PTSD in the U.S. military, and the politics of prevalence.

Accepted Manuscript PTSD in the U.S. Military, and the Politics of Prevalence Michael P. Fisher PII:

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DOI:

10.1016/j.socscimed.2014.05.051

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Please cite this article as: Fisher, M.P., PTSD in the U.S. Military, and the Politics of Prevalence, Social Science & Medicine (2014), doi: 10.1016/j.socscimed.2014.05.051. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Posttraumatic stress disorder prevalence is often disputed in US military contexts. Some perceive PTSD to be over-diagnosed, and some perceive it to be underdiagnosed. Disputes center on the diagnosis, screening technologies, or individuals diagnosed. Perceptions of PTSD prevalence have implications for policymaking and stigma.

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PTSD in the U.S. Military, and the Politics of Prevalence

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Michael P. Fisher a University of California, San Francisco

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Acknowledgements

I am deeply grateful to the public officials, veterans’ advocates, and researchers who participated in this study. I kindly thank Janet K. Shim, Robert Newcomer, Adele E. Clarke, and Stephen Zavestoski who provided feedback and guidance throughout various stages of this work. This study was supported in part by a grant from the Horowitz Foundation for Social Policy and the University of California, San Francisco’s Anselm Strauss Fellowship.

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University of California, San Francisco, Department of Social and Behavioral Sciences, 3333 California Street, Suite 455, San Francisco, CA 94118, USA; e-mail: [email protected]

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ABSTRACT Despite the long-standing codification of posttraumatic stress disorder (PTSD) as a

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mental disorder, the diagnosis is a controversial one whose legitimacy is at times disputed, particularly in U.S. military contexts (e.g., McNally & Frueh 2013; McNally 2003; 2007). These disputes often manifest in a struggle over prevalence rates. Utilizing data from in-depth

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interviews and relying on situational analysis methodology (Clarke, 2005), I highlight this

struggle in the wake of a decade of U.S.-led war in Afghanistan and Iraq. I focus on the objects

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of contestation employed by public officials, veterans’ advocates, and researchers to make or refute claims about PTSD prevalence. These objects of contestation include the diagnostic category and criteria; screening tools, procedures, or systems; and the individuals who express symptoms of the disorder. Based on these claims, I make two key interrelated assertions. First, PTSD is viewed by some public officials as an overly generalized or invalid diagnostic category

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that is often induced in or falsified by veterans or servicemembers. As such, PTSD is perceived by these stakeholders to be over-diagnosed. Compounding these perceptions are beliefs that PTSD is costly and negatively impacts military duty performance, and thus overall manpower.

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Second, there exist perceptions, largely on the part of veterans’ advocates but also some public

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officials, that many servicemembers and veterans are not seeking treatment (and thus, a diagnosis) when they experience symptoms of PTSD. Thus, PTSD is perceived by these stakeholders to be under-diagnosed. Paradoxically, some public officials make both claims: that PTSD is over-diagnosed and under-diagnosed. I conclude by exploring the implications of these findings.

Keywords: United States; mental health; posttraumatic stress disorder; military; veterans; stigma


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PTSD in the U.S. Military, and the Politics of Prevalence INTRODUCTION

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Posttraumatic stress disorder (PTSD) has been a recognized disorder in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM) for more than thirty years. However, it remains a controversial disorder whose legitimacy is at times disputed,

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particularly in U.S. military contexts (e.g., McNally and Frueh 2013; McNally 2003; 2007). This paper highlights the mechanisms by which PTSD is disputed in the wake of a decade of U.S.-led

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war in Afghanistan and Iraq. These disputes manifest not in questions about whether PTSD exists, but often in queries and statements about how many individuals are, or should be, diagnosed with PTSD; the struggle is over prevalence rates. As such, these disputes target many facets of the disorder, including the diagnostic category and criteria; screening tools, procedures,

disorder.

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or systems; and the individual servicemembers or veterans who express symptoms of the

PTSD is a trauma- and stressor-related disorder defined by criteria listed in the fifth

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edition DSM, the DSM-5.The diagnostic criteria for PTSD include past exposure to a traumatic event (that is, actual or threatened death, serious injury, or sexual violence), “intrusion”

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symptoms such as recurrent distressing memories, avoidance of stimuli associated with the trauma, negative alterations in cognition or mood associated with the traumatic event, and marked alterations in arousal and reactivity associated with the traumatic event (American Psychiatric Association, 2013). Symptoms must persist for one month following the trauma, cause significant functional impairment, and not be related to the physiological effects of a substance or another medical condition.


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Researchers approximate that the prevalence of PTSD among returning U.S. military servicemembers is between 5 and 20 percent, although some assert that the most reliable estimates to fall between 10 and 14 percent (Ramchand et al., 2010; Schell & Marshall, 2008).

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These Afghanistan- and Iraq-era estimates follow a long-standing debate over the prevalence of PTSD among U.S. military populations. In the late 1980s, researchers from the National Vietnam Veterans Readjustment Study estimated the lifetime prevalence of PTSD among Vietnam War

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veterans to be 30.9% and the prevalence at the time to be 15.2% (Kulka, 1990). However, these rates have been perceived by some to be imprecise (McNally, 2007). Although social scientists

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have at least partially explained discrepancies in estimates, the exact rate of PTSD among veterans of Vietnam or other wars remains a topic of debate.

