What’s In a Name? – Name Change Proponents Say Labeling PTSD a ‘Disorder’ Prevents Treatment

by U.S. Medicine

June 7, 2012

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Chiarelli, who oversaw the Army’s battle to reduce the suicide rate among soldiers before he retired, originally made a request to drop the ‘D’ last year in an effort to get at the stigma issue.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

Stigma a Treatment Barrier to Troops Suffering From Mental-Health Disorders
How big a role does stigma play in preventing troops from seeking mental
healthcare?
In a study published last year in the Archives of General Psychiatry, researchers found that reporting of depression, PTSD, suicidal ideation and interest in receiving care were twofold to fourfold higher on the anonymous survey, compared with the routine post-deployment health assessment (PDHA).1
In the study, 20.3% of soldiers, overall, who screened positive for
depression or PTSD reported that they were not comfortable reporting their answers honestly on the routine post-deployment screening.
Army researcher Maj. Gary H. Wynn, MD, who provided an overview of recent research in a presentation given at the 2012 APA conference, told U.S.
Medicine there are various reasons why troops do not seek mental healthcare, such as that they will be perceived as weak or that it will hurt their careers.
“Within the military, there is a concern about whether it will hurt one’s career,” he said. “There is a long-standing perception that, if someone goes to seek mental healthcare, they will somehow end up getting a bad report, and they
will lose their security clearance — all of these things that for the most part are not true. In some cases, if there are serious enough issues, then, yes, we do take people off of security clearances, and we do remove people from service.”

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

There is no “magic bullet” to solving stigma, but the military is trying various approaches, he said.
“We are looking at a multimodality approach,” Wynn said. “There is the embedded healthcare provider approach where the military is looking at putting mental-health providers out into clinics in primary care and moving them out of the hospitals.”
His presentation also suggested that, of those who begin PTSD treatment, between 20% and 50% walk away before its completion. Having a menu of options of evidence-based treatments may help patients stick with their care and bring those in who are not receiving care.
“Research takes time,” Wynn said. “I am optimistic with the continued
efforts of those in the mental-health community, the military leadership and Congress and others that we will overcome at least a portion of the stigma and barriers problem and be able to give people an array of options, including ones that allow them not to directly engage with mental health (i.e., virtual reality,
Internet-based cognitive behavioral therapies, recreational therapies) that we will be able to engage at least a significant chunk of the folks who are not presenting
for care out of some misperception regarding stigma.”
1. Warner CH, Appenzeller GN, Grieger T, Belenkiy S, Breitbach J, Parker
J, Warner CM, Hoge C. Importance of anonymity to encourage honest
reporting in mental health screening after combat deployment. Arch Gen
Psychiatry. 2011 Oct;68(10):1065-71. PubMed PMID: 21969463.

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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