contexts-2015-smith-38-43 published

38 contexts.org

dropping the disorder in ptsd

by r. tyson smith and owen whooley

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39FALL 2015 contexts

Retired U.S. Army General Peter Chiarelli, director of the organization

One Mind, wants to redefine Post Traumatic Stress Disorder (PTSD).

While a main priority of One Mind is to accelerate “the research-to-cure

time frame exponentially,” a core element of its “paradigm-changing”

program is advocating for changing PTSD to the lesser classification

of “post-traumatic stress,” or “PTS.” Dropping “disorder” in favor of

“injury,” Chiarelli’s organization hopes to reduce the stigma associated

with PTSD. “Injury” can be overcome, “disorder” implies something

permanent. As Chiarelli puts it, “No 19-year-old kid wants to be told

he’s got a disorder.”

Thanks to Chiarelli’s campaign, “PTS” is increasingly

accepted terminology in many military and policy settings.

Indeed, former President George Bush has said publicly he would

no longer use the word “disorder” when discussing veterans’

“post-traumatic stress” and earlier this year, Obama twice spoke

about “post-traumatic stress.” Additionally, there are efforts

being made to recognize June as “National Post-Traumatic

Stress Awareness Month” and June 27, 2015, as “National

Post-Traumatic Stress Awareness Day.” “Disorder” seems to be

falling out of military lexicon.

But the change is fraught. In the wake of two large-scale

wars involving more than 2.5 million U.S. soldiers, how we

define and conceive of war-related mental distress is significant.

Why, in this day of headline-grabbing veteran suicides and

deadly shootings on military bases, would a decorated military

veteran like General Chiarelli want to redefine a diagnosis that

has served an indispensable role in securing the mental health

treatment of veterans?

Thirty-five years ago, Vietnam veterans, along with allies

in the mental health field, won a hard-fought campaign for the

recognition of psychological wounds from war, establishing PTSD

as a mental disorder. However, once a diagnosis is recognized

and institutionalized, it can take on a life of its own. PTSD in 2015

is different than PTSD in 1980. In response, several advocacy

groups—most with ties to the Pentagon and affiliated non-profit

organizations—are now attempting to demedicalize PTSD. This

marked shift in the diagnostic politics of PTSD highlights the vicis-

situdes of medicalization—the process by which social problems

become defined and treated as medical in nature.

Diagnoses provide the interpretive framework by which

amorphous symptoms and experiences are transformed and rei-

fied into disease categories subject to the intervention of medicine.

As such, diagnoses can become, in the words of sociologist Phil

Brown, “an arena of struggle” in which medical professionals and

lay patient groups fight to secure diagnostic understandings that

promote their particular interests. PTSD has long represented an

exemplary case of successful, lay-initiated medicalization.

We join our separate research—Whooley’s archival work on the

history of psychiatric classification and Smith’s ethnography on

veterans’ returning from Iraq and Afghanistan—to explain the

emergence of the movement to “drop the D”.

medicalizing the trauma of warThe process of defining a disorder does not necessarily end

with its official recognition. It can continue in unanticipated ways

that sometimes run contrary to the spirit of the original impetus.

Instead, PTSD has undergone a series of changes since it official

recognition by the American Psychiatric Association (APA) in 1980.

For the overwhelming majority of mental disorders, the

underlying neurological and biological mechanisms are still not

well understood. For this reason, the construction of diagnostic

categories proceeds by expert consensus. Every decade or so,

the APA meets to discuss and revise the Diagnostic and Statisti-

cal Manual of Mental Disorders (DSM), the “Bible of American

psychiatry,” which defines criteria for every mental disorder.

When constructing diagnostic categories, psychiatrists fall back

on defining mental disorders by the presentation of manifest

symptoms. This process is vulnerable to subjective interpreta-

tions and political influences. Thus, behind the DSM’s neat lists

of symptoms are complicated histories; the final diagnostic

Contexts, Vol. 14, No. 4, pp. 38-43. ISSN 1536-5042, electronic ISSN 1537-60521. © 2015 American Sociological Association. http://contexts.sagepub.com. DOI 10.1177/1536504215609300

< PTSD affects millions, yet is experienced as profoundly isolating.



