Post traumatic Stress Disorder: A Chronological Account
written by Kevin Roberts, Ph.D.
Terrifying experiences that can turn human lives upside down and leave people with a sense of unpredictability and vulnerability, can also profoundly change the manner in which they subsequently manage their emotions, their environment, their very lives. The syndrome of Post Traumatic Stress Disorder (PTSD) can follow such divergent stressors as war trauma, physical and sexual assaults, accidents, and other natural and man made disasters that include floods, shipwrecks, earthquakes, explosions and fires (van der Kolk, Bessel A., 1995)
While the clinical diagnosis of Post Traumatic Stress Disorder was only formally adopted into the DSMIII just a few short years ago (1980), the experiences of terror and agony in the face of disaster has been with us since the beginning of time. Veith (1988) “suggested that emotional reactions to extremely stressful events are found in every century that has records of human behavior (Figley, C., 1993).” The history of the field of traumatic stress begins with the ancient Egyptian physicians’ reports of hysterical reactions. These reports became one of the first medical textbooks ever when published in 1990 B.C. (Figley, C.R., 1993).
Shay (1994) demonstrates how the Iliad by Homer, written 27 centuries ago, is parallel to posttraumatic stress of today. Achilles, the hero of the Iliad, (circa 700 B.C.) was undergoing traumatic battle experiences and suffering stress reactions similar to documented combat stress victims of the Civil War, World War I, World War II, Korean War, Vietnam War and the Gulf War. Also, Homer’s epic poem, The Odyssey, (circa 700 B. C.) describes the psychological travails of Odysseus, a recent veteran of the Trojan Wars who was returning home. His problems included flashbacks and survivor’s guilt (Figley, C. R., 1993).
Trimble (1981) writes that “indeed, the concept that following an accident a person may develop symptoms, mainly subjective and usually not associated with any clearly defined somatic pathology, is an old one.” He then goes on to quote from Shakespeare’s play, King Henry IV, (1597) from a piece highlighting Henry’s stress reaction to support the concept of symptom development after an accident.
Saigh (1992) writes in 1666, the Great London Fire occurred. Information regarding the effects of traumatic experience has been chronicled for centuries. Samuel Pepys, in his diary of 1666, writing six months after he had seen the Great Fire of London wrote “it is strange to think how to this very day I cannot sleep a night without great terrors of the fire; and this very night could not sleep to almost two in the morning through thoughts of the fire.”
Trimble (1981), in writing about accidents again, cited an experience of Charles Dickens. On Jun 9, 1865, Dickens was involved in a railway accident in Kent and “in a letter, described the horrifying scene of two or three hours work....amongst the dead and dying surrounded by terrific sights...Although that traumatic was enough to render his hand unsteady, it was some time after the accident that he wrote, I am not quite right within, but believe it to be an effect of the railway shaking. There is no doubt of the fact that, after the railway experience, the diary tells more and more about it (railway shaking, that is), instead of, as one might expect, less and less. Dickens developed a phobia of railway traveling, and summed up the sequalae as: I am curiously weak-weak as if I were recovering from a long illness.”
Scrignar (1988) writes that Dr. Jacob Mendes DaCosta (1871), was the first physician in the United States to study a group of physically sound, yet symptomatic Civil War veterans. They complained of palpitations, increased pain in the cardiac region, tachycardia, cardiac uneasiness, headache, dimness of vision, and giddiness. DaCosta theorized that since there was no evidence of myocardial disease, the condition was due to a disturbance of the sympathetic nervous system. DaCosta labeled the condition “Irritable Heart,” and it became known as DaCosta’s Syndrome.
Prussia, in 1871, introduced compensation laws. Rigler, (1879), after an increase in invalidism subsequent to railway accidents, coined the term “compensation neurosis.” While railways had been in use for some time, they began to be used for passenger travel in addition to the transportation of goods. Also, the coming of steam engines and iron rails, along with the appetite of the Industrial Revolution, produced a considerable increase in railway systems amidst some controversy initially (Trimble, M. R., 1981).
Trimble (1981) reports that with the passage of Workmen’s Compensation in the United Kingdom in 1880, the discussion of malingering was on the upswing. The tension between 1)injury and liability, on the one hand, and 2)malingering and compensation neurosis, on the other, can perhaps be viewed as having its most important beginning during this time. The tension has been sustained to this day. At one point, one view will be dominant and, at another point, the other will have taken the lead, only to have it all be reversed time and time again.
Herman (1992), similar to other authors, documents 1880 as an important date in the chronology of post traumatic stress disorder. Jean-Martin Charcot, the great French neurologist, then focusing on the study of hysteria, found that the symptoms resembled neurological damage that included motor paralyses, sensory losses, convulsions, amnesias. He felt these symptoms were psychological and not physical in origin. The parallel to understanding PTSD is obvious, multiple disorders and symptoms follow trauma.
