Posttraumatic Stress Disorder

   (PTSD)

   (See also Psychosis: Emergence: psychogenic [reactive] psychoses [1916].) Interest in the psychiatric consequences of trauma initially arose following the enactment of health and accident insurance systems in the second half of the nineteenth century. The consequences of accidents became litigable in court. The initial trigger of litigation was "railway spine," supposed injuries to the spinal cord following a railway accident.

   "Railway spine" (origin vague but in common use from the 1860s). In 1866, London surgery professor John Eric Erichsen (1818–1896), in six published lectures entitled On Railway and Other Injuries of the Nervous System, argued that physical symptoms following railway and other accidents that otherwise had left no evidence of a lesion were in fact organic in nature. ("No injury of the head is too trivial to be despised.") In his On Concussion of the Spine: Nervous Shock, and Other Obscure Injuries of the Nervous System, published in 1875, Erichsen spelled out his ideas more fully: " direct your attention to a class of cases in which the injury inflicted upon the back is either very slight in degree, or in which the blow, if more severe, has fallen upon some other part of the body than the spine, and in which, consequently, its influence upon the cord has been of a less direct . . . character. Nothing is more common than that the symptoms of spinal mischief do not develop for several days after heavy falls on the back" (pp. 36–37). For a while, spinal concussion was referred to as "Erichsen’s disease." This "organicity" argument became a target for more psychologically minded researchers to shoot at in coming decades. Erichsen abjured the "absurd appellation of the ‘railway spine’ " and did not use it.

   In 1881, Carl Moeli (1849–1919), a staff psychiatrist at Berlin’s Charité hospital, without mentioning Erichsen, discussed frank psychiatric changes following railroad accidents in four patients whose injuries were minor; it was, he said, clearly the traumatic psychological experience of the accident itself that had produced psychiatric changes. This is probably the first partial description of what was later known (in the DSM-III in 1980) as "posttraumatic stress disorder," or PTSD. Moeli’s article "On Psychic Disturbances Following Railroad Accidents" ("Über psychische Störungen nach Eisenbahnunfällen") appeared in the Berlin Clinical Weekly (Berliner Klinische Wochenschrift).

   In the English-speaking world, Herbert Page’s (1845–1926) Injuries of the Spine and Spinal Cord Without Apparent Mechanical Lesion and Nervous Shock in Their Surgical and Medico-Legal Aspects (1883) undertook a specific refutation of Erichsen. Page, who graduated in medicine in 1870, had his practice in London’s fashionable Harley Street and consulted to several railway companies as well as being surgeon to St. Mary’s Hospital. "There is something so altogether indefinite in the expression ‘concussion of the spine’—the ‘spine’ being so commonly used as a comprehensive term for muscles, ligaments, bones, joints, membranes, spinal fluid, spinal marrow and nerves going off from it—that when we speak of ‘concussion of the spine’ we must perforce use an expression scientifically inaccurate, and either more or less than adequate to describe a lesion affecting one only of the elements of which the ‘spine’ is composed" (p. 52). This kind of imprecision could only encourage litigation, he said. Nervous shock, for Page, was essentially psychological: "The collapse from severe bodily injury is coincident with the injury itself, or with the immediate results of it, but when the shock is produced by purely mental causes the manifestations thereof may be delayed" (p. 148).

   The issues raised by Erichsen, Moeli, and Page continued to reverberate in medicolegal settings for decades thereafter, and even today it is litigable to what extent trauma from accidents has psychological as well as physical causes.

   "Traumatic hysteria" (traumatic neurosis) (from 1877). In a lecture at the Salpêtrière hospice in December 1877, Jean-Martin Charcot described as "local hysteria" the disability of a body part arising from minor, local trauma. Charcot acknowledged that the English surgeon Benjamin Brodie (1783–1862) had floated the concept in 1837. Yet, Charcot’s was a more comprehensive description. The lecture was summarized in Progrès médical on May 4, 1878.

   In 1888, Hermann Oppenheim (1858–1919) in Berlin, the leading neurologist of his day, coined the phrase "traumatic neurosis" in the Berlin Clinical Weekly (Berliner Klinische Wochenschrift) in reference to railways accidents. There were, he said, psychiatric symptoms: "Most of the core symptoms concern the psyche and especially the affective domain. Mood changes and reactivity constitute the core of the mental side of the disorder" (p. 167). Yet, he considered the apparent neurological changes organically caused. Following the legislation on health-insurance in 1889 of the German chancellor Otto von Bismarck (1815–1898), the Imperial Insurance Office accepted "traumatic neuroses" (traumatische Neurosen) as an official diagnosis. As well, in 1889 Oppenheim published Traumatic Neuroses (Die traumatischen Neurosen), insisting that functional symptoms following accidents had in all likelihood an organic basis. He refused to believe such symptoms were an aspect of hysteria. This remained the single most influential work on the subject until the First World War, during which Oppenheim’s beliefs about organicity became widely discredited. From the fourth edition of his textbook Psychiatry (Psychiatrie) in 1893 onward, Emil Kraepelin incorporated Oppenheim’s traumatic neurosis, or "fright neurosis" (Schreckneurose), the term Kraepelin preferred, in his nosology.

