From Shellshock to PTSD (Post-Traumatic Stress Disorder)

From Shellshock to PTSD (Post-Traumatic Stress

Disorder)

Hysterical Muscular Paralysis

from War Neuroses 1918 film

“Trauma”• From the Greek meaning “wound”• Used in surgical contexts• Beginning in 1860s and 1870s, was

adopted in neurological and psychiatric settings

• In 1894, William James wrote “Certain reminiscences of the shock fall into the subliminal consciousness, where they can only be discovered in ‘hypnoid’ states. If left there, they act as permanent ‘psychic traumata’, thorns in the spirit, so to speak.” (Psych. Review, 1,99)

19th Century: Trauma Diagnoses• Traumatic neurosis (Oppenheim)—physical

trauma causes neuroses; was compensated by the German state in 1889. Sometimes called a “pension neurosis.”

• Railway Spine (in US and Britain)—similar to traumatic neurosis

• War hysteria (Bonhoeffer and Charcot) neurosis is due to weakness of the constitution

A Case of Traumatic Male Hysteria

British Bomb Throwers, 1915

The Sphere, 1915

Patient with word deafness; could only hear word “Bombs”

from War Neuroses, 1918 film

Early 20th C. War Neuroses

• Shellshock (Charles S. Myers) or bomb concussion, initially thought to be due to shell explosion, which produced tiny brain lesions

• NYDN—(not yet diagnosed, nervous?) term to replace shellshock in 1917 in Britain

Hysterical soliderand after cure

from War Neuroses

(1918)

Treatments for Shell Shock• Bedrest, relaxation, baths, massage

• Occupational therapies, e.g. farm-work

• Hypnosis and Suggestion (Max Nonne)

• Electrical Shock Treatments (Lewis Yealland, Kaufmann)

• Treatment by isolation, fake injections

• Psychoanalysis (Sandor Ferenczi, W.H.R. Rivers)

• Return home or to hospital

Electroshock TherapyMaudsley Hospital, 1918

The Kaufmann Cure

Transporting the Wounded

Sandor Ferenczi and Sigmund Freud

W. H. R. Rivers (1864-1922)Instinct and the Unconscious (1920)

Craiglockhart Hospital

Siegfried Sassoon (1886-1967)

Wilfred Owen (1893-1918)

"They"The Bishop tells us: "When the boys come

backThey will not be the same; for they'll have

foughtIn a just cause: they lead the last attackOn Anti-Christ; their comrades' blood has

boughtNew right to breed an honorable race,They have challenged Death and stared him

in the face."

"Were none of us the same!" the boys reply.

"For George lost both legs; and Bill's stone blind;

Poor Jim's shot through the lungs and like to die;

And Bert's gone syphilitic: you'll not find

A chap who's served that hasn't found some change.“

And the Bishop said: "The ways of God are strange!"

(Siegfried Sassoon, 31 October 1916)

Freud’s Death Instinct (Thanatos)

“The fateful question for the human species seems to me to be whether and to what extent their cultural development will succeed in mastering the disturbance to their communal life by the human instinct of aggression and self-destruction.”

Freud, Civilization and its Discontents, 1930

War Neuroses

• Abraham Kardiner: The Traumatic Neurosis of War (1941)

Spoke of “environmental, or reactive” responses to trauma rather than “defensive”—change in ego

• Roy Grinker and John Spiegel: War Neurosis (1945) descriptions of symptoms; personality

. dealing with overwhelming anxiety

American Medical Association, War Medicine 5 (1944)

Letting off Steam to shrink Resentment War Medicine (1944)

From the Cartoon Booklet, “The Story of Mack and Mike”

Post-Traumatic Stress Disorder (PTSD)

entered DSM 1980, revised 1987• Individual experiences “recognizable

stressor” –outside range of usual human experience

• Re-experiencing of traumatic event (thoughts, memories, dreams)

• Avoidance of stimuli associated with trauma, or numbing of general responsiveness

• Increased autonomic arousal not present before trauma

History of Trauma Diagnoses• Traumatic neurosis (19th c)• Railway Spine (19th c)• War hysteria (WWI)• Shell Shock (WWI)• Battle Fatigue or Combat Fatigue

(WWII) or Operational Exhaustion (Air Force)

• PTSD (Vietnam)• PTSD (Iraq and Afghanistan)

Reports of soldiers returning from combat duty in Iraq with PTSD range from 12.9 % (panel at Institute of Medicine,2007); 19-21% (chief of psychiatry, Walter Reed Army Instituteof Research, Psychiatric Times, 2006); to as high as 30% (Army Surgeon General, Veteran’s Today, 2006).

Traumatic narratives: (a) he was almost killed in a motor vehicle accident with pregnant fiance´, who was killed. He could not get her out of the car; b) she was sexually abused from ages 12 to19 by both older brothers, it was non-consensual; (c) he found son’s blood all over the basement after the son had cut his wrist in a drunken suicide attempt.

Non-traumatic narratives: (a) he worries about his looks. It is a big problem; (b) She has worried about what might happen to her children since their birth. When a child, she worried about her mother the same way. The problem is much worse in the past 5 years since the kids have not been nearby; and (c) she worries about losing her siblings. She is the youngest. People of her age are dying and she worries about being alone.

Equivocal narratives: (a) he was diagnosed with atrial flutter, which proceeded to fibrillation 1 year ago during a routine physical exam. He became obsessed with mortality after this benign cardiac abnormality; (b) she was locked in a room at a party with four men who started to approach her sexually, but she escaped; and (c) when 7 years old he was persuaded to fondle an old man. No force was used and he felt curious at the time, not upset.

J. A.Bodkin et al. “Is PTSD caused by traumatic stress? Journal of Anxiety Disorders 21 (2007) 176–182