Thursday, September 19, 2013

PTSD and Memory

Nic DeNinno spent fourteen months in combat in Iraq. He returned home to what he hoped would be a normal life. For a time things went well, but then he began to have nightmares and flashbacks. The Army diagnosed him as suffering from posttraumatic stress disorder (PTSD). David Finkel provides a moving account of DeNinno’s struggles in an article in The New Yorker: The Return.

DeNinno received what was apparently a standard form of treatment. He was provided anxiety suppressants and anti-depressants, but they seemed ineffective. Counseling was provided as well. When his behavior became erratic and potentially dangerous to himself and others he was sent off to a residential treatment center for a 28-day stint. He and others would receive group therapy and counseling. The main emphasis of the treatment would be to encourage "habituation."

Habituation is based on the notion that the more often one can review a traumatic memory the less the emotional impact will be from recall. One becomes used to the memory and its effect diminishes and eventually can be dealt with.

Finkel had detailed discussions with DeNinno about his memories and dreams, and described the issues others are having by letting the reader sit in on one of these habituation sessions. The trauma that bedevils these soldiers seems to be associated more with guilt than with terror or shock. In the bizarre environment of occupied Iraq, they were compelled to take actions, and justify those actions to themselves with logic that allowed them to carry on, but provided no justification now that they had returned to their home environments.

DeNinno repeatedly refers to himself and his dreams with the term "monster." He has difficulty relating what happens in his dreams and what happened in Iraq to his wife. He is afraid that she will hate him if she knows.

"’I’m afraid to tell her stuff,’ Nic said, breaking down. ‘I don’t want to tell her about the dreams I have. I don’t want to tell her about the nightmares I have. I don’t want her to know that her husband, the person she married, has nightmares about killing people. It just makes me feel like a monster’."

The use of habituation as treatment for people like DeNinno is based on a particular view of what human memory is and what it is used for. This view of the function of memory can by no means be assumed to be correct.

Alison Winter has produced a fascinating book detailing how the different theories about memory have struggled for dominance and affected society over the past century: Memory: Fragments of a Modern History.

Winter provides a history of contention between those who believe that memory is capable of faithfully recording every experience encountered, and those who believe that memory is a tool the brain uses to help it make sense out of situations encountered. According to the latter theory, it was never intended to be "photographic" in detail or accuracy. Indeed, accuracy is not even necessary for memory to serve its purpose. Winters tells the reader that these two radically different views are still dominating the discussion of memory today.

"From about 1940, forensic experts, military psychiatrists and administrators, clinical psychologists, filmmakers, and others were increasingly portraying memories as stable, permanent entities that could be ‘revived’ (if they were inaccessible) and in some cases even re-experienced given the requisite techniques. This became a foundation for the treatment of psychiatric casualties during World War II....and a widely accepted way of thinking about autobiographical memory in general."

These beliefs have been carried forward and applied to PTSD via habituation treatment.

"One of the most tenacious themes of twentieth-century memory research was the idea that people tormented by memories of terrible experiences could benefit from remembering them better. The assumption—broadly indebted to psychoanalysis—was that psychological records of traumatic events often failed to be fully ‘integrated’ into conscious memories. As long as these records remained ‘dissociated,’ the sufferer was compelled to ‘relive’ them instead of benignly remembering them. The more fully and appropriately one remembered terrible events, the more attenuated would be their emotional power."

The history Winter recounts provides little support for the notion of memory as an accurate recorder of the past. Instead, data indicates that memory is a poor observer of events and that it is easily misled by individual biases and expectations. It is also relatively easy to plant false memories in subjects and induce them to believe them to be true. Research has shown that people who claim to remember an event "as if it had just happened" will have unknowingly altered or embellished their recollections over time.

Winter attributes a theory of memory more consistent with research to Frederic Bartlett an Englishman who worked in the early twentieth century.

"Bartlett has come to stand for a kind of claim about memory that has become commonplace among academic psychologists: that memories have a constructive or reconstructive character. We do not merely forget information over time, we ‘reconstruct’ the content of our memories by adding to or otherwise altering them."

