I think it’s time for us to refine PTSD (post-traumatic stress disorder).

Thirty years ago when PTSD was added to the Diagnostic Manual of Mental Disorders, it was a break-through for psychologists to recognize what less-professional observers had known for millennia: that war causes emotional damage, just as it causes physical damage. To confirm that, you need only to go back to the Greeks, the tragedies of Homer, Aeschylus and Sophocles, as well as the history of the Peloponnesian War by Thucydides. As Jonathon Shay, a psychiatrist who works with Vietnam vets, says: “Athenian theater was created and performed by combat veterans for an audience of combat veterans; they did this to enable returning soldiers to function together in a democratic polity.”

But over the past three decades of working with PTSD, it seems as though our stressed-out vets are demonstrating two distinctly different symptoms that should be treated differently.

Stress caused by combat is a logical disorder. It’s a natural defensive mechanism, a shield that the brain dons when it knows someone or something is trying to kill it. One result is long-term  hypervigilance, the state of high alert to forestall and survive the next attack.

But as currently defined, PTSD also includes the guilt that some psychiatrists are calling “wounded souls.”  This stems not from what others are trying to do to them, but from what they have done to others.

Therapists such as Shay, a recipient of a MacArthur Foundation “genius” grant; Edward Tick, director of the private group Soldier’s Heart; and Brett Litz, a VA psychologist, argue that what happens in war may more accurately be called a moral injury — a deep soul wound that pierces a person’s identity, sense of morality and relationship to society.

My friend Jack Jager fits the latter diagnosis perfectly.

A dog handler during the war in Vietnam, Jager came home and tried to live a normal, civilian life, but couldn’t. And when his mom asked what had happened to him over there, he couldn’t tell her. Instead, he fled to Montana, got an isolated job as a long-haul trucker, drank heavily and fell in and out of marriages.

“I felt very guilty,” he told me a few years ago. “There are things I did that I feel very guilty about. I was brought up right, brought up to do right, but in war the compassion is not there. Human beings were not made to kill each other. I saw some soldiers who just could not pull the trigger on an adversary face to face, and they died. After all the depravity of war was over, I was afraid people would know what I was, so I just ran away from it.”

Jager is what I would call a wounded soul.

And I think psychology would be better served to break the PTSD diagnosis in half. There will always be overlap, but it makes sense to provide one kind of relief to those traumatized by what was done to them and another therapy to those traumatized by what they did to others.   

Dr. Tick, author of War and the Soul, agrees. He told me that combat stress/anxiety is a logical half of the PTSD diagnosis, but that spiritual injuries form the other half. “We really don’t have the words in our language to express our spiritual loss, but when I describe it to combat vets, they understand it immediately,” he said.       

Next we’ll look at what causes wounded souls.