DogFaceMedic

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I do not like the way PTSD is managed by modern psych and even made worse. The underlying diagnostic criteria are arbitrary and lead to ineffective therapies in most cases. Benzos, SSRI’s, atypical, and TCA’s are thrown at the soldiers with no clear endpoint. Also profoundly irritating are the whiners looking for disability.

What works for others out there for managing PTSD. I have a few thoughts on the matter, but would like more opinions.
 

IgD

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I do not like the way PTSD is managed by modern psych and even made worse.
What's up with the flamebait are you having a bad day :)

I have and continue to have great success treating patients with PTSD and other severe mental health conditions. The key is having a good patient-doctor relationship, making a proper diagnosis and using evidenced based meds and psychotherapeutic interventions. The other part of the treatment is using a multidisciplinary approach, having adequate support staff and other resources including a nurturing environment to facilitate the treatment.
 

AF M4

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What's up with the flamebait are you having a bad day :)

I have and continue to have great success treating patients with PTSD and other severe mental health conditions. The key is having a good patient-doctor relationship, making a proper diagnosis and using evidenced based meds and psychotherapeutic interventions. The other part of the treatment is using a multidisciplinary approach, having adequate support staff and other resources including a nurturing environment to facilitate the treatment.
I see tons of people post-deployment, review their history and screening questionnaires. If there's a problem, I send them to people like IgD for further eval and treatment.

When I or my patients have had specific concerns about different facets of their treatment, I have found the mental health boys to be quite accommodating in answering any questions. This stuff varies so much on a case by case basis and the personality of the individual that it is difficult to make broad generalizations.
 

Miss July

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The most effective treatment for PTSD hands down is therapy because it allows the patient to actually resolves the trauma. Medications are a useful aide in reducing related anxiety and depression, but don't address their cause.

Unfortunately most psych dx is arbitrary, and results depend on the connection between the patient and provider. EMDR & talk therapy can work very well, but it's hard. Patients (understandably) don't want to rehash the trauma and clinicians aren't always the most adept themselves.

I understand your frustration, wish it were simpler...
 

notdeadyet

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I do not like the way PTSD is managed by modern psych and even made worse. The underlying diagnostic criteria are arbitrary and lead to ineffective therapies in most cases.
PTSD has broad symptoms, not arbitrary ones. Much like the cold or the flu.

Treatment is NOT ineffective and hearing that from physicians is really frustrating and part of the reason that folks with PTSD don't get better care.

There's a four question Primary Care screen that's something like 87% sensitive and specific. If you suspect a soldier of PTSD, screen them, and if they come back positive, send them to psych for care. Recovery rates are good if they're treated properly. Throwing up your hands and saying PTSD "arbitrary" and that therapies are "ineffective" is just bad medicine.
Benzos, SSRI's, atypical, and TCA's are thrown at the soldiers with no clear endpoint.
Benzo's, TCAs and atypicals aren't typically thrown at folks with PTSD, definitely not first line. SSRI's are, and data has shown good results. Prazosin has also had a lot of good recent data. Group and individual psychotherapy has good data. This isn't like antibiotics, but welcome to mental health.
Also profoundly irritating are the whiners looking for disability.
Yep. It's a problem. As are folks looking for disability for TBI. Both are illnesses that don't always leave scars. So both will be abused.
 

Perrotfish

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There's a four question Primary Care screen that's something like 87% sensitive and specific. .
I would love to know how they got that sensitivity and specificity data. Generally sensitivity is determined by comparing the results of a screen to a 'gold standard' test. What, exactly, is the gold standard for PTSD diagnosis that they're comparing the screen to? Like a previous poster said, no matter how much time you invest in PTSD your diagnosis is going to be strongly biased by the provider-patient relationship and also the patient's baseline mental health disorders.

