From
Where I sit
How
PTSD went from ‘shell-shock’ to a recognized medical diagnosis
The symptoms of post-traumatic stress disorder
have been recorded for millennia, but it took more than a century for
physicians to classify it as a disorder with a specific treatment.
BY ERIN
BLAKEMORE
PUBLISHED JUNE
16, 2020
The
battles were over, but the soldiers still fought. Flashbacks, nightmares, and
depression plagued them. Some slurred their speech. Others couldn’t
concentrate. Haunted and fearful, the soldiers struggled with the ghosts of
war.
Which
war? If you guessed Vietnam, the U.S. Civil War, or even World War I, you’d be
wrong. These soldiers’ symptoms were recorded not on paper charts, but on cuneiform
tablets inscribed in Mesopotamia more than 3,000 years ago.
Back
then, the ancient soldiers were assumed to have been hexed by ghosts. But if
they were treated today, they would likely receive a formal psychiatric
diagnosis of post-traumatic stress disorder (PTSD).
Although
the diagnosis has its roots in combat, the medical community now
recognizes that PTSD affects civilians and soldiers alike. Patients develop
PTSD after experiencing, learning about, or witnessing a traumatic
event—defined as “actual or threatened death, serious injury, or sexual
violence”—and their intrusive symptoms affect their ability to cope in the
present.
Nearly
seven percent of American adults will likely experience PTSD during their
lifetimes, but it took hundreds of years, and the dawn of industrial-scale
warfare, for society to recognize the deleterious physical and mental effects
of experiencing, witnessing, or becoming aware of traumatic events.
"Traumatic
hysteria"
Medical
historians have documented many early accounts of what would now be classified
as PTSD. There’s Herodotus’ description of an Athenian soldier who
became blind after witnessing the Battle of Marathon in 490 B.C., and a
Shakespearean monologue in Henry IV, Part 1 in which Lady
Percy describes her husband’s sleeplessness and inability to enjoy
life after fighting a battle. Then there are more modern descriptions, like accounts
of Civil War combatants who developed what their doctors called
“soldier’s heart.”
But
though early physicians looked for a physical cause, it wasn’t until the 1880s
that psychiatrists connected the symptoms to the brain. At the time, women who
expressed vehement emotions were labeled with “hysteria,” a condition that
supposedly arose from the uterus. When French neurologist Jean-Martin Charcot
saw similar symptoms in men, he chalked them up to traumatic events—rather than
biological destiny—and the term “traumatic hysteria” was born.
“The
concept of trauma was entangled with feminine weakness from the beginning,”
says Mary Catherine McDonald, a historian of PTSD who works as an
assistant professor of philosophy and religious studies at Old Dominion University.
And when World War I blasted onto the scene, it challenged a common conviction
that psychological steadiness was a matter of personal character, masculinity,
and moral strength.
Shell shock and combat
fatigue
From
aerial combat to poison gas, WWI introduced terrifying new combat technology on
a previously unimaginable scale, and soldiers left the front shattered.
Seemingly overnight, the field of war psychiatry emerged and a new term—shell
shock—appeared to describe a range of mental injuries, from facial tics to an
inability to speak. Hundreds of thousands of men on both sides left World War I
with what would now be called PTSD, and while some received a rudimentary form
of psychiatric treatment, they were vilified after the war. As historian Fiona
Reid notes, “shell-shock treatment was constantly entwined with
discipline” in militaries that had trouble aligning their beliefs in courage
and heroism with the reality of men who bore invisible wounds.
By
World War II, psychiatrists increasingly recognized that combat would have
mental health ramifications—and concluded that too many men who were prone to anxiety or “neurotic tendencies” had been selected to
serve in the previous war. But though six times as many American men were
screened and rejected for service in the lead-up to the World War II,
military service still took its toll. About twice as many American
soldiers showed symptoms of PTSD during World War II than in World
War I. This time their condition was called “psychiatric collapse,” “combat
fatigue,” or “war neurosis.”
Military
officials assumed that removing men from combat situations or treating them with
injections of drugs such as sodium amytal would relieve their psychiatric
distress. It didn’t work: Nearly 1.4 million of the 16.1 million men who served in World War II were treated for
combat fatigue during the war, and the condition was responsible for 40 percent
of all discharges.
