods on a wider scale.

Meanwhile, Shatan and Lifton puzzled over the process by which Post-Vietnam Syndrome produced such dramatic and debilitating effects in its victims. One clue lay in its similarity to the emotional trauma in other groups of victims, such as the Hiroshima survivors documented by Lifton, as well as those who were imprisoned in Nazi concentration camps. Many Holocaust survivors aged prematurely, confused the present with the past, and suffered from depression, anxiety, and nightmares. Having learned to function in a world without morality or humanity, these survivors often found it difficult to relate to ordinary people in ordinary situations.

Shatan concluded that Post-Vietnam Syndrome, as a particular form of psychological trauma, was a legitimate mental illness—and should be formally acknowledged as such. Although the Vietnam War was raging in the late 1960s as the
DSM-II
was being assembled, no diagnosis specific to psychological trauma, let alone combat trauma, was included. As had been the case with
DSM-I
, trauma-related symptoms were classified under a broad diagnostic rubric, “adjustment reaction to adult life.” Veterans who had watched children bayoneted and comrades burned alive were understandably outraged when informed that they had “a problem in adult adjustment.”

When Shatan learned that the
DSM
was undergoing revision and that the Task Force was not planning to include any kind of diagnosis for trauma, he knew he had to take action. In 1975, he arranged to meet with Robert Spitzer, who he already knew professionally, at the APA annual meeting in Anaheim, California, and lobbied vehemently for the inclusion of Post-Vietnam Syndrome in
DSM-III
. Initially, Spitzer was skeptical of Shatan’s proposed syndrome. But Shatan persevered, sending Spitzer reams of information describing the symptoms, including Lifton’s work on Hiroshima victims—the kind of diagnostic data that was always sure to get Spitzer’s attention. Spitzer eventually relented and in 1977 agreed to create a Committee on Reactive Disorders and assigned one of his Task Force members, Nancy Andreasen, the job of formally vetting Shatan’s proposal.

Andreasen was a smart and tough-minded psychiatrist who had worked in the Burn Unit of New York Hospital–Cornell Medical Center as a medical student, an experience that would shape her attitude toward Post-Vietnam Syndrome. “Bob Spitzer asked me to deal with Shatan’s Syndrome,” Andreasen explained, “but he did not know that I was already an expert on the topic of stress-induced neuropsychiatric disorders. I began my psychiatry career by studying the physical and mental consequences of one of the most horrible stresses that human beings can experience: severe burn injuries.”

Gradually, Andreasen came to agree with Shatan’s conclusions: that a consistent syndrome of symptoms could develop from any traumatic event, whether losing your home in a fire, getting mugged in a park, or being in a firefight during combat. Since she had previously classified the psychology of burn victims as “stress-induced disorders,” Andreasen christened her broadened conceptualization of Post-Vietnam Syndrome as “Post-Traumatic Stress Disorder” and proposed the following summary: “The essential feature is the development of characteristic symptoms following a psychologically traumatic event that is generally outside the range of usual human experience.”

Despite the meager scientific evidence available on the disorder beyond Shatan and Lifton’s observations from the veteran rap groups, the Task Force accepted Andreasen’s proposal with little opposition. Spitzer later acknowledged to me that if Shatan had not pressed his case for Post-Vietnam Syndrome, most likely it would never have ended up in the
DSM-III
.

Since then, traumatized veterans have had a much easier time getting the medical attention they need, since both the military and psychiatry finally acknowledged that they were suffering from a genuine medical condition.

But while the
DSM-III
bestowed legitimacy on the suffering of soldiers traumatized in war—as well as the suffering of victims of rape, assault, torture, burns, bombings, natural disasters, and financial catastrophe—when the
Manual
was published in 1980, psychiatrists still knew precious little about the pathological basis of PTSD and what might be going on in the brains of its victims.

A Fear of Fireworks

The Kronskys were barely forty and enjoyed a happy marriage. He was a successful accountant. She translated foreign-language books into English. But the focus of their life was their two rambunctious children: twelve-year-old Ellie and ten-year-old Edmund. One evening, Mr. and Mrs. Kronsky and Edmund attended a holiday dinner at a friend’s home. (Ellie spent the night at a classmate’s birthday sleepover party.) After a festive dinner, the Kronskys climbed into their car and headed home on familiar roads. Edmund yawned and expressed disappointment that he had missed the Knicks game, though Mr. Kronsky assured him that they had taped it and Edmund could watch it tomorrow. And then, without warning, their lives changed forever.

