What Are the Wounds of War?

WASHINGTON -- Centuries before Iraq and Afghanistan, George Washington created the Purple Heart to honor troops wounded in combat.

But with an increasing number of troops being diagnosed with post-traumatic stress disorder, the modern military is debating an idea Gen. Washington never considered -- awarding one of the nation's top military citations to veterans with psychological wounds, not just physical ones.

Defense Secretary Robert Gates offered cautious support for such a change on a trip to a military base in Texas this month.

"It's an interesting idea," Mr. Gates said in response to a question. "I think it is clearly something that needs to be looked at."

The Pentagon says it isn't formally considering a change in policy at this point, but Mr. Gates's comments sparked a heated debate on military blogs, message boards and email lists. The dispute reflects a broader question roiling the military: Can psychological traumas, no matter how debilitating, be considered equivalent to dismembering physical wounds?

Supporters of awarding the Purple Heart to veterans with PTSD believe the move would reduce the stigma that surrounds the disorder and spur more soldiers and Marines to seek help without fear of limiting their careers.

The High Price Paid

"These guys have paid at least as high a price, some of them, as anybody with a traumatic brain injury, as anybody with a shrapnel wound," John Fortunato, who runs a military PTSD treatment facility in Texas, told reporters recently. Absent a policy change, Dr. Fortunato told reporters, troops will mistakenly believe that PTSD is a "wound that isn't worthy."

Opponents argue that the Purple Heart should be reserved for physical injuries, as has been the case since the medal was reinstituted by Congress in 1932. Military regulations say the award should go to troops with injuries "received in action with an enemy." Some opponents also note that PTSD can be faked, which can't easily be done with a physical wound.

"The Purple Heart was meant to be a badge of honor to show you were wounded in battle," says Bob Mackey, a retired Army lieutenant colonel who fought in the first and second Iraq wars. "I've been in combat three times. There's stuff I've had to deal with. But it's substantially different from being physically hurt."

The biggest difference, he says, is that some veterans may be diagnosed with PTSD even if they never saw combat or fought an enemy -- requirements, historically, for receiving a Purple Heart.

Lasting Torment

Military historians believe that the syndrome now known as PTSD -- usually characterized by nightmares, sleeplessness and anxiety -- has been around for as long as humans have gone to war.

The American Psychological Association formally recognized PTSD in 1980, and the term quickly entered the popular imagination as a way of describing the suffering of veterans emotionally traumatized by what they had seen or done in Vietnam.

Today, PTSD is emerging as one of the signature maladies of the long wars in Iraq and Afghanistan, which lack clear front lines and pit U.S. forces against enemies who operate out of densely packed civilian areas.

A recent California-based research institution Rand Corp. study concluded that 300,000 of the military personnel who have served in Iraq or Afghanistan have symptoms of the disorder, which can sometimes lead to suicide. The report found tragedies closely linked to the development of PTSD: Half of the 1.6 million troops who spent time in the two war zones had friends who were seriously wounded or killed, while about 45% saw dead or wounded civilians.

The young soldiers and Marines serving in Iraq and Afghanistan came of age in a culture obsessed with therapy and mental disease, but the Rand study suggests that today's troops are no more likely to be diagnosed with PTSD than those who fought in Vietnam. A 2006 study in the journal Science estimated that 18.7% of Vietnam veterans suffered from PTSD, a figure virtually identical to Rand's estimate for veterans of the current wars.

Military officers and psychologists fear that veterans of the two wars will suffer mental-health problems for decades to come, a largely hidden cost of the current conflicts.

"There's a financial cost to this, but more importantly there'll be a cost in lives if we don't get a handle on this problem now," Sen. Christopher Bond (R., Mo.) said in a recent interview. He is crafting a new bill designed to improve veterans' mental-health care.

Sen. Bond's bill would allow active-duty soldiers suffering from mental-health problems to use the much-larger network of Veterans Administration facilities and treatment centers. It would also train veterans to offer psychological assistance to other returning service personnel.

The Stigma

Many military personnel are reluctant to seek counseling for PTSD because they are afraid that seeking help would harm their careers. A recent survey by the American Psychiatric Association found that 75% of military personnel felt that asking for assistance would reduce their chances for promotion.

"There's a real fear that admitting to mental illness will mean being stigmatized," said Carolyn Robinowitz, the organization's president.

The Pentagon's Mr. Gates has worked hard to dispel that stigma, recently pushing through a rule change allowing military personnel to get counseling for PTSD without having it negatively affect their security clearances.

The question of whether veterans suffering from PTSD should be eligible for the Purple Heart is a deeply emotional issue for military personnel and their families.

Carol Schultz Vento's father, Arthur, was a World War II veteran who took part in the D-Day invasion and won a Bronze Star and two Purple Hearts during his service in Europe.

"From my perspective, the PTSD impaired his functioning more than the physical injuries," she says.

Ms. Vento is working on a book about the emotional traumas World War II veterans like her father suffered, and believes PTSD victims should be eligible for the Purple Heart.

"But for their war experiences, those veterans would not have been traumatized and struggle to adapt to postwar life -- and some don't make it," she says.

Robert Certain is a retired Air Force colonel who was shot down over Hanoi, Vietnam, in 1972 and held as a prisoner of war. He received a Bronze Star and two Purple Hearts and later became an Air Force chaplain and Episcopal priest.

'Obvious to the Warrior'

Mr. Certain suffered severe depression in the 1980s and was formally diagnosed with post-traumatic stress disorder in 2000.

Mr. Certain says that he is conflicted about whether veterans with PTSD should be eligible for the Purple Heart. In his own case, the disorder wasn't diagnosed until decades after the Vietnam War ended but he believes that making troops suffering from the disorder eligible for the award might persuade more of them to seek help.

In an email, he wrote: "The scars resulting from PTSD are almost all invisible to the observer, but always obvious to the warrior who has them."

Write to Yochi J. Dreazen at yochi.dreazen@wsj.com

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