History of Post-traumatic Stress Disorder in Combat Presented by Mylea Charvat, MS [email protected].

History of Post-traumatic

Stress Disorder in CombatPresented by

Mylea Charvat, [email protected]

PTSD in Ancient Literature

Though referred to by a number of different names, PTSD has been with us for as long as wars have been fought.

Herodotus, writing of the battle of Marathon in 490 BC, mentions an Athenian warrior who went blind when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body.”

Steven Bentley, “A Short History of PTSD: From Thermopylae to Hue, Soldiers Have Always Had A Disturbing Reaction To War The VVA Veteran, March/April 2005

PTSD in Ancient Literature

Herodotus also wrote of the Spartan commander Leonidas, who, at the battle of Thermopylae in 480 BC, dismissed his men from combat because he recognized they were mentally exhausted from previous battles.

PTSD in Ancient Literature

The Iliad makes a reference to what appears to be PTSD -- Ajax loses a duel, comes under a "spell" from Athena, slaughters a herd of sheep thinking they are the enemy, and then kills himself.

Evolution of PTSD

1678 Swiss physician Johannes Hofer coins the term “nostalgia.” to describe symptoms seen in Swiss Troops.

Symptoms of “Nostalgia” melancholy incessant thinking of home disturbed sleep or insomnia loss of appetite anxiety cardiac palpitations

Napoleonic Era

French physicians recognized numerous factors important in producing nostalgia: Cultural (rural vs urban conscripts) Social (boredom vs rigorous activity) Environmental (clement vs inclement weather) Battle (victorious armies suffering fewer

cases)

Napoleonic Era

Napoleon’s Chief Surgeon, prescribed a treatment for Nostalgia which consisted of: Regular exercise Listening to music “Useful instruction”

The U.S. Civil War

The Union Army 2,600 cases of insanity 5,200 cases of nostalgia.

In addition many “insane” soldiers were simply discharged and left to find their own way home.

In 1864 the War Department ordered that such soldiers be transferred to the Government Hospital until their families could retrieve them.

Franklin D. Jones, M.D., F.A.P.A, “Psychiatric Lessons of War in War Psychiatry, The Textbooks of Military Medicine, ed. Brigadier General Russ Zajtchuk, M.C., (Washington, DC: Office of The Surgeon General, Department of the Army, 1995),

The U.S. Civil War: Soldier’s Heart

1871 Jacob Mendez Da Costa (internist) noted the following symptoms in soldiers: Chest-thumping (tachycardia) Anxiety Breathlessness (hyper-arousal)

These symptoms were referred to first as Soldier’s Heart and later as Da Costa Syndrome.

Railway Spine

1867 – following a series of deadly train accidents in Great Britain:

Railway spine was characterized by: “…the manifestation of a variety of physical

disorders in otherwise healthy and apparently uninjured railway accident victims.”

Ralph Harrington, The Railway Accident: Trains, Trauma and Technological Crisis In Nineteenth Century Britain, in Traumatic Pasts: History and Trauma in the Modern Age ed. Mark S. Micale and Paul Lerner, Cambridge: Cambridge University Press.

World War I: “Shell Shock”

Symptoms of Shell Shock Staring eyes Violent tremors Blue, cold extremities. Unexplained deafness, blindness, or paralysis

F. C. Hitchcock. Stand To: A Diary of the Trenches 1915–1918. London: Hurst & Blackett, 1937; report, Heath field, England: The Naval & Military Press, Ltd., 2001.

World War I: Treating Shell Shock

1917: U.S. Army Surgeon General’s office creates comprehensive treatment program for shell shock

Placing psychiatrists in combat units Treatment is Centered on: Proximity (treating the soldier as close to the battle as

possible) Immediacy (treating the soldier as soon as possible) Simplicity (providing simple treatment such as rest, a warm

shower and food) Expectancy (the expectation that the solider will return to fight

after he has been treated)

World War II

Wyeth Pharmaceuticals placed this ad in Life Magazine on September 17, 1945, touting the benefits of their product in curing "battle reaction & mental trauma" caused by WWII...and colic

WWII: Combat Fatigue

Forward Treatment Employed. Unit cohesion recognized as a factor in

“resilience” to combat fatigue. Understanding that intensity and duration of

combat exposure increased risk for combat fatigue Concurrently it was noted that “replacement” troops

were more susceptible than “seasoned” Veterans – see unit cohesion.

DSM: 1952

DSM-I

what we now know as PTSD was called "stress response syndrome" and was caused by "gross stress reaction".

Vietnam War

1971 Marine Corps Recruiting Poster

Vietnam War

1968: Veteran’s Treated for “Stress Response Syndrome”

Informed that if their symptoms lasted more than 6 months after their return from Vietnam they had a "pre-existing" condition, making it a "transient situational disorder", and the problem was not considered service connected.

Vietnam War: DSM-II: 1968

Trauma-related disorders were lumped together in a category titled "situational disorders".

the jungles of Guadalcanal.

1980 DSM-III: PTSD

Post-traumatic Stress disorder first introduced as a diagnosis

Placed under a sub-category of anxiety disorders

DSM-III PTSD Criteria

Essential feature: Characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. The original stressor is usually experienced with intense fear, terror, and/or helplessness.

The precipitating stressor must not be one which is usually well tolerated by most other members of the cultural group (e.g., death of a loved one, ordinary traffic accident).

Evolution of PTSD: DSM-III-R

Changes in DSM-III-R: Specification of generic characteristics of traumatic

stressors Clearer organization of symptoms around three

dimensions of stress response (re-experiencing, avoidance and numbing, and physiological arousal)

inclusion of symptoms specific to children, and specification of onset and duration of the disorder.

DSM-IV Criteria Person Experiences Traumatic Event Person Experiences Fear, Helplessness or Horror The person experiences a combination of the following Sx which are still present > 4

weeks following the TE, last more than one month and cause significant distress

Re-experiencing >1Intrusive thoughts or memoriesTrauma related dreamsActing/feeling as though the trauma were reoccurringEmotional distress in response to triggersPhysical Sx in response to triggers

Avoidance >3Efforts to avoid trauma related thoughts or feelingsAvoidance of people, places or activities that trigger reminders of traumaMemory loss for all or parts of the traumaLoss of interest in activitiesFeelings of estrangement from othersExpectation of foreshortened future

Hyperarousal >2Difficulty with sleepIrritability and angerAttention and Concentration problemsHypervigilenceExaggerated startle reaction