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PTSD: a Diagnosis or an Identity?

The Unseen Wound

by JERRY LEMBCKE

The headline was alarming: “Almost half of New Vets seek Disability.” According to the May 28 Associated Press story, 45% of the 1.6 million veterans of the wars in Iraq and Afghanistan are seeking some kind of compensation for war injuries, more than double the percentage from previous wars. What’s more, today’s veterans typically pursue claims for 8-14 different ailments, compared with fewer than four for Vietnam veterans, and two for veterans of Korea and World War II. About 54% of the new veterans are getting some kind of health care through the Veterans Administration.

The numbers are high, wrote reporter Marilynn Marchione, because more troops are surviving wounds, and the awareness of PTSD and brain injuries is greater than ever. More aggressive outreach by advocacy groups may be swelling the numbers. As well, joblessness might be moving some veterans to pursue compensation cases as a form of income, according to the story.

The AP story, however, was also sprinkled with suggestions of something more ominous about the skyrocketing numbers, words conveying skepticism about some claims. “America’s newest veterans,” read the first paragraph, “are claiming to be the most mentally and medically troubled generation,” seeking compensation for injuries they say are service connected.” Even lay readers of the news could see the shadow of doubt cast over the reports by the words I’ve italicized, uncertainty we have to wonder if the reporter picked up from her sources.

The possibility that veterans might falsely pursue disability payments when what they really want is the income that a successful claim might yield is obviously a cause for concern. The cost that looms for the care of this generation of veterans runs to the hundreds of billions of dollars and will not peak for thirty years by which time costs will likely have escalated.

But there might be another and even more troubling dynamic at work: the association made between war injuries and military prowess, even heroism, that can lead some men to seek a diagnosis as a way to document their combat bona fides.

That troublesome association began in the years following the war in Vietnam when the loss of the war combined with the participation of many veterans in the anti-war movement led to the dismissal of Vietnam veterans by their fathers’ generation as “not real veterans,” Vietnam “not a real war.” The physical wounds returning from Southeast Asia exempted veterans carrying them from their second-guessing elders, but what about the majority who returned with no visible damage to validate their combat status? The answer involved the formulation of something unseen that nevertheless could be appreciated as a war injury, a “wound” even. The answer was PTSD.

Arising in the closing years of the war as a way to psychologize the dissent of Vietnam veterans, PTSD matured into a full-blown diagnostic category by 1980. Along the way it brought attention to the devastating effects of war trauma, and mobilized material and professional resources to ease the burdens brought home. But PTSD also doubled as a credential, a way for veterans to claim the unseen, the “wound on the inside” as it came to be called, as a badge of honor, a kind of Purple Heart. By the time troops embarked for the Persian Gulf in 1990, it was not uncommon to hear men claiming a combat-veteran identity with the boast, “I’m 100% PTSD.”

The U.S. incursion in the Persian Gulf was hardly a war so it was no surprise that the return of troops was accompanied by conflicted emotions and imagery. With no war stories to tell and virtually no wounds for display, virtual wounds became the currency of authenticity. Sleeping disorders, lethargy, depression, mysterious rashes, unexplained cancers—none of it confirmed by epidemiological studies—quickly dominated the coming-home narrative. Coming home sick, it seemed, was the way to say, “I’m the real-deal combat veteran.”

Troops headed to Iraq in the spring of 2003 with their homecoming already scripted: they would return with PTSD—news reporters said so.  Just as importantly, the conflation of wounds, seen or unseen, with martial accomplishment was by then so ingrained in the culture that expectations mutually held by soldiers, their families and friends, was that “hurt” was the only honorable way to come home.

Not all the damage was unseen, of course. Improvised explosive devices (IEDs) took a terrible toll of arms and legs. But it was the bundling of psychic trauma and brain injuries as Traumatic Brain Injury (TBI) soon after the invasion of Iraq that confounded the clinical picture: brain injuries could be traumatic but could trauma cause brain injury? By spring 2012, there were reportedly 25 veterans claiming TBI for every death due to IED explosions. How could that be when Humvees, the targets of choice for IEDs, are manned by units numbering only four or five? If one is killed, how can twenty more be injured by the same explosion?

These perplexing questions arise out of the obligation men feel to authenticate their combat identity, and the blurring of distinctions between trauma, wounds, and valor. In the end, the questions are about more than medical and psychiatric diagnoses. When the Department of Veteran Affairs in July 2010 proposed dropping the requirement that claims to PTSD be supported by documentation of the battlefield events that cause the trauma, Paul Sullivan Executive Director for Veterans for Common Sense supported the change saying, “PTSD is associated with deployment . . . . It’s a cultural thing.”

By that thinking, all soldiers who have been deployed have been traumatized; if trauma is a wound, all war veterans are wounded and eligible for disability; and if wounds document the combat experience that confirms manhood, the pursuit of a diagnosis for an “unseen wound” becomes a powerful imperative.  It’s a cultural thing.

Jerry Lembcke is Associate Professor of Sociology at College of the Holy Cross in Worcester, Mass. He is the author of the 2010 book Hanoi Jane: War, Sex, and Fantasies of Betrayal. His next book PTSD: Diagnosis or Identity in Post-empire America? is forthcoming. He can be reached at  jlembcke@holycross.edu.