In 1882, John Erichsen wrote an important book in the history of traumatology, concerning the development of “railway spine,” which was later called “Erichsen’s disease.” He felt that the “concussion of the spine” due to “violent shock of railway collision” could explain conditions that would later be viewed as the symptoms of PTSD. Erichsen’s thesis was supported and expanded by Clevenger (1889). Both books were used by litigant survivors of railway accidents (Figley, C. R., 1993).
Figley (1993) wrote that war became a focus of study for problems that became later known as PTSD. In war, melancholia was noted by Hammond in 1883, as having been present in combat veterans of the American Civil War. Shell shock emerged during World War I to account for PTSD like symptoms. This term was later replaced by war neurosis or traumatic neurosis. The current term, post traumatic stress disorder, became official in 1980.
Returning to railways, in 1885, a surgeon named Herbert Page rebutted Erichsen’s thesis stated in 1882 concerning railway spine (Trimble, M. R., 1981). It was his contention that survivors of railway accidents who complain of symptoms such as sleep disturbances, startle responses, and numbing of various body parts without any organic explanation, are suffering from “nervous shock.” Dr. Page, an employee for the London and Northwest Railway, “was one of the first writers to suggest a psychological origin for this heretofore mysterious disease (Figley, C. R., 1993).”
More than a century ago, Pierre Janet (1889) wrote that “when people react to experiences with “vehement emotions,” this interferes with proper information processing and appropriate action. He held that hyperarousal was responsible for the memory disturbances that accompany traumatization; interfering with information processing on a verbal, symbolic level, hyperarousal causes memories to be split off from consciousness and to be stored only somatically. Fragments of these “visceral’ memories return later as physiological reactions, emotional states, visual images, or behavioral reenactments (van der Kolk, Bessel A., & Saporta, J., 1993).”
As scientific evidence was mounting but still not yet prevailing, nineteenth century Europeans felt that someone who developed problems after a stressful life event had a weak nervous system, probably explained by heredity. Breuer and Freud (1893-95) rejected this theory. They theorized that unconscious processes contributed to stress responses. Also, they felt that traumatization had a great deal to do with the formation of neuroses (Horowitz, M., 1993).
Next in the significant chronology of post traumatic stress disorder, Emil Kraeplin (1896), the celebrated German nosologist, used the term schreckneurose (fright neuroses) to describe a specific, clinical syndrome “composed of multiple nervous and psychic phenomena arising as a result of severe emotional upheaval or sudden fright which would build up great anxiety; it can therefore be observed after serious accidents and injuries, particularly fires, railway derailments or collisions (Saigh, P. A., 1992).” Clinicians and scientists, conducting their work separately, converged in their observations and thoughts on this most difficult topic of trauma a century ago.
In 1911, Oppenheim devised the term “traumatic neurosis” while Breuer and Freud were the primary contributors. The most salient point is that the term “emerged with the growing recognition of the emotional impact of highly stressful events” (Figley, C. R., 1993).
Hermann (1992) explained that because of the catastrophe of the First World War, (1914) the reality of psychological trauma was forced upon the public consciousness. Manly honor and glory succumbed. Facing the unspeakable horrors, men began to break down in shocking numbers. The trauma was unimaginable. “Men began to act like hysterical women. They screamed and wept uncontrollably. They froze and could not move. They became mute and unresponsive. They lost their memory and capacity to feel.” One estimate by the British stated that 4% of their battle casualties resulted from mental breakdowns.
In 1918, W. H. R. Rivers, called for a humane psychotherapeutic approach to realize the goal of returning the patient/soldier to combat, not a punitive, traditionalist approach. Dr. Rivers established two principles later embraced by American, military psychiatrists. He had demonstrated, “first, that men of unquestioned bravery could succumb to overwhelming fear and, second, that the most effective motivation to overcome that fear was something stronger than patriotism, abstract principles, or hatred of the enemy. It was the love of soldiers for one another (Herman, J. L. 1992).”
In America, Scrigner (1988) stated that early 20th century, nonpsychiatric physicians, were usually doctors that concentrated on the cardiac aspects of combat soldiers in WW I. Nervousness was noted but certainly not emphasized by physicians focused on cardiac functions.
Neurologists (1919) that found themselves dealing with casualties accepted a psychological approach to the etiology and treatment of these neuroses, and techniques, such as suggestion or hypnosis were widely used (Trimble, M. R., 1981).
In a book written in 1940, Myers wrote about the distinction between shell concussion and shell shock. The book, Shell Shock in France, 1914-1919 regarded shell concussion as a neurological condition. Shell shock was seen as a psychic condition that developed because of exposure to extreme stress (Saigh, P. A., 1992).
