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Possible Compromise on Labeling of Combat-Related PTSD

BY Daniel Sagalyn  December 6, 2011 at 4:18 PM EDT

Marines in southern Afghanistan. Photo by Patrick Baz/AFP/Getty Images.

A skirmish has been brewing between U.S. Army brass and a seemingly unlikely interlocutor — the American Psychiatric Association (APA) — over a possible name change for combat-related Post Traumatic Stress Disorder, the mental illness that has afflicted hundreds of thousands of American soldiers.

But now indications of a possible compromise have emerged, even as the issue has triggered a wide-ranging debate among mental health professionals.

Some Army officers and mental health advocates have been calling for a change in the “PTSD” moniker on the basis that calling it a “disorder” is stigmatizing soldiers and preventing them from getting the help they need. Initial indications were that the 167-year-old APA  — which is in the process of updating diagnostic standards for PTSD and other conditions — felt the affliction should continue to be termed a disorder, based on traditional medical definitions and precedents.

However, Dr. John Oldham, the group’s president, said in an interview last week that he would be open to the suggestion of changing the name if it would help encourage those who have it to seek help.

“If it turns out that that [the word ‘injury’] could be a less uncomfortable term and would facilitate people who need help getting it, and it didn’t have unintended consequences that we would have to be sure to try to think about, we would certainly be open to thinking about it,” Oldham told the NewsHour in a telephone interview last week.

Oldham’s comments come six weeks after Army Vice Chief of Staff Gen. Peter Chiarelli sent the American Psychiatric Association a letter requesting that the group consider dropping the word “disorder” from the diagnosis and simply call it Post Traumatic Stress.

In an October interview with the NewsHour, the four-star general said using the term “disorder” perpetuates a bias against the condition and “has the connotation of being something that [was] a pre-existing problem” for an individual before entering the Army. In the eyes of some troops, it “makes the person seem weak,” Chiarelli said.

The number of combat veterans diagnosed with PTSD has skyrocketed over the past decade as hundreds of thousands of troops have been deployed to Iraq and Afghanistan, some multiple times. Rates of PTSD within the Army are estimated at 10 to 20 percent for combat infantry soldiers who experienced direct combat. In some units that experienced high combat, the rates of PTSD affliction are as high as 25 to 30 percent, according to military surveys.

The Army has come under fire for not doing enough to identify and treat soldiers with PTSD, compounding the stigma problem. Forty-nine percent of junior enlisted soldiers who tested positive for mental health problems said that seeking help would be seen as an indication of weakness. A comparable number — 42 percent — thought that other members of their unit might have less confidence in them if they received mental health services, according to the most recent survey.

Chiarelli told the NewsHour that “it seems clear to me that we should get rid of the ‘D’ if that is in any way inhibiting people from getting the help they need.” Calling it an injury,” for example, instead of a disorder “would have a huge impact,” making soldiers suffering from the condition more likely to seek help, he said.

Oldham had rejected the notion of just dropping the word “disorder” from the name of the diagnosis, which would leave it simply called “stress.” He said, though, that calling the phenomenon an “injury” — at least when it pertains to combat veterans — could be worth discussing.

“The suggestion to consider whether Post Traumatic Stress Injury might be a desirable term to introduce is an interesting one,” Oldham wrote in an email to the NewsHour. He indicated that while he was “not certain that the word ‘injury’ would convey the right meaning for all forms of what we now call Post Traumatic Stress Disorder,” nevertheless “it seems to me it would be relevant to think carefully about whether it might be useful for specified groups or circumstances.”

Dr. Matthew Friedman, another leader at the psychiatric association, takes a slightly different view and told the NewsHour he saw “no useful purpose” in changing the name of Post Traumatic Stress Disorder. Friedman is the chairman of a committee currently updating the definition of PTSD in the American Psychiatric Association manual on mental illness.

But Friedman, who heads the Department of Veterans Affairs’ National Center for PTSD, said “we would consider” changing the name if the Army requested it. “The Army is part of the field. And they obviously are a very important constituent,”he said.

The leaders of the American Psychiatric Association and Chiarelli are scheduled to meet in the next couple of weeks.

Oldham said that even after he and his colleagues consider a change in terminology, they will not necessarily “have a consensus that it makes sense.”

“I want to listen to General Chiarelli, I want to listen to these ideas, and I want the troops who need help to get help. And it’s an intriguing idea and I think it’s worth thinking about.,” he said.

