PTSD symptoms were first noted by Swiss military physicians in
1678. They named it Nostalgia. These symptoms included: Melancholy,
Excessive thoughts of home, disturbed sleep or insomnia, weakness,
loss of appetite, anxiety, palpitations, stupor, and fever
(Bentley, 2005). Around the same time, German, French and Spanish
doctors were also creating terms for the same symptoms. (Bentley,
2005).
Slide 4
By the 1700s a prominent French surgeon, Dominique Jean Larrey,
described the disorder as having three stages: Heightened
excitement and imagination. Periods of fever and gastrointestinal
symptoms. Frustration and depression Shortly afterwards, military
physicians in the United States began documenting the same kind of
symptoms from Civil War soldiers. Jacob Mendez Da Costa, a
cardiologist, described this constellation of symptoms as Soldiers
Heart, or Irritable Heart. The sharp increase in PTSD symptoms in
service personnel during the Civil War years has been attributed to
the arrival of modern warfare, the horrifying results of which left
many soldiers with psychological wounds which physicians were
unsure of how to treat (Bentley, 2005).
Slide 5
Unfortunately, soldiers who suffered from PTSD during these
times were often seen as weak. Robert C. Wood, the USA Assistant
Surgeon General in 1864, was known to have stated: It is by lack of
discipline, confidence, and respect that many a young soldier has
become discouraged and made to feel the bitter pangs of
homesickness, which is usually the first sign of more serious
ailments The belief that soldiers suffering from PTSD were merely
weak or malingerers remained in the public sentiment for years to
come. However, elsewhere the disorder was beginning to gain some
legitimacy. By 1905, PTSD, then known as Battle Shock, was regarded
as a legitimate medical condition by the Russian Army.
Slide 6
Slide 7
In WWI, it was believed that the psychological distress of
soldiers was due to concussions caused by the impact of shells.
This impact was believed to disrupt the brain and cause Shell
Shock. Shell shock was characterized by a dazed, disoriented state
that many soldiers experienced during or after combat. However,
even soldiers who were not exposed to exploding shells were
experiencing similar symptoms (Scott, 1990). Therefore it was once
again assumed that soldiers who experienced these symptoms were
cowardly and weak. Treatment was brief, consisting only of a few
days R&R before the soldier was expected to return to duty.
Because 65% of shell-shocked soldiers ultimately returned to the
front lines, treatment was considered a success.
Slide 8
Meanwhile, some scholars were questioning the term, shell
shock,. For example, Smith and Pear (1918) preferred the term, war
strain. These scholars also disagreed with the common misconception
of the time that the condition resulted in shock, Instead they
believed that this was a trauma related condition brought on by
such things as: Witnessing a mine explosion Being temporarily
buried alive in the dug-out, The sight and sound of injured or dead
comrades, or other appalling experiences which finally incapacitate
him for active duty.
Slide 9
The authors go on to suggest that the trigger for war strain
was considered to be intense emotional arousal and the suppression
of emotion, as well as fear (Smith & Pear, 1918). Resulting
symptoms were believed to include: Memory loss. Insomnia.
Nightmares. Pains. Emotional instability. Loss of self-confidence
and self-control. Convulsions. Obsessive thoughts, usually of the
darkest and most painful kind, even in some cases hallucinations
and delusions.
Slide 10
Another stress theory that arose during this time was war
neurosis, proposed by Sigmund Freud. Freud did not write a great
deal about the topic, but his colleagues did. Sandor Ferenczi, Karl
Abraham, Ernst Simmel, and Earnest Jones, published a book
entitled, Psycho-Analysis and the War Neuroses (1919). Freud wrote
the introduction to this book. In the following passage, Freud
explains his belief that war neuroses was brought about by
conflicts between soldiers war egos and peace egos: The war
neuroses differed from the ordinary neuroses of peace time through
particular peculiarities, so were to be regarded as traumatic
neuroses. He believed their existence had been made possible
because of an ego- conflict. The conflict took place between the
old ego of peace time and the new war-ego of the soldier, and it
became acute as soon as the peace-ego was faced with the danger of
being killed through the risky undertakings of his newly formed
parasitical double. Basically, the old ego protected itself from
the danger to life by flight into the traumatic neurosis in
defending itself against the new ego which it recognized as
threatening its life. (Ferenczi, Abraham, Simmel, & Jones,
1919, pp. 2-3).
