More than seventy of our beloved US military veterans kill themselves every day. Both passive and active suicides. And that statistic doesn’t even consider our civilian first-responders.
That number has not moved in a decade. It has become so familiar that it functions as background noise—a statistic trotted out at congressional hearings, printed on awareness bracelets, spoken with practiced gravity by people who have never once sat across from a man deciding whether tonight is the night.
I have sat across from that man. More than once.
My co-author and I wrote a paper proposing a neurobiological framework for reclassifying combat-related PTSD as PTSI: Post-Traumatic Stress Injury. Not disorder. Injury. The distinction is not semantic. It is the difference between telling a combat veteran that something is wrong with his mind and telling him that something happened to his brain that can be identified, located, and treated. It is the difference between a diagnosis that produces shame and one that produces a treatment plan.
We submitted it to two journals. Both rejected it. [I have included the rejection from Military Medicine’s Mr. Rothwell below this article.]
The first was JAMA Psychiatry—the most “prestigious” psychiatric journal in the world. They rejected the manuscript without providing a single reviewer’s comment. Not one word of feedback. Not one line of scientific critique. Nothing. A paper proposing to reclassify the diagnostic framework applied to millions of combat veterans, and the flagship journal of American psychiatry could not be troubled to explain why it said no.
That silence is its own message. It says: we do not owe you an explanation. It says: the classification is not up for discussion. It says: the gate is closed and we will not even tell you why.
The second was Military Medicine—the journal of the Association of Military Surgeons of the United States. They at least had the courtesy to provide reviews. What those reviews contained is more revealing than JAMA Psychiatry’s silence.
Because when the gatekeepers finally speak, you can hear exactly what they are protecting.
More than seventy of our beloved US military veterans a day kill themselves. Both passive and active suicides. And that statistic doesn’t even consider our civilian first-responders.
Major Strengths: None
That is how Reviewer 1 at Military Medicine opened the evaluation. Three words. Not “the argument has merit but requires stronger evidence.” Not “the framework is interesting but incomplete.” Major Strengths: None.
If you have ever submitted a paper to a peer-reviewed journal, you know what those three words mean. They mean the reviewer did not come to evaluate. The reviewer came to execute. The conclusion was reached before the first paragraph was read. Everything that followed was reverse-engineered to justify a decision that was already made.
And what followed was not a scientific critique. It was a credentialing exercise—a methodical effort to establish that the authors lack the proper titles and expertise to propose what they proposed.
The reviewer wrote that I possess “some laboratory training in basic neuroscience research that is unrelated to much of what is discussed in the manuscript.”
Some laboratory training.
Basic neuroscience research.
Let me tell you what that “basic” training actually looked like.
Reviewer 1 wrote that “previous commentaries in this journal have been authored by those with both scholarly activity in the topic area, usually with clinical experience.” I have published more on this subject than most of the people reviewing it. The difference is that my work reaches the people it is written for—the veterans, the operators, the first responders living inside the condition—rather than circulating in a closed ecosystem of citations that the people most affected will never read.
The “Basic” Researcher
I am a former research scientist at Duke University Medical Center, the University of Southern California, Cal State Long Beach, Scripps Institution of Oceanography and American University. Several were among the most rigorous research environments on the planet.
As an undergraduate at American University, I became the first scientist in history to successfully culture shark cells—a contribution to cellular biology and biophysics that required years of methodological innovation in an area where every previous attempt had failed. My research career spans biophysics, cellular physiology, and neuroscience across more than 13 years of institutional work at a level your anonymous reviewer apparently cannot be troubled to verify before carelessly rendering judgment. Not only is that bad form, it is bad science.
That is the laboratory record. Here is the publication record. And this includes my being a New York Times bestselling ghostwriter and editor of more than 50 published books.
I am the author of Silent Scars, Bold Remedies: Cutting-Edge Care and Healing from Post-Traumatic Stress Injuries—a book that was nominated for the Pulitzer Prize. More than 1,000 pages based on hardcore research over decades. My research. Decades.
