Unimportant Wounds: No Purple Hearts For PTSD

Front and center today in the New York Times is an article titled "Purple Heart Is Ruled Out For Traumatic Stress". The gist of the article is that the Pentagon has decided against awarding Purple Heart medals to soldiers whose primary war wounds are psychiatric or psychological, rather than physical in nature.

As reported by the Times, "The decision, made public on Tuesday, for now ends the hope of Iraq and Afghanistan veterans who have the condition and believed that the Purple Hearts could honor their sacrifice and help remove some of the stigma associated with the condition."

I have a few thoughts to share in response to having read this news, but before I do that, let's first make sure that we all understand the meaning of the terms 'Purple Heart', and 'Traumatic Stress'.

The Purple Heart, which is probably the best known medal regularly awarded to American soldiers, is conferred to recognize soldiers who have been wounded or killed while serving in the military. You can read more about the medal in the Wikipedia Purple Heart article, or by visiting this Purple Heart page on the Pentagon's website. In order to qualify for a Purple Heart, you have to have been wounded by an enemy of the United States during an official military action, and after a certain date, and you have to have been treated for that wound by a military doctor.

The term 'Traumatic Stress', is shorthand for Post-traumatic Stress Disorder (PTSD), which is an anxiety disorder that can develop in the wake of exposure to death, near-death, or significantly violent experiences including torture, assault, rape, car accidents, and, of course, after exposure to combat situations such as a soldier might regularly experience during the course of his or her duties. PTSD can occur at any time after exposure to a trauma, including many years afterwards. It is often a chronic condition. It can become entirely disabling. People affected with PTSD experience recurring, unbidden and horrifying memories of the trauma experience, from which they will often seek to escape by avoiding situations that remind them, however remotely, of their trauma. Such necessary avoidance can turn into a more or less complete withdrawal from the social and occupational world, and create a vulnerability to substance use and addiction problems (as substance use helps to reduce the significant arousal and hypervigilance associated with PTSD, at least at first and in the short term).

I find this decision by Pentagon officials to deny the Purple Heart to soldiers who have been traumatized during the course of their military service to be unfortunate (to put it nicely).

The decision to not award the medal to soldiers with PTSD seems to have turned on the definition of 'wound'. Traditionally, the term wound has meant a physical wound; one with blood involved and the penetration of the skin to damage internal organs (e.g., by a bullet, knife, bomb fragment, etc.). However, it is clear that physical wounds of this type are only one type of wound that occur routinely during the course of military duty. Non-physical wounds like PTSD are also a hazard of military service. There need be no blood associated with PTSD (although there could be) and there is not necessarily any penetration of the body or destruction of body parts, but there is a wound there nevertheless. Early terms for modern day PTSD such as "Shell Shock" were in use during World War I, and PTSD as we know it today has been a fixture of psychiatric diagnosis since the 1980s and the end of the Vietnam era. We know that this condition exists and that it is disabling. It is indeed a wound; just not an obvious one.

The Pentagon advisory committee seems to have rejected the Purple Heart for PTSD, in part, on the basis that PTSD is not a physical wound. A corollary reason was also offered according to the Times, namely that PTSD is not an objective enough disorder to prevent with absolute certainty the possibility that it could be faked by a motivated veteran fraudulently seeking undeserved benefits.

Reading between the lines, I sense another possible motive for the denial but I'm not entirely sure that I'm correct in this perception. Being awarded the Purple Heart is an honor; it is a form of election into an elite group. The gatekeepers of this award possibly recognize that a massive wave of soldiers are returning from Iraq and Afghanistan with PTSD and related "invisible" neuropsychiatric disorders such as Traumatic Brain Injury (TBI), and that if they were to open the medal to such conditions that they'd end up awarding it to more people than they'd like. Having the medal would then possibly become routine and whatever elite meaning it might once have had would be diluted to little more than an indication of veteran status.

There are deep flaws with the arguments used to deny the Purple Heart to veterans with PTSD, as outlined by the Times.