Slide 11
Freud also believed that war neurosis was best treated by the
cathartic method of psychoanalysis. After the war, Freud was called
upon by the Austrian War Ministry to give his opinion about the
rumoured brutal treatment of psychologically wounded soldiers by
Army Doctors. In 1920, he submitted a memorandum entitled,
Memorandum on the Electrical Treatment of War Neurotics. Consistent
with the views expressed in the introduction to Psycho-Analysis and
War Neuroses (Ferenczi et al., 1919), Freud confirmed that war
neurosis had physical causes that were best treated with
psychoanalysis rather than electrical shock treatment.
Slide 12
By the end of WWI, psychiatrists began to believe that what had
been known as Shell Shock was the result of emotional problems
rather than physical injury of the brain. Although this was a step
forward in the understanding and treatment of PTSD, psychiatrists
continued to believe that soldiers who were weak were predisposed
to the condition (Bentley, 2005). So, their primary aim was to use
psychiatric testing to screen out those they believed would sustain
psychological casualties in war (Bentley, 2005). There also
continued to be doubts among some military professionals about the
legitimacy of the condition.
Slide 13
Slide 14
WWII differed from previous wars due to its use of bigger
weapons and bombs, which placed soldiers at greater risk.
Additionally, soldiers were placed into smaller combat groups,
which reduced the social interaction which may have previously been
psychologically soothing for the soldiers. (Marlowe, 2000). WII
took a tremendous psychological toll on soldiers, despite the
extensive use of psychiatric screening for selection (Marlowe,
2000). Medical personnel were puzzled that although over one
million soldiers were screened out for psychological reasons, there
continued to be staggering numbers of psychiatric casualties in
war. In fact, even soldiers who had fought bravely on previous
tours were being affected (Scott, 1990). Overall, 25% of casualties
were caused by war trauma, and this rate increased to 50% for
soldiers engaged in long, intense fighting (PBS, 2003). In fact, so
many soldiers were affected that psychiatrists were confronted with
the reality that psychological weakness had little to do with
subsequent distress in combat. As a result of this they changed the
terminology from combat neurosis to combat exhaustion, or battle
fatigue (Bentley, 2005). Reflecting the consensus that all soldiers
were vulnerable to battle fatigue due to their environments, the
U.S. Army adopted the official slogan, Every man has his breaking
point (Magee, 2006).
Slide 15
In 1947, the U.S. Army released a documentary, entitled Shades
of Gray, about the causes and treatment of mental illness during
WWII. This documentary indicated the consensus at that time that no
one was immune to mental illness, and that environmental factors
play a large role in the development of psychological problems.
Combat exhaustion was thought to involve such symptoms as
hypervigilance, paranoia, depression, loss of memory, and
conversion. During WWII, treatments changed again. They included
extended rest in safe areas, administering sodium pentothal (or
other barbiturates) to induce repressed battlefield experiences,
and even giving alcohol to soldiers.
Slide 16
Although psychiatrists were advancing in their understanding of
war trauma, combat exhaustion was not universally accepted. General
George Patton was notable in his lack of sympathy for the
psychological afflictions of soldiers. He is said to have slapped
two soldiers who were recuperating in a military hospital while
yelling to a medical officer, Dont admit this yellow bastard.
Theres nothing the matter with him. I wont have the hospitals
cluttered up with these sons of bitches who havent got the guts to
fight (Magee, 2006). President Roosevelt received thousands of
letters about the incident, most of which indicated support for
Patton. Ultimately, though, Patton was reprimanded, ordered to
apologize, and relieved of command of the Seventh Army (Magee,
2006).
Slide 17
After WWII, medical professionals started considering the
biological factors involved in the soldiers psychological distress.
A disease based model was proposed and psychiatric medications
became more common (Marlowe, 2000). Unfortunately, this view of
PTSD led to a great deal of stigmatization, because if biological
factors were the sole cause of the development of these symptoms,
then afflicted soldiers could be considered as physiologically weak
or constitutionally disordered (Marlowe, 2000). Another explanation
relating to biology was that psychological problems arose in early
childhood, and that psychological problems were converted into
physical symptoms, manifesting themselves in such a variety of
diseases such as ulcers, arthritis, dermatitis, and hyperthyroidism
(Marlowe, 2000).