Ivan Pavlov’s (1927) studies, like the scientists and their work cited earlier, maintained the tradition of explaining the trauma response as the result of lasting physiological alterations. Pavlov coined the term “defensive reaction”, as a term for a cluster of innate, reflexive responses to environmental threat (van der Kolk, Bessel A., & Saporta, J. 1993). Pavlov, because of his scientific orientation had a natural kinship with stress researchers like Cannon (1929) and Selye. The behaviorists, while more clinically oriented than the stress researchers, worked similarly in that they both delved into psychophysiological responses to environmental stimuli.
Another development in the chronology of post traumatic stress disorder was the work of Walter Cannon (1929). Cannon wrote about the phenomena he termed “homeostasis” and the “fight-or-flight response.” He demonstrated that when a living organism is confronted with a threat to its physical integrity, the sympathetic nervous system is activated. The physiological responses that ensued prepared the organism for fight or flight as an adaptation for survival (Scrignar, C. B., 1988).
In 1935, Prasad described the emotional distress in India following a devastating earthquake (Saigh, P. A., 1992). In 1940, with the advent of World War II, “it was recognized for the first time that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure (Herman, J. L., 1992).”
Abram Kardiner (1941) “introduced the notion that ‘traumatic neuroses’ are ‘physioneuroses’ and that individuals suffering from the condition remain on constant alert for environmental threat (van der Kolk, Bessel A., van der Hart, O., & Burbridge, J., 1995).” Kardiner felt that the startle reaction was probably a conditioned reflex. He felt it to be the central element of the post traumatic stress reaction and related it to the development of irritability and psychosomatic symptoms in these patients (van der Kolk, Bessel, A., & Saporta, J., 1993).
In 1943, Adler described the “post-traumatic mental complications” of those people that escaped the Coconut Grove Fire in Boston. Her paper is very important because she clearly references the victim’s trauma-related ideation, nightmares, insomnia, and avoidance behaviors (Saigh, P. A., 1992).
On August 5, 1945, General George Patton issued a memorandum where by soldiers who claimed to be “nervously incapable of combat” were to be branded as “cowards.” Four days later, Patton slapped a hospitalized patient who had been diagnosed as having that condition. Such practices fly in the face of the military and scientific references cited earlier (Saigh, P. A., 1992). Cowardice or psychophysiologically spent?
A major development in the chronology of PTSD, was a publication by Grinker and Spiegel (1945) that cited the problems of “returnees” from World War II who suffered from “combat neuroses.” The symptoms included restlessness, aggression, depression, memory impairment, sympathetic overactivity, concentration impairment, alcoholism, phobia and suspicion (Saigh, P. A., 1992). Some clinicians preferred the concept of stress and utilized terms like combat or battle stress, battle fatigue, combat exhaustion and acute combat reaction (Scrignar, C. B., 1988). The similarity is apparent. In any case, the symptoms read like those of PTSD victims today of combat, fire, flood, earthquake, assault, rape and other traumatic events.
In their book entitled, Men Under Stress (1945), Grinker and Spiegal, described “physical symptoms in the acute posttraumatic state that seem to reflect neurochemical changes of the catecholamine system.” They described “flexor changes in posture, hyperkinesis, ‘violently propulsive gait,’ tremors at rest, masklike faces, cogwheel rigidity, gastric distress, urinary incontinence, mutism, and a violent startle reflex”. Contemporary studies, unaware of the earlier research, repeatedly confirm that the stress hormones of people with PTSD continue to react to minor stimuli as emergencies (van der Kolk, Bessel, A., & Saporta, J., 1993).
Hans Selye, a noted Canadian researcher in physiology, studied (1946) the organism’s reaction to traumatic stimuli to which it had not adapted. He coined terms such as “the alarm reaction,” the first stage of the “general adaptation syndrome.” Suffice it to say, Dr. Selye noted that if the stress became chronic, the arousal becomes a health hazard (Saigh, P. A., 1992).
Wolf and Ripley (1947), soon after Japan’s surrender, described the emotional adjustment of 34 Allied prisoners. They had been interred by the Japanese for three years. A significant number of them had war related nightmares and fears, blunted affect, memory impairment, anger and depression (Saigh, P. A., 1992).
A very large development in the chronology of PTSD happened in 1952. The American Psychiatric Association’s (APA) Committee on Nomenclature and Statistics included gross stress reaction as a psychiatric category in its Diagnostic and Statistical Manual of Mental Disorders (DSM I). The diagnosis was justified when there was exposure to “severe physical demands or extreme stress, such as in combat or in civilian catastrophe.” Furthermore, the DSM I went on to acknowledge that “in many instances this diagnosis applies to previously more or less “normal” persons who experience intolerable stress (Saigh, P. A., 1992).