Comparing prevalence rates across war eras implicitly raises questions about whether PTSD is a static construct over time. Although PTSD was incorporated into the third edition of

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the DSM in 1980, its roots lie in centuries past (Dean, 1997; Finley, 2011; Scott, 1990, 2004; Shepard, 2001; Young, 1995). Mental health practitioners and researchers often frame PTSD as a manifestation of these earlier phenomena—that is, as a fixed biopsychiatric construct that has

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been discovered and refined over time. However, some scholars assert that responses to traumatic stress do not constitute a singular entity but are instead products of the social,

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institutional, and technological environments within which they exist and through which they are understood (Young 1995; see also Conrad & Schneider, 1992). I approach this study assuming that both of these interpretations may prove true, at least

to a degree. That is, in accordance with the social constructionist framework of Brown (1995) that draws on the work of Freidson (1970), I postulate that biopsychiatric realities, identified through biomedical knowledge structures, could underlie the PTSD construct while the disorder


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is also acted upon and shaped by a range of individuals and institutions. I place particular emphasis on the cultural meanings—most notably, perceptions of prevalence—attached to PTSD via the actions of claims-makers and interested parties who influence and construct the disorder

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(Conrad & Barker, 2010). The manner in which the disorder is constructed and the cultural

meanings it carries may in turn affect who is (or is not) diagnosed. Stated differently, I view PTSD through a “social diagnosis” framework, wherein social actors are presumed to contribute

social factors (Brown, Lyson, & Jenkins, 2011).

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METHODS

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to the creation of a diagnosis which is interconnected with political, economic, cultural, and

This paper is part of a larger project focused on U.S. military and veterans’ PTSD policy between 2001 and 2012, the decade following the start of the U.S. led war in Afghanistan. The multi-pronged goal of the study was to investigate changes in military and veterans’ PTSD

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policy during this period, how social actors such as veterans’ advocates have shaped PTSD policy, and how individuals involved in PTSD policy making understand and frame issues related to PTSD diagnosis and disability compensation. This research utilized situational analysis

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methodology (Clarke, 2005), which involves qualitative fieldwork, and augments grounded theory’s analytical tools (Glaser & Strauss, 1967; Strauss & Corbin, 1998). Data sources for the

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overarching project included semi-structured interviews, document analysis, and participant observation. Human subjects protection approval for this study was granted by the University of California, San Francisco’s Committee on Human Research. The findings presented here stem from analysis of semi-structured interviews conducted

between June 2011 and December 2012. I conducted interviews with a purposive sample of 26 individuals involved in military or veterans’ mental health policy making. Potential interviewees


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were identified via publicly available documents and snowball sampling. As the study progressed, theoretical sampling (Glaser & Strauss, 1967; Strauss & Corbin, 1998) was used to ensure that selected interviewees contributed to a rich understanding of the emerging foci of the

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study, and that a diverse sample, and thus a wide range of perspectives, was represented. I

described the research to potential interviewees as a social-historical study of PTSD policy in the U.S. military context, and obtained verbal consent prior to interviews. The interviews ranged

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from 30 minutes to 3 hours in duration. With interviewee permission, I digitally audio-recorded the interviews and then transcribed and supplemented them with field notes.

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Overall, the sample comprised 16 current or former public officials employed by the Department of Veterans Affairs (VA), the Department of Defense (DoD), or Congress; 8 veterans’ advocates; and 2 university-based researchers. Of these 26 individuals, five had been trained as mental health care providers and 5 as health care providers. All interviewees possessed

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a bachelor’s degree, and one-half the sample had earned a doctoral or professional degree. Fourteen interviewees had served in the U.S. military previously or were currently serving. Data were coded and analyzed in accordance with the principles of grounded theory

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(Glaser & Strauss, 1967; Strauss & Corbin, 1998) and situational analysis (Clarke, 2005). I first analyzed words, phrases, and sentences to generate codes. Interviews were comprehensively

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reviewed and coded, whereas media articles and government documents were selectively coded for relevant themes that emerged as the study progressed. All coded data were uploaded into ATLAS.ti software, which enabled the further elaboration of codes and the clustering of related codes into categories. I utilized constant comparative analysis to move back and forth among the data to refine codes and categories. Data were further analyzed using positional maps, a tool of


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situational analysis (Clarke, 2005). Positional maps are useful for simplifying and visually plotting discourses that are articulated (or not articulated) in the data. FINDINGS

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These findings center on a positional map (Clarke, 2005) used to analyze claims

concerning PTSD’s prevalence conveyed by interviewees (see Figure 1). These claims fell into three categories (listed on the x-axis), each concerning an object of contestation utilized by

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stakeholders to make or refute claims about PTSD prevalence: the diagnostic category and criteria; the screening tools, procedures, or systems; and the individual servicemembers or

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veterans who express symptoms of the disorder. These claims were utilized by interviewees to make statements about the “true” prevalence of PTSD—that is, whether too many or too few servicemembers or veterans are being diagnosed—or to express uncertainty about the prevalence of PTSD (listed on the y-axis). The positional map shown in Figure 1 guides the themes

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discussed in the sections below.

Perceiving Over-Diagnosis: Categorical and Behavioral Several interviewees, particularly public officials, claimed that PTSD is over-diagnosed

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among servicemembers and veterans. They attributed the high number of diagnoses either to a flawed diagnostic category (categorical over-diagnosis) or to diagnosis-seeking behavior of

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individual servicemembers (behavioral over-diagnosis). These claims are represented in the upper row of Figure 1.

