Tuesday, May 18, 2021

The PTSD Story Part 2: WWI leading to Medical 203

PTSD was introduced as a diagnosis in the third edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1980, however, the PTSD story starts with World War I and the U.S. Army's Medical 203.

When writing about the ‘darker side’ of military mental healthcare, Russell, Schaubel, and Figley (2018) explain how all major European armies witnessed unprecedented, some would say epidemic, numbers of psychiatric casualties during WWI. Hundreds of thousands of military officers and enlisted members were being discharged, sent home, and given disability pensions for afflictions like shell shock and traumatic neuroses. European governments and military departments, they explain, became increasingly alarmed by this epidemic of war psychiatric casualties that existentially endangered the military’s capacity to fight and win wars, as well as producing skyrocketing disability pension costs threatening to bankrupt economies. In response, military leaders were forced to solicit the services of mental health professionals whose discipline was still in its infancy at that time.

What developed from the mental health professionals involvement came to be known as ‘frontline psychiatry’ where psychiatric casualties are treated as close to combat areas as possible with the firm expectation that the troops will return quickly to duty. Russell, Schaubel, and Figley explain that a comprehensive review of the military’s frontline psychiatry policies demonstrates its unquestioning effectiveness in preventing psychiatric evacuations. Note the focus on psychiatric ‘evacuations.’ The focus of the program is on preventing psychiatric evacuations not long-term mental health, which is reflected in the motto of the U.S. Army Medical Corps, ‘conserve the fighting strength’ (Jones and Wessely 2003), or as Russell, Schaubel, and Figley put it, to ‘preserve the fighting force.’

This is my own cynical evaluation of this process (which is part of the abovementioned darker side of military mental healthcare). How could frontline psychiatry fail? A soldier suffering combat stress reactions is taken off the frontline thus removing the stressor. They are kept close enough to the front to be reminded of their comrades fighting at the front, aka receiving support from their comrades, and how they are letting them down. The soldier returns to combat where their condition was indeed transient and they once again engage in combat in an effective manner. No psychiatric casualty going home. The same soldiers' fighting abilities may be impaired because of a mental disorder associated with the stress of combat and they are wounded or killed in action. WIA or KIA, no psychiatric casualty going home. They may desert because of their mental condition caused by the stress of combat, in which case they are a deserter and not a psychiatric casualty going home. They may abuse alcohol and/or drugs as a means of coping with the symptoms of their mental condition brought on by the stress of combat, in which case they are disciplined and possibly dishonourably discharged for behavioural problems. No psychiatric casualty going home. How could frontline psychiatry fail? It is genius, not unlike Catch-22.

In order to avoid a repeat of the same psychiatric attrition and subsequent disability pension costs of WWI, the Second World War saw the large-scale involvement of American psychiatrists in the selection, processing, assessment, and treatment of American soldiers. They were, however, hampered in their efforts because they were utilising a system of classification that was developed primarily for the needs of public mental health hospitals (Statistical Manual for the Use of Institutions for the Insane). ‘Psychiatric nomenclature which was barely adequate for civilian psychiatry was totally inadequate for military psychiatry’ (Brill 1966, 229), so the U.S. Army went about developing their own classification system. That classification system was published in War Department Technical Bulletin, Medical 203 issued on 19 October 1945 and came to be known simply as Medical 203 (Med 203). 

Med 203 included a 'combat exhaustion' diagnosis which we will explore in the next post.

This exploration will also demonstrate how the mental health discipline/professionals/practice came to gain credibility and how it is based in war time practices.

Sunday, May 9, 2021

The PTSD Story: Part 1

I am currently working on a chapter on PTSD in my book tentatively titled, Fear and Fight: Understanding Our Natural and Learned Responses to a Threat.

This chapter came about in the saw way this book came about. I was writing the conclusion and wanted a paragraph or two to explain how the new and better understanding about our natural and learned responses to a threat can help better understand PTSD and the treatment thereof. Research to provide that paragraph or two produced a great deal of information, so much so that a paragraph or two became a chapter in and of itself in my book.

The PTSD story is a fascinating story. It is a story that goes far beyond PTSD. It sheds light on the mental health discipline today and how it developed. It sheds light on the 'unholy alliance' between the mental health discipline and the military that poses dire consequences for military members and society as a whole. It sheds light on the 'unholy alliance' between the mental health discipline and many organisations. It sheds light on what is 'order' and how it becomes or is a 'disorder.' It is a fascinating story.

I will write a series of posts that discuss the PTSD story over the coming period of time, however, to start, what is PTSD?

There are a host of definitions of PTSD, however, the most accurate is:

PTSD is an initialism for ‘posttraumatic stress disorder’ which is a term that first appeared as an anxiety disorder in the third edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual for Mental Disorders (DSM).

