Major Hasan Did Not "Catch" Vicarious PTSD

I am a psychiatrist and I work at the Roseburg VA hospital in Roseburg, Oregon. Everyday, I treat combat veterans, many of whom suffer Post-traumatic Stress Disorder, or PTSD. Following the news of the horrific acts of violence performed by Army psychiatrist Maj. Nidal Malik Hasan at Fort Hood, there has been a great deal of discussion about how mental health providers might themselves be affected by treating soldiers returning from Iraq and Afghanistan suffering PTSD. It has been suggested that Dr. Hasan's behavior may have arisen from a "nervous breakdown" he suffered due to the stress of treating so many young soldiers returning from war. Phrases such as "secondary" or "vicarious" PTSD are being tossed around. This is the notion that seeing how war has ravaged the bodies of young soldiers, witnessing their emotional agony, and hearing their descriptions of the horrors of war exposes mental health workers to trauma so severe that they themselves can begin to develop PTSD. Let me be very clear about this, it is no more possible to get PTSD from listening to soldiers tell their tales of their traumatic war experiences than it is to catch gonorrhea from hearing one talk about an unfortunate sexual experience.

PTSD develops in a context of extreme fear, emotional intensity, adrenaline release, and a genuine sense that one's life or the life of another is in peril. I have treated soldiers with PTSD who have seen friends blown apart by explosions or disemboweled by machine gun rounds. Many have been wounded or terrified while lying exposed in the midst of a barrage of mortar shells. PTSD can also develop in victims of rape, particularly when threats of violence, torture or death are part of the crime. PTSD can arise after high speed car accidents or house fires that tear and burn flesh and threaten life. It does not occur in true form under other circumstances.

There is a condition that can develop when a mental health care provider or anyone else listens to one after another story of horror, pain, and emotional devastation. Some self-serving psychotherapists have tried to make it more than it is by referring to it as Vicarious Stress Disorder, or Secondary Traumatic Stress Disorder. Compassion Fatigue is another term bandied about to explain the inability to handle the next difficult case of emotional trauma when litanies of pain and loss are heard day after day. However, while Compassion Fatigue may be useful to explain why charities suffer from loss of contributions during extended runs of natural disasters or prolonged economic downturns, it must not be seen to explain failures of mental health professionals to provide skilled treatment. Although compassion may lead an individual to pursue a career in mental health care, it can never serve as the basis of treatment or be depended upon to sustain interest and capability in practice. The term "burnout" has been used, and may come close to what can occur after months of immersion in a difficult occupation. However, burnout is not unique to psychiatry. Burnout is equally likely to be seen in hair stylists, mechanics, special education teachers and librarians. The answer to burnout is a pleasant vacation, not psychiatric diagnosis and treatment.

The best characterization of the condition that arises from treating sufferers of trauma, loss, and pain is, weltschmerz. This word simply means world pain, that is, the wretchedness and despondency one can feel in seeing the misery that existence in this world can bring, particularly in regard to the brutality and the horrors we heap upon one another. As Philip Larkin noted in "This be the verse", his dark ode to weltschmerz, "Man hands on misery to man. It deepens like a coastal shelf." None of this is new.

If a therapist is already depressed from his or her own life struggles, then being bombarded by endless stories of loss, pain, hopelessness, horror, and despair can certainly exacerbate the emotional distress. It can precipitate Major Depression and anxiety disorders if allowed to progress. This is where training, maintenance of good therapeutic boundaries with patients, and conferencing and mutual support among mental health professionals is so important. Providing care to those with scarred and broken minds can be painful and difficult for even the most experienced professional. However, a well trained psychiatrist or psychologist is not driven into violent frenzy by dealing with the trauma of soldiers, nor do they acquire those soldiers' emotional wounds vicariously. The very notion is an insult not only to mental health professionals, but to the men and woman who have actually experienced the horrors of war and gone on to develop the anxiety, depression, hypervigilence, nightmares, and flashbacks of genuine PTSD. To return to my opening thoughts, I do not think for a moment that Major Hasan's being a psychiatrist had anything whatsoever to do with the despicable acts he committed. Stress from dealing with the emotional trauma of returning soldiers does not explain and certainly does not excuse his behavior.

Dr. Mendelson is the author of the new book, Beyond Alzheimer's (http://BeyondAlzheimersBook.com).

