Does John have post traumatic stress disorder? Can crime solving cure psychiatric illnesses? Why is John limping after being shot in the shoulder?
I attempt to explore the enigma that is our favourite army doctor and in the process:
- Solve the dilemma of how John got shot in the first place (doctors do not fight on the front line)
- Attempt to diagnose Dr Watson
- Explain why people get psychosomatic limp
- Suggest what John might really have suffered from (and its much more mundane than PTSD)
I actually have very little clinical experience working with soldiers who have returned from Afghanistan so this meta is a theoretical exercise in analysing John’s mental state from a psychiatric perspective.
Not Quite so Glamourous
In my previous metas I have discussed what doctors in the army actually do, how they join up and what kinds of careers/promotions prospects they have (see Semantics In Healthcare series).
In order to take a locum job at Sarah’s surgery in TBB John has to be a qualified GP – for full explanation: Exploring Dr Watson’s Army Career.
This does not necessarily mean he has to be an army GP. If you would like to know how John can realistically have other careers you can read: BAMF!John and Reality and Making John a Realistic Army Surgeon. However the most likely scenario is that John is a army GP and I am going to use this assumption for the rest of the meta
Army doctors do not engage in front line combat, they are confined to the hospital at base and patients are flown back to them in air ambulances. The medical officers who go out on patrol are not doctors, they are the army's equivalent of paramedics but they also belong to the RAMC.
Only on rare occasions a doctor with specialist trauma training will fly out with the paramedics to stabilise soldiers in the combat zone. An Army GP is not the first person who would be chosen for this kind of mission – in fact they would be one of the last doctors to be chosen. The types of doctors who are experienced at stabilizing massive trauma patients are Accident and Emergency specialists and anaesthetists.
Yes, you read that correctly – anaesthetists. The common saying in hospital is “if the s**t hits the fan, you want an anaesthetist.” Anaesthetists can intubate patients to protect their airway, ventilate, and sedate patients for defibrillation etc.
John, as an Army GP, would have done his Advanced Trauma Life Support course and he would know how to stabilised massive trauma but it is not part of his routine work and he therefore does not have as much experience in this field compared with specialists. Therefore, John would have spent 99% of his time back at base dealing with routine, non-life threatening illnesses.
How he managed to get wounded is something that I have speculated on before (Exploring Dr Watson’s Army Career). The only new theory I can think of is that his base came under sustained attack. The British are based in Helmand province – the major military hospital is in Camp Bastion. The Taliban managed to infiltrate Camp Bastion in September 2012 and initiated a 4 hour fire fight within and around the base. I can imagine John being injured in a situation like this (even though he wasn't in Afghanistan during 2012)
In this scenario the fire fight in which John was wounded would be the first real combat he has ever been personally involved in. This alone can be incredibly traumatic particularly as doctors do not undergo the same combat training as actual combat troops. Doctors who join the military do take part in an abbreviated course at Sandhurst to prepare them for military life. They are trained to use standard issue weapons and in military leadership skills as all doctors are commissioned officers. However they are not extensively psychologically trained for combat.
Much of basic military training is not really about technical skills but psychological conditioning. Marching into a warzone to kill the enemy has profound psychological effects that can be counteracted to some extent by correct training. Additionally desensitization occurs with increased exposure. If you spend all your time in the combat zone, you can become less sensitive to the fear and stress. Mental preparation also helps humans cope with stressful situations; it is usually unexpected stress that produces the greatest trauma.
Apart from lack of mental preparation – helplessness is another causative factor for psychological trauma. Humans (and rats) secrete less corticosteroids (“stress” hormones) if they believe they have some semblance of control. In similar conditions, people who feel helpless or at the mercy of external factors beyond their control experience a higher degree of physiological stress than people who feel in control. Humans who suffer long periods of helplessness induced stressed are more likely to become clinical depressed than subjects in the same situation who did not feel helpless
Although John is brilliant marksman and has clearly received good combat training, there is a great difference between training and reality. A sudden unanticipated attack on the base hospital without an organised military response may have left John feeling helpless/not in control particularly if he was forced into combat outside the base for whatever reason. It would have left him outside his comfort zone, without the necessary equipment such as body armour, and unable to take command.
We have seen that John generally reacts very well under stress and I do not doubt that he would have held himself together during the fire-fight despite how he was feeling. However even though he is able to remain logical and functional does not protect John from intense psychological problems in the aftermath.
Does John have a psychiatric condition?
