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This Calls for a Rant

28 May

Hello again.  

Well, someone just sent me this article about objections at the American Psychiatric Association meeting to removing the demoralizing and disabling “D” in the diagnosis known as PTSD, or Posttraumatic Stress Disorder, and changing it to an “I” – Posttraumatic Stress Injury . The naysaying came from key players on the DSM-V  committee (Diagnostic and Statistical Manual of Mental Disorders, due for updating for the first time since 2000).

The call for a change came from a Four Star General (now retired) named Peter Chiarelli, recently of the Pentagon.  The bureaucratic stonewalling came from Psychiatry.  Go figure.  How’s that for a reversal of stereotyped expectations?

You may have heard the articulate, truth-telling Chiarreli on public radio, talking about the spiking suicide rates among returning warfighters and vets.  After considerable study, he determined that calling PTS a "disorder" was perpetuating a bias against those who suffer from it; categorized what is in essence a brain injury – a neurophysiological and biochemical imbalance resulting from an external event - as a mental illness; and was a barrier to people getting the help they need.  

On the other hand, he argues, calling it an injury makes it far more palatable, implies hope for recovery (you recover from an injury, but you’re kind of stuck with a disorder), and renders the person blameless for a condition that is the result of external circumstance.  From everything I’ve seen and heard, the General is absolutely correct.  And it doesn’t just apply to warfighters.  A lot of people suffering from various civilian forms of PTS – from rape, assault, natural disaster, auto collision, traumatic childbirth or surgery, childhood sexual abuse - would be happy to dispense with being called “disordered”.

However, Dr. Matthew Friedman, a noted V.A. psychiatrist who chairs the subcommittee that’s updating the trauma section of the DSM V, and who has a lot of sway over what does and doesn’t happen in the treatment of posttraumatic stress within the Veterans Administration, stated his concerns on the APA panel.  Speaking for his committee, he said this would create confusion in the diagnostic process – make it harder for the clinicians to sort out.  To be fair, it could also present problems for insurance reimbursement if a condition isn’t classified as a disease or disorder – there would need to be a bureaucratic overhaul of policy in this regard and that admittedly would be a headache.  

Not all of psychiatry is against the idea, however.  Drs. Frank Ochberg and Jonathan Shay, two prominent experts in the treatment of PTS, have asserted that it’s time for a change, and that calling the condition an injury instead of a disorder means “brain physiology has been injured by exposure to some external force, not that we are just anxious or depressed by tragic and traumatic reality."  They agree with Chiarelli that the current nomenclature keeps people from seeking help and that stigma could be reduced by the change to “injury”. Ochberg even has a website called PTSInjury, which invites visitors to endorse the nomenclature change on a designated message board.

OK, so let’s ponder this.  On the one side, we have a humanistic, practical suggestion from the Army that could help a substantial number of service members, veterans and civilians suffering from PTS.  It reflects accurately on what we’ve only recently come to understand about PTS – that it’s a kind of hijacking of the primitive brain by our built-in survival response to threat, leading to a biochemical and neuro-physiological cycling that doesn’t want to quit.  

On the other side, we have a rejection of that suggestion from the Psychiatric establishment, either to keep things uncomplicated for the providers or to avoid taking on the hassle of adjusting the rules for coverage.  Or maybe it has to do with resistance to change and professionals just getting stuck in a way of seeing and doing things for too long.  

Are you wondering which position will triumph in this upcoming printing of the DSM-V, due out in May of 2013?  According to this piece, the suggested solution from Dr. John Oldham, the American Psychiatric Association president, which tried to bridge the two positions with a well-meaning if weak compromise, went nowhere.  With the clock running out, it looks like the term PTSD is likely to stand in the short term with this next edition.

The irony is that many folks in the Armed Services have already stopped using the D-word.  They either just lob it off altogether and call it “Posttraumatic Stress” or “PTS”, or else they use terms like “Combat Stress”, “Occupational Stress” or even “Posttraumatic Growth”.   

Heck, COL (R ) Jill Chambers suggested dumping the “D” back in 2008, around the time she was special assistant to Joint Chiefs Chair, ADM. Mike Mullen, and trolling around the country for solutions for traumatized soldiers. She came up with Resilience Training and what ultimately turned into Comprehensive Soldier Fitness – a system of stress remediation training that strengthens end-users on their own terms, without stigmatizing or demeaning them. 


Bottom line: policy-wise, the V.A. would do well to do some catching up to the DoD in this regard, not to mention their own savvy line staff and clinicians, who already know better; and it’s time the DoD made official what is already happening on the ground, in U.S. military installations all over the world.  

Let the APA committee catch up to reality on their own time.  Sadly, by the time they step up, they’ll have become irrelevant, at least on this issue. The rest of us will have moved on. 

Belleruth Naparstek

Psychotherapist, author and guided imagery pioneer Belleruth Naparstek is the creator of the popular Health Journeys guided imagery audio series. Her latest book on imagery and posttraumatic stress, Invisible Heroes: Survivors of Trauma and How They Heal (Bantam Dell), won the Spirituality & Health Top 50 Books Award