Allow me to introduce you to the main characters in the PTSD story:

The APA is the main professional organisation of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organisation in the world. The association publishes various journals and pamphlets, including the DSM. The DSM codifies psychiatric conditions and is used worldwide as a guide for diagnosing mental disorders. It is often referred to as ‘The Bible’ of psychiatry. The first edition of the DSM was published in 1952, and several new editions and revisions have since been released. PTSD was included in the third edition of the DSM published in 1980. The most recent edition of the DSM is the fifth edition, published in 2013, in which PTSD is classified as a trauma- and stressor-related disorder, a classification that is a major revision of how PTSD is conceptualised as we will see below. 

In the next post, we will commence the PTSD story not with the DSM but the US Army's Medical 203 which provided credibility and acceptance of the fledgling psychiatric and psychological discipline and laid the foundation for mental health practice as we know it.

Monday, August 24, 2020

'Junkie Jihadis'

Long story short, I was discussing the subject matter of my book (Fear and Fight: A New and Better Understanding of Our Natural and Learned Responses to a Threat) with a friend who served with the Australian Defence Force (ADF) in Afghanistan and referred to Colonel John M. House's, 'Soldiers must overcome their fear of death and injury in order to act and survive on the battlefield' (Why War? Why an Army? 2008). I said that this applies to equally to ADF personnel and  the Taliban militants they were fighting in Afghanistan. The ostensible explanation for how ADF personnel overcome their fear of death and injury on the battlefield is though courage, however, how do the Taliban militants do the same? My ADF friend immediately shot back with Taliban militants fight under the influence of drugs. 'What's going on here?'

The term 'junkie jihadis' is taken from an article written by Lukasz Kamienski titled, Junkie jihadis and the narcotic ways of war.’ Kamienski is also author of Shooting Up: A Short History of Drugs and War (2016). Kamienski would appear to support my ADF friend's assertion that Taliban militants/jihadis fight under the influence of drugs, however, the question, among many others, becomes, why?

One of the strategic uses of emotion to counter fear in war that Liaras and Petersen identify is the creation of anger. Sun Tzu also identifies this strategy in his The Art of War written some 2500 years ago when he explains to get soldiers to fight they need to be angered. Anger is the emotion of courage according to Biswas-Diener in Courage Quotient: How Science Can Make You Braver. Turning fear into anger in order to fight is also the principal strategy taught in women's self-defence.

Why would the Taliban militants/jihadis need to turn fear into anger in order to fight? Do they, in fact, need to overcome the fear of death and injury in order to act and survive on the battlefield? After all, do they not have enough reason to be angry, to hate (which is an anger-emotion family member)? America and their allies invaded their country, killing their comrades, friends, family, and fellow countrymen, destroying their homes, and occupying their country for two decades. This in addition to their religious beliefs behind their jihadism.

The question then becomes, if they do not need drugs to overcome their fear of death and injury in order to act and survive on the battlefield because anger and hate has replaced fear, why are they taking those drugs. And when I say drugs, I am referring to stimulants that are used to enhance combat performance (see Kamienski's Shooting Up). Not depressants or hallucinogenics, but stimulants. In their case 'captagon' which is an amphetamine based psychactive substance.

Thursday, July 2, 2020

Warfighting - Required Reading for all Self-Defence Activities

Warfighting is the U.S. Marines basic philosophical manual that provides the authoritative basis of how they fight and how they prepare to fight. The first chapter in Warfighting concerns the nature of war and the human dimension. The material in that chapter is applicable to all violent encounters and all who prepare themselves or others to engage in a violent encounter by fighting. It should be mandatory reading for all of those people.
Since war is a violent enterprise, danger is ever present. Since war is a human phenomenon, fear, the human reaction to danger, has a significant impact on the conduct of war.
The same is true of all violent encounters. 'Fight Activities,' such as the military, law enforcement, martial arts, self-defence, and combat sports, teach fight. As I explain in Fear and Fight: Understanding Our Natural and Learned Responses to a Threat, fear impinges upon a person's readiness and ability to engage in and succeed in a fight. This is why the Warfighting manual instructs, 
Leaders must study fear, understand it, and be prepared to cope with it.
It's not just Marine leaders that must study fear, understand it, and be prepared to cope with it. It is anyone who is involved in preparing themselves or others to engage in a violent encounter. If you do not study fear, understand it, and be prepared to cope with it, you are not teaching effective fight behaviour. You are not teaching effective self-defence.

Wednesday, June 10, 2020

How Did George Floyd Die and Who is Directly Responsible?

We are very aware of who George Floyd is and the circumstances surrounding his tragic death given the near non-stop media coverage in since the video emerged of the incident.

It is a terrible look with the officer kneeling on Floyd's neck and his passing after eight minutes and x seconds. I hadn't given much thought to the specifics of the incident until a comment on Facebook yesterday which set my mind in curiosity mode.