 

Comments

[poorpearl]

So I want to draw your attention to the following links to concurrent HuffPost blogs: the first is a letter from a military psychiatrist discussing his treatment of soldiers and veterans and the second is a review of a book. Both address directly the work of Huff Post blogger/author Robert D. Stolorow, PhD, whose book on trauma can be extremely helpful.

http://www.huffingtonpost.com/robert-d-stolorow/understanding-the-traumas_b_355122.html
http://www.huffingtonpost.com/helen-davey/counting-my-people-an-aut_b_354491.html

[poorpearl]

Dr. Mendelson, I do have a disagreement with you, though. I am also a psychiatrist and a psychoanalyst and I do not think that it is helpful or necessary to limit the diagnosis of PTSD to combat situations or to the few other situations that you seem to "allow." I guess I am a contextualist, nderstanding that what may be traumatic to one person in one situation one one point in time may not be so for the same person at another point in time, or not so for a different person at a different point in time, and so on. The point here is that when you take a Cartesian approach or medical model to trauma, you foreclose on understanding. When you say "(T)he recognition of the unique symptoms of PTSD that evolve in situations such as combat are critical for the treatment of our soldiers returning from Iraq and Afghanistan," I think the larger point, what must be underscored, is that returning soldiers and veterans need care and understanding of their experience. And that needs to be provided in an ongoing way by providing a relationship of empathic listening.

[poorpearl]

Dr. Mendelson, first of all thank you for your service to our veterans. The horrors of war do not end at the border or an the end of a deployment. Many scars are invisible. It is easy for many people to pay lip service, like many flag-waving politicians, who clamor for photo-ops with soldiers but then block passage of life-saving support, such as Tom Coburn (R_OK) who is single-handedly blocking passage of the Caregiver and Veterans Services Act of 2009.

[skialethia]

Well the man had little or practically no family support system. He was bullied and mocked at work. He was upset about his transfer from Walter Reid and seemed to perceive Ft. Hood as a "hostile" environment in much the same way that someone who's being harassed would perceive their environment as a constant and hostile "threat". Actually, other tragedies happened at Ft. Hood over the past years. You can Google it.
He was exposed to the horrors of war albeit vicariously, but none the less exposed from a vulnerable subjective perspective and not a "detached" professional perspective it seems. No one mentioned he was "well-trained" since he received a poor performance report, leading one to suspect that he was unable to cope with an aspect or aspects of his job, and therefore I question why you take offense when it has already been stated he performed "poorly".

Finally, he was dreading the thought of deployment perhaps in the company of a "hostile" group and dealing with a moral struggle derived from the fact that he might be put in a position that most human beings would find unthinkable which is to kill someone with whom we share a bond of ethnicity, culture and or faith. I know I would find it unthinkable and it would make me panic and stress to think I would be forced into such a situation.

.../

[skialethia]

.../2.

One more thing: I wrote this in another post: “This Hasan reminds me of the mother who had 5 children and was not coping with motherhood and heard God tell her to drown them in the bathtub to save them from some evil destiny." Actually she believed they would perish in he//. Hasan could have likewise believed that he was preventing some greater evil.

I'm always reminded of "Heart of Darkness" when I hear of such things, in particular the character Kurtz, who is "changed" by his environment losing his humanity.

Regardless, he did cannot be condoned, but to attribute this act to terr0rist links or fundamentalism in my opinion is ridiculous since no links were found, and I really believe we have something to learn from this tragedy and dismissing it in this way would constitute just plain ignorance.

[skialethia]

"what" he did cannot be condoned, but....

[skialethia]

corr: "what" he did cannot be condoned, but...

[bajed]

Thank you Dr. Mendelson. Many have been quick to attribute Major Hasan's actions to the fringe diagnosis of Compassion Fatigue. While I think it might be too early to call this an act of Islamic Terrorism, there are certainly some indicators that might lead some to that conclusion. I do not believe that there is any evidence to suggest Hasan is a victim of Compassion Fatigue and I am glad that you have pointed out how frivolous the diagnosis is within the mental health community.

[MorgaineChya]

Well, as long as Americans can find some way to blame all of the problems of a culture that produced a psychiatrist who, completely out of character, shot and klIIed dozens of his fellow military men and women, that's what's important.

[MED1025]

While Dr. Hasan didn't have second hand PTSD, he does appear to have a borderline personality.

[OtayPanky]

All the evidence I've heard points to someone who made a clear-headed decision to engage in a terrorist act, taking out as many as he could before being killed himself.

Here we denounce such decisions - while over in Al Quaida and related strongholds, they applaud it.

Whether you think it a good thing, or a bad thing, Hasan allowed himself to be immersed in radical Islamism, and tranformed by it. Why he went down that road is irrelevant, really. The overwhelming majority of Muslims in this country never do.

In that context, his actions make sense - and also merit the ultimate judicial punishment, just like Timothy McVeigh's or KSM's.

All this psych talk is really moot.