Post-Vietnam syndrome
A growing
recognition of the ubiquity of psychiatric injury during war prompted more
compassionate approaches to traumatized veterans. “The soldier suffers in the
modern war situation a privation hard to equal in any situation in civilian or
even primitive life,” wrote psychiatrist Abram Kardiner, whose 1941 book The
Traumatic Neuroses of War helped change views of what is now known as
PTSD. But, despite a growing recognition of the unique stresses of combat, as
well as studies that showed the effects of war could last for decades, soldiers
continued to face out-of-date views on their ability to bounce back from
combat-related psychiatric distress.
In
1952, the American Psychological Association published the Diagnostic
and Statistical Manual of Mental Disorders (DSM), the closest thing
psychiatry has to a bible. The handbook helps professionals diagnose mental
illnesses and strongly influences everything from research to public policy to
health insurance. But veterans’ symptoms were categorized under disorders like
depression or schizophrenia instead of being recognized as a distinct
diagnosis.
Enter
“Post-Vietnam syndrome,” a term coined in 1972 by psychiatrist Chaim Shatan. By
then, Vietnam veterans had been returning home for years, and many were beset
by emotional numbness, volatility, flashbacks, and rage. In part because many
experienced delayed symptoms, veterans had trouble accessing treatment and
benefits despite their invisible wounds.
Increasingly,
veterans turned to what psychiatrist Robert Lifton called “street corner psychiatry”—veteran self-help
communities who often combined their healing with anti-war protests. Along the
way, they met clinicians and researchers like Lifton and Shatan, who began to
advocate for the DSM to include some kind of post-combat stress diagnosis. In
1980, “post-traumatic stress disorder” became a formal diagnosis in the DSM’s
third edition. Twelve years later, it was also adopted in the World Health
Organization’s International
Classification of Diseases.
Invisible wounds
Today’s
definition of PTSD is more inclusive than ever—and the condition is recognized
among survivors of sexual abuse or assault, health crises and surgeries,
natural disasters, bereavement, mass shootings, accidents, and more. PTSD is
associated with everything from flashbacks and nightmares to
With
every passing year, researchers develop new treatments for PTSD and learn more
about how trauma affects the brain and body. They are also grappling with the
possibility that the effects of trauma and stress can be passed from one
generation to the next through chemical changes that effect how DNA is
expressed. A 2018 study, for example, found high mortality among the offspring of men who survived Civil War
prison camps in the 1860s. Scientists are still sparring over an earlier study that suggested the offspring
of Holocaust survivors inherited a different balance of stress hormones than
their peers.
Other
researchers, like Jessica
Graham-LoPresti, push against the limitations of the official
PTSD diagnosis itself. A clinical psychologist and assistant professor at
Suffolk University, Graham-LoPresti studies the effects of systemic racism on
African-Americans. “People of color experience a lot of symptoms in response to
the frequency and pervasiveness of racism that mirror the symptoms of PTSD,”
she says, noting that watching footage of police brutality can exacerbate the
fears and stresses of lives already touched by pervasive racist experiences.
“This is not new, but [this imagery is] causing a lot of hypervigilance,
emotional responses of stress and anxiety, and feelings of helplessness and
hopelessness.”
But though the
current definition of PTSD considers experiencing or witnessing a single
incident of racialized terror an inciting incident, it doesn’t allow for the macroaggressions
and intergenerational dynamics African-Americans experience every day. “It’s a
complicated conversation,” says Graham-LoPresti. “It is so new, and researchers
of color are starting to get a lot of pushback because the field is so
overwhelmingly white.”
As Graham
Lo-Presti works to connect the dots between racism and PTSD, her colleagues are
considering the potential effects of another pandemic: COVID-19. Psychiatrists
are bracing for a flood of patients traumatized both by surviving the illness
and losing their loved ones to it. In the wake of the SARS epidemic in Hong
Kong in 2003, some patients and healthcare workers developed PTSD—and in a
variety of studies, people who were quarantined exhibited more signs of post-traumatic
stress than people who were not.
But that doesn’t
mean that everyone who lives through a traumatic event will develop PTSD—or
that those with post-traumatic stress disorder can’t find healing and joy. As
with other chronic illnesses, PTSD can go into remission—and as the study of
PTSD matures, researchers have come to appreciate the brain’s heroic attempts
to heal itself after traumatic events.
“It’s such a
destructive idea to think that PSTD is dysfunction,” says McDonald. “We’re
getting it fundamentally wrong when we think it’s a sign of brokenness. It’s
the sign of the impulse to survive.”
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