In 1958, another important work related to our present day understanding of PTSD was published by Joseph Wolpe. His research utilized cats and Dr. Wolpe demonstrated that shock administered randomly to a cat in a cage resulted in fear. The animal, sensing danger, became agitated and anxious when exposed to the cage even in the absence of shock (Scrignar, C. B., 1988). This experiment can easily be extrapolated to humans; a conditioned traumatic response can continue long after the original event and even though circumstances have changed.
Etinger (1962) interviewed 100 Norwegian survivors of the Nazi concentration camps. 85 of the 100 “presented with chronic fatigue, reduced concentration, and increased irritability” (Saigh, P. A., 1992). Furthermore, most of these cases “experienced painful associations that could occur in any connection whatsoever, from seeing a person stretching his arms and associating this with his fellow prisoners hung up by their arms under torture, to seeing an avenue of trees and visualizing long rows of gallows with swinging corpses.”
In 1968, the American Psychiatric Association published DSM II. The diagnosis of gross stress reaction from DSM I was omitted from the 1968 nosology and the category of transient situational disturbance was introduced (Saigh, P. A., 1992).
Burgess and Holmstrom, in 1974, published an influential paper on the “rape trauma syndrome.” Not an example of war or a natural disaster, but rather an individual human crime perpetrated upon another. The symptom relationship to PTSD is evident. The authors found that in the acute phase, there was general physical soreness from the attack, tension headache, sleep disturbance, genitourinary disturbances, fear, anger and guilt. The long term phase was associated with rape-related nightmares, avoidance, fear and sexual dysfunction (Saigh, P. A., 1992).
Now, as the chronology draws closer to the present time, we see very familiar and somewhat recent events. Certainly, the Vietnam War is one of those. In 1975, Horowitz’s development of characteristic symptoms following a psychologically traumatic event that is generally outside the realm of human experience was also consistent with recent professional opinions (Saigh, P. A., 1992). Herman (1992) felt that in 1980, psychological trauma became a “real” diagnosis. “Thus the syndrome of psychological trauma, periodically forgotten and periodically rediscovered through the past century, finally attained formal recognition within the diagnostic canon.”
In an experimental study to investigate differences between Vietnam veterans and a nonveteran control group, Blanchard, Kolb, Pallmeyer and Gerardi (1982) played recordings of combat sounds. At the same time, both groups were monitored in terms of blood pressure, skin temperature, forehead muscle activity, and skin resistance. The PTSD group consistently differed from the control group with regard to heart rate, systolic blood pressure, skin temperature and forehead muscle activity (Saigh, P. A., 1992).
In 1987, DSM III was revised, with the newer version being titled DSM IIIR. The nosology recognized the development of symptoms following “a distressing event that is outside the range of usual human experience.” In DSM IIIR, different classes of trauma were provided. These included direct exposure to a traumatic event, observation of another(s) trauma or hearing about a serious trauma to a close friend or relative. All three of these could result in PTSD.
Ornitz and Pynoos (1989), following Blanchard’s study, investigated startle responses in seven childhood PTSD cases and six nonclinical controls. The results clearly indicated that the PTSD cases experienced a “significant loss of normal inhibitory modulation of startle response.” The authors proposed that the traumatic experiences the subjects had encountered (i.e., a school shooting incident) induced a long term brainstem dysfunction.
In 1990, Green, Lindy, Grace, Glesser, Leonard, Korol and Winget studied 120 adult survivors of the Buffalo Creek Flood. The assessments were done 14 years after the flood. Thirty four (28.3%) individuals met the criteria of a current PTSD diagnosis these many years after the event. Further, the researchers determined that there had been a PTSD diagnosis in 1974, 53 (44.25%) of those studied would have met the DSM IIIR PTSD criteria (Saigh, P. A., 1992).
This paper has presented the chronology of the diagnosis of Post Traumatic Stress Disorder (PTSD). The result of the investigation demonstrated that an historically rich, clinically and scientifically sound, and well documented phenomenon has been described. The phenomena of trauma and its resultant pain, anguish and despair has been with us since the beginning of time; it is not a creation of modern day doctors and lawyers. Further, it is not restricted to any particular race, religion, sex, age or station in life. Rather, trauma and its consequences are not the least bit prejudiced, it can strike any one of us, at any time. Traumatic events generally, and post traumatic stress disorder specifically, are worthy of the universal fear they engender and the victims are worthy of the universal respect they deserve. Pray that you and your loved ones never have to face the consequences of either war, natural or man made disaster, or physical or sexual assault, and pray that your prayers are heard.
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