[Marrigan]

This article is a breath of fresh reality. A step further, Hasan is an idiot if he really believes that the U.S. is actually in a war with Islam. How does he explain his own rise in military ranks? Geez, if that was the case, the very last person we'd want counseling returning veterans is a muslim shrink. If our govt. wanted muslims to disappear, they would disappear.

[seattleblue]

During a recent psyche evaluation for a social security disability claim, I told the lovely shrink that I believed that in 200 years people would view our "modern psychiatry" the same way we do blood letting. This caught her interest.

I then told here that when the US Navy discharged me years ago for being gay, their shrink told me that he didn't believe that I was gay. This was after I had just offered to crawl under his desk and prove my sexuality. Thirty years later and I'm still fantasizing about the shrink who thought I was really hetero.

I have seen a number of shrinks this year and the only thing they agree on is that I should come back next week. I told one this year that all the doctors should get together, open my file, and read out loud together. Its hard to take them seriously when they are all over the place.

[marre]

I cannot thank you enough for giving a clear and firm analysis of the function of mental health professionals and why they do not "catch" the malady. It needs to be heard. A shrink is not supposed to be warm and fuzzy and share one's pain. On the contrary, he must be outside the whole thing, clear-headed, and educated to ask the right questions so his patient can deal with the answers.
What seems more relevant to Major Hasan's case is the degree of isolation he felt, his apparent inability to form meaningful social relationships outside his family. This is sad and comes through even in simple news reports. Maybe the result was anomie, what Durkheim termed the isolation modern society inflicts, to the point that an individual feels divorced from society and makes up his own moral code.

[emilyringstrom]

I agree with this article, almost to the fullest, but feel the need to ask the following:

Can't a person just be insane? Why does there have to be a "logical explanation", to what makes no sense whatsoever? Can't someone "just" have a severe case of depression, and/or paranoia coupled with perhaps a sense of grandeur, or being on a mission of some sorts. And certainly, being a religious fanatic, helps...whatever the religion.
Many times there doesn't have to be a "trigger" to set someone off. Severe cases of depression can go on for years, and just gain strength in time, with no special reason, eating you up from the inside, feeding manic thoughts, which initially may cause anxiety attacks, but if left untreated, can become a way of being. A certain familiarity with these senseless thoughts sets in, and the anxiety wears off, which is where insanity begins in its truest sense...
It's then highly likely that you start looking for something to hold on to - be it religion, politics, or what not - something that gives you "answers", and "truth", which in turn becomes the only solid thing in your life. The only thing you don't have to question, giving you comfort in being fed with the answers you need...
I'm no psychiatrist, but I know the human psyche well enough to realize that everything isn't black and white, and I only wish that the media would paint their images and stories in more vivid colours.

[S1m0n]

"... a well trained psychiatrist or psychologist is not driven into violent frenzy by dealing with the trauma of soldiers, nor do they acquire those soldiers' emotional wounds vicariously."

This is an instance of the 'no true scotsman' fallacy. No one yet knows what was going on inside Dr Hasan's head and what sparked his rampage, but it's absurd to rule Dr Hasan's work out in advance.

Hasan is a psychiatrist, and has been about as well trained as many others also practising in the military and elsewhere. The record abounds with accounts of psychiatrists engaging in all kinds of behavior* which are theoretically just as 'impossible', but which occur nonetheless.

Drawing any further conclusions that these will have to wait until we have more information.

*From drug addiction to sexual abuse of patients, for instance. These, too, aren't supposed to happen, but regularly do.

[laurasworldnet]

I agree with this post. As someone who is familiar with PTSD, I know that there are triggers which can cause a person with the disorder to regress to a traumatized state, even many years after experiencing a trauma. For some, just watching a movie in which the actions mimic the dynamics of a traumatic situation can be enough to send them into a tailspin.

We don't know the Major's history and can't know it well enough to say, with any certainty, that he had not been deeply traumatized by something, sometime in the past. PTSD is not contagious, but an already traumatized person hearing these stories might very well be triggered into acting from that traumatized place.

[ARTIST50]

This article makes sense to me. I haven't heard why he joined the Armed Forces. Was it only to get a free education? Why did he put himself in this enviornment with his religious background?

[S1m0n]

He joined years before 911, when being a muslim was of no particular significance to the army. At the time, he was already a universite graduate with a Bachelor's degree and grades good enough to get him into med school.

The army did pay for his medical training and a further MA, but he had other options for proceding with his education. Joining the army wasn't the easiest or least demanding.