Slide 18
As psychology became more integrated with medicine, it became
clear that PTSD was far more complex than the medical model or
psychosomatic explanations would indicate.
Slide 19
Slide 20
By the time of the Vietnam War measures were being taken to try
and lessen the psychological impact of war on soldiers. From the
very beginning of the war, the military provided each battalion
with medical personnel trained to treat psychological problems
(Scott, 1990). At first, these measures seemed very successful, as
very few psychological casualties were reported. However, as the
war continued, and public outcry about the legitimacy of the war
led to even greater stigmatisation of soldiers, cases of combat
fatigue increased. Estimates are varied, but the figures below give
an indication of findings: 15.2% of male and 8.5% of female Vietnam
veterans had PTSD 20 years after the war 11.1% of male and 7.8% of
female Vietnam veterans had partial PTSD 20 years after the war
30.9% of male and 26.9% of female Vietnam veterans had PTSD at some
time in their lives.
Slide 21
Despite the enormous psychological toll of Vietnam on soldiers,
they received no heros welcome when they returned from war, and
often had to face homecoming alone, or alongside a few other
soldiers who had shared their experiences and could offer social
support. They were often met with hostile demonstrations by
anti-war activists. American society offered little acceptance of
Vietnam veterans even years after the war (Marlowe, 2000). The
harsh treatment of Vietnam soldiers, especially given their
psychological afflictions gave rise to our current beliefs about
PTSD. Pettera, Johnson, and Zimmer (1969) referred to Vietnam
combat reaction as a more extreme form of combat fatigue which was
mostly seen in soldiers nearing the end of their tours, and would
likely have long-term consequences (Marlowe, 2000). They provided a
comprehensive description of the symptoms of Vietnam combat
soldiers.
Slide 22
Early symptoms included insomnia, anorexia or both. Later
symptoms included: Insomnia Recurrent nightmares, which were
usually a reliving of a severe psychic trauma (friends and
colleagues severely injured, mutilated, or killed, the subject
themselves wounded close to a vital organ, or perhaps their unit
overrun by enemy with few survivors; anorexia progressing to
nausea; and sometimes even watery diarrhoea. Depression, including
guilt over not having saved his friends life or perhaps not having
grieved enough for him, as well as shame for having broken down
when others in his unit maintained emotional control severe
anxiety, to such a degree as to make the soldier ineffective in
combat. Soldiers experienced a deep fear of combat or the thought
of it, and noticed increasing tremulousness beyond their control
when in the field, especially if actual enemy contact was made.
(Pettera, Johnson, and Zimmer, 1969, p. 675, as quoted in Marlowe,
2000)..
Slide 23
Elements of this definition can be seen in the current
diagnostic criteria for PTSD
Slide 24
Slide 25
In the post-Vietnam period, it became clear that many soldiers
were suffering severe psychological problems as a result of their
traumatic exposure, yet psychiatrists were left without a
diagnosis. Chaim Shatan, a psychiatrist and advocate for Vietnam
veterans, raised awareness about the absence of a combat-stress
diagnosis in the DSM. In 1972, he wrote an article for the New York
Times calling it post-Vietnam syndrome,. He described it as an
affliction that occurred 9-30 months after Vietnam combat (Scott,
1990). Shatan described the syndrome as delayed massive trauma and
identified its themes as: guilt, rage, the feeling of being
scapegoated, psychic numbing, and alienation (Scott, 1990, p. 301).
Shatan expanded upon Freuds conceptualization of grief: Freud
explained the role grief plays in helping the mourner let go of a
missing part of life and acknowledging that it exists only in the
memory. The so-called Post-Vietnam Syndrome confronts us with the
unconsummated grief of soldiers and their impacted grief, in which
a never-ending past deprives the present of meaning. Their sorrow
is unspent, the grief of their wounds is untold, their guilt
unresolved. Much of what passes for cynicism is really the veterans
numbed apathy from an excess of bereavement and death (Shatan,
1973, as quoted in Scott, 1990, p. 301).