[Insert Figure 1: Positional Map of Claims Concerning the Number of Diagnosed MilitaryRelated PTSD Cases in the U.S.]


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Categorical Over-Diagnosis Interviewees focusing on the diagnostic category as a means to claim that too many cases of PTSD have been diagnosed articulated one of two arguments about categorical over-diagnosis

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shown in Figure 1: (1) PTSD is a sociopolitical, not clinical, construct created by the psychiatric community and veterans’ advocates, and is therefore not a valid clinical diagnosis; or (2) PTSD is a “catch-all,” “wastebasket,” or “garbage can” diagnosis. For the most part, these were

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mutually exclusive positions.

First, the claim that PTSD is a sociopolitical construct lacking biomedical validity was

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conveyed by a small minority of interviewees but has been suggested elsewhere (for example, Fleming 1985, Frueh 2000, Richardson, Frueh and Acierno 2010, Satel 2011). This claim criticizes PTSD because of a lack of what is considered sufficient clinical evidence to prove the (biological) existence of the construct. For example, one public official stated:

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Now, if you tell me that [a person] is bipolar, there’s clinical data to support that, and I know it’s episodic because when he’s off his meds he’s going to have a problem. But to tell me that he’s 60 percent PTSD and he can [function in everyday life at a high level] even though the symptomology says he can’t… Why is it like this?

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These interviewees evoked the politically-motivated nature of PTSD as a means for validating

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their argument. For example, some suggested that the APA’s Board of Trustees, the collective body overseeing modifications or additions to the DSM, was motivated by socio-political aims beyond identifying a scientifically valid disorder. So too, these interviewees felt, the advocates who worked alongside the psychiatric community in constructing the diagnosis were also motivated by such factors. For example, some interviewees perceived that advocates pivotal to the construction of the diagnosis were determined to use its prevalence as a means to critique the military’s war-related activities.


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Second, claims concerning PTSD as a “catch-all,” “wastebasket,” or “garbage can” diagnosis, were conveyed by a number of interviewees, mostly clinicians. These terms are often used in medical classification to describe overly generalized or invalid diagnoses, and sometimes

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indicate a temporarily agreed upon standard in lieu of a better or more valid category (Bowker & Star, 1999). Interviewees’ perceived validity of the current PTSD diagnostic category varied. For example, one public official (a non-clinician) rejected the validity of it entirely: “This label,

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PTSD, has become the ‘catch all’ to describe a range of symptoms… But when you think about the logic of the construct, it doesn’t make any sense.” Other interviewees conveyed a more

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moderate approach, highlighting not that the PTSD construct is altogether invalid, but that it obscures co-occurring diagnoses such as depression, anxiety, or substance abuse. Embedded in these perspectives is an assertion that the general public’s misperceptions, rather than clinicians’ diagnostic decisions, are of primary concern. In other words, these interviewees did not assert

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that the diagnostic criteria are being misused clinically or are fundamentally flawed, but that PTSD ensnares the public’s attention in misdirected and overly generalized ways. For example, one public official (a clinician) stated:

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The diagnostic criteria are still good and sharp, and I think most clinicians use them well but in the public mind, in the families and among the servicemembers and veterans, there is the sense that

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PTSD is the right tag for any deployment mental health issue… [But] not everybody who has nightmares, or startle, or gets withdrawn, or has trouble readjusting has PTSD.

In sum, interviewees expressed a range of opinions about the extent to which PTSD is a

valid disorder, and utilized these claims to state or imply that PTSD is over diagnosed. Assertions that PTSD is a sociopolitical construct lacking validity appear to represent a minority position, while claims about the “catch-all,” “wastebasket,” or “garbage can” nature of the disorder appear to be more mainstream, particularly among clinicians.


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Behavioral Over-Diagnosis Interviewees who focused on the individual servicemember’s or veteran’s behavior as a means for conveying that there are too many diagnosed PTSD cases expressed one of three

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claims about behavioral over-diagnosis, as shown in Figure 1: (1) veterans represent an overly “entitled” generation seeking disability compensation; (2) veterans are “incentivized” to seek or maintain a diagnosis; or (3) veterans are “counseled” to seek a diagnosis and disability

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compensation. In some instances, individual interviewees conveyed two or all three of these claims.

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First, the claim that veterans are overly entitled implies that servicemembers and veterans who seek a PTSD diagnosis and disability compensation are members of an “entitled” generation, or “me generation.” Servicemembers and veterans of current wars are seen by some interviewees as more expectant of financial remuneration than veterans of previous wars. For

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example, one public official stated: “[With] the soldiers, there is more of a sense of entitlement, definitely more of a sense of entitlement in soldiers is now-a-days, and it’s just different. What’s in it for me, what can I get out of it, what’s owed to me?” Moreover, some interviewees

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suggested that servicemembers and veterans are not simply seeking financial compensation but are in search of recognition of their sacrifices by the government and general public, a point for

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which previous research provides some evidence (Sayer et al, 2009; Sayer, Spoont, & Nelson, 2004). This perceived desire for recognition was thought to be heightened by the fact that the U.S. employs a fighting force composed of a quite small percentage of the U.S. population. In other words, interviewees felt that the general public’s lack of understanding of the sacrifices of servicemembers and veterans may lead to a greater desire for recognition on the part of servicemembers and veterans themselves. For example, one public official stated:


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I think it's a cultural change… In World War II… most people served and… knew people who had died… [or] had lost limbs… [or] were blinded. Today, less than one percent are serving… “I bore the burden. Take care of me…" It's a way to make society pay… I don't think it's the money,

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although the money is helpful, but it's more the recognition.