Also that screen isn't exactly rocket science, everyone knows how to answer the questions on post deployment screenings if you don't (or do) want to be discharged with little severance and probably no health benifits. More than anything else the Navy needs to invest time in developing a screen which isn't so easy to lie on. Maybe everyone needs psychotherapy post deployment, to screen for PTSD symptoms? Just a thought.

I'm not saying you're wrong that this is a treatable condition, but I do think that the OP is right that the diagnosis isn't as specific and DEFNINTELY not as sensitive as 87%.
 

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Also profoundly irritating are the whiners looking for disability.
Watch your bedside manner pal. Unbelievable that you would equate any of our military veterans as whiners looking for a disability. The former Marine in me may wind up correcting attitudes like that in the near future.

On the flip side, you did manage to put a smile on my face this morning. I think that it's wonderful that you're reaching out to others for PTSD advice. Because we've been involved in a "ghost war" (as opposed to jungle warfare), our troops may/will most likely have unique twists on combat fatigue.
 
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backrow

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Watch your bedside manner pal. Unbelievable that you would equate any of our military veterans as whiners looking for a disability. .
Then explain to me the EXPONENTIAL increase in the number of people who DIRECTLY ask for a sleep study when they are seen for a separation physical.

I asked the referral management people at one Naval Hospital about this and they said approximately 5-10 years ago they would see maybe 4-5 consult requests a month, and now that number is more like 40 or 50.

Yes, true disability deserves compensation. This mentality that "just because I served means I should get disability" that I saw in about 50% or more of the patients is ridiculous.
 

nontradguy

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Then explain to me the EXPONENTIAL increase in the number of people who DIRECTLY ask for a sleep study when they are seen for a separation physical.
I can't explain. I'm just a peon. I was only remarking on the attitude. If one is so vocal on being profoundly irritated by whiners, then I can only imagine the quality of care that the patients are receiving. Perhaps a medical examiner position would be a better fit.

I asked the referral management people at one Naval Hospital about this and they said approximately 5-10 years ago they would see maybe 4-5 consult requests a month, and now that number is more like 40 or 50.
Must be tough. (seriously....)


Yes, true disability deserves compensation. This mentality that "just because I served means I should get disability" that I saw in about 50% or more of the patients is ridiculous.
I agree. But, I'm sure that you're aware of the recent gross negligence on behalf of army medical corps for not recognizing (what may in fact be valid) PTSD cases.

Look, I apologize if the intensity of my response upset anyone. Perhaps as a vet, I'm a bit zealous with respect to those who've served. Those who are returning may have a different take on PTSD, as the style of warfare is much different than our previous wars. So, "whiners" and "50% increases" may be somewhat justified, but regardless, I hope that our troops are getting top mental care w/o attitude.
 

AF M4

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Then explain to me the EXPONENTIAL increase in the number of people who DIRECTLY ask for a sleep study when they are seen for a separation physical.

I asked the referral management people at one Naval Hospital about this and they said approximately 5-10 years ago they would see maybe 4-5 consult requests a month, and now that number is more like 40 or 50.

Yes, true disability deserves compensation. This mentality that "just because I served means I should get disability" that I saw in about 50% or more of the patients is ridiculous.
Oh yeah, I get this too. I thought it was really weird a few months ago when several patients who our clinic been seeing for years suddenly started filing long and aggressive complaints about us with our commanders. I mean, these were people that I'd had Christmas dinner with, had never had anything bad to say before and who had been some of our clinic's biggest advocates.

The only thing was that we'd done their retirement and separation physicals, and advised them that they didn't need a sleep study workup a month before they separated since their symptoms were more consistent with shift work and circadian rhythm changes.

Later on I sat in on the retirement briefing they give where they talk about listing every possible ailment, how much they're worth, and how much the military will try to screw you out of what you deserve. Now it all made sense; we'd been doing our jobs without realizing just how much of an incentive there is now to be disabled.

This soothed some distressed physicians who had been very disturbed at the sudden rise in complaints and took some of them personally. We're all a wee bit more jaded now.
 

