Should the ‘D’ in PTSD Be Changed to an ‘I’?

Taking the ‘D’ out of PTSD might do more harm than good, concluded authors of a RAND Corp. report issued in late summer.

In discussions leading up to the publication of DSM-5, U.S. Army leaders asked APA to change the term “posttraumatic stress disorder” to “posttraumatic stress injury.” The Army argued that “disorder” was a stigmatizing term among its soldiers and caused them to avoid evaluation and treatment (Psychiatric News, July 6, 2012).

“However, there is no known empirical evidence demonstrating that the proposed name change is perceived as beneficial among service members, or would result in a more socially acceptable category, or would increase the number of those seeking treatment,” wrote RAND’s Michael Fisher, M.S., and Terry Schell, Ph.D.

“The expectation of senior Army officials that changing the name of PTSD to PTSI would by itself reduce stigma and increase willingness to seek treatment is shown to be an interesting hypothesis, but one in need of empirical testing,” said Darrel Regier, M.D., M.P.H., director of APA’s Division of Research, in an interview with Psychiatric News.

Diagnoses serve many purposes, noted Fisher and Schell. They not only identify the signs and symptoms of a disorder and help determine treatment options, but also provide a common language for researchers, clinicians, patients, and policymakers. The creation of the PTSD diagnosis in DSM-III also legitimized the condition and explained why people with the condition were different from other, “healthy,” people, they said.

“The issue is not so much the name; the issue is all the other elements that support it,” agreed former U.S. Air Force psychiatrist Robert Ursano, M.D., a professor and chair of psychiatry at the Uniformed Services University of the Health Sciences and director of the Center for the Study of Traumatic Stress, in an interview. “We need to have a language that speaks to our patients about the stress injury they have received but also a language that addresses how to direct their care.”

Ironically, introduction into DSM-III of PTSD as a diagnostic category, a decision applauded by Vietnam War veterans and their advocates (including many psychiatrists), was seen as a victory for a population of already-stigmatized soldiers, offering them a path to treatment.

Any psychiatric diagnosis can be stigmatizing, but there is little evidence suggesting that PTSD is more stigmatizing than other mental illnesses in general, said the authors.

However, fear of discrimination by a soldier’s immediate superiors or unit commanders “is a significant barrier to the seeking of treatment by U.S. military service members,” they pointed out, but a new label for the same underlying condition might be equally stigmatizing or discriminatory.

Would a change in terminology lead to more treatment? Not likely, in the absence of evidence, the authors said.

“In fact, it may be the case that the public views psychiatric ‘injury’ as more permanent, more severe, or more disabling than psychiatric ‘disorder’,” they suggested. “The disorder is characterized not by the presence of stress itself, but rather by the failure to spontaneously recover from stress in a normal manner.”

There was another inconsistency in the Army’s request to rename PTSD, noted Fisher and Schell. The Pentagon does not now view PTSD in the same light as other combat injuries. It does not award the Purple Heart to soldiers who have only PTSD and no qualifying physical injury. By contrast, the Canadian Forces awards the Sacrifice Medal to any service member killed or wounded, including those with a “mental disorder diagnosed by qualified mental health practitioner and directly attributable to hostile action.”

“The strongest conclusion is that changing the name without changing some of the internal military practices of discrimination by commanders…would not have an appreciable impact on stigma reduction or treatment rates,” Regier said.

“A great deal of literature, science, and medical operations has been developed around the name posttraumatic stress disorder,” said Ursano. “That now conveys an entire way of approaching the problem in terms of medical care, and we don’t want to disrupt that major movement forward.”

More research among active-duty troops and veterans is needed to test some of these hypotheses, Regier added, noting that APA would evaluate the results of such research when considering revisions of DSM-5. ■

“The Role and Importance of the ‘D’ in PTSD” is posted at http://www.rand.org/content/dam/rand/pubs/occasional_papers/OP300/OP389/RAND_OP389.pdf.