Let me say that again for Reviewer 1, slowly: nominated for the Pulitzer Prize. Not for fiction. Not for poetry. For the work this reviewer has just dismissed as lacking scholarly activity in the topic area. I am the author of Healing in Plain Sight. I am the creator of TESS—The Emerging Science Series of ebooks—which translates cutting-edge neuroscience and trauma research for veterans and first responders and is available on Amazon for anyone, including anonymous reviewers, who might wish to educate themselves before passing judgment on another person’s credentials.
Reviewer 1 wrote that “previous commentaries in this journal have been authored by those with both scholarly activity in the topic area, usually with clinical experience.” I have published more on this subject than most of the people reviewing it. The difference is that my work reaches the people it is written for—the veterans, the operators, the first responders living inside the condition—rather than circulating in a closed ecosystem of citations that the people most affected will never read.
That is the scientific and literary record.
Now let me tell you what Reviewer #1 will never understand, because they are a coward.
I am a former US Army Airborne Ranger. 1st Battalion, 75th Ranger Regiment. I did not read about combat in a textbook like Reviewer #1 did. And I enlisted at the age of thirty-five, when your reviewers were thinking about that next mid-level job at NIH. After the Army, I conducted more than 220 high-risk security operations across dozens of hostile territories in countries Reviewer #1 has never set foot in. I ran anti-poaching operations in southern Africa—not behind a desk, not through a grant proposal, but on the ground, in the bush, where the consequence of a wrong decision is not a rejected manuscript. It is a body. There were many bodies.
I have been in more firefights than Reviewer 1 has been in faculty and journal meetings. I have held dying men in places that reviewer cannot find on a map. I have watched post-traumatic stress—not disorder, not a clinical abstraction, but the real, grinding, physiological aftermath of sustained combat—destroy people I loved. Not patients on a chart. Brothers.
And an anonymous reviewer hiding behind the blind review process at a journal that claims to serve the military medical community has decided that I have “some laboratory training in basic neuroscience research” and no standing to propose changing a single word.
I say again: that reviewer #1 is a coward. A coward who would not say these things to my face, who would not sign a name to the dismissal, and who does not possess a fraction of the experience—scientific, operational, or human—required to evaluate what was placed in front of them.
I call bullshit, Mr. Rothwell. You, too, are a coward.
The Cowardly Gatekeeper
The editor in chief of Military Medicine is Mr. Stephen W. Rothwell, Professor Emeritus at the Uniformed Services University of the Health Sciences. His field is cell biology—something I did as an undergraduate and performed worldclass research at age 21, something no other man, esp. him, was able to do. His research career was spent at the Walter Reed Army Institute of Research studying leukocyte physiology, immunology and hemostasis. He taught histology, physiology and anatomy to medical students for thirty-five years. His military experience consists of growing up as the son of an active-duty Army officer and serving twelve years in the US Army Reserves.
He has never deployed into combat. He has never heard a shot fired in hostility. He has never been in a fistfight, let alone a firefight. He has never held a man who was dying from something no one could see. He has never sat in a room with a veteran who was trying to explain what is happening inside his own skull while a clinician with a DSM checklist tells him he has a disorder. He has spent an entire career studying cells under microscopes while the men and women this journal claims to serve were carrying the physiological wreckage of combat through a system that cannot even name what happened to them correctly.
This is the man who decided that a former US Army Airborne Ranger and thirteen years of hardcore research experience, a Pulitzer-nominated book on this exact subject, multiple published works in the field, more than two hundred life-and-death missions, and a lifetime of operational experience across a hundred countries lacks the standing to challenge a diagnostic label in a commentary.
I call bullshit, Mr. Rothwell. You, too, are a coward.
His editorial summary of the rejection states: “A strong argument is that there are multiple benefits to patients if the disease process is treated as a disorder rather than an injury.”
Read that sentence again. Slowly. The editor in chief of a journal that exists to serve the military medical community has declared, as a matter of editorial judgment, that it is better for veterans to be told they have a disorder than to be told they have an injury.
Better for whom, Mr. Rothwell?
Not for the seventy-plus a day.
