A very modern trauma

Posttraumatic stress disorder is one of the defining disorders of modern psychiatry. Although first officially accepted as a diagnosis in the early 1980s, many believe that it has always been with us, but two new studies suggest that this unlikely to be the case – it may be a genuinely modern reaction to trauma.

The diagnosis of PTSD involves having a traumatic experience and then being affected by a month of symptoms of three main groups: intrusive memories, hyper-arousal, and avoidance of reminders or emotional numbing.

It was originally called ‘post-Vietnam syndrome’ and was promoted by anti-war psychiatrists who felt that the Vietnam war was having a unique effect on the mental health of American soldiers, but the concept was demilitarised and turned into a civilian diagnosis concerning the chronic effects of trauma.

Since then there has been a popular belief that PTSD has been experienced throughout history but simply wasn’t properly recognised. Previous labels, it is claimed, like ‘shell shock’ or ‘combat fatigue’, were just early descriptions of the same universal reaction.

But until now, few studies have systematically looked for PTSD or post-trauma reactions in the older historical record. Two recent studies have done exactly this, however, and found no evidence for a historical syndrome equivalent to PTSD.

A study just published in the Journal of Anxiety Disorders looked at the extensive medical records for soldiers in the American Civil War, whose mortality rate was about 50-80 greater than modern soldiers fighting in Iraq and Afghanistan.

In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.

In a commentary, psychologist Richard McNally makes the point that often these symptoms have to be asked about specifically to be detected, but even so, he too admits that the fact that PTSD-like symptoms virtually make no appearance in hundreds of thousands of medical records suggests that PTSD is unlikely to be a ‘universal timeless disorder’.

Taking an even longer view, a study published in Stress and Health looked at historical accounts of traumatic experiences from antiquity to the 16th century.

The researchers found that although psychological trauma has been recognised throughout history, with difficult events potentially leading to mental disorder in some, there were no consistent effects that resembled the classic PTSD syndrome.

Various symptoms would be mentioned at various times, some now associated with the modern diagnosis, some not, but it was simply not possible to find ‘historical accounts of PTSD’.

The concept of PTSD is clearly grounded in a particular time and culture, but even from a modern diagnostic perspective it is important to recognise that we tend to over-focus on PTSD as the outcome of horrendous events.

Perhaps the best scientific paper yet published on the diversity of trauma was an article authored by George Bonanno and colleagues in 2011. You can read the full-text online as a pdf.

It notes that the single most common outcome after a traumatic event is recovery without intervention, and for those who do remain affected, depression and substance abuse problems are equally, if not more likely, than a diagnosis of posttraumatic stress disorder.
 

Link to locked study on trauma in Civil War soldiers.
Link to locked study on trauma through history.

26 Comments

  1. jenjen1352
    Posted August 11, 2012 at 1:34 pm | Permalink

    I was diagnosed with PTSD 14 years ago, some months after the incident which pushed me over the edge a la Wile E Coyote. I doubt I would have received that diagnosis had my mother’s suicide been the only trauma in my life, but her long term paranoid schizophrenia and my absent father’s suicide appear to be just too much for my extremely resilient brain to cope with.

    Bit of a nuisance really, theoretically finally getting my freedom but not being able to use it.

    • Posted August 14, 2012 at 2:15 pm | Permalink

      Jen. Sheesh. Warmest regards, and tenderness to you. Wile E Coyote, indeed!

  2. nancylebovitz
    Posted August 11, 2012 at 2:30 pm | Permalink

    There’s a David Drake essay about the conditions of combat getting steadily worse– more continuous, longer duration, more loud noise, individual skills less important than luck….

    Maybe the amount of background stress affects the risk of PTSD.

  3. Posted August 11, 2012 at 3:36 pm | Permalink

    My great-great-grandfather fought in a few of the worst Civil War battles–well, his regiment did anyway–Cold Harbor & Cedar Creek were two that he was very likely in. He came to Colorado after the war, became a wealthy rancher, & had 9 kids. He abused my great-grandfather Willie reportedly by swinging him around the room by his legs so that his head hit the wall. So far as I can determine, he treated all of his others kids well. Willie became a reprobate, but had 7 kids. They suffered extreme neglect. It’s taken 5 generations to recover. I can’t know if he had PTSD, but it’s easy to imagine that might have been part of why he mistreated Willie. Or maybe not. He didn’t leave a journal so how could I possibly know?

