National Alliance on Mental Illness
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A Rose by Any Other Name Would Smell As Sweet—Or Would It?
By Jean Moore, NAMI Manager of Military and Veterans Policy and Support
What’s in a name? How much does a label affect your perception of something—or even someone? For some members of the military, a name means everything. More specifically: one word means everything. In recent months, there has been much speculation about changing the name of posttraumatic stress disorder (PTSD) to posttraumatic stress injury (PTSI). Changing that one word, some argue, will reduce stigma and encourage more military members and veterans to seek help for mental health issues.
However, modifying the name PTSD to PTSI, despite its apparently simple notion, is a complicated and contentious issue. As the new manager of military and veterans’ policy and support at NAMI, I was eager to discuss the topic with NAMI veteran affiliates and interested parties across the country. If NAMI were to offer an organization-wide position statement it would require consideration of the valuable opinions of NAMI’s military and veteran community membership. Needless to say, the topic has sparked much debate, and here is why.
To start, there are simply the sheer facts of the issue. Because of the nature of combat in Iraq and Afghanistan a large number of military service members have developed PTSD. 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. Army infantrymen are highly likely to experience at least one event that could lead to PTSD: 93 percent report coming under fire from artillery, rockets or mortars; 91 percent say their unit has been attacked or ambushed; and 87 percent say they know someone who has been seriously injured or killed.
The Department of Veterans Administration estimates that as many as 15 percent of returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have some form of PTSD. Between 2002 and 2008 an estimated 290,000 OIF and OEF veterans entered into the Veterans Administration Medical Center (VAMC) system. Of the nearly 37 percent who received a mental health diagnosis, 21.8 percent were diagnosed with PTSD. Despite high rates of PTSD in returning OIF and OEF veterans, roughly half of the soldiers who return from war with signs of mental illness do not seek treatment, and many more drop out of therapy early. One can only imagine that the cost of these invisible wounds will last for some time and have a significant impact on the health of military families and veterans.
Compounding the issue are the estimated 10 percent of Gulf War veterans and 30 percent of Vietnam War veterans known to live with PTSD.
Enter the U.S. Army, led by former Army Vice Chief of Staff, Retired General Peter Chiarelli. In an article for PBS, Chiarelli states that “calling the condition a ‘disorder’ perpetuates a bias against the mental health illness and is a barrier to veterans getting the care they need.” He eventually dropped the word disorder and began referring to the condition simply as posttraumatic stress.
The new name was adopted by officials at the highest levels of the Pentagon, including Defense Secretary Leon Panetta. However, posttraumatic stress 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 is not explicitly labeled a disease, disorder or injury. When some psychiatrists suggested posttraumatic stress injury as an alternative, Chiarelli heartily endorsed the idea. Last year, General Chiarelli called on the American Psychiatric Association (APA) to modify the name of posttraumatic stress disorder.
The name for PTSD has transformed over the years and the condition has gone by many different names. In the 17th century, Swiss military physicians referred to PTSD-like symptoms as nostalgia and German doctors referred to the condition as heimweh (homesickness). Later, French doctors referred to the symptoms as maladie du pays (homesickness) and the Spanish called it estar roto (literally, “to be broken”). More recent names include battle shock, shell shock, war neurosis, neurasthenia, combat neurosis, combat exhaustion and battle fatigue.
The American Psychiatric Association was in fact already in the process of updating diagnostic standards for all mental illness in the soon to be published revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). President Dr. John Oldham’s asserts that he is open to the suggestion of changing the name if it would encourage those who have experienced the condition to seek help.
Dr. Matthew Friedman, executive director of the VA’s National Center for Posttraumatic Stress Disorder, and chair of the committee that is currently updating the definition of PTSD in the DSM, believes, however, that changing the name of the condition could have “unintended negative consequences” because “it would confuse the issue and set up diagnostic distinctions for which there is no scientific evidence.”
According to Dr. Friedman the net effect of such a modification would be to tinker with a psychiatric diagnosis rather than actually help patients. “To change to PTSI without anything else would accomplish nothing positive,” he argued in a PBS article. Dr. Friedman believes that the focus should not be on altering condition names, but on enhancing how the U.S. military handles traumatized troops. Reportedly, a better approach would be for the U.S. military to follow the Canadian military's route to helping soldiers with wartime psychological trauma: sponsor peer counseling centers for veterans and embark on an education campaign to raise awareness about mental health—invisible—wounds.
While Dr. Friedman feels that it is “unfortunate” that the Pentagon refuses to entitle soldiers with PTSD to receive the Purple Heart, some proponentsof the PTSD name change idea believe that changing the designation from PTSD to PTSI will encourage the awarding of the Purple Heart to warriors with invisible wounds.
For Lt. Col. (Ret.) Kenny Allred, NAMI Veterans and Military Council Chair, the argument is that “psychological wounds, including posttraumatic stress disorder, that are the result of direct and indirect hostile action, including terrorism, should be eligible for award of the Purple Heart with the same level of appreciation and recognition as those awarded to warriors with visible wounds … Denying soldiers with emotional wounds the same award as those with physical wounds denies the parity of those wounds and the reality of modern combat.”
Proponents also believe that nomenclature is important: a one-word change could go a long ways to reducing barriers to care. To them the word disorderindicates weakness and refraining from attaching disorder to trauma is a step in the right direction.
Furthermore, some argue that calling the condition a “disorder” perpetuates a bias against the mental health illness and connotes a pre-existing problem the individual had prior to entering military service.
Psychiatrists in opposition to the PTSD name change argue that posttraumatic stress disorder has more in common with bipolar or depressive disorder than a bullet wound. Some assert that changing the designation from PTSD to PTSI assumes that there is a cure, when there is often not. According to Ellen Harris, president of NAMI Oklahoma, “the only way to really overcome stigma, like any prejudice, is not to bow to it; but to rise above it with knowledge, understanding and compassion.”
APA President Dr. John Oldham recently moved to bridge the divide between the two camps by proposing to maintain the PTSD moniker for civilian cases, such as following a rape or other trauma; and creating a subcategory for combat-related “injuries.” The proposal, however, has fallen by the wayside.
As a Persian Gulf /Desert Storm War veteran, I am grateful that there is such a spirited debate surrounding such an important issue in the military and veteran community. I look forward to supporting NAMI’s efforts to seek out, listen, and engage people of diverse perspectives and experiences in ways that are inclusive, respectful, relevant and responsive, as we continue to develop a position. Post your thoughts on the issue of changing the name of posttraumatic stress disorder (PTSD) to posttraumatic stress injury (PTSI) in the comment section.