It is worth noting that some veterans’ advocates implicitly refuted claims of behavioral over-diagnosis by expressing a diametrically opposing view of the concept of entitlement. These interviewees noted that disability compensation is an implicit part of the recruitment package of

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benefits that the military promises servicemembers who may become injured, and that health

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care is an explicit part of the benefits package. These opposing perceptions of “entitlement” suggest that government and servicemember understandings of their social contract may vary substantially in some instances.

Second, the claim that veterans are “incentivized” suggests that the veterans’ disability compensation system, by the very nature of providing disability compensation to those with

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PTSD, induces some servicemembers and veterans to remain or become ill. For example, one public official stated: “So there is a real incentive to stay sick, to have your symptoms, because it's a very major financial issue.” Yet another public official implied that financial recompense

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not only prompts veterans or servicemembers to remain ill, but that this financial incentive will

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in fact lead to illness: “If you start paying people for being crazy, and [then] take away their money, they get well. What kind of an incentive [have you] created? What have you done?” Underlying these interviewees’ position is an implicit claim that military institutional culture, supported by a set of policies and procedures, produces or maintains PTSD. Third, the claim that veterans are “counseled” focuses on veterans being encouraged to seek a PTSD diagnosis and disability compensation. Interviewees conveying these claims suggested that servicemembers and veterans are advised by individuals within the VA or by


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veterans’ advocates to list all perceived physical or psychological ailments upon discharge. For example, one public official stated: “Everybody is telling [servicemembers] ‘you need to make sure you apply for your benefits so that when you go the VA you can get service.’ … and the

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culture is, make sure you get that documented.” Some interviewees noted that servicemembers who report their mental health issues upon return from deployment or retirement from active duty are following a very practical, logical path, since it reportedly can be difficult to prove that

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mental health problems are service-connected if they are not noted initially upon return from deployment. A service-connected injury or illness makes a veteran eligible for certain treatment

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coverage or, in some instances, the receipt of disability compensation. As with the claim pertaining to veterans as “incentivized,” the statement that veterans are “counseled” implies that an institutional culture, supported by a set of policies and procedures, is responsible for producing PTSD or too much diagnosis of PTSD.

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In sum, interviewees expressed a range of views as to why they perceive servicemembers and veterans are seeking a diagnosis and disability compensation. Their claims imply varying types of responsibility, either on the part of servicemembers and veterans seeking a diagnosis or

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disability compensation, or on the part of the bureaucratic systems in which they operate. Perceiving servicemembers and veterans as “entitled” generalizes the responsibility to an entire

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“generation” of individuals, while perceiving servicemembers and veterans as “incentivized” or “counseled” emphasizes individual responsibility in the context of a government system that presumably encourages diagnosis or disability compensation-seeking. In some instances individual interviewees conveyed two or all three of these claims. Correspondingly, these individuals perceived the “true” prevalence of PTSD among servicemembers and veterans to be lower than the current recorded number of cases.


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Compounding Concerns: Over-Diagnosis, Cost, and Military Manpower Interviewees who conveyed one or more claim about categorical over-diagnosis almost always conveyed one or more claim of behavioral over-diagnosis. Most often, these claims were

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conveyed by public officials, some of whom were also clinicians. These concerns about overdiagnosis often co-occurred with two additional concerns: PTSD’s perceived high economic cost and perceived negative impact on military duty performance, and thus on overall military

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manpower. These claims, taken together, represent a cluster of multipronged cultural meanings that some individuals, particularly public officials, attached to the disorder. Underlying this set of

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beliefs is the perception that military benefits systems and procedures can induce PTSD or prompt falsification of PTSD symptoms. Correspondingly, PTSD is not always viewed an inevitable consequence of war among these participants. The relationships between these claims are displayed by the overlapping and compounding claims represented by the three circles in

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Figure 2, which I discuss next.

[Insert Figure 2: Compounding Concerns: Over-Diagnosis, Cost, and Military Manpower] As illustrated by the middle circle of Figure 2 (and as discussed in the sections above),

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interviewees conveying concerns about the diagnostic category almost always conveyed concerns about diagnosis-seeking of individual servicemembers. As illustrated by the overlap

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between the left-hand and middle circle in Figure 2, interviewees concerned with over-diagnosis tended to express concerns about the economic costs of PTSD. That is, compounding their concerns about the “high” number of diagnosed individuals was a concern about the high costs of PTSD treatment and, especially, disability compensation, which is offered through the VA and, in some instances, the Social Security Administration. In essence, there exists a stated claim,


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largely on the part of public officials, that the government is facing difficulty affording these benefits. As illustrated by the overlap between the right-hand and middle circle of Figure 2, some

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public officials concerned with over-diagnosis also implied that PTSD leads to military-duty impairment which can negatively impact overall manpower. Further, they asserted that the

military is interested in identifying and addressing mental illness only insofar as it assists the

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military in returning servicemembers to duty or, in extreme circumstances of impaired

functioning, removing them from duty. These perceptions allude to the inherent tension of

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mental illness in a military environment: mental illness is congruent with the military’s mission so long as it does not interfere with one’s job performance. Since mental illness, by definition, entails some sort of functional impairment, there is often a presumption that this functional impairment will equate to a servicemember’s job performance.