John has clearly been traumatised by the events that culminated in him being shot in the shoulder but does he actually have post-traumatic stress disorder?
PTSD can happen to anyone who undergoes significant trauma. There are situations that everyone will agree are traumatic like being shot in the shoulder. However the severity of the trauma experienced by different people in the same situation can vary greatly. Not everyone who experiences a traumatic situation will go onto develop PTSD. This is a psychiatric disorder rather than a physiological response to trauma.
In the same way not everyone becomes clinical depressed after bereavement and clinical depression is not the “normal” reaction to grief.
How to Diagnose PTSD
The diagnostic criteria used in the UK is from ICD-10 diagnostic manual, which defines PTSD as “severe psychological disturbance following a traumatic event characterised by involuntary re-experiencing of elements or the event with symptoms of hyperarousal, avoidance and emotional numbing.”
2 or more “persistent symptoms of increase psychological sensitivity”
- Difficulty falling or staying asleep – not enough evidence
- Irritability or outbursts of anger – John does have an outburst in front of Mrs Hudson “Damn my leg!”
- Difficulty in concentrating – Not really
- Hypervigilance – John does not spot Stamford and is aware of him after Stamford says “John” so I would not say that he is hypervigilant at all times.
- Exaggerated startle response – John does not appear particularly startled or distressed by suddenly seeing Stamford or by the phone call from Mycroft Holmes. This appears to be the only time we actually see him being surprised.
- Persistent remembering/reliving in intrusive flashbacks, vivid memories or recurring dreams. Experience stress when exposed to circumstances resembling or associated with the stressor
- Actual or preferred avoidance of circumstances resembling or associated with the stressor which has not been present before.
- Inability to recall either partially or completely some important aspects or the period of exposure to the stressor.
The diagnostic manual DSM-IV used in American and other health systems based on America goes into slightly more detail and has a different scoring method. I am not going to go into this because John’s psychiatrists would be British and be mostly using ICD-10.
The difficulty in diagnosing John is that his symptoms only appear in the first half hour of the first episode after which he apparently becomes completely cured.
We do see in the beginning of ASIP that John has a dream sequence in which he is seeing soldiers in combat. I emphatically do not believe that John would have been dressed like any of those soldiers. Doctors in the field hospital usually dress like this:
They do not routinely leave the base, and when they do they do not wonder around in combat zones wearing body armour. In fact they do not have their own specialist combat equipment and armour/rifles are not something you can pick up at random when you feel like it.
Sticking to my earlier theory that the base was attacked/bombed, John may have been forced outside the compound and engaged in a fire-fight without the same equipment as the soldiers in the footage. This dream sequence is John watching the other combatants he happened to end up with fighting for their lives. Perhaps it is the last few moments before he got shot.
Either way, John does have at least one dream about the “stressor event” but we do not know whether he has persistent recurring dreams. Even if he does, this is not a unique symptom of PTSD – many people who have been traumatised but do not have PTSD also relive the event through a variety of different ways.
The other thing that comes across in John’s demeanour during the first part of ASIP is that he does have outbursts of anger. For example he shouts “damn my leg” at Mrs Hudson. However I cannot convincingly say that any of the other symptoms of psychological sensitivity are positive.
John does not preferentially avoid similarly stressful situations that resemble his original traumatic episode. For example he volunteers to help Sherlock out on his case despite understanding that it will involve a certain degree of danger. He is exhilarated by running from the police, which may resemble attempting to escape from insurgent fire. He is not overtly distressed when he is once again placed in a powerless situation by Mycroft’s kidnapping. In fact, as Mycroft points out, one of his psychosomatic symptoms, the tremor in his hands, disappears when he is under stress.
We do not have enough information to gage what his memory of the actual traumatic event is like and therefore it is not possible to judge, whether he has difficulty remembering the actual event.
I am not convinced that John does have PTSD, not because Mycroft says so in the warehouse scene, but because John becomes a completely different person in the course of one day. The outbursts of anger and irritability are gone; we are never informed that he has any more trouble with nightmares (so I am going to assume that he doesn’t).
Anxiety disorders like PTSD take longer than a day to recover from. Having purpose, self-esteem, social support etc is very helpful but there is no instant miracle cure.
However because we haven’t seen the full course of John’s condition – it is impossible tell whether his symptoms have improved and we are simply witnessing the tail-end of what was once PTSD. Perhaps if John hadn’t met Sherlock he might have got better on his own anyway – we just don’t know.