Men and women who actually saw combat. Unlike you, who sits behind a desk and dispenses institutional orthodoxy cleverly disguised as knowledge. You have spent thirty-five years teaching anatomy to students who will go on to treat the people I served beside—and when one of those people with real-world experience and a physician-researcher placed a paper on your desk proposing to help them, you sided with an anonymous reviewer who could not find a single strength in the argument. Not one. That is not editorial judgment, Mr. Rothwell. That is institutional cowardice dressed in a lab coat.
Not for the men I served with who are in the ground.
Not for the ones still breathing who have been told for decades that something is wrong with their minds when the truth is that something happened to their brains—and the people who control the vocabulary refuse to say so. Cowards like you, Mr. Rothwell.
Two Journals, One Pattern
JAMA Psychiatry would not even explain its rejection. Military Medicine explained it—and the explanation was worse than the silence.
The pattern is not complicated. It is, in fact, the oldest pattern in institutional science: protect the paradigm. When a classification becomes embedded in insurance codes, treatment protocols, pharmaceutical research pipelines, VA disability ratings, and the career structures of every clinician who has built a practice around it, the classification stops being a scientific hypothesis and becomes infrastructure.
Challenging it threatens not just an idea but an industry. The gatekeepers are not protecting the science. They are protecting the architecture that was built on top of it—and the paychecks and reputations that depend on that architecture remaining undisturbed. BigPharma. The American Medical Association. The American Psychiatric Association. Protected guilds. BigMoney.
JAMA Psychiatry guards the gate with silence. No comments. No explanation. The message is: you are not worth engaging. Military Medicine guards the gate with credentialism and snobbery. The message is: you are not qualified to speak. Both arrive at the same destination: the conversation does not happen. And that is the point. The conversation is the threat. Not the reclassification. Not the science. The conversation. Because once it starts, the fortress cracks.
And there was a second reviewer at Military Medicine who saw through it.
Reviewer 3 called the commentary “well-written,” praised its “logical structure and applicable neurobiological framework,” found the science “accessible” and the call to action “strong.” This reviewer identified two areas for improvement and explicitly stated that with those additions, the military medical community could “engage in thoughtful conversation on the changes the authors propose.”
That is a revision recommendation. It is not a rejection. The editor had a choice between a reviewer who found zero strengths and built a rejection on academic snobbery and cowardice, and a reviewer who found the work compelling and offered a clear path to publication.
Mr. Rothwell chose the snob. He chose the coward because he is like minded. He chose the anonymous paper executioner over the scientist who actually engaged with the work.
That choice tells you everything about what these journals are for and who they are willing to protect. And it is not us combat-tested service members. It is the paradigm. It is the infrastructure. It is the comfortable, unchallenged, catastrophically failing status quo.
The Weight of a Word
Words are not neutral instruments. Every veteran who has sat in a VA clinic and been told he has Post-Traumatic Stress Disorder has received a message whether the clinician intended it or not: something is wrong with you. Your mind is disordered. The problem is in your psychology. The architecture of the word points inward—toward pathology, toward dysfunction, toward a self that has been broken in some fundamental way.
Injury points somewhere else entirely. Injury says: something happened to you. Your brain sustained damage that can be identified, located, and treated. You are not disordered. You are wounded. And wounds heal.
I wrote an entire book about this. It was nominated for the Pulitzer Prize. I created a science translation series to put this research into the hands of the veterans and first responders who need it. I have published, lectured, and worked in this space for years. And Reviewer 1—whose identity is protected by a process designed to encourage honest evaluation but which in this case has enabled dishonest dismissal—wrote “Major Strengths: None” and called my background “basic.”
The neurobiological evidence is clear and growing clearer every year. Combat-related trauma produces measurable physiological changes—neuroinflammation, amygdala hyperactivation, prefrontal cortical suppression, dysregulation of the hypothalamic-pituitary-adrenal axis. These are not psychological abstractions. They are not disorders. They are injuries. They show up on scans. They respond to physiological interventions. The science has moved. The label has not.