40 contexts.org

categories often represent negotiated accom-

modations to competing interests. The history

of PTSD, in fact, refl ects these tensions. The

diagnosis was co-created by psychiatrists and

veterans’ advocacy groups.

Lay advocates seek a medical diagnosis

for three primary reasons. First, a medical diag-

nosis legitimizes the experience of distress, as

a diagnosis is thought to reduce stigma and

alleviate personal responsibility. Second, it pro-

vides an interpretive schema to make sense of

what can be diffuse and ambiguous problems.

A diagnosis can explain the distressing symp-

toms a sufferer has been experiencing in silence, be it PTSD or

fi bromyalgia, and in turn, can serve as a basis for an identity.

Finally, having a personal problem defi ned as “medical” is a

means to secure resources like treatment, reimbursement, and

disability support.

While mental distress from the trauma of war has been

sporadically recognized under different monikers—among them,

“shell shock,” “combat neuroses,” “soldier’s heart,” and “oper-

ational fatigue”—PTSD did not exist prior to 1980. As sociologist

Wilbur Scott recounts, in the mid 1970s, Vietnam veterans, led

by the group Vietnam Veterans Against the War (VVAW), sought

to change the military culture around war trauma by medical-

izing it. Along with sympathetic allies in the mental health fi eld,

notably Sarah Haley, Robert Jay Lifton, and Chaim Shatan,

veterans fought for offi cial diagnostic recognition for what

was fi rst termed “Post-Vietnam Syndrome Disorder” and later

“Post-Combat Disorder.” This early diagnosis originated from

what Scott referred to as “street-corner psychiatry” through

“rap groups” run by VA outreach centers, and the diagnosis

was consciously tied to the anti-war effort.

After a decade of lobbying the APA, contesting the skepti-

cism among psychiatrists who were ambivalent about a specifi c

diagnosis for combat stress (DSM-I contained a “gross-stress

reaction” diagnosis but it was dropped from DSM-II), veterans’

advocates secured the diagnosis of “Post Traumatic Stress

Disorder.” With its inclusion in the 1980 DSM-III, the psychic

consequences of war were acknowledged. Traumatized combat

soldiers could be treated as psychiatric patients.

the expansion of ptsdFrom its inception, PTSD fi t awkwardly in

the DSM-III. As a disorder caused by a traumatic

event, PTSD was always understood as emanat-

ing from social factors. This departed from the

DSM-III’s biomedical model of mental disorders,

which treats disorders as analogous to physical

diseases. Changes to PTSD in subsequent edi-

tions of the DSM have sought to bring it into

alignment with the prevailing model of mental

disorders.

Like the DSM itself, PTSD has been

expanded over the decades to include more and

more cases under its purview. In this process, the distinct social

nature of the precipitating trauma has been de-emphasized.

First, the DSM-IV (1994) broadened the notion of what is con-

sidered a traumatic event. The DSM-III instructed psychiatrists to

interpret trauma objectively as a recognizable stressor “gener-

ally outside the range of usual human experience” that would

“evoke signifi cant symptoms of distress in almost everyone.”

The revisions for DSM-IV reoriented the diagnostic focus toward

the subjective reactions of individuals; trauma became defi ned

not by the inherent qualities of the event but by an individual’s

response to it. The loss of a loved one (a sad, but normal

stressor) is made equivalent with combat

(a recognizably extraordinary experience)

if the subjective reactions (avoidance,

numbing, hyperarousal, etc.) to these

events are similar.