   The war neuroses: "shell shock," et cetera (from 1915). (See also Anxiety and Phobias: "irritable heart" [soldiers’ heart] [1871].) In the tradition of Oppenheim, previous posttraumatic diagnoses had focused more on pseudoneurological symptoms. With the rise of the war neuroses, psychiatric symptoms as such become attributable to trauma. Such terms as "soldiers’ heart," "war neuroses" (Kriegsneurosen), and "general nervous shock" had been used to refer to the psychological casualties of combat even before the First World War. Yet, it was in 1915 that Charles S. Myers (1873–1946), a medically qualified psychologist with the British Expeditionary Force fighting in France, used, in an article in the Lancet, the new military term "shell shock" for the large numbers of psychological casualties who had started to be evacuated home as early as December 1914. (The war began in August 1914.) The term became enormously popular as way of explaining posttraumatic stress in soldiers without attributing it to "hysteria."

   In the United States, it was Thomas W. Salmon (1876–1927), medical director of the National Committee for Mental Hygiene (see Clifford Beers), who helped create a psychiatric service for the United States Army. According to historian Ben Shepherd, author of A War of Nerves, Salmon advocated diminishing shell shock by keeping out of military service "all insane, feeble-minded, psychopathic and neuropathic individuals" (p. 125).

   During the Second World War, the U.S. military used the term "operational fatigue" (or "combat fatigue") for what had previously been called shell shock. As Roy R. Grinker, Sr. (1900–1993) and John Paul Spiegel (1911–?), medical officers in the Army Air Forces, noted in their book Men Under Stress in 1945, "[Such] terms are temporary expedients to hide the neurotic nature of the illness to which they are usually applied. . . . Unlike the diagnosis of neurosis, which is prejudicial, this diagnosis permits the grounding of a man and his subsequent return to flying status" (p. 208). Yet, Grinker and Spiegel stipulated that the phrase "operational fatigue" was just a synonym for "war neuroses." (On Grinker and Spiegel, see Barbiturates: narcotherapy.)

   "Acute grief" (1944). Following a fire at the Coconut Grove night club in Boston on November 28, 1942, 491 people died and psychiatric symptoms set in among many of the survivors and relatives of the victims. Harvard psychiatrist Erich Lindemann (1900–1974), who was already interested in the consequences of grief for gastrointestinal disorders, was called in to counsel the afflicted, and in the American Journal of Psychiatry in 1944, he described preventive intervention—meaning counselling and "verbalizing his feelings of guilt"—in the management of "acute grief." "It is of the greatest importance," Lindemann said, "to notice that not only over-reaction but underreaction of the bereaved must be given attention, because delayed responses may occur at unpredictable moments and the dangerous distortions of the grief reaction, not conspicuous at first, be quite destructive later and these may be prevented" (p. 147). The article placed trauma on the map for American psychiatry as a source of psychiatric symptomatology. The techniques he described became part of the counseling of patients with posttraumatic stress disorder (see below).

   "Posttraumatic stress disorder" (1980 and after). Following a persistent political campaign by the Vietnam War veterans, led in part by such figures as Yale psychiatry professor Robert Jay Lifton (1926–), in 1980 the American Psychiatric Association accepted in its new diagnostic manual, DSM-III, the diagnosis posttraumatic stress disorder (PTSD), listing both acute and "chronic or delayed" versions. Classified under the anxiety section, PTSD was said to occur "following a psychologically traumatic event that is generally outside the range of usual human experience." The syndrome consisted of (1) "reexperiencing of the trauma," as evidenced by recurrent recollections of it, by dreams, and by the sudden feeling that it was reoccuring; (2) a psychological "numbing," characterized by diminished interest in normal events, feelings of detachment, and emotional narrowing; (3) two out of six such symptoms as "exaggerated startle response" or "trouble concentrating" (pp. 237–238).

   DSM-III-R (1987) considerably increased the number of symptoms, any two of which would permit a patient to qualify for the diagnosis, adding, for example, "anniversaries of the trauma," and "persistent symptoms of increased arousal" such as irritability and reactivity to events somewhat resembling the circumstances of the trauma (p. 250).

   DSM-IV (1994) added characteristic symptoms that might be expected in young children with PTSD, such as "repetitive play . . . in which themes or aspects of the trauma are expressed" (p. 428). According to medical historians Mark Micale and Paul Lerner in their book, Traumatic Pasts, "At the beginning of the twenty-first century, PTSD is perhaps the fastest growing and most influential diagnosis in American psychiatry" (p. 3). PTSD clinics proliferate, and the U.S. Society for Traumatic Stress, founded in 1985, has given risen to a far-flung international network of traumatic-stress societies. The concept has not remained without sceptics, however, and readers may the consult The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (1995) by McGill University anthropologist Allan Young (1938–), on the conversion of what was formerly known as shell shock into a growth industry. In 2000, the Pfizer company began indicating its product Zoloft (sertraline), initially launched in 1992 as an antidepressant, for "posttraumatic stress disorder." (See Selective Serotonin Reuptake Inhibitors.)