The Role and Importance of the 'D' in PTSD

In December 2012, the American Psychiatric Association (APA) board of trustees voted on changes to the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Among the decisions was one to retain the word “disorder” in the term “posttraumatic stress disorder” (PTSD). U.S. Army leadership initially requested the change in terminology, stating that the word “disorder” is stigmatizing and that removing it would encourage more individuals suffering from symptoms to access care. Although the APA has issued its ruling, the term “posttraumatic stress” (PTS) is being used informally by some individuals within military communities. It is unclear whether informal use of the term will continue, or whether military leaders will continue to advocate future changes to the DSM. Our intent is to further the discussion regarding the removal or revision of the term “disorder.” We explore the rationales for not changing the diagnostic terminology, and to the extent possible, anticipate what the effects of widespread informal use of new terminology might be.

What Is PTSD?

PTSD is classified as a trauma- and stressor-related disorder and is now defined by criteria listed in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the DSM-5. The diagnostic criteria for PTSD include past exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence; intrusion symptoms such as distressing memories or dreams; persistent avoidance of stimuli associated with the traumatic event; negative alterations in cognitions and mood; and marked alterations in arousal and reactivity (APA, 2013). To constitute a diagnosis, symptoms must persist for one month following the trauma, cause significant functional impairment, and not be attributable to the physiological effects of a substance or another medical condition.

Key Issues

• After considering the matter, the APA opted not to change the name of posttraumatic stress disorder (PTSD) despite a request by senior U.S. Army leadership.
• The Army's reasoning was that the term “disorder” is stigmatizing, and that removing or replacing it—for example, with the term “injury”—would encourage more U.S. military service members suffering from symptoms to access care.
• Some individuals within military communities are already using the term “posttraumatic stress” (PTS) informally, although the impact of this use—on mental health stigma or otherwise—is unclear.
• Few studies specifically demonstrate stigmatization among U.S. military service members with PTSD, and no known studies have shown that PTSD-related social stigmas reduce the utilization of treatment.
• Psychiatric diagnoses are used within institutions such as the U.S. military in ways that may adversely affect how a diagnosed individual is treated—for example, when determining eligibility for security clearances or fitness for deployment.
• Without changing the broader institutional factors that result in discrimination against those with the PTSD label, modifying that label seems unlikely to result in a significant increase in individuals willing to be diagnosed or treated.

Reference

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Washington, D.C.: American Psychiatric Association Press, 2013.

This research was conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.