In a bid to reduce stigma and improve treatment rates, a small group of clinicians, as well as military personnel, is lobbying the American Psychiatric Association (APA) to change the name of posttraumatic stress disorder (PTSD) to posttraumatic stress injury (PTSI) for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). The APA's policy is that a rolling name change is available if the current term is determined to be harmful.
Currently led by anesthesiologist Eugene Lipov, MD, clinical assistant professor, University of Illinois Chicago, and chief medical officer of Stella Center, Chicago, the formal request for the proposed name change to the APA's DSM-5-TR Steering Committee in August 2023.
The APA Steering Committee rejected the proposed name change in November 2023, citing a "lack of convincing evidence." However, Lipov and his colleagues remain undeterred and continue to advocate for the change.
"The word 'disorder' is both imprecise and stigmatizing," Lipov told Medscape Medical News. "Because of stigma, many people with PTSD — especially those in the military — don't get help, which my research has demonstrated."
Patients are more likely to seek help if their symptoms are framed as manifestations of an injury that is diagnosable and treatable, like a broken leg, Lipov said. "Stigma can kill in very real ways, since delayed care or lack of care can directly lead to suicides, thus satisfying the reduce harm requirement for the name change."
Neurobiology of Trauma
Lipov grew up with a veteran father affected by PTSD and a mother with debilitating depression who eventually took her life. "I understand the impact of trauma very well," he said.
Although not a psychiatrist, Lipov pioneered a highly successful treatment for PTSD by adapting an anesthetic technique — the stellate ganglion block (SGB) — to reverse many trauma symptoms through the process of "rebooting."
This involves reversing the activity of the sympathetic nervous system — the fight-or-flight response — to the pretrauma state by anesthetizing the sympathetic ganglion in the neck. Investigating how SGB can help ameliorate the symptoms of PTSD led him to investigate and describe the neurobiology of PTSD and the mechanism of action of SGD.
The impact of SGD on PTSD was supported by a small neuroimaging study demonstrating that the right amygdala — the area of the brain associated with the fear response — was overactivated in patients with PTSD but that this region was deactivated after the administration of SGB, Lipov said.
"I believe that psychiatric conditions are actually physiologic brain changes that can be measured by advanced neuroimaging technologies and then physiologically treated," he stated.
He noted that a growing body of literature suggests that use of the SGB for PTSD can be effective "because PTSD has a neurobiological basis and is essentially caused by an actual injury to the brain."
A Natural Response, Not a Disorder
Lipov's clinical work treating PTSD as a brain injury led him to connect with Frank Ochberg, MD, a founding board member of the International Society for Traumatic Stress Studies, former associate director of the National Institute of Mental Health, and former director of the Michigan Department of Mental Health.
In 2012, Ochberg teamed up with retired Army General Peter Chiarelli and Jonathan Shay, MD, PhD, author of Achilles in Vietnam: Combat Trauma and the Undoing of Character, to petition the DSM-5 Steering Committee to change the name of PTSD to PTSI in the upcoming DSM-5.
Ochberg explained that Chiarelli believed the term "disorder" suggests a preexisting issue prior to enlistment, potentially making an individual appear "weak." He noted that this stigma is particularly troubling for military personnel, who often avoid seeking so they are not perceived as vulnerable, which can lead to potentially dire consequences, including suicide.
"We received endorsements from many quarters, not only advocates for service members or veterans," Ochberg told Medscape Medical News.
This included feminists like Gloria Steinem, who championed the rights of women who had survived rape, incest, and domestic violence. As one advocate put it, "The natural human reaction to a life-threatening event should not be labeled a disorder."
The DSM-5 Steering Committee declined to change the name. "Their feeling was that if we change the word 'disorder' to something else, we'd have to change every condition in the DSM that's called a 'disorder'. And they felt there really was nothing wrong with the word," said Ochberg.
However, Lipov noted that other diagnoses have undergone name changes in the DSM for the sake of accuracy or stigma reduction. For example, the term mental retardation (DSM-IV) was changed to intellectual disability in DSM-5, and gender identity disorder was changed to gender dysphoria.
A decade later, Lipov decided to try again. To bolster his contention, he conducted a telephone survey of 1025 individuals. Of these, about 50% had a PTSD diagnosis.