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In sum, PTSD was often perceived by public officials to be costly and to negatively impact military duty performance, and thus reduce overall military manpower. Claims regarding economic cost and military manpower frequently traveled with and compounded concerns about

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over-diagnosis, as represented in Figure 2. These claims, taken together, represent a cluster of multipronged cultural meanings that some individuals, particularly certain public officials, attach

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to the disorder: it is over-diagnosed and costly, and negatively impacts military manpower. Underlying this set of beliefs is the perception that PTSD can be induced in or falsified by returning servicemembers, and is therefore not an inevitable consequence of war, at least not at the levels being seen among Afghanistan and Iraq veterans. Instead, the disorder’s prevalence was viewed as a mutable factor which could be molded or downplayed, particularly as the economic and manpower resources of the military were being threatened.


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Perceiving Behavioral Under-Diagnosis: Stigmatization and Discrimination Claims of perceived behavioral under-diagnosis attribute the “low” number of diagnosed servicemembers and veterans to stigmatization or discrimination (see Figure 1). Stigmatization is

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the devaluation or dehumanization that results from denigration of a social category or attribute (Goffman, 1963; Jones, 1984; Link, Phelan, & Bresnahan, 1999). Discrimination is the

differential treatment—for example, rejection or exclusion—of individuals because of their

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social category or attribute (e.g., Link, Yang, Phelan, & Collins, 2004). A handful of researchers have asserted that discrimination is an aspect of stigmatization (Link & Phelan, 2001), but most

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view them as separate, interrelated concepts. Research suggests that servicemembers with mental illnesses may regularly face elements of both (Britt, 2000; Hoge et al., 2004; Kim, Thomas, Wilk, Castro, & Hoge, 2010; Schell & Marshall, 2008). Veterans’ advocates, public officials, and researchers conveyed various claims about stigma and its presumed relationship with

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diagnosis and treatment seeking, as well as the implications of attempting to reduce stigma (rather than change institutional policies and practices which could engender stigma). Several interviewees, including public officials, veterans’ advocates, and researchers,

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suggested that risk of stigmatization is a barrier to seeking a PTSD diagnosis or treatment, and that therefore PTSD is under-diagnosed. Servicemembers and veterans who display or admit

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symptoms of PTSD, or who receive a PTSD diagnoses, were perceived by interviewees to be discredited or devalued by their peers. Although disagreement existed as to whether stigmatization had decreased in recent years, most perceived it to exist at a reasonably high level. A subset of these interviewees suggested that too few servicemembers and veterans are diagnosed and treated because of stigma. More generally, stigma related to PTSD is often thought to have an inverse relationship with diagnosis and treatment seeking in the U.S. military


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context. However, there is little known empirical evidence demonstrating such a relationship within this context (see Fisher & Schell, 2013). Data are limited to a handful of recent studies which show that PTSD stigma is negatively associated with treatment-seeking intentions (e.g.,

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Blais & Renshaw, 2013; Blais, Renshaw, & Jakupcak, 2014). Another body of research has examined similar relationships among people with other mental disorders such as depression, but the research findings are not consistent and suggest that such relationships may vary by social or

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situational context (e.g., Hoyt, Conger, Valde, & Weihs, 1997; Rost, Smith & Taylor, 1993; Sirey et al., 2001; see also Fisher & Schell, 2013). Moreover, it is not well understood whether

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mental health stigmatization is related specifically to mental health symptoms, diagnostic labels, or acts of treatment-seeking themselves (Fisher & Schell, 2013).

As scholars have noted, focusing on stigma inherently places a burden on the individual person to overcome their stigmatized role, whereas focusing on a phenomenon such as

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discrimination would place the onus for remedial action on the individuals or institutions discriminating (Link & Phelan, 2001; Sayce, 1998). Consistent with such thinking, some interviewees noted that focusing on stigma surrounding PTSD without targeting greater

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institutional factors may not address the underlying issue of discrimination. For example, one veterans’ advocate stated:

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If you boil it down, the issue of stigma, specifically when it revolves around mental health, [is] two things. One, mental health discrimination. Two, the stigma itself is inappropriate behavior, meaning that when somebody is stigmatized, that person is at the receiving end of inappropriate behavior.

A number of interviewees suggested discriminatory policies or practices that could be more productive targets than stigma per se. Notably, some interviewees perceived that servicemembers fear that their outward display of PTSD symptoms or their seeking of mental


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health treatment would threaten their military careers. For example, one public official stated: “[Servicemembers] don’t want anything to be in their military record because… there is some implication in some circles that you don’t have the right stuff and therefore you’re not fit for

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further deployment.” Similarly, others suggested that servicemembers may face differential treatment by military commanders, who are often privy to psychiatric information about servicemembers within their command.