Our paper made this argument. JAMA Psychiatry could not be bothered to respond. Military Medicine’s Reviewer 1 found zero strengths. The editor found it more beneficial to keep calling veterans disordered.
And tomorrow morning, seventy-plus more of my brothers and sisters will die. How about that statistic, Mr. Rothwell? Does that fit neatly into your editorial framework? Can you look at that number from behind your desk at USUHS or your house and tell me with a straight face that the current classification is working?
The Circular Fortress
The logic of these rejections, stripped to the skeleton, is this: only credentialed psychiatrists may challenge a psychiatric classification. If you are not a psychiatrist, you lack standing. If you are a psychiatrist, you are inside the system and have no incentive to dismantle it. The classification is therefore unchallengeable—not because it is correct, but because the people who control the conversation have arranged the rules so that no one outside the walls can speak and no one inside the walls will.
This is not science. This is a fortress built in a circle. And inside that fortress, the bodies stack up.
The reclassification from PTSD to PTSI is a neurobiological argument. It does not require a psychiatric credential. It requires an understanding of neuroscience, an understanding of trauma, and the willingness to follow the evidence wherever it leads—even if it leads to the conclusion that an entire diagnostic framework has been pointing in the wrong direction for forty years.
I have the neuroscience. I have the publications. I have the Pulitzer nomination. I have the trauma. I have followed the evidence. And I have something no anonymous reviewer, no silent editorial board at JAMA Psychiatry, and no cell biologist slash editor in chief at Military Medicine will ever have: I have been inside the thing these cowards are classifying. I have carried it. I have fought it. I have watched it win.
They have read about it in journals. Their own journals. The ones that rejected the paper that might help fix it.
Fire That Rings True
I am not asking JAMA Psychiatry to break its silence. I am not asking Military Medicine to reconsider its decision. I am not asking Reviewer 1 to validate my credentials—that reviewer is not qualified to do so. I am not asking Mr. Rothwell to reexamine his editorial judgment—his judgment has already been weighed and found severely lacking on all levels.
I am telling you what is going to happen.
The paper will be strengthened with more saddening statistics—by the end of this month, more than 2,100 men and women, all veterans, will have killed themselves. The empirical evidence will be deepened. The counterarguments will be addressed and dismantled within the neurobiological framework. And it will be published. The conversation this work is designed to start will happen—in journals like CRUCIBEL who have the courage to host it, in clinical settings where the practitioners are tired of watching the current paradigm fail, and in the rooms where veterans sit across from someone who finally tells them the truth: you are not disordered. You are injured. And we know how to help.
The gatekeepers of the dead will not stop this. They are cowards protecting an institution of death and doom and destruction over those of us who actually served and still serve our country.
I have been shot at by people who were better at their jobs than Reviewer 1 is at theirs. I have walked through doors in places where the consequence of failure was not a rejection letter but a flag-draped coffin. I have built a career across domains—military, scientific, operational, literary—that most academics cannot comprehend because they have never left the building they were trained in. I have a Pulitzer-nominated book on the subject they claim I know nothing about. I have publications they did not bother to check.
I have more experience with the condition, its causes, its consequences, and its treatment than Reviewer 1 and Mr. Rothwell combined—and that is not arrogance.
That is basic arithmetic.
These cowards would have me accept that I have “some laboratory training in basic neuroscience research” and should go quietly.
Yes, I will go quietly, you fuckn cowards. Into the darkness where the real work gets done.
Two journals said no. Two gates closed. And not one gatekeeper had the operational experience, the scientific range, the publication record, or the moral authority to justify the rejection of a paper written to save the lives of the men and women they claim to serve.
This paper will be published in multiple places. The reclassification will happen. The word will change from disorder to injury. And when it does, the veterans who are still alive to benefit from it will not have JAMA Psychiatry or Military Medicine to thank.
