Richard A. Bryant
History of PTSD
Many people trace the historical roots of the PTSD diagnosis back to antiquity. For example, it has been suggested that descriptions of the disturbing nature of traumatic memories can be found in Homer’s Iliad [1]. Others have found accounts of stress responses in the Napoleonic Wars, Spanish conflicts in the 17th century, and the American Civil War [2]. This is hardly surprising considering that people can be very distressed by traumatic events. How this early recognition has transitioned to a formal diagnosis has been a lengthy process, influenced by many societal and political issues.
The initial conceptualizations of traumatic stress were marked by confusion over whether anxiety arising from trauma reflected organic damage to the brain or emanated from psychological dysfunction. Early debates about the etiology of traumatic stress arose in the 19th century, partly as a result of increasing industrialization. As railways became commonplace across the Western world, accidents among railway workers (and passengers) were very commonplace. These injuries often resulted in conditions characterised by generalized somatic reactions (including dizziness, fatigue, headaches, as well as symptoms of anxiety). Whereas neurologists initially attributed these reactions to spinal damage (hence the term railway spine as one of the very early descriptors of traumatic stress), some blamed these responses on psychological factors. For example, Professor Erichsen of University College London wrote in 1875:
Despite this recognition of psychological factors, the prevailing view at the time by neurologists was that traumatic stress responses were a result of damage to the nervous system.
It is important to understand that the timing of this development occurred in the context of increasing political concerns about the societal costs of railway accidents. In 1846 an act was passed in the UK permitting those who suffered as a result of a railway accident to claim damages from railway companies; this led to many claims for psychological damages and, perhaps because railway companies were most unpopular with the general public, they tended to lose nearly every case [3]. Not surprisingly, this led to a situation in which insurance companies were suspicious that motivational factors were driving these claims, and either consciously or unconsciously, stress responses may be confounded by the lure of compensation. This possibility was even recognized in the Lancet, which in 1861 noted:
These debates were fostered by developments in World War I, which saw all sides faced with the most horrendous numbers of casualties. The controversy over the extent to which traumatic stress was a function of organic or psychological disturbance raged throughout the war, as military leaders tried to stem the tide of the hundreds of thousands of troops who showed signs of marked distress, termed “shell shock.” Medical figures commonly believed that the reactions (which ranged from inexplicable paralysis, conversion reactions, fatigue, and amnesia to explicit anxiety states) arose from exposure to bomb blasts or mustard gas that adversely affected the central nervous system [5]. As the war progressed, society became increasingly aware of the horrors endured by troops. For the first time, writers and poets expressed the suffering of soldiers rather than portraying them simply as brave warriors. British poet Wilfred Owen (who clearly suffered a form of psychological distress after his experiences in the war) wrote graphic poems of the horrors experienced in the trenches. For example, in his classic poem “Dulce et Decorum Est” he wrote:
Gas! Gas! Quick, boys! – An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling
And flound’ring like a man in fire or lime …
Dim, through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning
Such prose led to far greater societal acceptance of the validity of traumatic stress as a condition. However, military agencies saw the situation differently. Trench warfare resulted in massive loss of manpower that hugely dented the war effort. For example, the Battle of the Somme in 1916 alone saw tens of thousands of men withdraw from the frontline because of shell shock. In his compelling account of wartime psychiatry, Shephard [6] points out that military commanders were apparently personally removed from the trauma faced by troops in the trenches, and presumed that stress responses reflected cowardice. In fact, it was commonly believed that the public attention being given to stress reactions was fostering “soft-hearted” soldiers, which was undermining the war effort. This led to policies on all sides that attempted to discourage people from reporting stress reactions by reducing the possible motivations of removal from the frontline. This resulted in the birth of frontline psychiatry, which held that treating people as soon as possible in relation to the war reduced reinforcement of illness behavior, and encouraged return to normal functioning. In this episode, we can see how cultural, legal, and political issues were shaping the construct of traumatic stress.