Home for Heroes
In my opinion John is traumatised by being shot in the shoulder but he hasn’t developed PTSD. His main problem is that he has lost purpose.
Many servicemen find it difficult to adjust to civilian life after spending so long in a hermatically seal existence within the armed forces. Although combat personnel are more likely to suffer from this, John clearly also found civilian life difficult to cope with. Unlike some servicemen, he has not actively sort to reintegrate himself into civilian society. He relied on the army to find him accommodation and he did not get back in contact with his civilian friends/family on his return.
Added to this, John has also lost his job. I think many people can relate to the emptiness and loss of purpose this can have. The medical profession in not something you can enter halfway through, most people who go to medical school appropriately expecting to be in the same profession until they retire 40 years down the line. The job becomes an integral part of your life and your self-worth.
John’s psychosomatic symptoms do not have to be a result of trauma. GPs and neurologists often see a wide variety of patients with “functional” problems i.e. motor conditions that have no identifiable underlying cause. Mostly psychosomatic symptoms manifest in patients who have troubled and stressful social lives/lack of social position but onset is not always directly related to specific traumatic events. For example: long term unemployed workers, single mothers trying to survive on benefits, the chronically ill and isolated pensioners some of the most common patients I have seen with functional problems. Around 30% of all patients referred to neurologists on the NHS have functional problems so it is definitely not uncommon. I imagine with all the social and psychological problems that being in a combat can bring, many war veterans are at high risk of developing psychosomatic symptoms
John’s loss of purpose and the belief that he has a psychiatric condition can just as easily have lead to his psychosomatic limp rather than the initial combat stress.
What Sherlock does is fulfil his sense of purpose – John has something useful to do. He is helping to fight crime; at the end of ASIP he has also saved Sherlock’s life and the lives of countless other potential murder victims.
As Mycroft says, John still likes danger. He certainly wasn’t traumatised so much by his combat experience that he could no longer bear to participate in high-octane adrenaline fuelled situations.
If John doesn’t have PTSD why was he diagnosed? And why did he keep going to therapy when it wasn’t working?
I think the problem is that John believes he has PTSD and it took a day with Sherlock and Mycroft to convince him that he doesn’t.
Mind over Matter
The most likely scenario is that John believes he has PTSD, this is why he sits through those therapy sessions even though he doesn’t feel they are being particularly helpful. He diligently tries the interventions his therapists suggest like keeping a blog, even though he has nothing to write. The therapist would have told him to avoid stressful situations which would have made life even more boring for an adrenaline junkie like John.
Doctors are often guilty of diagnosing themselves (then sticking to their diagnosis whether or not the rest of the medical profession agrees). Doctors are advised by the General Medical Council not to do this because it is impossible to remain impartial or take a logical approach. Emotions get mixed in with the clinical process which will skew any conclusions.
However as a doctor self diagnosis is almost irresistible. We spend so much of our time thinking about the symptoms of illness and disease, it is hard not think of a medical explanation when life is not going to plan. Given that the diagnostic criteria for psychiatric diseases are all very subjective, it is very easy to diagnose yourself with a psychiatric disorder.
What we see in the case of John and therapist is what you could call folie et deux, although to be fair to the therapist John would have been referred to her by a psychiatrist and she would have no reason to question the diagnosis.
Therapists are not doctors; they usually have a background in clinical psychology, although you can qualify as therapist without any prior experience in psychology or psychiatry. Therapists generally do not diagnose patients (that is the psychiatrist’s job), they work with patients who have already been diagnosed.
I personally think that John gave a very convincing story to the civilian psychiatrist once he left the army and was diagnosed at that point. He would then have been referred to the therapist – cognitive behavioural therapy is one of the main treatments for PTSD. An army psychiatrist who has seen hundreds of cases ofPTSD probably would not have diagnosed John.
I will discuss John's discharge from the army in more detail in Part 2
The time he spent with Sherlock and Mycroft convinced John that he doesn’t really have the symptoms of PTSD. Mycroft makes a concerted point to tell John that his psychosomatic symptoms are not due to his combat trauma rather than to his lack of purpose. Sherlock drags John through the backstreets of London on a wild goose chase and then ends up being pursued by the police.
Once John got his head around the fact that he doesn’t have PTSD, and did something that he really enjoyed involving tonnes of adrenaline fuelled action – his problems seem to evapourate. I am sure that John was still traumatised by the war - his trauma has not evapourated, but his despair and loss of purpose have and at the end of ASIP he has a new life to look forwards to