Ref.: Ms. No. MILMED-D-26-00049 From Disorder to Injury: A Neurobiological Framework for Reclassifying Combat-Related Trauma Military Medicine
Dear Mr. Garner, The Editorial Staff regrets to inform you that your manuscript has been rejected from further consideration for publication in Military Medicine. The comments of the reviewers, below, should provide you with the basis for this editorial decision. On behalf of Military Medicine, we would like to express our sincere appreciation for providing us with your manuscript for review. We wish you the best in publishing your work elsewhere
Yours sincerely,
Stephen W. Rothwell, PhD
Professor Emeritus USUHS Editor in Chief Military Medicine
Editor’s comments:
Both reviewers give well reasoned responses as to why this commentary is not ready for publication. A strong argument is that there are multiple benefits to patients if the disease process is treated as a disorder rather than an injury.
Reviewers’ comments:
Reviewer 1: Major Strengths: None Major Weaknesses: The definition of PTSI is contrary to the standard of the accredited professional mental health medical community; however, neither author is certified as a mental health professional. Dr. Lipov is board certified, but the certification is for anesthesiology, not psychiatry. The training of Mr. Garner has some laboratory training in basic neuroscience research that is unrelated to much of what is discussed in the manuscript, nor does he have peer-reviewed research, published or otherwise, in the areas discussed in the manuscript. This reviewer realizes that this is a commentary and not a scholarly article; however, previous commentaries in this journal have been authored by those with both scholarly activity in the topic area, usually with clinical experience. These authors use this unique format to express views and opinions in a fashion that cannot be done in a scholarly format. Instead, authors have chosen to submit a commentary based upon an area where they have limited scholarly experience. The evidence and opinions presented this commentary lack cohesiveness, broad statements with an even broader citations (definition of injury from the ICD11) will make it difficult for readers to verify the veracity of the statements being made. Finally, the authors committed a misnomer that states the currently accepted management of PTSD is medication only, when the military, VA, and civilian treatment options employ a plethora of non-pharmacological therapies such as transcranial magnetic stimulation, cognitive behavioral therapy, exposure therapy, etc. Finally, the shopping list of alternative therapies, much of which have not been controlled with proper placebo or masking, a necessary part of brain/mental health clinical trial design, especially when the treatment can be detected by the study participants, who are typically susceptible to subject-expectancy bias due to the underlying brain injury and/or certain mental health conditions.
Specific issues that need to be addressed by author(s): NA
Reviewer 3: Thank you for the opportunity to review this thoughtful commentary article. The authors present an important consideration for a shift in language based on recent research, updated science, and patient-centered practices regarding trauma and trauma treatment. Although the authors make a compelling argument, there are a few opportunities to consider to fully capture the ideas and novel perspective the authors wish to represent. Major Strengths: The authors have developed a well-written commentary with a logical structure and applicable neurobiological framework for consideration. The current state of molecular injury and circuitry reset science is summarized and accessible, providing solid support for their call to action. The ideas for improvement make sense from a practical perspective. The shared lived experience and anecdotal clinical observations of the authors are compelling and add to the credibility of their argument. The authors present a strong call to action for the military medicine community, and the journal in particular. Their written confidence in the proposed shift from PTSD to PTSI is appreciated. Major Weaknesses: This commentary has two major flaws. 1. There is a lack of rigorous empirical evidence to ground their proposal. While there is a pending study with a large sample size and a reference one of the author’s published work, the evidence base is too thin to warrant a paradigm shift at this scale. 2. The authors have not pre-empted limitations, flaws, or gaps in their proposal, leaving obvious counter-arguments left to be discussed. Although this could generate discussion within our community, the readers of this referred journal would benefit from a tempered article from the authors. Additionally, should the authors self-identify any potential counter-arguments and present responses to those counterarguments ground in the neurobiological framework they used to develop their main thesis, it would demonstrate to the readers the thoughtful and complete development of this proposed change. Specific issues that need to be addressed by author(s): 1. Lack of landmark/novel/or seminal study to warrant paradigm shift; 2. Counter-argument with considerations based on the neurobiological framework. Improvements to this current draft can be elevated further so that our military medical community can engage in thoughtful conversation on the changes the authors propose. By presenting a more balanced commentary with stronger empirical evidence, our community can better benefit from the ideas the authors present.
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