Second, DSM-IV extended what

it meant to “experience” trauma to

include witnessing an event or receiving

information about it. PTSD could occur

in individuals that did not directly undergo the trauma. As

anthropologist Allan Young observes, DSM-IV signaled “the

repatriation of the traumatic memory… back home from the

jungles and highlands of Vietnam.” Embracing this expansion,

some psychiatrists argue that PTSD should be extended to non-

life threatening events (for example, divorce) and that PTSD can

develop from indirect witnessing of traumatic events, even on

television. These changes have increased the number of potential

traumas eligible for a PTSD diagnosis far beyond the bounds of

the extreme violence of war.

Diagnostic patterns clearly demonstrate that shift. PTSD

now includes more civilians, women, and children. To win

inclusion in DSM-III, veteran advocates extended the notion of

trauma beyond combat to include victims of other types of physi-

cal trauma (like burn victims). Feminist groups long recognized

the overlap between PTSD and the symptoms experienced by

women suffering from what they referred to as “rape trauma

syndrome” and embraced the disorder as a way to recognize the

mental distress of rape victims. With DSM-IV’s explicit inclusion of

Why would a decorated military veteran want to redefi ne a diagnosis that has served an indispensable role in securing the mental health treatment of veterans?




While mental distress from the trauma of war has been sporadically recognized under different monikers— “shell shock,” “combat neuroses,” “soldier’s heart,” “operational fatigue”—PTSD did not exist prior to 1980.

sexual assault as a traumatic event, diagnostic practices changed,

and PTSD is now twice as common in women as in men. Built

on two different models of trauma—combat and rape—the

concept has split along gendered lines, with veterans stress-

ing geopolitical violence and feminists, interpersonal violence.

Interestingly, even sexual trauma taking place within the U.S.

military has come to be called “military sexual trauma”—not

PTSD—thereby maintaining a gendered distinction.

reassessing ptsdPTSD has morphed into something broader, more civilian,

and increasingly a part of international contexts (as journalist

Ethan Watters has documented in his book, Crazy Like Us). At the

same time, the U.S. has fought its first large-scale wars since the

diagnosis was established. With these developments, the “drop

the D” movement is reassessing the benefits—and pitfalls—of

medicalization. Returning to the initial goals of PTSD’s medi-

calization—to decrease stigma, increase

self-understanding, and open access to

resources—we see that the evolving diag-

nosis fails to serve these ends for veterans,

and, to a significant extent, the institution

of the military as well.

First, medicalization has not necessarily

alleviated the longstanding stigmatization

of soldiers experiencing mental distress

from war. Dozens of military health stud-

ies show that stigma remains a significant

impediment to receiving PTSD treatment; roughly 60% of sol-

diers report that seeking mental health help would be perceived

as weakness. Of the American soldiers in Iraq and Afghanistan

who had a “serious mental health disorder,” only 40% stated

that they were interested in receiving help according to Charles

Hoge, doctor and retired Army colonel. A 2008 Rand study

concluded that “just 53% of service members with PTSD or

depression sought help from a provider over the past year, and

of those who sought care, roughly half got minimally adequate

treatment.” Self-stigma, the internalization of prevailing preju-

dices against mental illness, continues to undermine treatment

among soldiers; those who met the criteria for a mental disorder

were more likely than those who do not to associate the diagno-

sis with embarrassment and weakness. There is also a growing

concern that the public awareness of PTSD has hurt veterans,

particularly when seeking employment.

Our interviews with veterans confirm that “toughing it

out” remains an essential part of military life. Given the asso-

ciations between military masculinity and invulnerability, many

soldiers suffer from mental and moral anguish, but their suffer-

ing is dismissed or disrespected by fellow service members and

military superiors. As Nathan, an Iraq and Afghanistan veteran

explained, “Usually the guys with PTSD won’t admit [to], you

know, crying. They don’t have an issue. They can handle it fine.

So, they don’t look into things. And it’s seen as a weakness.”

Another veteran admitted his reluctance to take seriously the

post-deployment health assessment, worrying that if he provided

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Army Col. Michael J. Roy, left, who oversees exposure therapy at Walter Reed Army Medical Center, conducts a demonstration of a life-like simulator meant to help treat PTSD.