    • Posted August 14, 2012 at 2:19 pm | Permalink

      Bingo. It’s hard for me to imagine a response to this article that would better sum and illustrate my own reaction. Which is something between incredulity and disgust.

      It is hard to find historical accounts of continental drift before the 19th century, btw. The earth’s crust must have started behaving the way it does after Wegener suggested it do so.

  4. Posted August 11, 2012 at 4:07 pm | Permalink

    I entirely agree that responses to trauma (both “normal” and “pathological”) are fundamentally cultural. However, I’m somewhat wary (in a more general way) of retrospective research into the past prevalence or presence of particular disorders. The profound and structuring influence of discourse (and available theoretical/hermeneutic frameworks) cannot be denied, even when (at risk of over-simplifying) a given perceptual symptom is or might be temporally or historically constant. (Not to mention placing far too much faith in various institutional, clinical and/or editorial gatekeepers.)

    I find this all the time when directly querying people about their experiences of psychosis. The language of (and division between) hallucinations and delusions, for instance, so structures individuals’ self-descriptions, that is, that it takes a surprising amount of careful work and patience to “facilitate” exploration and acknowledgement of other, more subtle and ineffable, changes. (Though this seems far less true of first episode patients.) Were it not for a few brave and stubborn phenomenologists, I could easily see these experience simply vanishing from both the first person and clinical literatures… But has psychosis fundamentally changed, or rather its articulation?

    In this context, one might also reference particular cultural/historical manifestations of common underlying “symptom types”, such as the “Truman Show” delusion….

    (Of course my overarching argument oversimplifies things to the extent (only partial, though, IMO) that discourse itself directly structures and/or reconfigures experience, perception, and embodiment.)

    • dedangelo
      Posted August 12, 2012 at 1:57 pm | Permalink

      Exactly. Further, the gender-specific nature of PTSD, i.e, men have PTSD; women have personality disorders, points once again to the failings of objective psychiatric diagnoses.

      • skyewriter
        Posted August 16, 2012 at 5:34 am | Permalink

        Preposterous, to assign gender to PTSD. More mysterious is the Psych community’s rejection of Complex PTSD (as often observed in abused children, regardless of male, female or androgynous) as being genuine.

        I recall the term “shell shock” being used to describe the trauma in soldiers pre-Vietnam. Regardless, the victims of war are not only those who fought in them or the unfortunate people whose country and culture were decimated and Westernized. The families, the children of Veterans frequently lived on a battlefield — I know this was true for me (a woman who was once a little girl with a brutal alcoholic father who relived his time on the front lines in the US Army and often used me as a punching bag or soccer ball). There have been people and events in the past twelve years that have triggered agony in me so extreme, I didn’t care whether I lived or died. The pain is so extreme it has a physical component and sometimes involves Dissociation.

        So what will the newest DSM call this exquisitely painful inconvenience: Post Traumatic Stress by Proxy? And only males will be afflicted? I’ve sought appropriate therapy and treatment for PTSD and will continue to do so. At the first mention of Personality Disorder, I’ll leave the office and refuse to pay the tab. How pathetic these “Mental Health professionals” are. WOMEN: advocate for yourselves, do the research and if the first opinion seems hackneyed and wrong, get yourself a second opinion (and do not make any mention of the first opinion).

  5. Posted August 12, 2012 at 12:46 am | Permalink

    There are certainly a number of accounts of hyper-arousal from the Middle Ages. I was reading one of them to my students — an account of a warrior you had to let wake up by himself, because otherwise he would snap awake and try to kill you — and one of the students said, “That’s just like my dad — he was in Vietnam.” So one aspect of PTSS, at least, is recorded from an earlier time period. There’s a medievalist working on this.

  6. Kerry Maxwell
    Posted August 12, 2012 at 3:02 am | Permalink

    Might have been Julian James?, but I seem to remember hearing an argument for The Odyssey being a tale of PTSD (post Troy stress disorder).

  7. Arthur
    Posted August 12, 2012 at 12:31 pm | Permalink

    The Australian moral philosopher and intelligence researcher James Flynn has shown that QI has been steadily rising for at least the last century or so. this gain is in abstract thinking ability and at the expense of practical thinking. Perhaps excepting the consequences of trauma has been getting more difficult for intelligent man.