[aspiecelia]

I disagree with this article completely. We do not yet have enough information and it is possible the military will not let us have access to all of the clues in this case. While he was vicariously exposed to horror stories he was also workplace bullied, and bullied about his religion. It is well documented that PTSD, actually complex PTSD is caused by workplace bullying over a long period of time and there have been many violent episodes as a result. The reaction people have to traumatic situations are dependent on their personaltiy traits, the traumas they may have suffered in the past(cumulative affect), and the support they get during and after the trauma,
Workplace bullying is an area which psychiatry in the US knows little about yet it is epidemic. The military has not addressed it. Remember this is a military doctor who wrote this article. We know there has been some pressure in the military to decrease the number of PTSD diagnoses and they are sending soldiers with PTSD back into combat. The lack of insight about the effects of trauma by the military stuns me.

[Leatherhelmet]

I doubt in the history of the US there was a workplace bullying episode that resulting in
a murderous rampage like this.

I have seen the Associated Press tried to claim he might have "secondary" PTSD.

His radical writings and background with radical imams cannot be dismissed.

[snapshot1940]

"I doubt in the history of the US there was a workplace bullying episode that resulting in
a murderous rampage like this."
Where do you suppose the term, Going Postal, originated. There are scores of instances where such behavior has happened. It is also all too common in school situations.

[aspiecelia]

There have been several shootings as a result of workplace bullying. It is quite horrendous in Alaska. Here is an article about the shooting at the hospital where I live that happened about a year ago. They have the workplace bullying institute coming for workshops as the shooting did not stop managment. The board even tried to get the borough to conduct a complete audit of what is going on there.
http://www.foxnews.com/story/0,2933,458084,00.html

[SD Mendelson]

Aspiecelia, There are many significant psychiatric problems other than PTSD. To say that a form of suffering is not PTSD is not to diminish its importance.

What is paramount is whether PTSD exists as a unique condition distinct from depression, anxiety, disappointment, ect . Moreover, there is the question as to whether there is nosological and clinical validity to the current tendency in psychiatry to construct entities referred to as "Spectrum Disorders" in the consideration of PTSD. In fact, there are aspects of PTSD that are unique and that arise out of unique situations. Unique aspects of PTSD include "flashbacks' or dissociative-like states triggered by sights, sounds, smells, etc, similar to those experienced at the seen of the trauma. A unique aspect of PTSD is the difficutly in discriminating "here and now" from "there and then". These phenomenon suggest unique changes occuring in the hippocamus, amygdala, and other areas of the brain that process fear and memory. These are aspects of PTSD that simply cannot be generated by common disappointments and stresses of life. PTSD does require an experience of horror , legitamate fear for life and limb of the self or of people close to you, generally in the context of a sense of helplessness to do anything about it. The recognition of the unique symptoms of PTSD that evolve in situations such as combat are critical for the treatment of our soldiers returning from Iraq and Afghanistan.

[aspiecelia]

Workplace bullying is not common disappointments and stresses of life, it is psychological terror. The research on workpklace bullying has been done over a long period of time. It has shown that it does indeed cause complex PTSD. It has been made illegal in several other countries. In the US we have a culture of bullying, so everyone thinks it is normal. In fact the research shows the symptoms are worse than women who have been raped. I was gang raped a long time ago and recovered from that relatively easily. I then made the mistake of moving to Alaska and was bullied by two long term serial bullies at a bush hospital which has caused PTSD. I have been researching this for years, only in the US is it denied, but things are changing some of the better psychiatrists and psychologists have been reading the research.

[VoteLibertarian]

You are still clinging to this bullying malarkey? The guy was a islamic extremist murderer, that's it. Life in the brig.

[Idytme]

As someone who has had PTSD, whether or not you agree with what the doctor said is irrelevant. Re-read the entire post. One can be depressed, one can have rage, one can have a variety of conditions and they are not PTSD, as this is related to a specific trauma and much research has pointed toward adrenaline as making sort of deep groves into your brain that do not go away. Think about escaping the attack of a lion. It is a great adaptive response for our survival in hunter and gatherer days, (you will always avoid lions) but doesn't always help us in modern times.
PTSD has been talked about a lot in the media. And this exposure is mostly for the good. But the negative side is that it is now a common word and is mis-applied. I do not know how the psychiatric world would categorize bullying, it can be horrific (and in this case, it doesn't seem to apply according to reports so far). When it might turn to PTSD is if the person had been beaten or terrified for their lives, which goes beyond the definition of "bullying" into some kind of "assault".
Yes, you cannot "catch" PTSD. It is your own personal chemical response to a situation. I am not going to even try to analyze the psychiatrist who perpetrated this crime, but it wasn't PTSD.

[aspiecelia]

I am someone who has had PTSD for four years and has studied it extensively. I am also a health care professional. It looks like Hasan may also possibly be on the autism spectrum and those people get bullied their whole lives. They are trying to say he has schizoid personality disorder, but no Schizoid would have a desire to be a psychiatrist. You are aware that others disagree with this guy, right.