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dropping the disorder in ptsd
by r. tyson smith and owen whooley
ShawnWeismiller,U.S.AirForce
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categories often represent negotiated accom-
modations to competing interests. The history
of PTSD, in fact, reflects 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
fibromyalgia, and in turn, can serve as a basis for an identity.
Finally, having a personal problem defined 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 field,
notably Sarah Haley, Robert Jay Lifton, and Chaim Shatan,
veterans fought for official diagnostic recognition for what
was first 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 specific
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 ptsd
From its inception, PTSD fit 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 significant symptoms of distress in almost everyone.”
The revisions for DSM-IV reoriented the diagnostic focus toward
the subjective reactions of individuals; trauma became defined
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 redefine a diagnosis that has served
an indispensable role in securing the mental
health treatment of veterans?
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4. 41FALL 2015 contexts
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 ptsd
PTSD 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
JohnJ.Kruzel,U.S.Dept.ofDefense
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.
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5. 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.MarkWarner,FlickrCC
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.
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6. 43FALL 2015 contexts
trauma… So goes the thinking of those who would rename this
multifaceted distress.
resistance
Mental 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 resources
Erin 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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