Perrotfish

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Oh yeah, I get this too. I thought it was really weird a few months ago when several patients who our clinic been seeing for years suddenly started filing long and aggressive complaints about us with our commanders. I mean, these were people that I'd had Christmas dinner with, had never had anything bad to say before and who had been some of our clinic's biggest advocates.

The only thing was that we'd done their retirement and separation physicals, and advised them that they didn't need a sleep study workup a month before they separated since their symptoms were more consistent with shift work and circadian rhythm changes.

Later on I sat in on the retirement briefing they give where they talk about listing every possible ailment, how much they're worth, and how much the military will try to screw you out of what you deserve. Now it all made sense; we'd been doing our jobs without realizing just how much of an incentive there is now to be disabled.

This soothed some distressed physicians who had been very disturbed at the sudden rise in complaints and took some of them personally. We're all a wee bit more jaded now.
To be fair, the military WILL try to screw you out of what you deserve. How else to you explain the huge difference in the disability ratings given out by the VA vs. the departments of the Navy/Airforce/Army, when supposedly they're using the same standards? Why are line officers 2/3rds of the board that determines your disability status (unless this has changed recently)? Why do such a large percenage of the servicement who have the means and legal savy to appeal their disabiliy ratings given a higher rating after the appeal? It's not unreasonable to teach veterans to push back a little.

I sympathize with the command structure, I really do. We're the only nation in the world that tells our armed forces that the funding for disabled veterans is something that they need to carve out of their own budget (which means a perpetually shrinking budget during protraced warfare). However the fact is that the miliary does try to minimize costs by minimizing disability ratings, and the injuries that are the least visible (psych/neuro) are always the most affected.
 
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DogFaceMedic

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Yes, I was baiting a bit, and we benefit from some thoughtful comments – and some others.
No disrespect to SSRI's in not adding it to my list: I don't think they work well either.
There is a selection bias in psych – those who find it helpful complete the surveys. Many others quit b/c it doesn't work well, they feel they are being treated as something is wrong with them, and they present to ER's and clinics w/ other related issues like SI or etoh. This problem cannot be well quantified.
The psych drugs are euphemistically called mood stabilizers, but in fact are a form of permanent sedation and suppressing consciousness, rather than a cure.
What is the end point of pharm? More specifically, how does pharm lead someone out of their symptoms?
 

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To be fair, the military WILL try to screw you out of what you deserve. How else to you explain the huge difference in the disability ratings given out by the VA vs. the departments of the Navy/Airforce/Army, when supposedly they're using the same standards? Why are line officers 2/3rds of the board that determines your disability status (unless this has changed recently)? Why do such a large percenage of the servicement who have the means and legal savy to appeal their disabiliy ratings given a higher rating after the appeal? It's not unreasonable to teach veterans to push back a little.

I sympathize with the command structure, I really do. We're the only nation in the world that tells our armed forces that the funding for disabled veterans is something that they need to carve out of their own budget (which means a perpetually shrinking budget during protraced warfare). However the fact is that the miliary does try to minimize costs by minimizing disability ratings, and the injuries that are the least visible (psych/neuro) are always the most affected.
I'm sure one of the reasons for the difference between VA and active duty disability ratings is that the active duty ones have guys like me doing the retirement/sep physicals and the VA has guys doing them who've actually been trained on how to do disability physicals.
 

IgD

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Yes, I was baiting a bit...
Very inapprorpriate. A family or service member looking for help with PTSD might have found your post and could have been scared away from getting appropriate help.

The psych drugs are euphemistically called mood stabilizers, but in fact are a form of permanent sedation and suppressing consciousness, rather than a cure.
That's not at all accurate. It's almost like you've never had any mental health training at all. Where are you in the medical education pipeline???
 

