基調講演
テーマ「PTSD in the War on Terror」
演者 Allan Young(慶應義塾大学 社会学研究科 特別招聘教授)
通訳 宮坂 敬造(慶應義塾大学 文学部 教授)
(ヤング) Thank you very much for your introduction. It is my pleasure to be here today and to bring to you the warmest regards from my own university, McGill University in Montreal. It is a great honor for me to be here, and I am especially honored to be invited for this occasion, marking the launching of an ambitious program of intellectual exploration and achievement. I would also like to express my gratitude for this invitation and for the kindness and generosity of my hosts. The talk that I will be giving is part of a two-part study. I will have time only to present the first part, and perhaps in the comments later in the day I can say a few words about the second half as well.
Post-traumatic stress disorder is representative of a family of reactive conditions that were first described in the 19th century. The family consists of two branches. One branch is composed of somatic conditions resulting from psychological stress combined with intense physical demands. The second branch consists of syndromes induced by severe psychological shocks, often combined with intense fear. These disorders are called the post-traumatic syndromes and they include, historically, shell shock traumatic neurosis and PTSD. The two families are separate and they are contemporary in the current psychiatric classification, but it is likely that - the next edition, DSM-V 2011 - they will be brought together into a single family of mental disorders.
(ヤング) Prior to 1980, there was no agreement among experts concerning the causal mechanisms responsible for post-traumatic syndromes. The situation changed in the USA when the American Psychiatric Association created a mandatory classification system, the so-called DSM-III, and designed PTSD to fit this system. Most mental disorders included in the DSM system are diagnosed with lists of symptoms, and no assumption is made about the mechanisms that might connect these symptoms.But PTSD is different, its symptoms are connected by a causal principle and then inner logic. And I would like to tell you - I know many people who are familiar with what those symptoms are, but I would like to make them clear nonetheless. And there are a group of four symptoms. The first, a precipitating event, which creates a distressful memory. Number two, the memory is re-experienced over and over in intrusive images, thoughts, anxiety dreams, nightmares, and symbolically marked physical symptoms. Number three, patients adapt to these traumatic memories by avoiding situations that trigger remembering and by numbing themselves to the emotional impact when they do remember. Finally number four, there is a conscious and unconscious anticipation of the recurrence of intrusive memories, and this stimulates the autonomic nervous system, and there is a state of arousal associated with a variety of symptoms such as difficulty sleeping, irritability, startled response.
(ヤング) PTSD acquires its unity and its uniqueness from its distinctive causal mechanism, traumatic memory. Traumatic memory is imprinted on each of those categories of symptoms. Without the imprints of memory, the individual symptoms are entirely nonspecific. That is to say, the symptoms are associated with other psychiatric disorders as well, notably depression and generalized anxiety. Isolated symptoms are not intrinsically pathological, such as problems sleeping. Therefore, clinical diagnosis of PTSD requires evidence of all four clusters of symptoms. That is to say, diagnosis requires evidence of the process that constitutes cases of PTSD, and this is a key point, as you will see for everything that I have to say from this point on.
(ヤング) Most PTSD researchers and practitioners believe that the history of PTSD is a closed book. They believe that knowledge of the history of PTSD is unnecessary for understanding PTSD from a scientific point of view. Their conclusion is entirely mistaken. PTSD is a product of history and it cannot be fully understood outside of its history.
(ヤング) Interest in post-traumatic syndromes has fluctuated over the last century. The periods of most intense interest have tended to coincide with military conflicts. At first glance, this is what you might predict: modern warfare exposes massive numbers of civilians and combatants to terrible events, and so we might predict that there will be corresponding spikes in cases of post-traumatic disorders and likewise spikes in resources invested in research, clinical care, pensions and so on. In reality, these spikes in the history of post-traumatic syndromes have been associated with only four events - not all wars, but only four events - World War I, the Holocaust, the Vietnam War and today the post-9/11 war on terrorism.
(ヤング) Each of these four conflicts - World War I, the Holocaust, the Vietnam War, the current so-called war on terror - is associated with a distinctive species of post-traumatic illness. The illness that we call PTSD is itself the product of a trauma culture linked specifically to the Vietnam War, and there are features of it that are really unique, that set it off from the other three conflicts - perhaps I can chat about later.
The war on terrorism has produced yet another variety of posttraumatic illness. It too is called PTSD, and it too shares similarities with the DSM-III model of PTSD. However, there are also significant differences that set it apart from the past, and this is the theme of my talk today.
