Soon after Peter Chiarelli became vice chief of staff of the Army in 2008, a subordinate showed him a bar graph depicting the number of soldiers determined by the Department of Veterans Affairs to be at least 30 percent disabled. The tallest column was on the far left.
Those are amputations, Chiarelli thought. Or burns.
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Then he examined the graph more carefully. Burns were off to the right, accounting for just 2 percent of disabled soldiers. Amputations were in the middle, at 10 percent. The big column, which represented 36 percent of seriously injured soldiers, was labeled “PTSD or TBI.”
Chiarelli was dumbfounded. PTSD, or post-traumatic stress disorder, is the catchall term to explain the anxiety, anger, and disorientation people can experience after exposure to physical harm or the threat of it. An insurgent attack would qualify, as would the threat of one, which most troops in Iraq faced every day. TBI, or traumatic brain injury, can happen when a soldier suffers a concussion from the blast of a roadside bomb. While some soldiers appeared to recover from concussions quickly, for others the effects lingered for months, or even indefinitely.
What stunned Chiarelli was not just the high percentage but the long-term persistence of PTSD and the aftereffects of concussions. He had been the operational commander of all American ground forces in Iraq. Before that, he’d led an Army division that was responsible for Baghdad. And yet the prevalence of debilitating post-traumatic stress and serious brain injuries was news to him. He had assumed that the stress of a near-miss would dissipate. So, too, would the effects of a concussion. He figured they were no big deal.
“If I had a platoon that lost folks, I had combat-stress teams, and I made sure they were flown to whatever base they needed to go to,” he said. “I knew what my football coach told me about traumatic brain injury: ‘Shake it off and get back in the game.’”
The graph sobered him. As vice-chief, his job wasn’t to focus on war strategy. He was responsible for “the force”—for training and equipping soldiers, modernizing weapons and overseeing the budget, and ensuring the well-being of the half-million men and women in the Army, the second-largest U.S. employer after Walmart. But it also was personal: he had put many of these soldiers in harm’s way in Iraq, and he believed he had a duty to those who returned harmed.
So Chiarelli set out to learn everything he could about PTSD and TBI. The task took on even greater urgency a month later, when the Army tallied that 115 soldiers had committed suicide in 2007. That was the most since the Army began counting in 1980 and nearly twice the national suicide rate. Chiarelli’s boss, General George Casey Jr., asked him to figure out why so many soldiers were taking their own lives.
Chiarelli could see that PTSD, TBI, and military suicide were overlapping circles. But by how much? Not every soldier with a concussion was going to experience post-traumatic stress. Many stressed-out soldiers had not been subjected to explosions. And when it came to suicides, TBI did not appear to be a main cause. But all of it fit under the rubric of mental health, an issue that had never really been on the front burner at the Pentagon.
Despite failures at Walter Reed and other Army hospitals early in the Afghanistan and Iraq wars, the military was providing extraordinary care to troops who had been burned, absorbed bullets or shrapnel, or lost limbs. (The Department of Veterans Affairs, which treats those who have left active service, was a deeply troubled institution that would be accused in 2014 of falsifying patient-care records.) The advancements in prosthetics and limb transplants since 2001 had been, in Chiarelli’s view, “nothing short of amazing.” But he soon discovered the same couldn’t be said for mental health and brain injuries. “What we were doing for their minds wasn’t a tenth of what we were doing for their arms and legs,” he said.
The broad-shouldered Chiarelli, whose face bore the worry lines of a general who had written too many condolence letters, summoned two military doctors, one an expert on PTSD, the other on TBI. He met with each for two hours. Then he went to Walter Reed and talked to physicians there. What they told him about the severity of the problem differed from what he had heard from the first two doctors. Frustrated, he contacted one of the few civilian doctors he knew, an accomplished plastic surgeon in Los Angeles who was providing advanced reconstruction treatment to soldiers disfigured by explosions. That doctor connected Chiarelli with David Hovda, the director of UCLA’s Brain Injury Research Center, who agreed to speak with a group of military doctors at the Pentagon.
Hovda began his presentation by projecting a slide of three brain scans. The one on the right, filled with splotches of yellow and red to indicate healthy activity, was of an uninjured person. On the other two slides, instead of yellow and red, there were large areas of dark blue and purple. The middle one, Hovda said, showed a comatose patient. The one on the left was the brain of a UCLA football player who had been injured in the first half of a game, went back to play the second half, and then walked into the emergency room the following day, complaining of a severe headache.
To Chiarelli, it was an epiphany.
“Those were the kids we were missing” in Iraq and Afghanistan, he said. “They’d go out and get concussed on a Tuesday, and they’d be out on patrol again on Thursday.”
