Military psychiatrists seek new name, and less stigma, for PTSD

This article is re-posted from The Washington Post.

By Greg Jaffe

The Washington Post

Published: May 6, 2012

It has been called shell shock, battle fatigue, soldier’s heart and, most recently, post-traumatic stress disorder, or PTSD.

Now, military officers and psychiatrists are embroiled in a heated debate over whether to change the name of a condition as old as combat.

The potential new moniker: post-traumatic stress injury.

Military officers and some psychiatrists say dropping the word “disorder” in favor of “injury” will reduce the stigma that stops troops from seeking treatment. “No 19-year-old kid wants to be told he’s got a disorder,” said Gen. Peter Chiarelli, who until his retirement in February led the Army’s effort to reduce its record suicide rate.

On Monday, a working group of a dozen psychiatrists will hold a public hearing in Philadelphia to debate the name change. The issue is coming to a head because the American Psychiatric Association is updating its bible of mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders, for the first time since 2000.

The relatively straightforward request, which originated with the U.S. Army, has raised new questions over the causes of PTSD, the best way to treat the condition and the barriers that prevent troops from getting help. The change also could have major financial implications for health insurers and federal disability claims.

Chiarelli took on the problems of PTSD and suicide after two tours in Iraq and pressed harder than any other officer to change the way service members view mental-health problems. His efforts, however, have not resulted in a reduction in suicides.

Dropping ‘disorder’

PTSD refers to the intense and potentially crippling symptoms that some people experience after a traumatic event such as combat, a car accident or rape. To Chiarelli and the psychiatrists pressing for a change, the word “injury” suggests that people can heal with treatment. A disorder, meanwhile, implies that something is permanently wrong.

Chiarelli was the first to drop the word “disorder,” referring to the condition as PTS. The new name was adopted by officials at the highest levels of the Pentagon, including Defense Secretary Leon E. Panetta. But PTS never caught on with the medical community because of concerns that insurers and government bureaucrats would not be willing to pay for a condition that wasn’t explicitly labeled a disease, disorder or injury.

Some psychiatrists suggested post-traumatic stress injury as an alternative, and Chiarelli heartily endorsed the idea.

The question for the working group of doctors debating the change is whether the nightmares, mood swings and flashbacks normally associated with PTSD are best described as an injury.

Those in favor of the new name maintain that PTSD is the only mental illness that must be caused by an outside force.

“There is a certain kind of shattering experience that changes the way our memory system works,” said Frank Ochberg, a professor of psychiatry at Michigan State University.

The intensity of the trauma, whether it is a rape, car crash or horrifying combat, is so overwhelming that it alters the physiology of the brain. In this sense, PTSD is more like a bullet wound or a broken leg than a typical mental disorder or disease. “One could have a clean bill of health prior to the trauma, and then afterward, there was a profound difference,” Ochberg wrote in a letter backing Chiarelli’s request for a change.

Psychiatrists who oppose the change argue that PTSD has more in common with bipolar or depressive disorder than a bullet wound.

“The concept of injury usually implies a discrete time period. At some point, the bleeding will stop. Sometimes the wound heals quickly, sometimes not,” said Matthew J. Friedman, executive director of the Department of Veterans Affairs National Center for PTSD. A disorder can stretch on for decades.

Although everyone is equally susceptible to a gunshot wound, not everyone exposed to trauma suffers from PTSD. Genetics, military training and even the cohesion in a soldier’s platoon all play a role in determining whether a combat experience results in PTSD or simply a bad memory, experts said.

“The word ‘disorder’ reflects the fact that some people are more vulnerable than others,” said John Oldham, president of the American Psychiatric Association.

Treatment for the malady often includes remembering the traumatic event under controlled conditions until it loses its power.

Origins of PTSD

PTSD made its first appearance in the diagnostic manual’s third edition, which was published in 1980. The doctors who lobbied for its inclusion viewed it as a measure that would finally legitimize the pain and suffering of Vietnam War veterans.

Before the creation of the PTSD diagnosis, Vietnam War-era hawks saw troops suffering from such symptoms as weaker than their World War II-era colleagues. “The view was that they should just suffer in silence,” said Charles Figley, director of Tulane University’s Traumatology Institute. The antiwar doves often portrayed Vietnam War veterans as crazy, deranged and dangerous.

“PTSD was a validation that what the Vietnam veterans were reporting was true, and it connected them to other veterans in other wars and other people who had experienced trauma,” Figley said.

Political fallout

The name-change debate is also being influenced by bureaucratic politics. In 2008, the military considered awarding the Purple Heart to troops suffering from PTSD, but ultimately decided that brain science had not advanced far enough to prove that people were suffering from the condition.

A change to “injury” would make it easier to revise the award criteria, advocates of the name change say.

“To be injured in the service to your country is entirely honorable in the military culture,” said Jonathan Shay, a psychiatrist who specializes in treating the psychic wounds of war and has worked closely with the U.S. military. “To fall ill is not dishonorable, but it is unlucky.”

A shift to “injury” could make it harder for service members to collect permanent-disability payments for their condition from the government, some experts warned. “When you have an injury, you follow a treatment regimen and expect to get better,” Figley said. “This change is about medicine, but it is also about compensation. We are talking about hundreds of millions of dollars.”

Finally, the name change has unearthed other sensitive arguments about the best way to prevent PTSD in the military.

“The whole history of psychiatry is to change the names of conditions. If the problem doesn’t go away, we change the name,” said Bessel van der Kolk, a professor of psychiatry at Boston University. “It makes us feel momentarily better. But it doesn’t change anything.”

If the Army really wanted to protect soldiers, it would limit the number of tours that troops are permitted to do in Afghanistan, van der Kolk said. Medical studies have suggested that a soldier’s resilience is depleted with each battlefield tour. “As long as you have repeated deployments, you will have devastating effects on people,” he said.