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The Stigma Paradox

Some interviewees, particularly public officials, conveyed paradoxical statements about

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and actions related to stigma. That is, many individuals who emphasized a need to reduce PTSDrelated stigma in the military also conveyed other messages which could lead to the stigmatization of servicemembers and veterans expressing symptoms of or seeking treatment for PTSD. For example, some labeled them as individuals with an invalid diagnosis or as

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malingerers, assertions that may be stigmatizing and serve as barriers to PTSD treatment in military contexts (Zinzow et al., 2013).

The paradoxical nature of stigma in the U.S. military context is illustrated by Figure 3,

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which shows the concurrent forces working likely to encourage as well as discourage diagnosis and treatment seeking, and how these forces may be institutionalized. The upper and lower text

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boxes within Figure 3 represent interviewees’ paradoxical messages pertaining to stigma. The dotted arrows pointing upward and downward represent the pathways through which these stigma-related messages could lead to broader institutional manifestations. Specifically, potentially stigmatizing messages about over-diagnosis could become institutionalized into government practices and lead to less treatment seeking, while messages about the importance and normalization of treatment seeking could, if communicated effectively, lead to an increase in


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the number of servicemembers and veterans willing to seek a diagnosis or treatment. Messages conveying the former have, in certain instances, been incorporated into institutional practice (Lee, 2008), while the latter messages are often disseminated through large-scale DoD and VA

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stigma reduction programs (Defense Centers of Excellence for Psychological Health and

Traumatic Brain Injury, N.D.; U.S. Department of Veterans Affairs. National Center for PTSD, 2013). The horizontal line in the middle of the figure represents PTSD’s actualized prevalence,

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or the number of individuals willing to be diagnosed or treated, which, at least in theory, can increase or decrease based on the institutional and organizational forces described above.

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This paradox may indicate that the public officials conveying paradoxical messages feel that certain individuals are truly suffering from symptoms while other individuals are falsifying them. Or this paradox may signify that these public officials do not feel that PTSD-related stigmatization is a substantial problem but label it as one because of its mass appeal, political

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acceptability, or prioritization at the institutional level. In either case, the military has implemented numerous programs and initiatives which reportedly seek to reduce stigma among servicemembers and veterans (see Weinick et al., 2011).

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Such paradoxes are neither novel nor limited to the case of PTSD. Similar paradoxical relationships have been shown within other institutional environments and in regard to other

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mental health issues—for example, among health care providers treating patients with substance use disorders (Van Boekel, Brouwers, van Weeghel, & Garretsen,, 2013). The existence of this phenomenon across institutional contexts lends some credence to second hypothesis above: it may be that some professionals hold potentially stigmatizing attitudes and beliefs about mental illness, but also adopt contradictory rhetoric for social, political, or institutional purposes. [Insert Figure 3: The “Stigma Paradox”]


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Some veterans’ advocates and public officials noted that they had themselves observed such paradoxical statements and actions. For example, one veterans’ advocate stated: “We say we want to address the issue of stigma, but then when individuals do engage in help-seeking

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behavior, we want to criticize them. We want to label them, you know, entitlement kind of

junkies. So what is it?” This “stigma paradox” represents a perplexing situation for a range of individuals, including public officials, veterans’ advocates, and researchers, but particularly

experience) symptoms of a mental illness such as PTSD?

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servicemembers and veterans. What is one to do if he or she experiences (or perceives to

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In sum, fear of PTSD-related stigma was perceived by many interviewees to inhibit servicemembers and veterans from seeking a PTSD diagnosis or treatment, despite the fact that the scientific literature contains little evidence to prove such a link (e.g., Blais & Renshaw, 2013; Blais, Renshaw, & Jakupcak, 2014; see also Fisher & Schell, 2013). Moreover, a number of

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interviewees emphasized a need to reduce PTSD-related stigma in the military while also conveying paradoxical messages that could, in theory, lead to such stigmatization. Taken as a whole, these findings suggest that military-related institutions have leaped ahead of the scientific

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knowledge base to assert that mental illness stigma is a barrier to treatment seeking (and thus diagnosis), and to respond to this presumed stigma. However, this attention to stigma and the

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corresponding responses to stigma tend to place the burden of action on the individual servicemember or veteran to overcome their stigmatized role, rather than problematizing the policies and practices of military-related institutions and organizations vis-à-vis PTSD. Moreover, these actions to address stigma are potentially problematic given that servicemembers may paradoxically be receiving messages (perhaps even from the same individuals) that they


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should and should not seek treatment if experiencing symptoms of PTSD or other mental illnesses. Perceiving Under-Diagnosis or Uncertainty: Screening

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Claims centering on military or VA screening efforts conveyed one of two messages (see Figure 1). First, some interviewees communicated uncertainty about whether too many or too few servicemembers and veterans are diagnosed with PTSD, and attribute this uncertainty

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largely to imperfect screening or diagnostic tools. Screening is suspected by some to include a number of false positives. For example, one public official stated: “A lot of money and effort and

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time get put into the screening. And then you have the question, and I think it's still an open question, about whether or not you're catching more people and treating more people.” The same public official continued to describe a type of false negative that does not result from screening or diagnostic tools per se, but from a culturally- or bureaucratically-induced tendency of

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servicemembers not to reveal their mental health issues: “… or the [servicemembers] get too cynical about being screened every time they turn around [and] have their pat answer, ‘No, no ma'am, I'm fine.’” In nearly all instances when screening or diagnosis was discussed, recent or

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impending improvement of tools or procedures for implementing them was also mentioned. Again, individuals conveying these claims highlighted scientific limitations as the source of

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diagnostic uncertainty.