    • Ciaran
      Posted August 13, 2012 at 9:02 pm | Permalink

      Good points, neat speculative correlation.

      One could bring plenty of collateral evidence to the table too (black humored pun intended): think of our rampant ‘meetings culture’ which stifles any hint of practical action with all its powerpointed disempowerment.

      Today I was directed to a local council dept to seek practical help with the results of a recent crime. The council officer suggested that he could hold a ‘multi-agency partnership meeting’ so that they could all talk about the issue and, I quote verbatim, so that ‘no one person would have to be responsible for doing something’.

      If you didn’t have PTSD before, you’ll surely end up with a severe and enduring case of it after a few rounds with these over-QI’d pillocks.

  8. Casey
    Posted August 13, 2012 at 1:20 pm | Permalink

    I have no psychology training at all, but the first thing that came to mid after reading this article was this. I wonder if there’s any correlation between the amount of people “living in comfort” and the amount of soldiers with PTSD. For example, during the Civil War, the men fighting in the war were mostly farmers and used to working hard ad seeing people get hurt or even killed. And everyone, because of the state of medicine at the time, was used to people dying horrible deaths. Fast forward to Vietnam and most people were living in urban and suburban environments, working at the local diner bussing tales and had never seen anyone die in their lives. Maybe the increase in PTSD had something to do with the idea that modern soldiers are much further removed from their normal comfort zones than the soldiers of earlier wars.
    Just a thought…

  9. Posted August 13, 2012 at 3:23 pm | Permalink

    I was recently diagnosed with PTSD, forty-two years after Viet Nam. It was my first visit to VA because I no longer had private health insurance. I had the opportunity to go through a pilot program using Cognitive Behavioral Therapy at San Diego VA. It has been and is life changing. My life was a long, long struggle with myself and my past; it always will be, but it is easier now that I understand a little about it. For those who have served, seek help at VA! You don’t have to suffer alone.

  10. Jeff Dworkin
    Posted August 13, 2012 at 3:42 pm | Permalink

    It seems to me that one factor (as other posters mention) is that up until the 20th century, death was a regular occurance that many more people were exposed to throughout their lives both of humans and animals. Let us not forget that hangings in the 18th century was popular public entertainment whereas half of the people I know would probably need therapy for years if they ever witnessed one.

    The other factor is the chaning nature of combat in the modern era, where there is no defined front-line, and in general no organized large scale battles. Instead you have low-intensity, high stress situations that first started becoming obvious during the Viet-Nam war. When I was in the Air Force in the late’70s some of the guys in my unit had served in there, and told stories of never really being able to let your guard down because an inflitration or mortar or some other kind of attack could happen at any time and at any base. You took your weapon to the shower with you.

  11. Allene Swienckowski
    Posted August 13, 2012 at 5:39 pm | Permalink

    The leap to ascertain that PTSD did not affect Civil War soldiers or others who fought previously is indeed a strange conclusion that the malady did not exist prior to so-called modern wars. To rely on recorded “primary sources” (notes in medical files) does not even suppose that the medical professional would have thought to have recorded anything beyond physical trauma. Is it possible that because there are no recorded medical records pointing to the massive psychological issues endured by slaves that the slaves did not suffer emotionally from bondage?
    History is reported from the eye of the beholder and that beholder may not have understood or cared anything about the psychological trauma of the patient who lost a leg or legs, etc., and therefore, said medical report probably did not include even a whiff of emotional impairment, if observed. We do see what we expect to see, regardless of how myopic that vision might be.

  12. J Frazer
    Posted August 13, 2012 at 8:17 pm | Permalink

    Medical records are the wrong place to be looking historically. It’s very recently that psychiatric conditions have become considered a medical concern in most places; before that, many thought it merely a sign of weakness, something should be ‘toughed out’.

    There are many historical accounts of being plagued by traumatic memories, hyper-vigilance, “battle fatigue”, and even events we might consider ‘flashbacks’ when viewed through the modern psychiatric lens. Flashbacks, as seen in the movies, don’t really exist even now.

    It’s same thing showing up again and again, but it’s expression differs according to culture.