Bartlett believed memory was a support function for frameworks that the brain (mostly subconsciously) derived to help decide how to respond to a given stimulus. All new perceptions were compared and graded against an established framework and either used to modify that framework, or were disposed of.

"Bartlett believed that consciousness was unusual in most mental processes, but he retained the idea that all new information must be placed in the context of a well-organized existing framework in the mind. When material would not fit easily into that framework, either the framework would change or, if no accommodation could be made, material would be discarded."

A simple thought experiment adds credence to this view. Consider a Republican and a Democrat listening to a speech describing the Affordable Care Act (Obamacare). Then ask each what they had learned from the speech. Every comment they heard would be passed through a partisan filter and some of what survived may have been committed to memory.

Given this view of memory, what might one conclude about PTSD and the problems of Nic DeNinno?

It is reasonable to postulate that constant dwelling on the offending memory might be counterproductive. Given that memory is malleable and reconstructive, there is no reason why each reenactment isn’t subtly modulated to obtain some effect the subconscious brain desires. The net effect could be to make the emotional response more powerful.

The notion that a memory unused decays also suggests that in some cases simply avoidance is the best strategy.

"This new approach asserts something more along the lines of ‘out of consciousness, out of mind.’ It follows suggestions....that the more often a memory is recollected and described, the more vivid it becomes. This raises the question whether merely trying not to think about a particular memory could weaken it—something the old psychoanalytic paradigm would have rejected. Michael Anderson and John Gabrieli, psychology professors at the University of Oregon and Stanford, claim to have found support for this idea. When their test subjects avoided a specific memory it became weaker....It was also part of a new account of PTSD. It proposed that PTSD worsens as you think about it, because each time you recall the painful events, the stress hormones that accompanied the painful memory are triggered and intensify that memory, making the emotions more vivid the next time it is recalled."

It is disturbing that those who study memory can look at the same world and arrive at two opposite conclusions. But it should not be surprising; voters do it, politicians do it, economists do it, why not psychologists? The very fact that individuals are using perception and memory in biased ways to support existing mental frameworks should be proof that Bartlett was correct. This puts the notion of "rational deliberation" in doubt.

One is also troubled by the imposition of any "one-size-fits-all" solution to PTSD. It is likely that both approaches, habituation and its opposite, might be appropriate for different individuals. Dwelling on a memory might make sense when the emotion aroused is fear; it might make no sense when the emotion aroused is guilt.

Iraq and Afghanistan did not provide soldiers with the same set of experiences as World War II.  Joshua Phillips provided a look into what it was like for soldiers trained for combat to spend months enmeshed in a civilian population in which friendlies and enemies were indistinguishable.  His book is titled None of Us Were Like This Before: American Soldiers and Torture.  Phillips was concerned with the reasons soldiers resorted to rough tactics, including what most would classify as torture.  It is a tale we all should read.  What is of concern here is the effect of that behavior on the soldiers.  The trauma for many was guilt for the deeds they had performed that were so inconsistent with who they were before combat, and so inconsistent with who they wanted to be when they returned home.  What the soldiers Phillips interacted with described is eerily similar to the story DeNinno told Finkel.  Phillips also included these results from a study of PTSD in veterans of Vietnam.
"The researchers found a strong correlation between increased exposure to combat and psychological trauma. But the report also found that ‘abusive violence had the strongest correlation with PTSD’ for Vietnam veterans. This abusive violence included, but wasn’t exclusive to, the ‘degree of involvement in torturing, wounding, or killing hostages or POWs.’"

"’We can go into long philosophical discussions of torture....but the one thing the research has shown is that it is not good for the people doing it,’ said Dr. Richard Kulka, the chief author of the study."
The point is not to accuse anyone of torture.  The point is that harming others, in any way, can induce feelings of guilt.  Guilt can be a strong, all consuming emotion.  Habituation just doesn't seem appropriate.

 It is difficult to be optimistic about PTSD treatment—or just about anything else to be honest.

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