Perrotfish

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The psych drugs are euphemistically called mood stabilizers, but in fact are a form of permanent sedation and suppressing consciousness, rather than a cure.
This really isn't true of anything other than a benzo. Serotonin is an activaor, it's the same thing you have too much of in mania or when you take cocaine. Would you call those people sedated?
 

bryce

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I asked the referral management people at one Naval Hospital about this and they said approximately 5-10 years ago they would see maybe 4-5 consult requests a month, and now that number is more like 40 or 50.

5-10 years ago Troops weren't 'coming back' from deployment #5 or 6. 5-10 years ago, their wives hadn't left them, they hadn't suffered an injury, their money wasn't suddenly gone from their accounts...

These are all realistic issues that unless you've been there in the Hell of it all you cannot understand. I recently lost a soldier who was 5 days short from returning from his 3rd combat tour since 2005. He was out with his squad and every single one of them were injured in an ambush with 2 K.I.A.'s. I know these men. These guys are brothers in blood and tears. I've been where they are right now, and I promise you that when these guys return to seek treatment the very last thing that they need is people who are their "superiors" judging them for seeking help.
 
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DogFaceMedic

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....I promise you that when these guys return to seek treatment the very last thing that they need is people who are their "superiors" judging them for seeking help.
I completely agree. In fact soldiers seeking some form of support -- not necesary help -- are deeply distrustful of behavioral health b/c they have a high risk of being labeled "ill" and dx'd w/ pathology, which absolutely will impact careers despite the promises of the DoD or VA.

To those who are taking cheap shots: think. The issue is not to be decided by simplistically lashing out w/ haughty comments. The problems w/ PTS/PTSD, I propose, can be a crisis of consciousness, rather than a biological neuro-psychic pathology. (TBI is a different issue, as there is a physical injury.) As such, pharm therapy is potentially counterproductive and even harmful.

Thoughts?
 

IgD

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To those who are taking cheap shots: think. The issue is not to be decided by simplistically lashing out w/ haughty comments. The problems w/ PTS/PTSD, I propose, can be a crisis of consciousness, rather than a biological neuro-psychic pathology. (TBI is a different issue, as there is a physical injury.) As such, pharm therapy is potentially counterproductive and even harmful.

Thoughts?
Sounds like the corpsmen I heard of handing out psychotropic meds and giving out medical advice without the proper training, licensure or credentialing. Or maybe me with little surgical experience walking into the OR and trying to engage a surgeon who has done thousands of procedures about why I think they are unnecessary.

So what exactly is your background and what training do you have?
 

backrow

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5-10 years ago Troops weren't 'coming back' from deployment #5 or 6. 5-10 years ago, their wives hadn't left them, they hadn't suffered an injury, their money wasn't suddenly gone from their accounts...
And what exactly does that have to do with Sleep Apnea???? If you had actually read my post I was going slightly tangential in a response to someone talking about disability claims.

And what does a wife leaving you, and money being gone from an account have anything to do with PTSD? sure depression.....but the base of PTSD is having experienced an event that was so horrific that it caused you to fear for your life.

Once again, legit things I take seriously, however, when the yoeman or aviation mechanic, etc, etc who never set foot in CENTCOM beyond Kuwait/Bahrain/or the other "undisclosed location" and has never had an IA/GSA tells me they have PTSD from their deployment then I just have to laugh. Or the any number of people from one of my commands who marked "exposure to detonations/explosions" on their PDHRA's when the only thing they ever came close to was controlled detonations by EOD from several kilometers away.

When I get a Marine or someone who has been on a GSA/IA who went outside the wire, and maybe even experienced an IED or being shot at, then I take a completely different approach.
 
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DogFaceMedic

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Sounds like the corpsmen I heard of handing out psychotropic meds and giving out medical advice without the proper training, licensure or credentialing. Or maybe me with little surgical experience walking into the OR and trying to engage a surgeon who has done thousands of procedures about why I think they are unnecessary.

So what exactly is your background and what training do you have?
Your posts are always thoughtful and worth reading even when I disagree. In this case I querry whether the only appropriate qualification is to be a Psych attending?

