PTSD in Afghanistan and the violence that does NOT inevitably follow

On today’s morning’s Morning Edition Andrew Exum, a fellow at the Center for a New American Security, made the following statement:

What’s important to note when you talk about the Afghans is, these are a people who are suffering en masse from PTSD. The Afghans have suffered through three decades of violence, and unfortunately I don’t think that that violence is going to end anytime soon.

I am sure Mr. Exum knows what he’s talking about in terms of military strategy and no doubt he has good advice to give our nation’s leaders. And indeed, the Afghan people have suffered. As a gross indicator of suffering, there are currently 2.8 million Afghan refugees; one in four refugees in the world is an Afghan, making Afghans by far the largest group of refugees (anyone know what the second largest group is?). But I take issue (and you should too) with his psychiatric acumen.

People are suffering; but not everyone has posttraumatic stress disorder (PTSD). Best estimates of the prevalence of PTSD in Afghanistan are in the 30-50% range (see Lopes Cardozo et al, 2004, in the Journal of the American Medical Association), although to be honest even these suffer from a lack of access to national samples. “En masse” is not a third-to-a-half.

Moreover, it’d be hard to argue that there’s much that is “post” about PTSD diagnoses in Afghanistan. With continuing fighting on the ground, it’s probably more appropriate to diagnose (if we must) PTSD symptoms as acute stress reactions, some of which may develop to full-blown PTSD.

However, most disturbing is not Exum’s misstatements about PTSD prevalence rates, but rather the statement that follows it. The connection between violent behavior and PTSD is complicated, although it certainly has gotten a lot of play in the press (the New York Times ran a piece last year on violence among returning Iraq War vets that essentially blamed PTSD for murder rates among these men and women). Violent behavior seems to be more prevalent among people with PTSD than among people without PTSD (thought to be connected to the anger and irritability that are symptoms of the diagnosis), but violence is in no way an inevitable outcome of the disorder. To state that war will not end in Afghanistan immediately following a statement that everyone there has PTSD is therefore most unfortunate. PTSD is not a barrier to peace, anymore than other injuries caused by war.

A theme I’ve touched on before is the misuse of psychological diagnoses to indicate suffering. This has a long and storied history as regards PTSD, and it irks to no end those of us who actually work with patients with PTSD. People with PTSD are suffering in a maladaptive way. Suffering on its own is terrible enough, but it’s not maladaptive; let’s not degrade the terms for maladaptive suffering by misusing them.

For more on PTSD, suffering, and Afghanistan, including a fascinating discussion of Afghan idioms of distress (it turns out there are plenty of good words for different types of psychological problems in Afghanistan already), see the recent work of my friend Ken Miller here, here, and here.

1 Response to “PTSD in Afghanistan and the violence that does NOT inevitably follow”

  1. 1 Ken Miller November 5, 2009 at 12:26 pm


    Excellent post (and not just cuz you cited my work at the end!). Those sort of sweeping “everyone has PTSD” comments are silly, misguided, and quite common. Why isn’t it enough to say there’s a lot of suffering in Afghanistan? Do we need try and add legitimacy and drama to our claims of suffering there by making claims of psychiatric disorder? Afghans are dealing with enormous grief at all that’s been lost, and are highly stressed by the extremely difficult conditions of everyday life. It’s not just about the violence: it’s the poverty, unemployment, malnutrition and lack of healthcare, family violence, unsafe housing, the profound corruption at every level… talking about PTSD is this context is frankly a bit beside the point. It’s just not a very useful starting point.

    The echoes of Vietnam are quite striking. 40,000 more troops? Really? Such hubris to ignore the history of Afghanistan’s encounter with foreign invaders…

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