PTSD: Weakness or Wound?

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This week, the American Psychiatric Association is meeting in Philadelphia. Among the presentations in the “military track”—a spate of meetings directed towards practitioners focused on military or war related psychology and psychiatry—the top listed presentation is titled “Combat Related PTSD: Injury or Disorder?” Based on conversations I’ve had in the past couple weeks with psychiatrists and psychologists who ply their trade among wounded warriors, this is the hottest of hot topics.

In the next year, the psychiatric community will re-issue its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current manual, DSM-IV, defines Post-Traumatic Stress Disorder. A core element of the discussion will be whether or not to change the description of PTSD in DSM-V from a disorder to something else. But to what? I’m convinced the definition must include the word injury.

Some medical practitioners believe that the use of the word disorder in PTSD discourages servicemembers from asking for help because they feel that a disorder is a weakness. I absolutely concur. Others inside the military community feel the same way. General Peter Chiarelli, former vice chief of staff of the Army, has pushed to drop the word disorder from the vernacular, referring only to PTS. I think simply dropping the word disorder is wrong — it moves us further away from treating this as a combat wound.

Here’s the rub. It is entirely honorable to be wounded in the service of one’s country, but Post-Traumatic Stress Disorder is seen as breaking under the stress of combat or as a pre-existing condition. Some service members view PTSD as weakness. The services apparently do as well: a blood-and-bone wound, or a Traumatic Brain Injury (TBI), warrants award of the Purple Heart medal; no Purple Heart medal is authorized for PTSD. Importantly, PTSD is caused by some outside influence, not—as in all other mental health illness—something internal. The trauma that brings on PTSD changes the way the brain functions and the physical size of parts of the brain. It is a wound.

I’ve written before that leadership not lexicon is what’s necessary to change the stigma of asking for help. But in this case we have an opportunity to change the discussion at its core. If the APA decides to re-define what has been called soldier’s heart, nostalgia, shell shock, battle fatigue, and finally as Post-Traumatic Stress Disorder, we’ll be well on the way to doing so.

For the record, I hold neither an MD or PhD degree. But I hold something else: a PTSD diagnosis and a certification as combat-disabled for PTSD. Further, I work with other traumatized service members every week at the DoD’s premier PTSD/TBI research and treatment facility, the National Intrepid Center of Excellence (NICoE). While I’m certain that the APA will dig into all the issues at hand here, I also hope that the conversation will include survivors rather than just practitioners. It’s important to hear what soldiers—young, highly impressionable soldiers who feel peer pressure and have reason to fear retribution from sergeants and junior officers—say about this issue.

My sense is that the solution will be something like replacing the word disorder with the word injury, thus PTSD will become PTSI. But it might be better to move more fully away from the current usage. Something closer to Traumatic Stress Brain Injury, perhaps, echoing the terminology for Traumatic Brain Injury. Either way, this is important work and I can only hope the APA moves in the right direction.