Differences Over What to Call PTSD

Among mental health professionals, there has been skepticism of Chiarelli’s idea of changing the name of PTSD by merely eliminating the word “disorder.”

“Just to drop the D, to me, that’s problematic,” said Dr. William Nash, a retired Navy psychiatrist. Using a generic term such as “post traumatic stress,” Nash believes, does not offer soldiers, mental health professionals and military leaders the “possibility of discriminating” between normal reactions to stressful situations that will resolve over time, and those problematic symptoms that demonstrate a need for varying levels of intervention.

But Chiarelli also has many supporters among psychiatrists and psychologists who believe PTSD should be renamed an “injury.”

“To be injured in the service of your country is entirely honorable,” said Dr. Jonathan Shay, one of the leading critics of calling PTSD a disorder and the author of two seminal books about combat-induced psychiatric wounds. If you recover from an “injury to the point that you are fit for duty, there is no stigma or obstacle placed before you in terms of honor, respect and advancement because you were once injured.”

“I don’t think the American Psychiatric Association appreciates the power of the term and concept of “injury” to give constructive meaning to personal sacrifices and losses among service members,” Nash wrote in an email to the NewsHour. “In war, injuries are inherently honorable. Diseases and disorders are not.”

Nash, who rose to the rank of Navy captain before retiring and was a lead author of the Navy and Marine Corps’ Combat Operational Stress Control doctrine, would actually like to see the term PTSD preserved but only for the most “full-blown” cases of longer-term and most severe illness that require the fullest treatment.

However, troops with a wide range of serious but less extensive combat-induced symptoms — such as severe and persistent distress, sleeplessness, and feelings of panic, rage, shame and guilt — should be referred to as having an injury, he said.

Oldham, who served as an Air Force psychiatrist, said that as a veteran he understands that the word “disorder” resonates negatively in military circles. “I certainly think that there is a general comfort level that is greater, I’m sure, to the term ‘injury’ than to something that is a ‘disorder,’” he said.

Besides exploring the word change, the PTSD expert group at the American Psychiatric Association should consider other terms — such as “Operational Stress Injury” — which is what the Canadian military uses, Oldham said.

The Canadian military coined the term Operation Stress Injury around 2000, to “soften that blow” of being labeled with PTSD” according to Lt. Col. Stephane Grenier, a Canadian who at the time had been diagnosed with PTSD and depression after his experience in Rwanda. The term is intended for the military culture, not healthcare professionals.

It helps soldiers “get their minds around the notion that the body can become ill, the body can become injured, and the mind can get ill and the mind can also get injured,” Grenier said.

The notion of the psychiatric association adopting the Canadian model is a good middle ground, according to Dr. Frank Ochberg, the founder of Columbia University’s Dart Center for Journalism and Trauma.

If the psychiatric association “includes Operational Stress Injury as a legitimate alternative medical term for PTSD and other injuries (hidden wounds) received in military service, we could compromise our way out this controversy,” Ochberg said in an e-mail to the NewsHour. The psychiatric association “does write the dictionary of terms. It has compromised before, when one group of members disagreed with another … Now the nomenclature debate finds psychiatrists on one side and advocates for veterans on the other. The APA needs to listen to patients, not just doctors.”

A Wrongheaded Debate?

Some psychiatrists question whether the dispute over changing the name will ultimately do any good.

Altering the name would be a “waste of peoples’ energy,” said Dr. Bessel van der Kolk, professor of psychiatry at Boston University Medical School.

“There are so many important things to address that this would be the last order of priority,” said van der Kolk, expressing skepticism that the association will ultimately change the PTSD name. “New terms are invented with every generation in order to over come the stigma of the previous term. So people don’t like psychologically wounded people,” he said. “Whatever name you give to it, sooner or later it would become a derogatory word.”

Other mental health experts think the focus should instead be on altering Army policies. “What is most important is what happens after they [soldiers] get a diagnosis,” Dr. Elspeth Ritchie, a retired colonel and psychiatrist, told the NewsHour. If troops are kicked out of the Army for medical reasons after being diagnosed, “they’re not going to report it,” she said.

Similarly if, after leaving the military, veterans cannot get a job in law enforcement or related fields because they have Post Traumatic Stress Disorder, “then they quickly are going to learn from each other, ‘I’m not going to seek help,’” she said.

One initiative to help reduce stigma, would be for the Army to combine behavior health with primary healthcare because “people hate to go into mental health clinic, or the behavior health clinic where everybody in there is perceived as a dirt bag or sleaze ball, and they don’t want to be perceived that way,” Ritchie said.