Approximately two thirds of respondents agreed that a name change to PTSI would reduce the stigma associated with the term "PTSD." Over half said it would increase the likelihood they would seek medical help. Those diagnosed with PTSD were most likely to endorse the name change.
Lipov conducts an ongoing survey of psychiatrists to ascertain their views on the potential name change and hopes to include findings in future research and communication with the DSM-5 Steering Committee. In addition, he has developed a new survey that expands upon his original survey, which specifically looked at individuals with PTSD.
"The new survey includes a wide range of people, many of whom have never been diagnosed. One of the questions we ask is whether they've ever heard of PTSD, and then we ask them about their reaction to the term."
A Barrier to Care
Psychiatrist Marcel Green, MD, director of Hudson Mind in New York City, refers to himself as an "interventional psychiatrist," as he employs a comprehensive approach that includes not only medication and psychotherapy but also specialized techniques like SBG for severe anxiety-related physical symptoms and certain pain conditions.
Green, who is not involved in the name change initiative, agrees that the term "disorder" carries more stigma than "injury" for many groups, including those who have experienced childhood trauma, those struggling with substance abuse, or who are from backgrounds or peer groups where seeking mental healthcare is stigmatized.
Patients like these "are looking to me to give them a language to frame what they're going through, and I tell them their symptoms are consistent with PTSD," he told Medscape Medical News. "But they tell me don't see themselves as having a disorder, which hinders their pursuit of care."
Framing the condition as an "injury" also aligns with the approach of using biologic interventions to address the injury. Green has found SGB helpful in treating substance abuse disorder too, "which is a form of escape from the hyperactivation that accompanies PTSD." And after the procedure, "they're more receptive to therapy."
Unfortunately, said Lipov, the DSM Steering Committee rejected his proposed name change, stating that the "concept of disorder as a dividing line from, eg, normal reactions to stress, is a core concept in the DSM, and the term has only rarely been removed."
Moreover, the committee "did not see sufficient evidence…that the name PTSD is stigmatizing and actually deters people with the disorder from seeking treatment who would not be deterred from doing so by PTSI."
'An Avenue for Dignity'
Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness (NAMI), noted that the organization does not have an official position on this issue. However, he shared his own personal perspective.
There may be merit in the proposed name change, said Duckworth, but more evidence is needed. "If it's clear, after rigorous studies have been performed and there's compelling data, that calling it a 'disorder' rather than an 'injury' is actually preventing people from getting the care they need, then it merits serious attention."
If so, Duckworth would be "interested in having a conversation with the policy team at NAMI to start to see if we could activate the DSM Committee."
Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto, Toronto, Ontario, Canada, and head of the Mood Disorders Psychopharmacology Unit, said the name change initiative is a "really interesting proposal."
McIntyre, chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, who is not involved in the initiative, has also heard "many people say that the term 'disorder' is stigmatizing and might even come across as pejorative in some ways."
By contrast, "the word 'injury' parallels physical injury, and what we currently call 'PTSD' is a psychological or emotional injury no less devastating than torn tissue or broken bones," added McIntyre, who is also the chairman of the board of the Depression and Bipolar Support Alliance.
Ochberg agreed. "In the military, 'injury' opens up an avenue for dignity, for a medal. Being injured and learning how to deal with an injury is part of having yet another honorable task that comes from being an honorable person who did an honorable thing."
While disappointed, Lipov does not plan to give up on his vision. "I will continue to amass evidence that the word 'PTSD' is stigmatizing and indeed does prevent people from seeking care and will resubmit the proposal to the DSM Steering Committee when I have gathered a larger body of compelling evidence."
Currently, Lipov is in active discussions with the special operations force of the US Army to obtain more evidence. "This will be the follow-up to bolster the opinion of Peter Chiarelli," he said. "It is known that suicide and PTSD are highly related. This is especially urgent and relevant because recent data suggest suicide rate of military personnel in the VA may be as high as 44 per day," Lipov said.
Lipov is the chief medical officer and an investor in the Stella Center. Green performs SGBs as part of his psychiatric practice. Ochberg, McIntyre, and Duckworth reported no relevant financial relationships.
Note: This article originally appeared on Medscape.
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