By Sandra Basu
WASHINGTON — What’s in a name matters for post-traumatic stress disorder (PTSD), according to proponents of changing what the condition is called, because the word “disorder” keeps some sufferers from getting the treatment they need.
The issue came to the forefront last month at the annual American Psychiatric Association meeting, where retired Army Vice Chief of Staff Gen. Peter W. Chiarelli made the case for the name change in a revision of the Diagnostic and Statistical Manual of Mental Disorders
The debate is “not about the definition of a disease,” Chiarelli said, but “is about taking away a barrier to care.”
“I think it is a huge issue,” Chiarelli said in an APA video from the meeting. “I think it is an unquantifiable issue, one that we will never totally know the number, but I view the ‘D’ as a barrier to care for a certain portion of the population that does not want to be classified as having a disorder.”
A Call for Change
Chiarelli, who oversaw the Army’s battle to reduce the suicide rate among soldiers before he retired, originally made a request to drop the ‘D’ last year in an effort to get at the stigma issue.
Retired Army Chief of Staff Gen. Peter W. Chiarelli
Military leaders have been concerned that stigma keeps servicemembers from getting the help they need and contributes to the high suicide rate among servicemembers and veterans. A report released late last year by the Center for New American Security (CNAS) stated that, from 2005 to 2010, troops took their own lives at a rate of approximately one every 36 hours and, although only 1% of Americans have served in the military, former military personnel represent 20% of suicides in the United States.
Two psychiatrists, Frank M. Ochberg, MD, and Jonathan Shay, MD, PhD, who wrote the APA in April backing a name change, said they believe using “injury” is a more-accurate term and that “the brain physiology has been injured by exposure to some external force.”
“It is not a weakness,” they wrote in a letter of support for the change to APA president John Oldham, MD. “It is really not, in its origin and manifestation, a disease. It came from something that happened, like a traumatic amputation. No military surgeon diagnoses a soldier or Marine whose foot has been taken off by a mine as suffering from ‘Missing Foot Disorder.’ To those who live with the impact, PTSD is an injury — and a painful one at that.”
Not everyone agrees. Mathew Friedman, MD, PHD, who serves as the executive director of the VA’s National Center for PTSD and who chairs the key APA committee that will make a recommendation on the issue for the revised DSM, publicly said that, in his view, there is no evidence for the need for a name change.
“I believe it would be a mistake to do so because, not only would nothing be accomplished by such a change in a diagnostic label, but because there would be unintended negative consequences,” he said.
What’s In a Name? – Name Change Proponents Say Labeling PTSD a ‘Disorder’ Prevents Treatment
Friedman, who made his case for keeping the name PTSD at the APA forum attended by Chiarelli, said that a disorder, whether it be PTSD or depression “reflects a disturbance in the biological as well as the psychological and development processes underlying mental function.
“We know from abundant research that PTSD is clearly associated with biological alterations, especially in brain function. So is depression. According to this logic, we should call depression suffered in the war zone a major depressive injury to split it off from all other depressive episodes,” Friedman said. “So to change PTSD to PTSI without changing anything else would, in my opinion, accomplish nothing positive. And, on the negative side, it would confuse the issue and set up diagnostic distinctions for which there is no scientific evidence,” he said.
He suggested that a useful model could be the way the situation is handled in Canada. While the military uses the term “operational stress injury,” the medical diagnosis has remained PTSD.
“These changes are proof that stigma can be addressed successfully without changing the diagnostic label. So, we can have it both ways, keep the PTSD diagnostic term and have it regarded as an injury,” Friedman said at the forum.
Canadian soldiers with PTSD also are eligible for the Sacrifice Medal, he pointed out, but “unfortunately, the DoD decided not to give a Purple Heart for PTSD.
“I realize it is a complicated, contentious issue but I think it would have gone much further in reducing stigma than changing the name of PTSD to PTSI.”
The next DSM is set to be published in May 2013, with public comment accepted for the revisions until June 15, 2012.
Those who support the name change said they will continue their campaign. Ochberg and Shay created a website http://www.posttraumaticstressinjury.org/ that includes endorsements from individuals and organizations that support a name change.
Ochberg said that getting rid of “disorder” in PTSD also is a matter of honor.
“I believe the science already supports injury, [but] if you want to argue it is a draw and that the validity of injury is no more or less valid than the validity of disorder, what about the advantage of the therapist and the patient in doing therapy and what about the advantage to the PTS wounded person in feeling honored and being honored?” Ochberg told U.S. Medicine.
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