It's a Wound not a Disorder

In the summer of 1943, along the northern Sicilian coast, Lieutenant General George Patton was visiting the 15th Evacuation Hospital for an inspection. As the general moved along the ward, he met “the only arrant coward” Patton claimed to have seen in his army “sitting, trying to look as if he had been wounded.” When Patton asked about his injury, the soldier replied that he “just couldn’t take it.” As one of the doctors remembered, “The General immediately flared up, cursed the soldier, called him all types of a coward, then slapped him across the face with his gloves, and finally grabbed the soldier by the scruff of his neck and kicked him out of the tent.” A week later, Patton repeated the scene at the 93rd Evacuation Hospital, where he slapped another seemingly uninjured private. (1)

37 years later, in 1980, the American Psychiatric Association (APA) added Post-Traumatic Stress Disorder (PTSD) to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III), filling a significant gap that existed in psychiatric theory and care.

The significant change this addition created was in the origin, or root cause, of post-traumatic stress. Until 1980, the root causes for mental health issues were thought to come solely from inside of us. Adding PTSD to the DSM directly challenged that conventional thinking. For the first time, an event that happened outside of us could be considered a root cause of a mental health condition. The key to how we got there and understanding the science behind PTSD is how we think about and treat "trauma."

The initial entry in the DSM-III limited the number of external causes of PTSD to war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions), and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). The original framers of the diagnosis of PTSD believed traumatic events were distinctively different from other painful life experiences such as divorce, loss of reputation, rejection, serious illness, regret, or financial ruin. They believed most of us have the means to cope with everyday stress. But a traumatic event that is outside the range of everyday human experiences is more likely to overwhelm our capacity to adapt to the immense fear that comes with the event.

So PTSD is unique among psychiatric diagnoses because of its dependence on the source of the trauma. That's why a PTSD diagnosis cannot be made unless you have been directly or indirectly exposed to a traumatic event.

In 2013 the fifth edition of the DSM included some noteworthy revisions to how we diagnose PTSD. The research showed that PTSD wasn't just a fear-based anxiety disorder. Negative thinking and mood swings, as well as angry, impulsive, reckless, and self-destructive behaviors, are considered part of the diagnostic process. PTSD also found its way into a brand new category in the DSM. Today, it is classified as a Trauma- and Stressor-Related Disorder that occurs after exposure to a traumatic or otherwise adverse environmental event. (2)

The historical evolution of post-traumatic stress once thought of as "shell shock" or "battle fatigue" and restricted to members of the military that saw combat, can be instructive in looking for new ways to view and treat PTSD going forward. Data on the treatment of PTSD shows there are differences in our individual capacity to cope with overwhelming stress. Most people that are exposed to traumatic events don't develop PTSD. But others do. That's because all of us filter a traumatic experience through our individualized thinking and feeling self before deciding whether or not it is an extreme threat. Almost everyone considers events such as rape, torture, genocide, and severe war zone stress traumatic. People simply have different trauma thresholds. Some are more susceptible than others to developing the symptoms after an extremely stressful event.

The etymology of trauma dates back to the 1690s. It’s a Greek word that means “a wound.” This suggests that post-traumatic stress is actually a psychological wound that hasn’t fully healed rather than a "disorder." None of today's leading experts in post-traumatic stress view it as a disorder either. Instead, they treat it as an unresolved psychological wound that our body continually asks us to pay attention to and heal.

Who are some of the thought leaders on the treatment of trauma, and what are they saying?