  13. jcasey12
    Posted August 13, 2012 at 10:23 pm | Permalink

    Here’s an excellent book on the topic from a few years ago (author a combat veteran of Vietnam).

  14. nancy
    Posted August 14, 2012 at 12:26 am | Permalink

    Soldiers have come home from every war with lifetime disabilities from stress. Only the name has changed: Combat Stress Reaction, Shell Shock, Combat Fatigue, Vietnam Syndrome, even Soldier’s Heart.

    The expectation was that you put the war behind you and moved on. Our culture has changed, thankfully, from callously telling these war casualties to “be a man” or marginalizing the few that couldn’t keep their symptoms hidden inside their own home.

    It was there. It wasn’t discussed.

  15. Posted August 14, 2012 at 5:56 am | Permalink

    This is an interesting point and far be it from me to contradict eminent research, especially as I have not studied this area. Surely, PTSD has existed and as the article points out is perhaps an issue of diagnosis. Furthermore I appreciate the problem of historical records and that as Richard McNally puts it ‘often these symptoms have to be asked about specifically to be detected.’

    However, using an arbitrary example; the British Government gave posthumous pardons(1) to soldiers shot for desertion in WW1 who are now said to have been suffering from PTSD. If symptoms such as ‘intrusive memories, hyper-arousal, and avoidance of reminders or emotional numbing.’ were suffered by these victims is it not PTSD? If not what is it? Should we give it a different category? As each situation is different and specific and therefore, should be referred to differently. It follows that soldiers fighting in Afganistan suffer, not with PTSD but ATSD for example.

    (1)Editorial,‘300 WWI soldiers receive pardons’ (BBC News Wednesday, 16 August 2006) accessed 8th August 2012

  16. marcellas
    Posted August 14, 2012 at 7:59 pm | Permalink

    As a behavioral psychologist its baffling to witness the disregard of conditioning and habituation in all this discussion of neurology. By conditioning I an referring to both classical and operant, (Skinner and Pavlov). Look closely at anyone with PTSD and you will see clearly that their suffering is being reinforced or “conditioned”. They expect to receive some consideration for their suffering or to avoid something aversive by it or both. Cultural expectations shape the expression of distress, and all this occurs subconsciously and automatically. This explains why the person’s symptoms and suffering are completely genuine, and tend to significantly improve once they are declared “100% disabled”.

  17. Posted August 15, 2012 at 8:06 am | Permalink

    Good post! There’s also a book out there for anyone who’s interested in a more in-depth analysis of the historical nature of PTSD. It’s called “The Harmony of Illusions” and is written by Allan Young.

    And as a commentary to the replies to this post, I think that people shouldn’t equate historical to false, as some here are wont to do. Knowledge being historical and/or constructed doesn’t mean that it isn’t true. That’s a dichotomy that I think it’s best to try and move past, similar to what most modern history and sociology of science has done.

    • Posted August 16, 2012 at 7:16 pm | Permalink

      I agree with you comment, but isn’t it rather a matter of trust? It is difficult to believe in “historical” as true unless it part of our experience or memory.

  18. sats
    Posted August 15, 2012 at 11:45 am | Permalink

    Dr David Nutt, referred to in another article on your blog writes about treating PTSD with psychedelics in his book ‘Drugs without the hot air’. ‘Because pharmaceutical companies know that any drug with a chemical similarity to an illegal psychoactive substance is unlikely to be approved, they tend to avoid these areas of research altogether.’

  19. Posted August 19, 2012 at 5:13 am | Permalink

    According to Achilles in Vietnam, by Jonathan Shay, the Illiad is the
    description of the PTSD of Achilles. Put far too simplistically, his
    commander cheated him, his buddy was killed, and he went berserk. I
    am no expert on the matter, but Shay says that these are typical of
    the circumstances that cause PTSD in recent times.

    If you want to buy the book, please don’t get it from
    Amazon (see http://stallman.org/amazon.html).

  20. Posted August 29, 2012 at 11:34 am | Permalink

    PTSD is now controlled via supercomputers by amnesia walling brain. The U.S. military currently uses this on all soldiers. By mm microwave laser to cerebellum soldiers are forced to forget yesterdays trauma and left with an altered reality. The general population is also mind controlled via the same technology.


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