(ヤング) DSM-III, the 1980 diagnostic manual, conceived traumatic memory as an unchanging essence and as an accurate reproduction of the victims’own traumatic experience locked in memory as a visual image. DSMIII, and later editions, assumed that all competently diagnosed cases of PTSD are homogeneous. They assume that the symptoms are held together by a single inner logic, the one that I described a moment ago of a precipitating event that is inscribed in the memory, the memory then that is responsible for avoidance and numbing behavior and autonomic arousal. In practice, however, and in reality, traumatic memories are not homogeneous but heterogeneous. They are formed in diverse ways. The technologies employed by researchers and clinicians play an important part in the process of building these traumatic memories, and these technologies are often specific to historical period and specific to the culture of trauma at that time.
(ヤング) I am going to describe the culture of trauma that has emerged in connection with the terrorist attacks of 11 September, 2001. These attacks resulted in the destruction of the two World Trade Center Towers, a section of the Pentagon building and four airliners, with all of their passengers: nearly 3,000 people were killed. The death and destruction prompted the invasion of Afghanistan and justify sweeping anti-terror legislation called the Patriot Act. President Bush called the attacks an act of war, politicians and journalists in the United States compared the attacks to the surprise attack on Pearl Harbor in 1941 and the terror bombing of London during The Blitz in World War II. The American people were told that 9/11 was the beginning of a war of terror and that the targets, the Pentagon, the World Trade Center had been chosen for their symbolic importance. The true target of the attacks was the minds of the American people.
(ヤング) Most of the so-called survivors of the World Trade Center attacks were the relatives of the dead, the direct victims of the attacks. People actually in the World Trade Center: almost all of them died. The City of New York offered these survivors’ relatives psychiatric counseling.
The administration also wished to protect the survivors’ privacy and it was decided that PTSD researchers would not be given access to the survivors. The survivors were to be regarded as mourners and not research subjects.
(ヤング) Trauma researchers were displeased with this decision. They claimed that 9/11 was a collective trauma. The attacks had created an emergency comparable to an epidemic of infectious disease. This trauma, in contrast to previous events, did not belong to individuals; it did not belong to the survivors. Columbia University epidemiologists, writing soon after the attacks, described the situation in the following way, and I quote them: “Terrorism is an assault on the mental state of an entire population. Public mental health should be a central element in any effective defense against terrorism. September 11 was the first major event since World War II that tied public health directly to national defense.”
(ヤング) In an editorial published four years later in The New England Journal of Medicine, perhaps the most important medical journal in the United States, a prominent PTSD researcher appealed to Washington, asking the administration to bring an end to what she called the moratorium on research. The survivors, she claimed, were being punished rather than protected, for the moratorium deprived them of the opportunity to contribute to the collective welfare, and I quote her from this editorial: “The public needs to be alerted to the necessity of research and the public needs to be prepared for operational procedures that would be implemented in the aftermath of terrorist attacks in the future. It is imperative to develop a culture of education in which the academic community can freely communicate what is and what is not known, so that survivors of terrorism will understand the value of their participation in research to the generation of useful new knowledge.”
(ヤング) In reality, the effects of the so-called moratorium were limited only to researchers who were accustomed to working with the victims in the old days and who understood trauma in the conventional way, according to the Vietnam model. Naturally, they were attracted to the victims who had escaped from the towers and to the survivors who had been traumatized by the sudden deaths of loved relatives in horrifying circumstances. But there were other researchers, many of them entirely new to the PTSD field, who understood the novelty of the 9/11 attacks.
The terrorism in America theme and the body count made the attack special of course, but there was something more. 9/11 was also special because of television: the transmission of traumatic images across the country and around the world, the images of an airliner flying into the towers, people dropping hundreds of feet to certain death and crowds fleeing before a toxic cloud billowing over Lower Manhattan.
(ヤング) The new generation of researchers remembered work published in 1999 by a researcher named Lenore Terr. They remembered a paper she had written describing children’s traumatic reactions after watching real time television coverage of the Challenger Space Shuttle Disaster.
Terr had called this response of the children, distant traumatic effects, that is, trauma mediated by television. These new researchers understood that the victims of distant trauma on 9/11 could be numbered not in the thousands but in the millions. And they also understood that there was no obstacle now - moral, political, or technological - standing between themselves and access to the traumatized masses.
(ヤング) I have located - and I believe my search has been exhaustive - 29 empirical studies describing the distant traumatic effects of terrorist attacks in the United States, published from the year 2002 to until 2007.
This research has been published in the top medical journals in the United States. Some of the articles have been preceded by editorials that call attention to the unusual importance of the post-9/11 research.
