Dropping the ‘Disorder’ from PTSD. What Do Psychiatric Labels Mean?

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Whitney Shefte/The Washington Post via Getty Images

SSgt James Ownbey, a marine who served in Iraq as an explosive ordnance disposal (EOD) technician in 2007 and two other deployments and now suffers from a traumatic brain injury (TBI), Post Traumatic Stress Disorder (PTSD) and numerous physical ailments, sits in his living room on Wednesday, June 23, 2010

What’s wrong with me? The question of where to draw the line between normal and abnormal and how to label our mental differences has become more vexing than ever. It’s an issue that fuels the continuing debates over Americans’ liberal use of psychiatric medications and the possible overdiagnosis of conditions like Asperger’s syndrome. Now it’s at the heart of an interesting move by the military.

As our colleagues over at the Battleland blog reported today, Pentagon officials are trying to remove the disorder from posttraumatic stress disorder (PTSD), arguing that posttraumatic stress is a “normal reaction” to very serious events in soldiers’ lives. As the reasoning goes, if it’s normal, then it should be neither labeled a disorder nor stigmatized:

Military mental-health workers constantly try to reduce the stigma associated with mental-health ills, and one way to do that is to not term the problem a disorder.

Some veterans agree, but others — fearful the name change is simply a way of minimizing what they’re going through — don’t. “It’s a double-edged sword,” a long-time Army psychiatrist says privately. “We’re trying to reduce the stigma associated with the condition, but it’s in the DSM-4 [the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the accepted roster of various mental conditions] as PTSD. And some veterans fear that deleting disorder will jeopardize the VA benefits they get for it.”

The question of whether PTSD is a normal response to an abnormal experience runs straight to the crux of the debate. Most studies suggest that at least two-thirds of people exposed to traumatic events do not develop anything like full blown PTSD. So, in a broadly statistical sense, it doesn’t seem to make sense to call it a “normal” response.

(More on TIME.com: Why Are Women More Vulnerable to PTSD than Men?)

On the other hand, given that a significant minority are affected, one might call the condition a common variant of normal.

But the problem with labeling people who experience posttraumatic stress as normal begins when the symptoms interfere with daily function in work or relationships. It’s all normal variance until it handicaps or disables you, basically — and then you’re talking about a condition (no matter what you label it) for which you may need help.

Posttraumatic stress might be no big deal if it all it did was improve your reaction time and make you more vigilant — both symptoms that are seen in people with PTSD. But if the same condition has you waking up screaming from nightmares or lashing out irritably at your wife and children, that’s another story. If PTSD isn’t keeping you from driving to work for fear of an IED explosion or driving you to drink day and night to stop the flashbacks, it may be a normal variation in response to stress that doesn’t require assistance or mitigation.

But in cases where it prevents you from being who you want to be and doing what you want to do, disorder is a perfectly appropriate term. And medical and psychological treatment is absolutely advised and should be covered by insurance. Whether the behaviors associated with PTSD are statistically “normal” or “abnormal” doesn’t matter. What matters is that they get in the way of your ability to have a happy, productive life.

(More on TIME.com: How Fear Changes What We Hear)

As another example, consider the case of the autism spectrum disorder known as Asperger’s syndrome. If your symptoms of Asperger’s include being a programming whiz and feeling slightly awkward at parties, there’s no reason to call it a “disorder” or to see yourself as having anything other than a variant type of brain that provides some advantages and some disadvantages.

But if the disabilities associated with Asperger’s cause life problems — if your social awkwardness leads to unwanted isolation, for instance, or if sensory experiences become so overwhelming that they prevent you from working — then that part of the condition can rightfully be called a “disorder.” Then, the behaviors that create problems should be mitigated through psychological or other treatments.

It appears that the Army’s main concern about terms like disorder and abnormal is the stigma attached to them. As Battleland reported:

Last month, the Army’s No. 2 officer and top mental-health advocate, General Peter Chiarelli, used PTS repeatedly before opening up about the change. “I drop the D,” he said. “That word is a dirty word.”

Stigma is associated with labels when they are seen as threats to social order. So PTSD and Asperger’s syndrome are stigmatized because unaffected people fear the associated behaviors that they find strange or unpredictable. The same holds true for many other conditions and disabilities.

(More on TIME.com: Study: Scientists Revive Old, Fading Memories)

But to fight stigma, it’s not necessary to minimize the realities of associated disabilities.  By disconnecting stigma from disabilities and distinguishing both from normal variance, we can get a much better sense of how to cope.

Stigma can be addressed by informing and educating both people affected by the conditions themselves and those around them about what to expect and how to handle it.  Greater exposure to affected people also tends to minimize fear of the unknown, which often enhances stigma.

As for any handicaps or disabilities presented by these disorders, treatment needs to be provided to improve coping and change behaviors that cause distress. Beyond that, what is “normal” or not matters little — only what works to get you through the day.

Related Links:

Drugging the Vulnerable: Atypical Antipsychotics in Children and the Elderly

Study: Why Some Transgendered People Have Higher Levels of Autistic Traits

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