One would think the lessons learned from WWI might have led to more sophisticated understanding, and management, of traumatic stress in WWII. Stress factors continued to plague the war effort. Nearly one-third of all medical discharges from the British Army in WWI were because of psychological issues [7]. This situation seems to have increased military commanders’ conviction that signs of distress indicated weakness, or even treason. This was exemplified by the infamous slap by General George Patton of a fearful soldier, who complained he was incapable of functioning. Ironically, the widespread attention to this incident led to a public backlash, and further highlighted community awareness of traumatic stress responses in those affected by the horrors of war. This perspective did not alter the prevailing view of authorities that social forces were pivotal in reinforcing trauma survivors’ response to the event. For example, British authorities expected massive stress reactions during the Blitz, which was feared would cause massive destruction throughout London (approximately 40,000 were actually killed). The Ministry of Health employed a strong approach of encouraging the “stiff upper lip” attitude by encouraging people to expect quick recovery from stress reactions, which would only be transient in those who experienced them. Subsequent analyses have noted that economic and political concerns during this period dominated policies, and although relatively few cases of traumatic stress were detected, in all probability genuine cases were neglected for the sake of minimizing a feared epidemic of traumatic stress reactions [6].
In considering the history of traumatic stress, we can see that it has oscillated in its professional and societal conceptualizations over time. In earlier times, it was definitely considered a transient response to trauma; this was partly motivated by the political inclination to encourage resilience and downplay the likelihood of people exaggerating their stress reactions. As time progressed, however, it became increasingly accepted that traumatic stress conditions could be long-lasting in some individuals. An undeniable conclusion in this unfolding history of PTSD is the effect of economic, societal, and political influences on the construct.
DSM and PTSD
This changing conceptualization of traumatic stress is seen in the formal diagnostic definitions provided to describe traumatic stress in the DSM. Going back to the initial publication, we can see that in DSM-I, “gross stress reaction” was used to describe those people psychologically affected by traumatic exposure [8]. In the post-war era, this very generic category was seen as clinically useful for initially classifying military veterans, ex-PoWs, rape victims, and survivors of the Holocaust. Consistent with wartime psychiatrists’ views of traumatic stress, this diagnosis was considered a temporary state, and if the condition persisted the person would subsequently be described as suffering a “neurotic reaction.” DSM-II eliminated the category of “gross stress reaction,” replacing it with “situational reaction,” an even broader category intended to describe adverse psychological reactions to traumatic and non-traumatic experiences, and still considered a transient state.
The Vietnam era saw a major shift in U.S. perspectives on post-traumatic mental health, with widespread awareness of the difficulties that troops experienced during deployment. Unlike previous wars, this was often an unpopular war and so there was greater sensitivity to those who were forced to fight it. As public attention had increased during prior wars, the media attention and lobby groups that emerged from the Vietnam War led to widespread recognition of the mental health problems arising from deployments. It was in this context that in 1980 DSM-III introduced PTSD as a formal diagnosis [9]. This was the first time that the spectrum of conditions previously termed rape trauma syndrome, post-Vietnam syndrome, prisoner-of-war syndrome, concentration camp syndrome, war sailor syndrome, child abuse syndrome, and battered women’s syndrome were all categorized together. The core criteria of the DSM-III diagnosis of PTSD were three major symptom clusters (reexperiencing, numbing, and miscellaneous) that have formed the basis of more recent iterations of the diagnosis. There were shifts in the diagnosis in DSM-III-R [10] and DSM-IV [11], but the major structure of PTSD has remained steady for 20 years, with reexperiencing, avoidance, and arousal forming the basis of the disorder. These symptoms have been based on the notion of fear circuitry, such that the traumatic event creates extremely strong fear reactions that have a cascading effect on neural, behavioural, and cognitive processes. Phenomenologically, this leads to intrusive memories, nightmares, and flashbacks that contribute to the person wanting to engage in avoidance behaviours. It is also hypothesised that it triggers more passive avoidance responses, such as emotional numbing, dissociative amnesia, and social withdrawal. This state of affairs results in elevated anxiety states, involving sleep disturbance, heightened startle reactions, and hypervigilance to threat. To limit overdiagnosis of transient responses, PTSD is only diagnosed after at least 1 month of trauma exposure. Importantly, in addition to the symptoms being present, it is imperative that the person suffers impairment or clinically significant distress as a result of the symptoms.