(ヤング) Now, I would like to say a few words about the technology used by these researchers studying so-called distant PTSD, and the technology is a very important part, and it is the very heart of the argument that I will be making. Post-9/11 research is based entirely on self-reports obtained from the respondents, the informants or from their parents, since some of the informants are grade school children. Structured interviews collected information on PTSD symptoms and television viewing. The answers consisted of ticking off the options that were given to the informants.
Information was collected in various ways: by telephone interviews obtained by random digital dialing, by questionnaires given to undergraduate students and grade school children in class, by an electronic diary technology that required informants to record what they were thinking or feeling when prompted by a hand-held computer and a web-based technology developed by Knowledge Networks Incorporated, a marketing survey research company with ongoing access to 60,000 American households. None of these studies included a qualitative research element.
(ヤング) Some of these studies were based on single interviews. The informantwas contacted once, the responses were obtained and that was all. Other studies obtained responses at intervals, beginning a few weeks or months following the attacks. In some studies, informants, including very young children, were asked to recall their emotions and viewing habits months, sometimes years, in the past.
(ヤング) TV images are not included in the DSM list of PTSD traumatic events, and if you go and you look in the DSM, it will list typical events: nothing is said about television. However, the post-9/11 researchers are utterly convinced that the traumatic effect of these images, television images, is the real thing, and they believe that they have demonstrated a statistical association between the onset of symptoms and exposure to TV images. Four studies have demonstrated a so-called dose-response relationship between viewing and symptoms. That is to say respondents who watch many repetitions of these images were more likely to report trauma symptoms.
One study reported that individuals who watched the images - at the time of 9/11 - who watched the images more than six times were at a very substantial risk: one in seven individuals in this group could be expected to develop full-blown PTSD. Another study reported that pathogenic effects increased when people watched the 9/11 events in real time, that is to say, as they were recurring.
(ヤング) Television coverage of the 9/11 events also included commentaries, but the PTSD researchers had concentrated almost exclusively on images, and this is what one would expect. Traumatic memory is hugely associated with visual images in the clinical literature and in clinical narratives, often in the form of so-called flashbacks and flashbulb memories.
(ヤング) I have finished speaking now about the technology, and what I originally hope to do at this point was to make a historical comparison between post-9/11 America and Germany from the years 1943 to 1945 and then the post war period, during which German cities were subjected to a very intense air war comparable, paralleling very closely, to what had happened in Japan during those same years. I do not have time to make this comparison, but I would like to tell you what the conclusion of the comparison was. And it is that, despite the very intense air war (very large numbers of civilian deaths - estimated a minimum of 400,000), despite the fact that these attacks were repeated over and over again, so that the so-called dose-response effect would be expected, people being repeatedly traumatized over a period sometimes of several years. In spite of all of those circumstances, the psychiatric record (very, very incomplete record) indicates an absence of any epidemic of post-traumatic disorders.
And this is an extremely provocative finding when one compares the psychiatric consequences of the air war in Germany during World War II with the consequences of what we can describe, I think quite fairly, as relatively trivial trauma: this trauma at a distance in the United States, which was followed by what has been described by PTSD researchers and epidemiologists as an epidemic of PTSD in the months and years following 9/11. Now having made that comparison with Germany, I would like to return to the United States in 2007.
(ヤング) So, after making this comparison and doing my very best to look at exhaustively the German documentation, the American documentation, I was left with two questions, and these were the questions. Why was there no epidemic of post-traumatic disorders following the German Air War, nothing comparable to the psychiatric aftereffects of the 9/11 attacks? How great was the epidemic in the United States? It is said that there were, by epidemiologists, 7 million cases of distant PTSD. This question that I am asking can be interpreted in two ways. Number one, why was there no epidemic of post-traumatic disorders following the German Air War. The other question, equally legitimate: why was there an epidemic following 9/11? These are equally legitimate questions and deserve to be answered empirically. Unfortunately, I must concentrate only on the second one: why was there an epidemic following 9/11?
(ヤング) The answer to that question is going to be very complicated, and again because of time I want to focus on a single element, a single part, but I believe an indispensable part, of the answer to my question: why was there an epidemic following 9/11? And my answer concerns the technology that I described a moment ago. But I ask you, before I begin, to remember something I said at the very beginning of the talk, at which point I said that the symptoms of PTSD consist of four groups or clusters of symptoms and those symptoms are connected to one another by an inner logic. They constitute a traumatic process and not simply symptoms.