I am old (relatively speaking), practice medicine, and Jung supervised my senior high school thesis. ;) I will not change to psych just to discuss problems w/ ptsd. Psych does/should not have a monopoly on this.

My issue is that PTSD as a concept is deeply flawed and simplified; consequently, the standard therapies help some, but fail to help or even harm many others.
 

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And what exactly does that have to do with Sleep Apnea???? If you had actually read my post I was going slightly tangential in a response to someone talking about disability claims.

And what does a wife leaving you, and money being gone from an account have anything to do with PTSD? sure depression.....but the base of PTSD is having experienced an event that was so horrific that it caused you to fear for your life.

Once again, legit things I take seriously, however, when the yoeman or aviation mechanic, etc, etc who never set foot in CENTCOM beyond Kuwait/Bahrain/or the other "undisclosed location" and has never had an IA/GSA tells me they have PTSD from their deployment then I just have to laugh. Or the any number of people from one of my commands who marked "exposure to detonations/explosions" on their PDHRA's when the only thing they ever came close to was controlled detonations by EOD from several kilometers away.

When I get a Marine or someone who has been on a GSA/IA who went outside the wire, and maybe even experienced an IED or being shot at, then I take a completely different approach.
Yeah, we may have to create a separate thread on sketchy disability to claims to avoid the bleedthrough on the disability issues for things such as sleep apnea vs. PTSD.

I do get what you are saying and have encountered it quite a bit myself. It seems to be just another version of the common human phenomenon of seeing that someone is receiving a payout for a certain reason and then trying to attach yourself to that crowd which is receiving the payout. One sees the exact same thing with Hurricane Katrina, the BP oil spill, all those 1-800-BAD-DRUG commercials that law firms put out, and so on.

The central idea behind all of them is that you take a cause that is noble in itself and deserves compensation (like PTSD) and then people start testing out how many degrees of separation they can be from the main event or diagnosis before they stop getting paid.

It gets irritating when you reach the boundaries of people's attempts (i.e., my buddy's wife's second cousin was in Iraq and saw a bomb go off, then I heard a car backfire yesterday and got really scared), and have to draw the line, and the person testing the boundary uses the prestige of the deserving issue of PTSD as cover to say that you're cheating them.
 

bryce

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And what exactly does that have to do with Sleep Apnea???? If you had actually read my post I was going slightly tangential in a response to someone talking about disability claims.

And what does a wife leaving you, and money being gone from an account have anything to do with PTSD? sure depression.....but the base of PTSD is having experienced an event that was so horrific that it caused you to fear for your life.

Ever seen Jarhead? Trust me, I hate to say it, but that happens everyday. And you can bet your dollar that this, in a combat zone after getting shot at, IED'd, Mortared, and the rest of the suck does compound issues tenfold.

Now please don't think that because I merely answered your post in different manner [one from an individual whom actually Lived it] that I am attacking you. I am frankly proposing that there are outliers that unless you have endured through this yourself, you simply don't know.

My PSgt's daughter passed away the day after we got hit from a RPG that sent the vehicle that he was in 45 feet down an embankment in Ah-Hala in June, 2004. He still struggles to this day with issues pertaining to the entire situation [obviously from the death of his only child] and it has caused him such problems that he got out via early retirement... Of course that was after 'they' patched him up after a week in the hospital and sent him back to finish out his tour.

I am not defending anyone that really is a coward that maybe wasting your precious time, but I am & will always defend my soldiers and troops. So please don't act like a 16 yr. old girl and begin questioning me. I was injured in Iraq in 2004 and after being medically evacuated I received "care" that was terrible at best. I've seen what happens on the total flip side of things where surgeons are only there to pay off their student loans and really not care about the troops. I know that you aren't one of these individuals, however they are out there.
 

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Bryce, please keep in mind that there are a lot of prior-enlisted people on this forum and a lot of senior members with significant experience in the sand. You'd be surprised to learn how many on here shared time with you in the suck.
 
