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Former President George W. Bush has joined the chorus of voices calling for dropping the "D" from "PTSD."
In a rare public appearance last month to announce the kickoff of his institute's Military Service Initiative, Bush said that along with pressing for jobs and educational opportunities for veterans, the initiative aims to remove the stigma of having post-traumatic stress disorder or getting treatment for it.
One thing that would help, Bush believes, is lopping off the term "disorder."
"As most doctors will tell you, post-traumatic stress is not a disorder. Post-traumatic stress, or PTS, is an injury that can result from the experience of war. And like other injuries, PTS is treatable," Bush said during the Empowering Our Nation's Warriors Summit in Dallas.
In pushing for the change, Bush joins retired Army Gen. Pete Chiarelli and veterans' groups lobbying the medical community to consider PTSD an injury rather than a psychological disorder.
When he served as Army vice chief of staff, Chiarelli pressed for the change within the ranks and also called on the American Psychiatric Association, which publishes the diagnostic manual used to determine psychological conditions, to do the same.
Chiarelli, who favors "post-traumatic stress," or the term used by the Canadian military, "operational stress injury," believes those are more accurate than "disorder."
"Are you telling me that a woman who has been violently sexually assaulted has a disorder if she later has issues with male relationships or other problems? It's ridiculous. It's an injury, and science already is starting to prove there are physical changes in the brain following a trauma," said Chiarelli, who serves as CEO of One Mind for Research, a consortium supporting advancements in brain research.
How real is the stigma?
The number of post-9/11 veterans with PTSD is unknown; a 2010 Rand Corp. study placed estimates at 5 percent to 20 percent, or 125,000 to 500,000 people.
Drawing on reviews of previous studies, Rand published a paper in August concluding that changing the name of the condition "seems unlikely to result in a significant increase in individuals willing to be diagnosed or treated."
The authors said few studies exist that demonstrate any social stigma attached to "PTSD" in the military and whether labeling it a disorder dissuades some sufferers from seeking treatment.
They also suggested that making the condition less stigmatizing may actually reduce the number of those affected seeking help.
"The diagnosis encourages treatment utilization, research ... and the development of practice guidelines to improve the effectiveness of treatment," the authors wrote.
But Chiarelli said researchers need only talk to affected troops and veterans to see that the negative associations of having a psychological disorder keep some from seeking treatment.
"If you are a 19-, 20-, 21-year-old kid, you don't want to be told you have a disorder. I hear from former troops that they are looking for a job and don't want people to know, or are worried they'll lose their [security] clearance," Chiarelli said.
'Old as war itself'
Former Army infantry Capt. Adrian Bonenberg sought treatment for PTSD after two tours in Afghanistan. Now earning his master's degree at Columbia University, Bonenberg said he favors "injury" over "disorder," even though the current nomenclature didn't deter him from getting help.
"Having trouble processing trauma is a very human, understandable reaction," he said. "The people who had no difficulty seeing horrible things, having to touch the body parts of people [they] knew and considered friends, ... those are the ones with disorders.
"Most of the guys I know who saw heavy combat, the things we saw and did weighs heavily on us," he said. "It's not an internal disorder. It is an injury, as old as war itself."
In changing the diagnostic manual in late 2012, the APA Board of Trustees altered the requirements for PTSD to make the diagnosis more appropriate for combat-related PTSD, to include dropping a stipulation that patients experience "fear, helplessness or horror" in reaction to a traumatic event.
Since many troops don't experience those reactions — because they are trained to deal with trauma — it was thought the previous definition excluded a majority of those with combat-related PTSD.
But the board still decided not to drop the "D."
At the time, Dr. Matthew Friedman, a psychiatrist and then-executive director of the VA's National Center for PTSD, declared: "PTSD is PTSD. To change it to PTSI would reverse 32 years of research and not reduce stigma or increase treatment seeking."
Nearly two years later, Bush and others continue to disagree.
At a March 12 hearing on the Veterans Affairs Department's proposed fiscal 2015 budget, Sen. Richard Blumenthal, D-Conn., said many employers discriminate against veterans for fear they may have a psychiatric disorder.
"Calling it a disorder gives it a stigma that is completely unjustified," Blumenthal said.
Bush said the Military Service Initiative, supported by Chiarelli, former Joint Chiefs Chairman retired Marine Gen. Peter Pace and others, will continue to advocate for dropping the "D" — if not to convince the medical profession, then at least to change the perceptions of employers.
"Veterans receiving treatment for post-traumatic stress are not damaged goods," Bush said. "Employers would not hesitate to hire an employee getting treated for a medical condition like diabetes. ... They should not hesitate to hire veterans getting treated for post-traumatic stress."