The symptoms by themselves in isolation are nonspecific. They could be symptoms of depression. They could be symptoms of generalized anxiety disorder. Or, in fact, they do not have to be symptoms at all, but rather mild distress that perfectly normal people have. What makes them PTSD symptoms is that they have the imprint of traumatic memory. So, they must be part of this process and do not constitute symptoms by themselves.
(ヤング) I want to emphasize that this interpretation that I have just given,that PTSD is glued together by an inner logic, is not my interpretation. I am an ethnographer. I am not prescribing what diagnosticians should do. I am reporting what is the ethnographic understanding of PTSD and that is very important to understand at this point.
(ヤング) Having said that, it is surprising to turn to the research on post -9/11 PTSD and to discover the following. In these studies - the research - a majority of informants reported only one or two symptoms. Typically a person checked off “since 9/11, I experience difficulty falling asleep.”
That would be a typical symptom. The researchers call these individual symptoms traumatic. And these isolated symptoms were the basis of startling headlines in leading papers in the United States, including the most important newspaper, The New York Times. And this is the quote: “The bottom line is that a minimum of 422,000 New Yorkers experienced PTSD as a result of September 11.”
(ヤング) So, here we see a rather startling contradiction, or rather an apparent contradiction, between the diagnostic logic, psychiatry, and the reality portrayed by the researchers. But I want to underline at this point, as I am coming now to the concluding part of my talk, I call this contradiction to your attention, not to criticize it, because that is not the role of the ethnographer, but rather to explain why. Given this very obvious contradiction, we are led to the following question: why do researchers, referees, editors, and knowledgeable readers believe that the isolated symptoms reported that constitute this epidemic are truly traumatic?
(ヤング) And now that I have asked the question, I want to give the answer, and the answer will be at the very end of my talk. I will just have a two-minute summary once I finish. But before I give the answer, I want to make a point that is important to me and has been emphasized in the past week speaking to students. I am often asked by my own students, and by psychiatrists and researchers, what is the purpose of medical anthropology, aside from producing more medical anthropologists and producing papers and books that medical anthropologists will read and exchange amongst each other? Is there something distinctive? Is there something in the history of anthropology, not just medical anthropology but social anthropology, that will provide a distinctive perspective for every one, not just for medical anthropology, but for psychiatry, for patients and for researchers? And I want to give in my answer an example of what medical anthropology might in fact be able to contribute.
(ヤング) Again the question: why do knowledgeable readers believe that isolated symptoms are traumatic and, therefore, an epidemic has occurred after 9/11? An answer can be found in Claude Levi-Strauss’ famous monograph “The Savage Mind.” He describes the style of reasoning in which an object or a phenomenon is represented not in its entirety, but by only one of its parts. People see the part, and this perception of the single part invokes in their minds the entire phenomenon, even though there is no other evidence of that phenomenon. In other words, a visible part is regarded as evidence of an invisible whole.
(ヤング) In the 9/11 research, each informant is interviewed and identifies one or two ambiguous symptoms. These responses are then collected by researchers and then re-presented on the printed page in the form of tables. In the tables, all four sets of symptoms appear, and the process that defines PTSD emerges on the page. The whole becomes visible.
What has become visible in this collective body represented on the page, the traumatic process, can now be taken for granted in the bodies of the individuals.
(ヤング) In this way, 9/11 researchers have discovered an epidemic of terror-induced PTSD, and I agree with them: there is an epidemic, and it is a collective phenomenon. What we disagree about is what collective means and what is its origin.
(ヤング) So the question: what is its origin? There are several possible answers; I will mention two. The first possibility is the answer given by the researchers and that prevails, I think, in PTSD psychiatry today, and that answer is that the researchers are correct: Al-Qaeda is responsible for an epidemic of PTSD in the United States. Another answer is the answer that I provided in my talk today, and I would like to summarize what it is. Number one, PTSD is a heterogeneous phenomenon. Number two, its manifestations must be understood in historical context. Number three, the epidemic of PTSD following the 9/11 attacks in the USA is a product of the researchers and the research technologies. And number four, these researchers call the new epidemic phenomenon distant PTSD; a more accurate name would be virtual PTSD.
(ヤング) If this argument that I have made is of any interest to you and you would like to pursue it further, I would be pleased to direct you to a much more elaborate account that I have written and that is fully documented and that will be published in the United States later this year. And I thank you very much for your attention.
(註1) Allan Young 2007 “PTSD of the Virtual Kind --Trauma and Resilience in Post 9/11 America.”In Trauma and Memory, Nadav Davidovitch and Michal Alberstein eds. Paolo Alto: Stanford University Press.