Slide 26
Shatans piece in the New York Times gained a great deal of
support for legitimising post-Vietnam syndrome in the DSM (Scott,
1990). Ultimately, this description became accepted and the
condition was renamed Post Traumatic Stress Disorder. PTSD has
remained a diagnosis in the DSM. The Diagnostic and Statistical
Manual of Mental Disorders, In the United States the DSM serves as
a universal authority for psychiatric diagnosis. In the most recent
version the criteria for PTSD are defined as follows:
Slide 27
Criteria A: Stressor The person has been exposed to a traumatic
event in which the person has experienced, witnessed, or been
confronted with an event or events that involve actual or
threatened death or serious injury, or a threat to the physical
integrity of oneself or others, and their response involves intense
fear, helplessness, or horror. Criteria B: Intrusive recollection
The traumatic event is persistently re-experienced in at least one
of the following ways: Recurrent and intrusive distressing
recollections of the event, including images, thoughts, or
perceptions. Recurrent distressing dreams of the event. Acting or
feeling as if the traumatic event were recurring (includes a sense
of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes, including those that occur upon
awakening or when having drunk alcohol. Intense psychological
distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event Physical reactions upon
exposure to internal or external triggers that symbolize or
resemble an aspect of the traumatic event.
Slide 28
Criteria C: Avoidance/Numbing Persistent avoidance of stimuli
associated with the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by at least three of
the following: Efforts to avoid thoughts, feelings, or
conversations associated with the trauma Efforts to avoid
activities, places, or people that arouse recollections of the
trauma Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant
activities Feeling of detachment or estrangement from others
Restricted range of affect (e.g., unable to have loving feelings)
Sense of foreshortened future (e.g., does not expect to have a
career, marriage, children, or a normal life span)
Slide 29
Criteria D: Hyper-arousal Persistent symptoms of increasing
arousal (not present before the trauma), indicated by at least two
of the following: Difficulty falling or staying asleep Irritability
or outbursts of anger Difficulty concentrating Hyper-vigilance
Exaggerated startle response Criteria E: Duration Duration of the
disturbance (symptoms in B, C, and D) is more than one month.
Slide 30
Criteria F: Functional significance The disturbance causes
clinically significant distress or impairment in social,
occupational, or other important areas of functioning. Our current
understanding of PTSD is that intrusion, avoidance, and arousal
symptoms are all present for at least one month, and cause
significant problems in functioning. The introduction of these
criteria was a great step forward in our understanding of PTSD, as
the criteria indicate that the cause of the trauma is outside of
the individual, rather than the result of a weakness in the
individual (Friedman, 2007). Additionally, the current criteria
acknowledge both psychological and biological components of the
disorder.
Slide 31
We also now believe that PTSD can arise as a result of threat
to the physical integrity of another, So, even individuals, such as
family members or helping professionals who are exposed to the
traumatic experiences of others, can be susceptible to developing
PTSD symptoms themselves (Bride, Robinson, Yegidis, & Figley,
2004).
Slide 32
As our understanding of PTSD evolved, so has the treatments
available. One of the main treatments used is Cognitive Behaviour
Therapy. CBT involves educating patients about PTSD symptoms and
cognitive changes in the areas of safety, trust, control, intimacy,
and self esteem. PTSD sufferers are also helped to identify their
negative, irrational thoughts, (NATs) and learn skills for
challenging these beliefs Additionally, some medications, such as
Zoloft (sertraline) and Paxil (paroxetine), have been approved for
the treatment of PTSD, but are primarily used when therapy alone is
ineffective (Friedman, 2007).
Slide 33
Cognitive behavioural therapy (CBT) aims to help suffers manage
their problems by changing how they think and act. Trauma-focused
CBT uses a range of psychological treatment techniques to help the
client come to terms with the traumatic event. For example, the
therapist may ask the client to confront traumatic memories by
thinking about the experience in detail. During this process the
therapist will help with any distress felt, while identifying any
unhelpful thoughts or misrepresentations about the experience. By
doing this, the therapist can help the client gain control of fear
and distress by changing the negative way of thinking The client
may be encouraged to gradually restart any activities that have
been avoided since the experience. It is the norm to have
approximately 6-12 weekly sessions of CBT.