• Bessel van der Kolk, MD, author of The Body Keeps the Score, is widely recognized as the world’s leading trauma treatment expert. He describes trauma as “not the story of something that happened back then, but the current imprint of that pain, horror, and fear living inside [the individual]. These events leave us stuck and result in a change in how we perceive and react to danger." He has been instrumental in bringing greater visibility and credibility to nontalk treatments, EMDR (Eye Movement Desensitization and Reprocessing) in particular.
• Dr. Peter Levine, who developed Somatic Experiencing (SE), another nontalk therapy for trauma, teaches us that the nervous system is designed to keep us psychologically intact when we perceive we cannot keep ourselves safe in a situation. Psychological trauma can happen to anyone when they are unable to complete a satisfactory flight, fight, or freeze response when they perceive a threat.
• Dr. Stephen Porges, the founder of Polyvagal Theory (the Science of Safety), suggests, “Trauma is a chronic disruption of connectedness. Once you understand the physiology behind PTSD symptoms, you realize why you cannot simply think your way out of your trauma. Post-traumatic stress symptoms are biologically based and somatically experienced.” This means the PTSD-related symptoms people experience relate distinctively to the body, not just the mind. When we perceive a threat (whether it’s real or imagined), our body’s way of directing our attention to something that’s going on inside us is to trigger us.
• Physician Dr. Gabor Maté describes trauma as “a wound that leaves an imprint on your nervous system, then shows up later on [as triggers] in ways that aren’t helpful.” Sometimes it marinates undetected in our bodies and brains for years to affect us mentally, emotionally, physically, and even spiritually.

Other leaders in the field, including Janina Fisher, Pat Ogden, and Deb Dana, also take a body-based approach to healing trauma and were influential in my own journey toward holistically healing from my own diagnosis.

While some may be dismissive of the idea of calling post-traumatic stress a wound versus a disorder, a simple change to how we label it could have a profound impact on the stigma associated with it, the attitudes our Veterans and active duty members of the military have about it, and how the general public views and accepts it.

Stigma refers to the discrediting, devaluing, and shaming of a person because of characteristics or attributes they possess. According to a 2003 report by the Carter Center, stigma, as it relates to mental health in general, is defined as “a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses.” (3)

Continuing to call post-traumatic stress a disorder arguably contributes to stigma about it. A study released by the National Institutes of Health found common stereotypes of Veterans that sought treatment for PTSD included labels such as dangerous, violent, and crazy. It also exposed a belief that combat veterans are responsible for having PTSD. As a result, most participants reported avoiding treatment early on to avoid the label of mental illness. (4)

Because of stigma, some questions might be worth considering:

1. How many Veterans, first responders, law enforcement officers, firefighters, legal workers, teachers, and medical workers have undiagnosed PTS and are not receiving treatment?
2. Could we be witnesses to an epidemic of traumatic stress in our society without realizing it?

Other stereotypes that contribute to the stigma against PTSD include fearing embarrassment and shame, and if they seek help, fearing they’ll be hospitalized. Members of the military, including Veterans, fear losing their security clearance or their job, being judged as the weak link, or becoming an outcast in a culture that depends on camaraderie and the concept of mission over self to succeed.

Common sense tells us we can heal from a wound. But healing from a disorder is an altogether different challenge. The data suggests it's counterproductive to individuals and our society to keep calling PTS a disorder. What if we called it a post-traumatic stress wound (PTSW) instead?

General Patton's adherence to outdated information about "shell shock" led to the fateful incident known as "the slap heard around the world." He would later write in his journal, "The greatest weapon against the so-called battle fatigue is ridicule. If soldiers would realize that a large proportion of men allegedly suffering from battle fatigue are really using an easy way out, they would be less sympathetic." In his defense, though he understood the strain battle put on the human psyche, General Patton also knew it was the commander’s job to maintain fighting strength. Victory, not to mention shorter casualty lists, depended on keeping able-bodied soldiers at the front. Yet it parallels other important issues of command, our armed forces, and society at large. The slapping incident simply demonstrates how military needs and changing medical knowledge can clash. Recognizing post-traumatic stress as an unresolved wound is a step in the right direction, the implications of which are worthy of a national conversation.

Education is key to increasing awareness and breaking down stigma related to PTSW. In organizations and in our personal lives, we must learn to challenge our leadership, co-workers, friends, and family when we hear inappropriate language or judgment related to people with PTSW, substance use disorders, or any other mental health conditions. In the workplace, creating a culture of awareness and feedback is a leadership imperative that is critical to dismantling stigma and addressing unconscious bias.

In my next newsletter, I'll write about my own workplace experiences where the existence of PTSW was mishandled.