Over the last decade, a controversial question has surrounded the Purple Heart: do veterans with post-traumatic stress disorder deserve it?
The Pentagon currently does not award Purple Hearts to veterans suffering from PTSD. Supporters of this policy argue physical wounds have always determined eligibility for the Purple Heart. Some believe the science regarding PTSD is too primitive; indeed symptoms can be difficult to diagnose, and objective tests remain elusive. There are concerns that some veterans might attempt to fake the diagnosis.
But critics say that denying Purple Hearts to these veterans reinforces the stigmatization of mental illness—in other words, that conditions of the mind are less real than conditions of the body. As a physician who has worked with veterans suffering from PTSD, I can tell you the manifestations of this condition are very real. Symptoms can include flashbacks, paralyzing anxiety, hypervigilance, and self-harm.
Whether veterans with PTSD receive the Purple Heart has the potential to shape both the policies and the perceptions surrounding mental health in this country.
According to the Department of Veterans Affairs, PTSD afflicts up to one in five veterans from Iraq and Afghanistan in a given year, and as many as one in three veterans from earlier conflicts like Vietnam during their lifetime. As of 2013, roughly 400,000 veterans affiliated with the VA carried this diagnosis. These figures suggest psychological trauma is a staggering, but often unrecognized, burden on our troops.
To propel this reform, a growing number of supporters seek to change the name to“post-traumatic stress injury.” After all, advocates say, PTSD stems from exposure to external trauma, much like any physical injury. Many veterans internalize the term “disorder” as being shameful, hiding the diagnosis from colleagues, family, and friends. As a result, these brave soldiers often don’t get the care they need and suffer alone.
This debate drew national attention in 2008 when Secretary of Defense Robert Gates vowed to look into the matter. The proposal attracted a wide range of opponents, including veterans groups and the New York Times editorial board.
In 2009, the Department of Defense announced it would not award Purple Hearts for the condition, citing many of the above concerns
But a great deal has changed in the near-decade since that ruling. We now know more about PTSD than ever before. New findings suggest PTSD may stem from physical damage to the brain, much like chronic traumatic encephalopathy in the National Football League. Researchers have novel insights into the role that blast waves and traumatic brain injury play in its development. Suicide among veterans has become a national crisis, and we’ve learned those with PTSD have markedly increased risk for suicidal thoughts and behaviors.
The ranks of those supporting Purple Hearts for PTSD has swelled, including public endorsements from the National Alliance on Mental Illness, mental health experts, and outspoken veterans. In fact, during 2011, branches of the military expanded Purple Heart eligibility for those who sustained concussions or mild traumatic brain injuries; but again, PTSD was left aside.
Some argue veterans with psychological conditions should receive a separate award. In 2009, a former Marine captain proposed the creation of a “Black Heart” medal for those suffering from PTSD. This might be a step forward, as veterans with PTSD would receive some degree of recognition. Still, separating physical injuries from psychological ones perpetuates the notion that conditions of body and mind are unequal.
The Purple Heart is a precious award that should not be taken lightly. My late grandfather received one after he was wounded by shrapnel in Europe during World War II, and it’s a badge of honor for our family. Handing out this medal to anyone with mild anxiety, depression, or sleeplessness could undermine its inherent value.
But that doesn’t mean we should ignore the mental toll of war.
In 1943, Lieutenant General George S. Patton Jr. famously slapped shell-shocked soldiers during the invasion of Sicily, disgusted by their “cowardice.” Nearly 75 years later, we’ve made huge strides in our understanding behind the neuroscience and the implications of these psychological injuries; yet more can still be done to acknowledge the wounds these warriors bear.
Nathaniel P. Morris is a resident physician in psychiatry at the Stanford University School of Medicine.