The distinction being made between physical and mental wounds is invalid and out of date

First, the distinction being made between physical and mental wounds is very probably a false distinction. Brain imaging technologies have shown us the subtle physical nature of many so-called non-physical psychiatric diseases. Static brain images allow us to confirm that subtle brain damage has occurred and correlate it with behavioral changes. Functional brain imaging allows us to view altered brain functioning as it occurs within the brains of diagnosed patients, and to compare their functioning with that characteristic of normal patients. It has become very clear that there are physical brain changes associated with PTSD and related disorders, though these changes are in some cases functional in nature (manifesting as altered patterns of activity and heightened or lowered thresholds for activation) rather than lesions (e.g., easy to image brain damage). A physical bullet or bomb fragment may not have entered traumatized soldiers' bodies, but troubling experience surely has, and that experience has altered their physical brains to create an enduring and physical, if hidden and subtle, wound.

In my estimation, the idea that psychiatric wounds are somehow fundamentally different in substance than physical wounds is all but completely discredited. It is still a popular idea, but you are more likely to hear it taken seriously by people who are not all that up-to-date regarding Neuroscience. Yes, there are behavioral aspects characteristic of PTSD that are are not also present for someone who has been shot, to pick an arbitrary example, but that is not the point. The point is that there are real physical brain changes associated with mental disorders; that many (but not all) mental disorders occur because of physical brain "wounds" that are not visible to the naked eye.

The "no award because of the possibility of fraud" argument is both uninformed and insulting.

The idea that the Purple Heart should not be awarded because some soldiers might be faking their wound fails to take into account that it is also possible for soldiers bearing physical wounds to have "faked" those wounds. That soldiers will occasionally self-harm or put themselves into harm's way (they must hope in a non-lethal manner) as a way of escaping from their mandate to fight is well documented, and was even part of the premise of the French movie, "A Very Long Engagement", that came out in 2004. In the cases I've linked to here, these sorts of self-motivated wounds were identified and the schemes backfired, but these are only the cases that have been identified. Some number of self-motivated wounds probably do escape detection, and it seems likely (if you can agree with the premise of my argument) that at least a few veterans who have been awarded the purple heart have obtained it through fraudulent activities. They were wounded, yes, but not exactly in accordance with Purple Heart rules.

I make the argument that fraud is possible even if Purple Heart awards are limited to physical wounds not to try to undermine the credibility of veterans who have that award, but rather to make the point that a limited amount of such fraud is inevitable and irrelevant to the larger process of recognizing soldier's wounds in a public and meaningful manner. If a few cases of fraud remain undetected, so be it, so long as the vast majority of deserving soldiers gain the recognition and the honor they need and deserve. To argue otherwise, I think, is to throw the baby out with the bathwater that is is essential to the process of washing. It is undoubtedly the case that some minority of soldiers seeking diagnoses of PTSD are exaggerating or even outright faking. To suggest, however, that the majority of soldiers with PTSD are faking it, or that such authentic cases of PTSD should be allowed to be invalidated because of a few fake cases seems fundamentally disrespectful and insulting.

Excluding worthy recipients from receiving the Purple Heart for prejudicial reasons is not an honorable way to maintain the honor associated with that award.

The third point that I've surmised and which I may be wrong about - the one about the desire on the part of some within the military establishment to preserve the eliteness of the Purple Heart by maintaining its exclusivity - is essentially a point about the way that honor gets created. What seems to be being argued here (if I'm correct) is that the value of the honor associated with the Purple Heart is subject to the laws of supply and demand. Honor for the select can only be created by denying that same honor to others. By saying that soldiers with legitimate PTSD are not worthy of the honor of having a Purple Heart no matter the authenticity and severity of their illness, the military is in some sense denying the validity, the importance and the meaning of those soldiers' wounds. They are implying (I think) that a psychiatric wound is a lessor wound; maybe even a shameful wound. Certainly not a worthy wound that you can feel publicly proud about. This seems to me to be a wrong and, I believe, fundamentally dishonorable position for the military to take.

There are maybe two kinds of honor we can distinguish between. The kind created by segregating an elite group from the unwashed masses, and the kind that follows from doing the right thing. While the the former sort of honor is cheapened by allowing too many people to share in it, the latter is most definitely not. In deciding that, for now at least, the Purple Heart will not be awarded to veterans with PTSD because that diagnosis is judged to not be objective enough or physical enough to qualify, the military is also deciding (in my humble opinion) that the honor associated with the Purple Heart is of the easy-to-tarnish variety. I respectfully disagree.