As the Kronskys passed through an intersection, a speeding SUV hurtled through a red light and slammed into the rear of their car on the passenger side. Edmund was sitting in the back seat with his seatbelt unbuckled. The rear doors crumpled and wrenched open, and Edmund was thrown out of the car into the middle of the intersection. A large pickup truck was bearing down on the intersection from the opposite direction.

The driver of the pickup had no time to swerve, and Mr. and Mrs. Kronsky watched in horror as the vehicle rolled over Edmund’s body. Despite the rapid arrival of an EMS team, the boy could not be saved.

For the next two years the Kronksys grieved together, avoiding friends and family. Then, ever so gradually, Mrs. Kronsky started to recover. First, she began translating books again. Then she reached out to their old friends, and eventually started going to the movies with them and sharing a meal afterwards. Though she could never fully let go of the tragedy of losing her son, by the end of the third year she had resumed most of the routines of her former life.

For Mr. Kronsky, it was a different story. Two years after the accident, he was still visiting his son’s grave almost every day. He had no interest in any social activities, even after his wife began seeing their friends again. He was always irritable and distracted. Sloppy mistakes began to creep into his accounting work. Loyal clients went to other firms. While he had previously managed his family’s finances with obsessive fastidiousness, he now ignored them almost completely. His entire universe consisted of a single memory repeated over and over, day after day: the pickup trampling his small, frightened son.

As Mrs. Kronsky continued to recover, Mr. Kronsky only grew worse. He drank heavily and provoked explosive arguments with his wife, which is what prompted them to see me. After our first session, it was clear that Mr. Kronsky was suffering from PTSD and a complicated grief reaction. I worked with them for a few months and helped wean Mr. Kronsky off alcohol. Antidepressant medication helped mitigate some of his more severe mood swings and his outbursts of rage, and eventually the marital discord diminished—or at least the number of fights decreased. But other problems persisted.

Despite my best efforts, Mr. Kronsky was unable to function effectively at work and failed to resume any of his former social and recreational activities. Most of the time he sat at home watching television, at least until some program triggered a memory of his son’s death and he swiftly flicked it off. With his business collapsing, his wife became the breadwinner; this became a source of increasing tension, since he resented that she was the one providing for their family. Meanwhile, she grew increasingly frustrated with her husband’s unwillingness to even
try
to do anything outside of their home.

Finally, Mrs. Kronsky decided she could no longer live with a disabled husband who refused to try to move on. She believed their home was an unhealthy environment for her daughter, who came home from school each day to inevitably find an angry father sulking around the house or curled up on the sofa—a father who treated Ellie as if she was dead, too. Finally, Mrs. Kronsky moved out with her daughter and filed for divorce. She continued her career, saw her daughter go off to college, and eventually remarried. Mr. Kronsky’s life had a much different outcome.

Unable to overcome the horrific event that cost him his son, he returned to his abuse of alcohol and eventually cut me off, too. When I last interacted with him, he remained trapped in a bleak, isolated existence, avoiding all contact with other people, including those who wished to help him.

Why did Mr. Kronsky develop post-traumatic stress disorder and not Mrs. Kronsky, even though they both experienced the same trauma? When the
DSM-III
Task Force voted to authorize PTSD, there was no knowledge about how trauma produced its immediate and enduring effects and no understanding of how to alleviate its consequences. If a soldier is hit in the head by flying shrapnel, we know what to do: stop the bleeding, clean and bandage the wound, get X-rays to assess any internal damage. PTSD, in contrast, was a complete mystery. If this is a serious mental illness with a clear-cut cause, shouldn’t we be able to figure out
something
about how it works?

Once PTSD was legitimized by its inclusion in
DSM-III
, funding for research on the disorder started pouring in. However, it required the “brain revolution” in psychiatry—the new brain-imaging techniques in the 1980s and the increasing number of psychiatric neuroscientists inspired by Eric Kandel—before researchers could make headway and begin to understand the intricate neural architecture of the brain that underlies PTSD. Gradually, in the 2000s, new brain-focused research revealed the pathological process that is believed to cause the condition.

This process involves three key brain structures: the amygdala, the prefrontal cortex, and the hippocampus. These three structures form a neural circuit that is essential for learning from emotionally arousing experiences, but if an experience is
too
extreme, the circuit can turn against itself. For example, imagine you are visiting Yellowstone National Park. You stop your car to take a stroll in the woods. Suddenly, you spot a huge bear not far away. You immediately feel a rush of fear because your amygdala, a part of your primordial emotional system, has sounded the alarm for danger and signaled for you to flee. What should you do?