The military doctors had been willing to listen to Hovda when Chiarelli, who had four stars on his collar, asked them to attend the session. But when Chiarelli brought Hovda back to Washington to help develop a new protocol for treating service members exposed to blasts, the doctors insisted the military didn’t need to change. Existing methods, they said, were fine.
Chiarelli was incensed. So, too, was General James Amos, then the second-in-command of the Marine Corps. He shared Chiarelli’s view that more needed to be done to address mental health issues. At the initial meeting of Hovda and the doctors, the two generals had jumped out of their chairs. “We’re going to bring some people in here who understand we’ve got a goddamned problem,” Chiarelli huffed, before walking out of the room.
It wasn’t going to be easy. And addressing battlefield concussions was only one of his challenges. He convened regular meetings to examine the case of every active-duty soldier who had committed suicide in the previous months. Were there warning signs? What should the Army have done differently? And he devoted hours each week to discussing post-traumatic stress. To dispel the stigma around it, he no longer referred to it as a disorder.
He learned that troops claiming post-traumatic stress—PTS, he insisted, not PTSD—were diagnosed with a twenty-question test. Are you feeling irritable or having angry outbursts? Have you lost interest in things you used to enjoy? There was no blood test or brain scan.
“Imagine going to your doctor because you think you have a broken leg and your doctor asks twenty questions, and then your doctor says, ‘You don’t have a broken leg. You can go home.’ You’d say, ‘Aren’t you going to X-ray my leg?’ That’s how we diagnose PTS,” he said. “This is like having a heart attack, and when you show up in a hospital, it’s 1945.”
Experts told him it would be years, if ever, before more advanced tests could be developed for PTS. So Chiarelli directed his energies toward expanding mental health treatment programs in war zones and on domestic bases, and he pushed military doctors to explore the efficacy of alternative therapies.
He achieved more headway in screening for traumatic brain injuries. In 2010, the Army and the Marine Corps developed a set of guidelines to follow after service members were exposed to a blast. If they were in a vehicle that was damaged by an explosion, or they were within fifty meters of a bomb detonation, or if they lost consciousness, they had to be given a thirty-question cognitive test. If they didn’t get at least twenty-six questions correct, they were to be sent to a doctor for an evaluation. And even if they passed the cognitive test the first time, they were supposed to be reevaluated the following day.
Howard Schultz is the chairman and chief executive of Starbucks Coffee. Excerpted from For Love of Country: What Our Veterans Can Teach Us About Citizenship, Heroism and Sacrifice by Howard Schultz and Rajiv Chandrasekaran (Alfred A. Knopf). Copyright 2014 Howard Schultz and Rajiv Chandrasekaran.
Rajiv Chandrasekaran is an associate editor of The Washington Post.
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The nation’s second-highest ranking Army officer is calling on mental health professionals to change the name of the condition that has afflicted hundreds of thousands of U.S. soldiers. But some of those doctors are resisting the change.
The term Post Traumatic Stress Disorder, or PTSD, carries a stigma that has discouraged too many soldiers from understanding the condition and seeking proper treatment, Gen. Peter Chiarelli, the Army vice chief of staff told the PBS NewsHour. He would like to see PTSD called Post Traumatic Stress Injury, or PTSI, instead.
“It is an injury,” Chiarelli said. Calling the condition a “disorder” perpetuates a bias against the mental health illness and “has the connotation of being something that is a pre-existing problem that an individual has” before they came into the Army and “makes the person seem weak,” he added.
“It seems clear to me that we should get rid of the ‘D’ if that is in any way inhibiting people from getting the help they need,” Chiarelli said. Calling it an injury instead of a disorder “would have a huge impact,” encouraging soldiers suffering from the condition to seek help, according to the four-star general.
Rates of PTSD in the Army are estimated at 10-20 percent for combat infantry soldiers who experienced direct combat. In some units with high combat involvement, the rates are as high as 25-30 percent.
Chiarelli’s call to change the name to PTSI comes at a time when the American Psychiatric Association is in the process of updating its “bible” of mental health illnesses. Officially called the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV), it classifies and defines the criteria for mental health conditions. It is used by health and mental health professionals, ranging from psychiatrists to physicians to psychologists, according to the association.
The manual currently says that for a person to have PTSD, he or she must have been exposed to a traumatic event, and then have a number of symptoms for more than one month. The individual persistently re-experiences the event, such as through distressing dreams or intrusive recollections. The person also must seek to avoid stimuli associated with the trauma, such as avoiding activities that remind him or her of the event. Another symptom is increased arousal, including hypervigilance or difficulty staying asleep.
Chiarelli is not the only one calling for a name change. Former Army 1st Lt. Paul Rieckhoff, the founder and executive director of Iraq and Afghanistan Veterans of America, said from a “national messaging standpoint,” changing the name would help reduce the negative connotations associated with PTSD.
