With more than 2 million service members returning home from Iraq and Afghanistan, post-traumatic stress disorder and traumatic brain injury have become the signature wounds of both conflicts.
But while the Pentagon has decided TBI, or mild concussions received as a result of enemy action, qualify for the status of a Purple Heart, the military hasn't yielded on PTSD.
Thomas Bush Jr., 54, an Air Force combat veteran who has PTSD, thinks his comrades-in-arms' invisible wounds qualify them for the medal.
"That's a very open discussion with a lot of vets," said Bush, of Riverside.
To receive the Purple Heart, a service member must have suffered an injury in combat.
The language specifically disqualifies PTSD by name.
"PTSD is an anxiety disorder caused by witnessing or experiencing a traumatic event; it is not a wound intentionally caused by the enemy from an 'outside force or agent,' but is a secondary effect caused by witnessing or experiencing a traumatic event," Pentagon spokeswoman Eileen Lainez said in an email to the Middletown Journal.
Oftentimes, Bush said, if a service member has combat-related PTSD, he may be the only survivor of a traumatic event and carried out the mission under fire.
"If it's a true case of PTSD from combat, I think it should be awarded," he said. "Sometimes you can't just put a Band-Aid on a wound that's in your head."
Vietnam veteran Ricky A. York said he's had combat-related PTSD, but isn't sure a Purple Heart should be given to soldiers who carry wounds, as he did, inside them. For 43 years, the former cavalry soldier avoided talking about Vietnam to his family before he wrote a book about it.
"I can tell you I have injuries, but they aren't physical," said York, 66, of Kettering, a retired General Motors autoworker. "That's a pretty big distinction to actually be physically wounded. ... I don't know if I'd agree it's the same as being shot or stepping on a mine.
"I just think personally if I said I deserve a Purple Heart and there's a veteran there with one arm or a leg missing, I don't know how he would look at it," he said. "I sure don't want to offend one of those guys."
The numbers of service members receiving Purple Hearts has risen by thousands since the Sept. 11, 2001, attacks. The Marine Corps, for example, has issued more than 8,700, said Navy Lt. Matt Allen at the Pentagon. The Navy, which has its own special forces and combat construction workers and provides support on the ground to Marines, has awarded 800 more.
The Military Order of the Purple Heart and the Veterans of Foreign Wars say post-traumatic stress doesn't merit the award.
"PTSD is not something new," said John E. Bircher, a Military Order of the Purple Heart spokesman in Springfield, Va. "There's hardly anyone who has ever been in combat, and certainly someone who has been wounded, who doesn't suffer some form of PTSD."
Medals aren't awarded for illness or disease, but for "achievement and valor," said Joseph E. Davis, a VFW national spokesman in Washington, D.C.
"The Purple Heart is awarded for a physical wound received while engaged with an enemy force," he said in an email to the Middletown Journal. "PTSD is considered an illness and not an injury."
He noted soldiers who suffered Gulf War syndrome, and Korean War veterans who had frostbite in the freezing depths of Korean winters, also didn't qualify for the award.
"Not to diminish the illness or effects of PTSD, but it is the VFW's belief that awarding the (Purple Heart) for PTSD is not consistent with the original purpose and would denigrate the medal," he wrote.
Larry C. James, director of the School of Professional Psychology at Wright State University, said some have concerns soldiers could fake PTSD to get the medal. The retired Army psychologist, however, believes few would try.
"Ninety-nine percent of these young men and women are honest," he said. "Integrity and character is part of the military."
Charles R. Figley, director of the Traumatology Institute at Tulane University in New Orleans, said counselors can tell if someone has combat-related PTSD. The military and veterans should be the ones to decide to change the rules, said Figley, a Marine veteran who served in Vietnam.