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DogFaceMedic

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Let me re-direct a bit:

A problem w/ our current approach is the starting point of PTSD as a pathology, whereas everyone has some level of PTS but that does not mean it is an actual disorder. If it is a neuro-psych pathology in the amygdala, then pharm therapy is frequently appropriate. But if it is an adjustment to crisis based in consciousness, then pharm is problematic and even harmful.

Real case: soldier has PTSD symptoms and w/ counseling to go over what was bothering him (a form of CBT), it became clear he felt guilty about one event. He sought out other soldiers involved and no one blamed him for anything; guilt and symptoms evaporated. Drugs had papered over the problem until the real issue came through. In this case a variety of techniques helped, such as private counseling, meditation, re-living events, CBT, etc.

But, what happens when the individual has real guilt? E.g., they actually caused casualties or failed their duty? Guilt is a moral crisis of consciousness. Pharm in this case cannot cure, it can only symptomatically dull the senses. In soldier terms: we all have the lingering feeling: did we do our duty? If we doubt ourselves, we are at risk of poor adjustment. To adapt to these crises of consciousness requires individual specific CBT, psych counseling, veterans clubs (VFW or Am Legion), friends, church or a priest. Pharm may delay, obscure, and otherwise prevent adjustment to a crisis of conscience.

I've seen way too many soldiers hateful toward behavioral health, hating the drugs for how they make them feel, presenting in an ED w/ substance abuse and SI – something ain't right.
 

IgD

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A problem w/ our current approach is the starting point of PTSD as a pathology, whereas everyone has some level of PTS but that does not mean it is an actual disorder. If it is a neuro-psych pathology in the amygdala, then pharm therapy is frequently appropriate. But if it is an adjustment to crisis based in consciousness, then pharm is problematic and even harmful.
The "current approach" and "starting point" you mentioned is different from the Army and Navy/Marine Corps combat stress doctrine. I don't understand where you are coming from. Tell us a little more about your background and context where all these situations are occurring so we can better understand your position.

Pharm in this case cannot cure, it can only symptomatically dull the senses...
There isn't really a medical basis for that statement. Decades ago doctors prescribed a lot of tranquilizers but that isn't the way the modern drugs work. On the flipside, if someone is so ridden with guilt that they can't sleep or take care of themselves, psychotropic meds could help stabilize that so they would be able to participate in counseling in a more meaningful way.

In soldier terms: we all have the lingering feeling: did we do our duty? If we doubt ourselves, we are at risk of poor adjustment.
In previous wars, soldiers were told they didn't have a problem. They were told they had adjustment problems, were weak and led to believe that they needed to resolve psychological conflicts that didn't exist. That's all changed in the current combat stress doctrine.
 
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I’ve seen way too many soldiers hateful toward behavioral health, hating the drugs for how they make them feel, presenting in an ED w/ substance abuse and SI – something ain’t right.
Welcome to pysch in the military. That's pretty much par for the course. Doctor's can't magically "cure" every single person who has PTSD, TBI, depression, chronic injuries, and a recent divorce.
 
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DogFaceMedic

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Welcome to pysch in the military. That's pretty much par for the course. Doctor's can't magically "cure" every single person who has PTSD, TBI, depression, chronic injuries, and a recent divorce.
Magic would solve everything.
 
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DogFaceMedic

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The "current approach" and "starting point" ...
Specifically, the dominant "current approach/starting point" appears to be that PTSD at outset is a pathology. Defining it is as a pathology at the outset determines the clinical approach. I think this may be fundamentally flawed. TBI is of course a different issue.

In previous wars, soldiers were told they didn't have a problem. They were told they had adjustment problems, were weak and led to believe that they needed to resolve psychological conflicts that didn't exist. That's all changed in the current combat stress doctrine.
This may be too much of a generalization. THe work of Lord Moran from World War I is illuminating about the nature and limits of moral courage under the worst conditions.