A second set of critiques centered on inadequate or biased screening procedures and

systems. For some interviewees, these faulty systems resulted in too few servicemembers and veterans being diagnosed with PTSD (screening under-diagnosis). In particular, veterans’ advocates focused on screening under-diagnosis. Specifically, these advocates suggested that the military and VA did not screen properly or frequently enough during or after deployments, and


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that this was a particular problem during the early years of the wars. Interviewees conveying this claim perceived the cost associated with screening for and treating PTSD to be a barrier to offering adequate screening services.

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Veterans’ advocates also perceived the military and VA’s screening procedures and

systems as leading to deliberate misdiagnosis. Specifically, advocates highlighted cases wherein servicemembers were diagnosed with personality disorder or adjustment disorder rather than

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PTSD, even when some individuals’ symptoms may have more accurately indicated the presence of PTSD (Dao, 2012; Kors, 2007; Lee, 2008). Very significant here, military disability systems

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consider personality disorders and adjustment disorders as pre-existing conditions not caused by war-related experiences. Therefore, these diagnoses can provide an efficient channel for discharging mentally ill servicemembers from the military via means that render them ineligible for certain benefits such as medical retirement. Many veterans’ advocates suggested that

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concerns about costs and maintaining a highly functional, mentally healthy fighting force were primary drivers of the government’s diagnosis of personality disorder or adjustment disorder in lieu of PTSD. Some advocates noted as evidence of their assertions a controversial email (which

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garnered national media attention) in which a VA employee urged her staff to refrain from giving PTSD diagnoses because of the alleged large number of compensation-seeking veterans

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(Lee, 2008). Again, individuals conveying claims focused on procedures and systems implied that military institutions may intentionally deny servicemembers and veterans of appropriate PTSD diagnoses.

In clear contrast to veterans’ advocates, certain researchers and public officials suggested

that the alleged misdiagnoses were likely justified. Some defended the military clinicians’ initial judgments, while others noted that the military relaxes their standards for military recruitment in


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times of manpower shortages—for example, through the use of waivers allowing certain individuals with mental disorders to join the military. This relaxation of standards was a suspected cause of the large number of “pre-existing” mental illness diagnoses in the military. In

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essence then, government screening procedures, ostensibly guided by clinical judgment, may be subject to economic and social influences in extenuating circumstances.

In sum, there exists substantial controversy over screening, both in terms of the tools used

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as well as the procedures and systems guiding their use. Clinicians tended to focus on tools and the uncertainties associated with their use, while veterans’ advocates tended to focus on the

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procedures and systems guiding the use of these tools. Stated differently, veterans’ advocates implied that governmental practices intentionally deny servicemembers and veterans of PTSD diagnoses for reasons such as the high economic cost of PTSD, while clinicians tended to highlight scientific limitations as the key source of diagnostic uncertainty. These findings

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highlight how screening is much more than a diagnostic tool; accurate screening also relies on procedures being applied, to the extent possible, in an unbiased manner. However, research has found that clinicians may utilize a range of informational sources and decision-making strategies

CONCLUSIONS

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in the face of diagnostic uncertainty (Swoboda, 2008).

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Disputes over PTSD’s legitimacy, particularly during the period leading up to its

codification as a disorder in the DSM-III, are well documented in the social science literature (Scott, 1990, 2004; Young, 1995). This paper highlighted the continued struggle over PTSD’s legitimacy more than a quarter century later. I presented two primary interrelated findings pertaining to this struggle. First, PTSD has been viewed by some public officials as an overly generalized or invalid diagnostic category which is over-diagnosed because, as these officials


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argue, it can be induced in or falsified by veterans or servicemembers. These individuals also tended to perceive PTSD as a disorder which is costly to government and which negatively impacts military duty performance, and thus overall military manpower. Second, despite beliefs

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about over-diagnosis, veterans’ advocates and some public officials perceive that

servicemembers and veterans are not seeking treatment (and thus, a diagnosis) when they

experience symptoms of PTSD. Some public officials paradoxically espouse both sets of beliefs.

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Taken together, these findings lead to at least two broader implications. First, these

disparate perceptions of prevalence have served as catalysts for policy and collective action (and

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inaction). Scholars have previously described the impact of disease prevalence on policy (e.g., Arksey, 1994; Brown, Zavestoski, Mayer, McCormick, & Webster, 2002), whereby prevalence is an object of contestation and a subsequent policy lever. Likewise, in this study, perceptions that PTSD was being over-diagnosed (or under-diagnosed) served as impetuses for policy

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inaction (or action). For example, certain public officials worked to downplay and curtail the perceived “high” (and presumably mutable) prevalence of the disorder. They felt that acknowledging PTSD through increased policy and planning efforts would lead to a flood of

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compensation-seeking veterans. Further, this policy inaction may have decreased the actual number of individuals diagnosed with PTSD since it inhibited organizational expansion and

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restricted acknowledgement and awareness of the disorder and treatment options available (U.S. Government Accountability Office, 2005, 2006) The inverse seemingly also occurred, but largely after 2007 when PTSD-related policy

action became commonplace. Veterans’ advocates as well as some researchers and public officials felt that a substantial number of PTSD cases had gone undiagnosed. They prompted policy and collective action to counter military-related institutional forces and to ensure that


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individuals experiencing symptoms of PTSD could obtain a PTSD diagnosis as well as appropriate treatment and benefits. Salient examples of this collective action included responses to the apparent misdiagnosis of personality disorder, increased government mental health

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screening efforts, and a general focus on reducing the stigma (or discriminatory policies and practices) purported to inhibit diagnosis- or treatment-seeking. Such policy or collective action, if effective, would have increased the actual number of individuals willing to seek a diagnosis or

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treatment.

