The nation's second-highest ranking Army officer is calling on mental health professionals to change the name of the condition that has afflicted hundreds of thousands of U.S. soldiers. But some of those doctors are resisting the change.
The term Post Traumatic Stress Disorder, or PTSD, carries a stigma that has discouraged too many soldiers from understanding the condition and seeking proper treatment, Gen. Peter Chiarelli, the Army vice chief of staff told the PBS NewsHour. He would like to see PTSD called Post Traumatic Stress Injury, or PTSI, instead.
"It is an injury," Chiarelli said. Calling the condition a "disorder" perpetuates a bias against the mental health illness and "has the connotation of being something that is a pre-existing problem that an individual has" before they came into the Army and "makes the person seem weak," he added.
"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," Chiarelli said. Calling it an injury instead of a disorder "would have a huge impact," encouraging soldiers suffering from the condition to seek help, according to the four-star general.
Rates of PTSD in the Army are estimated at 10-20 percent for combat infantry soldiers who experienced direct combat. In some units with high combat involvement, the rates are as high as 25-30 percent.
Chiarelli's call to change the name to PTSI comes at a time when the American Psychiatric Association is in the process of updating its "bible" of mental health illnesses. Officially called the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV), it classifies and defines the criteria for mental health conditions. It is used by health and mental health professionals, ranging from psychiatrists to physicians to psychologists, according to the association.
The manual currently says that for a person to have PTSD, he or she must have been exposed to a traumatic event, and then have a number of symptoms for more than one month. The individual persistently re-experiences the event, such as through distressing dreams or intrusive recollections. The person also must seek to avoid stimuli associated with the trauma, such as avoiding activities that remind him or her of the event. Another symptom is increased arousal, including hypervigilance or difficulty staying asleep.
Chiarelli is not the only one calling for a name change. Former Army 1st Lt. Paul Rieckhoff, the founder and executive director of Iraq and Afghanistan Veterans of America, said from a "national messaging standpoint," changing the name would help reduce the negative connotations associated with PTSD.
"We believe that PTSD is a wound you suffer in combat, just like a bullet wound, and if you don't take care of it, and you don't treat it, it's going to be a problem," Rieckhoff said.
However, the chairman of psychiatrists' committee overseeing the professional guidebook update of the PTSD diagnosis, Dr. Matthew Friedman, said he "sees no useful purpose to change the name."
He told the PBS NewsHour: "There is stigma attached to any mental illness. And PTSD is no different."
The discomfort with such a diagnosis "may be amplified in military culture," he acknowledged. In other settings, such as in the civilian world, "PTSD may be even less of a stigma," he said.
Friedman is also the executive director of the National Center for PTSD, the Department of Veteran Affairs' center for research and education on the prevention, understanding, and treatment of PTSD.
A diagnosis of PTSD does not imply that a soldier "doesn't have the right stuff," because it gives primacy to being exposed to a traumatic event, Friedman said.
This line of thinking sounds like "doctors are dancing on the head of a pin," argued Chiarelli. He emphasized that a name change would not be carried out for the sake of physicians, but help encourage afflicted soldiers and their commanders to embrace diagnosis and treatment. "If it was only doctors I had to convince to seek help, I wouldn't care if it had a 'D' at the end of it."
The soldier himself might be an obstacle to receiving treatment, said Chiarelli. "I have to convince a 19-year-old kid who thinks he's invincible that he's got an issue ... that he has to deal with. A no-kidding injury that he can't see. That many of his buddies don't even believe is real," he said. "But I need to get him the help that he needs ... A disorder is something, to a 19-year-old kid, that [seems] pre-existing that makes me weaker than other people."
Schizophrenia previously labeled as "disorder"
There is some precedent for changing the name of a mental health disorder, according to Dr. Frank Ochberg, a clinical professor of psychiatry at Michigan State University. "Schizophrenia is called schizophrenia, although there were times when it was called schizophrenia disorder, or schizophrenia reaction," he said.
There are other mental health disorders that are not labeled as disorders, he added.
"If you look through the (manual), you'll see that diagnosis after diagnosis is named disorder. But not all," Ochberg wrote in an email to the PBS NewsHour. "There is a chapter on 'Impulse Control Disorders' and some of those have non-D names: kleptomania, pyromania, pathological gambling, trichotillomania."
PTSD's emergence after Vietnam
The diagnosis of PTSD was first included in the third edition of the manual in 1980. Ochberg, who at that time was involved in updating the manual, said he and his colleagues wanted it called a disorder because -- only half-jokingly -- "we figured if we did, then Blue Cross would pay for it."
Ochberg was "part of the Vietnam generation who opposed the war but ultimately recognized the price the warrior paid," he said. "I saw the similarity between the rape trauma syndrome and military trauma. My take on the history of the time was that PTSD was the common ground between the male trauma of combat and the female trauma of rape, and incest and battering."
"All syndromes coming out of the DSM in 1980 were disorders," said another leading mental health professional, Charles Figley, director of Tulane University's Traumatology Institute.
An expert on trauma and author of the 1978 book, "Stress Disorders Among Vietnam Veterans: Theory, Research," Figley said calling the condition a disorder reflected a combination of factors. "Part [of it] was politics. To give Vietnam veterans their due. The hawks thought they [veterans with the illness] were whiny babies, and the doves thought they were crazy. So it was an effort to legitimize the pain and suffering they were going through."
Revising the manual of mental illnesses
The American Psychiatric Association began preliminary work on updating its dictionary of mental health illnesses in 1999, and opened the draft text to public comment.
The committee received hundreds of comments, but not on changing the name of PTSD, said Friedman.
Asked if the committee revising the entry for PTSD would be open to changing the name if the Army formally made such a request, Friedman said "we would consider it" and that "the Army is part of the field. And they obviously are a very important constituent."
According to Friedman, the current name of the condition has proved helpful. "The most important thing about the name PTSD, prior the 1980 version of the manual," is that "we had a whole bunch of syndromes that were all named by the stressor," he said. "There was rape trauma syndrome, there was battered wife syndrome, there was war sailor syndrome, there was post-Vietnam syndrome, concentration camp syndrome, and on and on."
The "brilliance" of those who wrote the manual in 1980 is that "they understood that it really didn't matter what the particular stressor was," Friedman said. "If it was a traumatic stressor and the individual's coping capacities were exceeded, that it was the response rather than the stressor that matter."
The revised Diagnostic and Statistical Manual will be released in final form in May 2013.