How did George Floyd die and who is directly responsible?

You will recall that I have researched and written a book tentatively titled, The Science Behind All Fighting Techniques. A chapter in that book is dedicated to Shime Waza (strangulation techniques). The police call these techniques neck restraints or neck holds for obvious reasons.

There are two types of these techniques that target the neck. The either target the carotid artery(s) or the front of the neck. Applying pressure to the side of the neck occludes the carotid artery(s) reducing blood supply to the brain resulting in loss of consciousness in 10-12 seconds. Applying pressure to the front of the neck forces the tongue backward blocking the windpipe passage and depriving the body of oxygen.

Floyd remained conscious therefore it is unlikely that the knee of the officer on the neck occluded the carotid artery(s). Floyd continued to speak saying that he could not breathe, therefore, I could not see how the knee was producing pressure on the front of the neck forcing his tongue backward to block the windpipe passage and deprive the body of oxygen. In that case he should not have been able to speak. In any event, when I studied the photograph, and I won't reproduce it because there is no need to share this horrible image of his last moments more than it has been, the officer had his knee on the side of the neck and not the back or front.

I hypothesised that the officers sitting on his back prevented his lungs from expanding thereby rending it impossible for Floyd to breath. The knee on the neck was to prevent Floyd from squirming, which it did thus preventing him from relieving the pressure on his back. I hypothesised that it was the officers on Floyd's back that are directly responsible for Floyd's death and not the officer kneeling on his neck.

Turns out that the independent coroner concurs with my hypothesis. There were two autopsies conducted. The following is extracted from a New York Times article about the subject:

The criminal complaint supporting a murder charge for the officer, which referred to the Hennepin County medical examiner’s preliminary findings, said the autopsy had discounted traumatic asphyxia or strangulation as the cause of Mr. Floyd’s death.

The private autopsy by doctors hired by Mr. Floyd’s family determined that he died not just because of the knee on his neck — held there by the officer, Derek Chauvin — but also because of two other officers who helped pin him down by applying pressure on his back. All three officers were fired last week, as was a fourth officer at the scene.

There is more in the article supporting the second narrative.

The inability to breathe was not complete because apparently we have around 6mins worth of oxygen in our bloodstream without it being replaced.

And then there is EDS, 'excited delirium syndrome.' From my as yet unpublished book,
It has been suggested that sudden deaths that have occurred when a neck restraint has been applied by law enforcement officers may be explained through ‘excited delirium syndrome’ (EDS). 

The actual cause of death associated with EDS is not known, however, it is often linked to the level of catecholamines in the body.

DiMaio and DiMaio (2006) suggest that EDS deaths result from a fatal cardiac arrhythmia (irregularity in rhythm) caused by, in addition to the release of catecholamines due to the struggle to restrain the individual experiencing the excited delirium episode, the excited delirium itself triggering a release of catecholamines. DiMaio and DiMaio suggest that the highest levels of catecholamines occur approximately three minutes after cessation of the activity, therefore, EDS fatalities often occur after the struggle has taken place and the subject has been subdued. 

What are the ramifications associated with this narrative. I am no lawyer so this is in no way definitive. The kneeling officer is charged with 2nd degree murder. If he was not directly responsible for the death of Floyd he may be found not guilty. The two officers sitting on his back are charged with being accomplices. If they are directly responsible for Floyd's death they are not accomplices.

The State Attorney laid the charges and he is a politician before being a prosecutor. It would be politically difficult for him to amend the charges particularly that the optics convict the kneeling officer in the public's mind. If these officers are not convicted, riots will most definitely ensue. If they are convicted of these charges, innocent men of THESE charges may be being sent to prison (the emphasis for the benefit of those who will argue send them to prison nonetheless).

One of the outcomes of this situation is relevant for martial arts and combat sports. Police and politicians are responding to calls for change by banning the use of neck holds/restraints by police (even though they were not used in this case). France has come out and banned their use by police after the Black Lives Matter protests. These techniques are described as being dangerous whenever used. In my chapter I refer to a coroner who called for their ban in the 90s and referred to them as a 'lethal weapon' because they are capable of causing death whenever used.

If they are potential lethal weapons and can cause death whenever used, why are they not banned from being taught by martial arts and used in combat sports? In light of this argument/discussion, ANYONE teaching these types of techniques in martial arts or combat sports should morally and ethically, if not legally, consider their continued teaching and use of these techniques. That consideration would include being fully informed about the subject and these techniques. To the best of my knowledge my chapter is the most comprehensive study of the subject.

As luck would have it, as soon as I published this post I read this news article about a subject dying from EDS while being restrained by police officers:

“Mr McGlothen had underlying heart disease and clearly was suffering from excited delirium. The combination of these factors caused his death.”