The resulting situation is one wherein the findings of psychiatric epidemiology have the

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powerful potential not only to describe or estimate the “true” prevalence of a mental disorder but also to shape the actualized prevalence, or the number of individuals willing to be diagnosed or treated. In other words, as epidemiologists seek to estimate the number of PTSD cases, the basis for their estimates will be the number who are willingly screened and who then self-report

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symptoms of the disorder. This number will inevitably be affected by servicemembers’ and veterans’ negative or positive experiences associated with presenting symptoms of the disorder to different people or authorities. Epidemiological estimates of prevalence may then prompt

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public policies that generate structural conditions enabling or discouraging individuals to present with symptoms. This situation may go on to exhibit a circular pattern, whereby the actualized

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prevalence informs further estimates of the “true” prevalence, which informs policy and so on. The immediate result is that PTSD prevalence becomes a moving target that science seeks to pinpoint but also cannot help but influence in the process. This situation occurs against an already uncertain scientific backdrop, as there exists a range of disparate prevalence estimates (see Ramchand et al. 2010) for stakeholders to adopt and use to inform policy.


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Second, this study highlights complexities of confronting mental health stigma amidst a debate over PTSD prevalence. Although stigma associated with mental illness has been studied and partially addressed in military contexts (see Acosta, Becker, Cerully, Fisher, Martin,

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Vardavas, Slaughter, and Schell , in press), institutional attitudes, notably perceptions by some public officials that PTSD is over-diagnosed, have not until very recently been considered as possible causes of mental health stigma or barriers to treatment seeking (e.g., Zinzow et al.,

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2013). Moreover, current government stigma reduction efforts are not designed to change any institutionalized beliefs about over-diagnosis that exist in military contexts. Thus, institutional

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resistance to increased PTSD treatment seeking may exist regardless of the presence of mass media campaigns or similar behavioral interventions that focus on changing the behavior of stigmatized individuals. In addition, the experience of receiving conflicting messaging (stating or implying that PTSD is over-diagnosed and under-diagnosed) could engender its own set of

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consequences for servicemembers or veterans experiencing PTSD symptoms. These findings should be considered in light of this study’s limitations. First, the politically charged nature of PTSD along with the secretive cultures of military-related

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institutions appeared to present barriers to data collection. The study’s response rate was 52%, and it is not known whether the views of the people who declined an interview would have

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differed from the perspectives of the interviewees. Second, the sample did not include local-level policymakers or advocates (i.e., people working only at the state or community level); nor did it contain individuals such as servicemembers or veterans who were not involved in policy or advocacy. These decisions about sample selection may have limited the range of perspectives included in the research, but also sharpened the study’s core emphasis on federal level policymaking and social action. Finally, while not a limitation per se given the methods and


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scope of the research, it is important to note that these findings are not intended to be generalizable to a broader range of individuals within or across U.S. military institutions. Nor do these findings address issues pertaining to PTSD prevalence outside this context—for example,

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external to military institutions or outside the U.S. Further research is needed to understand the

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full range of perspectives on and social action pertaining to PTSD prevalence.


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ICD-11 Complex PTSD in US National and Veteran Samples: Prevalence and Structural Associations with PTSD.

PTSD in the military: special considerations for understanding prevalence, pathophysiology and treatment following deployment.

5-HTTLPR and DISC1 risk genotypes for elevated PTSD symptoms in US military veterans.

Missed opportunity to screen and diagnose PTSD and depression among deploying shipboard US military personnel.

US politics: campaigns as usual.

US research politics. Goodwin stumbles.

US politics and ideology enter exam rooms.

Predictors of the Onset of Schizophrenia in US Military Personnel.

Diagnostic Utility of the Posttraumatic Stress Disorder (PTSD) Checklist for Identifying Full and Partial PTSD in Active-Duty Military.

Military Beliefs and PTSD in Active Duty U.S. Army Soldiers.

US drug regulation. AIDS politics change rules.

Suicide Among US Military Personnel.

Spirituality factors in the prediction of outcomes of PTSD treatment for U.S. military veterans.

White matter abnormalities associated with military PTSD in the context of blast TBI.

Principles for developing animal models of military PTSD.

The biomedicalisation of war and military remains: US nuclear worker compensation in the 'post-Cold War'.

abuse and PTSD exposure among the active-component U.S. military, 2001 to 2008.

Take politics out of the NHS and show us it is a true priority.

Erosion of the healthy soldier effect in veterans of US military service in Iraq and Afghanistan.

The role of military social support in understanding the relationship between PTSD, physical health, and healthcare utilization in women veterans.

Trends in the diagnosis of SLAP lesions in the US military.

US Military Child and Adolescent Psychiatry Training Programs and Careers of Military Child Psychiatrists.

Suicide Among US Military Personnel--Reply.

Prazosin for military combat-related PTSD nightmares: a critical review.