“We believe that PTSD is a wound you suffer in combat, just like a bullet wound, and if you don’t take care of it, and you don’t treat it, it’s going to be a problem,” Rieckhoff said.
However, the chairman of psychiatrists’ committee overseeing the professional guidebook update of the PTSD diagnosis, Dr. Matthew Friedman, said he “sees no useful purpose to change the name.”
He told the PBS NewsHour: “There is stigma attached to any mental illness. And PTSD is no different.”
The discomfort with such a diagnosis “may be amplified in military culture,” he acknowledged. In other settings, such as in the civilian world, “PTSD may be even less of a stigma,” he said.
Friedman is also the executive director of the National Center for PTSD, the Department of Veteran Affairs’ center for research and education on the prevention, understanding, and treatment of PTSD.
A diagnosis of PTSD does not imply that a soldier “doesn’t have the right stuff,” because it gives primacy to being exposed to a traumatic event, Friedman said.
This line of thinking sounds like “doctors are dancing on the head of a pin,” argued Chiarelli. He emphasized that a name change would not be carried out for the sake of physicians, but help encourage afflicted soldiers and their commanders to embrace diagnosis and treatment. “If it was only doctors I had to convince to seek help, I wouldn’t care if it had a ‘D’ at the end of it.”
The soldier himself might be an obstacle to receiving treatment, said Chiarelli. “I have to convince a 19-year-old kid who thinks he’s invincible that he’s got an issue … that he has to deal with. A no-kidding injury that he can’t see. That many of his buddies don’t even believe is real,” he said. “But I need to get him the help that he needs … A disorder is something, to a 19-year-old kid, that [seems] pre-existing that makes me weaker than other people.”
Schizophrenia previously labeled as “disorder”
There is some precedent for changing the name of a mental health disorder, according to Dr. Frank Ochberg, a clinical professor of psychiatry at Michigan State University. “Schizophrenia is called schizophrenia, although there were times when it was called schizophrenia disorder, or schizophrenia reaction,” he said.
There are other mental health disorders that are not labeled as disorders, he added.
“If you look through the (manual), you’ll see that diagnosis after diagnosis is named disorder. But not all,” Ochberg wrote in an email to the PBS NewsHour. “There is a chapter on ‘Impulse Control Disorders’ and some of those have non-D names: kleptomania, pyromania, pathological gambling, trichotillomania.”
PTSD’s emergence after Vietnam
The diagnosis of PTSD was first included in the third edition of the manual in 1980. Ochberg, who at that time was involved in updating the manual, said he and his colleagues wanted it called a disorder because — only half-jokingly — “we figured if we did, then Blue Cross would pay for it.”
Ochberg was “part of the Vietnam generation who opposed the war but ultimately recognized the price the warrior paid,” he said. “I saw the similarity between the rape trauma syndrome and military trauma. My take on the history of the time was that PTSD was the common ground between the male trauma of combat and the female trauma of rape, and incest and battering.”
“All syndromes coming out of the DSM in 1980 were disorders,” said another leading mental health professional, Charles Figley, director of Tulane University’s Traumatology Institute.
An expert on trauma and author of the 1978 book, “Stress Disorders Among Vietnam Veterans: Theory, Research,” Figley said calling the condition a disorder reflected a combination of factors. “Part [of it] was politics. To give Vietnam veterans their due. The hawks thought they [veterans with the illness] were whiny babies, and the doves thought they were crazy. So it was an effort to legitimize the pain and suffering they were going through.”
Revising the manual of mental illnesses
The American Psychiatric Association began preliminary work on updating its dictionary of mental health illnesses in 1999, and opened the draft text to public comment.
The committee received hundreds of comments, but not on changing the name of PTSD, said Friedman.
Asked if the committee revising the entry for PTSD would be open to changing the name if the Army formally made such a request, Friedman said “we would consider it” and that “the Army is part of the field. And they obviously are a very important constituent.”
According to Friedman, the current name of the condition has proved helpful. “The most important thing about the name PTSD, prior the 1980 version of the manual,” is that “we had a whole bunch of syndromes that were all named by the stressor,” he said. “There was rape trauma syndrome, there was battered wife syndrome, there was war sailor syndrome, there was post-Vietnam syndrome, concentration camp syndrome, and on and on.”
The “brilliance” of those who wrote the manual in 1980 is that “they understood that it really didn’t matter what the particular stressor was,” Friedman said. “If it was a traumatic stressor and the individual’s coping capacities were exceeded, that it was the response rather than the stressor that matter.”
The revised Diagnostic and Statistical Manual will be released in final form in May 2013.