PTSD should be categorized as a PTSD Injury, or PTSI.
“Post-traumatic stress disorder” is a label given to a set of symptoms set forth in the diagnostic and statistical manual of mental disorders (DSM-IV; American Psychiatric Association 1994), the clinical manual treatment providers used to determine diagnoses. DSM-5 was revised in 2013 as an update to the 1994 edition, but in many experts’ opinions, the draft model which was surrounded by controversy, did not go far enough. During the drafting and debate process, even experts in the field were unable to agree on diagnosis, and what characteristics and symptoms will be considered diagnostic for the disorder, as well as the future name for PTSD.
The name, PTSD, was created in 1980 as a new diagnosis, and further codified in DSM-IV; American Psychiatric Association 1994. PTSD was used most often in reference to victims of combat, the term was “shell shock,” “battle fatigue” and “soldier’s heart.” Diagnoses in any medical specialty are important because they allow for standardization of diagnosis and treatment by the medical and mental health communities as well as reimbursement and payment by insurers.
Having the PTSD diagnosis has helped millions of people in various ways:
- It gave a name to something that was confusing, frightening and disabling.
- It allowed research into causes and remedies.
- It enabled insurance coverage and disability payment.
- It fostered self-help for those with the condition and collaboration among those who study and treat the condition.
- The name, PTSD, has helped all of us who care about trauma and its consequences.
Mental wellness experts, psychiatrists and military leaders and other proponents of change pressed the American Psychiatric Association (APA) to change the word “disorder” to “injury,” hopefully reducing some of the baggage the word carries and the reluctance of those suffering from it to seek help. PTSD Injury, or dropping the “disorder” altogether has been the focus of like-minded experts.
“No 19-year-old kid wants to be told he’s got a disorder,” says Gen. Peter Chiarelli, a champion in the cause for the name change. His concern for the rising suicide rate among current military women and men serving in our wars has him passionate about solutions and understanding for a soldier who, going back to the old name, experienced and saw things that broke his or her heart.
An argument for dropping the word “disorder” and replacing it with “injury” is that PTSD is the only mental illness that must be caused by an outside force: A person is psychologically well-adjusted before something happens that renders him or her unable to function normally. Or, as Frank Ochberg. M.D., a professor of psychiatry at Michigan State University, puts it, “There is a certain kind of experience that changes the way our memory system works. One could have a clean bill of health prior to the trauma, and then, afterwards, there was a profound difference.” In this way, he insists, PTSD is more like a bullet wound or a broken leg than a mental disease or disorder. It is an injury that can heal with proper medical treatment.
But the name has also been a source of stigma. The “D” in PTSD, the word, “disorder,” discourages some from seeking care, from revealing their condition and from feeling a sense of honor, when their PTSD is just as honorable as any physical injury. When an injury is earned in battle, awards are given. There is no Purple Heart for PTSD. While the APA uses the term, “disorder,” for most diagnoses, there are many diagnoses without that word, Anorexia, Bulimia, Parasomnia, Social Phobia to name a few.
The former Vice Chief of Staff of the Army, an advocate for reducing the stigma of PTSD, argues strongly in favor of dropping that word, “disorder,” because, “disorder” perpetuates a bias 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.”
The current version of DSM-5, as published by American Psychiatric Association notes the following:
Posttraumatic Stress Disorder
DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV. As described previously for acute stress disorder, the stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events. Also, Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder. See, Highlights of Changes from DSM-IV-TR to DSM-5, American Psychiatric Association, May 2013.
Mental wellness experts, including psychiatrist Frank M Ochberg, MD and Jonathan Shay, MD, PhD, have been proponents of shifting the PTSD paradigm (PTSD Injury) to a framework with less stigma attached where the effects of trauma are seen as an injury, rather than a disorder. In the context of PTSI, the word “injury” has less stigma attached to it then “disorder.” It also shifts the framework to identifying a condition that is more treatable while offering hope to victims who want to heal from this injury, rather than manage a disorder. Recategorized as Post traumatic stress injury (PTSI), this rebranding of both symptoms and diagnosis, has found a groundswell of support by prominent members of both the psychiatric community, as well as members of the military community, including General (Ret.) Peter Chiarelli, former Vice Chief of Staff of the U.S. Army. General Chiarelli is currently the CEO of the corporation, One Mind for Research.
In a letter to the President of the American Psychiatric Association, Frank M Ochberg, MD Jonathan Shay, MD, PhD endorsed General (ret) Chiarelli’s position, adding their own reasoning for a new name: Post Traumatic Stress Injury. Ochberg and Shay believe that the “injury model” and the injury name is correct from a medical and a public perception point of view.
Dear Dr. Oldham:
We write to you in support of the request from General (Ret) Peter Chiarelli that the American Psychiatric Association change the name Posttraumatic Stress Disorder (PTSD) to Post Traumatic Stress Injury (PTSI) in its next edition of the Diagnostic and Statistical Manual. When he first made this request, General Chiarelli was Vice Chief of Staff of the United States Army. Now retired, General Chiarelli is CEO of the corporation, One Mind for Research.
This request pertains only to the name, and expresses no opinion on the existing DSM-IV or proposed DSM-V criteria. General Chiarelli’s request springs from the culture of the U.S. Armed Forces, which finds the label “Disorder” to be stigmatizing, compared to the term “Injury,” which is not.
General Chiarelli represents soldiers who suffer in silence. He has concluded that changing the name of PTSD to PTSI will reduce barriers to care, with palpable benefit to his service members, their families, and the nation. General Chiarelli comes forward as suicide rates of young veterans are on the rise, as media attention to invisible wounds of war is increasing, and as next-of-kin struggle to overcome their loved ones’ aversion to intervention.
In a PBS News Hour interview with producer Dan Sagalyn, the General elaborated:
“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.
Veterans are not alone in feeling this way.
Gloria Steinem sent us a personal communication in support of a change from disorder to injury, noting the beneficial effect this would have upon women as well as men. “I think that’s great, to change to injury….there are a whole raft of people who are adversaries to such (disorder) labeling. To stigmatize psychological injury by the death and destruction of war, defining this as “disorder,” is to prevent healing.” Ms. Steinem addressed the APA in 1980, thanks to the efforts of the APA Committee on Women. Issues of sensitivity to language on behalf of our patients mattered then, as they do now. Survivors of rape and battering have reason to resent a stigmatizing label, when their posttraumatic reactions are consistent with an injury model.
The complete letter can be read Posttraumatic Stress Disorder Letter.
While the APA did not fully endorse the change from “disorder” to “injury, the debate continues and organizations like General Chiarelli’s One Mind for Research not fully endorse the change General Chiarelli’s One Mind for Research continues to make change and impact the mental wellness landscape.
Is it time we end the stigma of a “disorder” and label PTSI Injury traumatic events an “injury”?
Would PTSI Injury remove the stigma of a “disorder” and encourage those suffering from a traumatic event, or PTSD Injury, to seek help?