42 contexts.org

accurate responses about his mental health his fellow soldiers

might wonder, “Is this guy a pussy or what?”

Second, the changing face of PTSD has diluted its fit for

soldiers trying to make sense of their particular experiences in war

and their subsequent reactions. If one benefit of the medicaliza-

tion of PTSD was to provide veterans with an understanding of

their war trauma and a basis for shared identity, what happens

when the dominant, cultural associations of the diagnosis shift?

Of particular importance here is the mismatch between the mas-

culine culture of the military and the increasing prevalence of the

diagnosis among women and civilians. As a result, some veterans’

advocating the name change claim that soldiers “prefer the old

terms such as ‘battle fatigue’ because anyone can get PTSD”

and have petitioned the Defense Secretary that “any new name

be unique to combat and utilize terms such as ‘war’ or ‘battle.’”

The concern around the expansive definition of PTSD joins

a long-held criticism of medicalization within some antiwar

veterans’ circles: conceiving of war trauma as mental illness is

wrong because the behaviors that manifest themselves as PTSD

are actually normal reactions to abnormal circumstances. PTSD

pathologizes individuals instead of pathologizing the true toxin,

war itself. Some activists therefore advocate jettisoning the

diagnosis altogether and focusing their energies on combating

the seemingly endless growth in militarism.

But what of the final goal of PTSD’s early advocates, that

of securing resources? To be sure, the recognition of PTSD has

opened access to resources that veterans would not otherwise

have. The Iraq and Afghanistan wars are the first major wars

since the institutionalization of PTSD, and PTSD has become the

most common military service–related mental health diagnosis.

Whereas access to resources undoubtedly benefits veterans,

concerns over the cost have driven select members of the mili-

tary and political leaders to advocate “dropping the D”. Former

Defense Secretary Leon Panetta said that “post-traumatic stress

will remain a critical issue for decades to come.” (Note the miss-

ing “disorder”). On the other side of the political aisle, former

President George Bush, the person most responsible for today’s

soldiers’ psychological distress, has stated that PTSD is mislabeled

as a disorder and that calling it “post-traumatic stress” would

go a long way in erasing its stigma.

While military leaders do not publicly state that the diag-

nosis strains military resources, the treatment costs are at odds

with their overall mission; high rates of PTSD mean more expen-

ditures, fewer boots on the ground, and more bad headlines.

And these costs continue to swell; a 2012 study of six years of

data from the Veterans Health Administration (VHA) by the Con-

gressional Budget Office found the cost of

treating a typical patient with PTSD in the

first year of treatment averaged $8,300.

From 2004 to 2009, the VHA spent $3.7

billion on the first four years of care for all

the veterans tracked by the study. This is to

say nothing of the tremendous VA backlog

plaguing veterans’ care and compensation

which deflates the true costs. The costs

are particularly glaring given the mixed

efficacy of PTSD treatments, which pale in

comparison to the incredible advances in

other domains of military medicine.

If “disorder”—a term suggesting chronicity—were

dropped, perhaps soldiers might be more willing to seek treat-

ment. “Injury,” a term more suggestive of something people

can heal from, could change perspectives. Perhaps the VA

would then be less strapped with providing indefinite care. And

perhaps PTS would better reflect the unique experience of war

The gendering of PTSD can complicate female vets’ experiences.

Sen.

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Mental health in the military—the paradoxical context in which health and routine violence coexist—is hardly straight-forward. Dropping the word “disorder” is possibly as thorny as getting the PTSD diagnosis recognized in the first place.




trauma… So goes the thinking of those who would rename this

multifaceted distress.

resistanceMental health in the military—the paradoxical context in

which health and routine violence coexist—is hardly straight-for-

ward. Dropping the word “disorder” is possibly as thorny as getting

the PTSD diagnosis recognized in the first place. General Chiarelli

and One Mind’s efforts have rekindled longstanding debates over

how to publicly appraise and evaluate “invisible injuries.”

Resistance to the movement is vigorous. Matthew Fried-

man, director of the National Center for PTSD at the Department

of Veterans Affairs, has campaigned against a change to “PTS”

or “PTSI,” stating that “injury” suggests a short-term recovery

process, whereas disorder better honors a condition that can

last for decades. Dropping “disorder” may also jeopardize dis-

ability payments. Some wonder whether a change could be an

attempt by the VA and Pentagon to eschew their accountability

for long-term care. After all, the traditional diagnostic category

has been instrumental in helping veterans secure long-term dis-

ability coverage and treatment. Other critics of the change note

that dropping one word will not result in any difference, since

the cultural associations are already there. “Schizophrenia,” for

example, does not have the word disorder in it, yet it remains

very much stigmatized.

For other critics, dropping “disorder” represents a mere

nominal change further obscuring the reality that war is what

psychologically harms people. Here the limits of medicalization

may be seen. Does the transformation of war trauma into a

medical diagnosis sufficiently capture the moral valence of the

issue of war in the first place? Perhaps attention and effort

could be focused less on helping those who cannot cope with

the trauma of battle and more on the collective mobilization to

avert such trauma from happening? If PTSD were considered

a serious, dangerous public health threat, wouldn’t we want

to prevent it in the way we do other public health threats, like

cancer, cardiovascular disease, and obesity?

For now, the status quo has been upheld; the recently

published DSM-V maintains the DSM-IV’s PTSD diagnosis. The D

remains. The work group charged with reviewing the diagnosis

rejected a proposal to include a subtype of PTSD for wartime

trauma exclusively. In fact, by adding a dissociative subtype

and a subtype for children six years and younger, the revision

expanded the diagnosis.

Nevertheless, the history of the PTSD diagnosis reveals the

extent to which medicalization can go awry for the lay groups

who fought for the establishment of its classification in the first

place. Once recognized, PTSD, like other diagnoses, is shaped by

an array of interests and transformed into something no longer

strictly moored to the original definitions. In the case of PTSD,

members of the military brass—worried about stigma, high

rates of prevalence, and rising costs—have allied with soldiers

and veterans who are concerned with stigma, help-seeking, and

identity to demedicalize PTSD and bring it back into the military

fold. Given the vagaries of PTSD to this point, the movement

might want to heed the experiences of their medicalizing pre-

cursors and consider the potential unintended consequences

of such a campaign.

recommended resourcesErin P. Finley. 2012. Fields of Combat: Understanding PTSD among Veterans of Iraq and Afghanistan. Ithaca, NY: Cornell University Press. An ethnographic illustration of PTSD’s devastating effects on veterans and their families.

Allan V. Horwitz. 2002. Creating Mental Illness. Chicago, IL: Uni-versity of Chicago Press. A thorough study of how most mental illnesses are forms of deviant behavior, normal reactions to stress-ful circumstances, or cultural constructions.

Ken MacLeish. 2013. Making War at Fort Hood: Life and Uncertainty in a Military Community. Princeton, NJ: Princeton University Press. An ethnography of post-9/11 American soldiers and their understand-ings and experiences of the U.S. military’s routine violence.

Wilbur J. Scott. 1990. “PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease,” Social Problems 37(3):294-310. An early sociological analysis of the politics involved in securing the diag-nosis of PTSD in DSM-III.

R. Tyson Smith and Gala True. 2014. “Warring Identities: Iden-tity Conflict and the Mental Distress of American Veterans of the Wars in Iraq and Afghanistan,” Society and Mental Health 4(2):147-161. Examines veterans’ postwar psychological distress as the result of strains from conflicting understandings of self.

Allan Young. 1997. The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press. An in-depth history of how PTSD came into being and evolved through DSM-IV.

R. Tyson Smith is in the sociology department at Haverford College. He studies

health, the military, and criminal justice. Owen Whooley is in the sociology depart-

ment and is a senior fellow at the Robert Wood Johnson Foundation Center for

Health Policy at the University of New Mexico.

OneMind wants to destigmatize post-traumatic stress by “dropping the D.”



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