After Gilgamesh loses his friend Enkidu, he experiences symptoms of grief, as one may expect. But after this phase of mourning, he races from place to place in panic, realizing that he too must die. This confrontation with death changed his personality.
The first case of chronic mental symptoms caused by sudden fright in the battlefield is reported in the account of the battle of Marathon by Herodotus, written in bc History, Book VI, transi. George Rawlinson :. A strange prodigy likewise happened at this fight. Epizelus, the son of Cuphagoras, an Athenian, was in the thick of the fray and behaving himself as a brave man should, when suddenly he was stricken with blindness, without blow of sword or dart; and this blindness continued thenceforth during the whole of his afterlife.
The following is the account which he himself, as I have heard, gave of the matter: he said that a gigantic warrior, with a huge beard, which shaded all his shield, stood over against him; but the ghostly semblance passed him by, and slew the man at his side.
Such, as I understand, was the tale which Epizelus told. It is noteworthy that the symptoms are not caused by a physical wound, but by fright and the vision of a killed comrade, and that they persist ewer the years. The loss of sight has the primary benefit of blotting out the vision of danger, and the secondary benefit of procuring support and care.
William Ellery Leonard :. The minds of mortals Kings take the towns by storm, succumb to capture, battle on the field, raise a wild cry as if their throats were cut even then and there.
And many wrestle on and groan with pains, and fill all regions round with mighty cries and wild, as if then gnawed by fangs of panther or of lion fierce.
This text shows very vividly the emotional and behavioral reexperiencing of a battle in sleep. Jean Froissart ? He sojourned in at the court of Gaston Phoebus, Comte de Foix, and narrated the case of the Comtc's brother, Pierre dc Beam, who could not sleep near his wife and children, because of his habit of getting up at night and seizing a sword to fight oneiric enemies. The fact that soldiers are awakened by frightening dreams in which they rcexperience past battles is a common theme in classical literature, as, for instance, Mercutio's account of Queen Mab in Shakespeare's Romeo and Juliet I, iv :.
Etiologic hypotheses were put forward by army physicians during the French Revolutionary wars and the Napoleonic wars They had observed that soldiers collapsed into protracted stupor after shells brushed past them, although they emerged physically unscathed. I could soon realize that something unusual was happening in me Your eyes can still see with the same acuity and sharpness, but it is as if the world had put on a reddish-brown hue that makes the objects and the situation still more scary I had the impression that everything was being consumed by this fire The psychiatrist Pinel is often depicted as freeing the insane from their chains; in his treatise entitled Nosographie Philosophique , he described the case of the philosopher Pascal who almost drowned in the Seine when the horses drawing his carriage bolted.
During the remaining eight years of his life, Pascal had recurring dreams of a precipice on his left side and would place a chair there to prevent falling off his bed.
His personality changed, and he became more apprehensive, scrupulous, withdrawn, and depressive. The Industrial Revolution and the introduction of steamdriven machinery were to give rise to the first civilian man-made disasters and cases of PTSD outside the battlefield. The public's imagination was struck by the first spectacular railway disasters, and physicians at the time were puzzled by the psychological symptoms displayed by survivors.
This controversy was to last until World War I. This new diagnosis was vehemently criticized by Charcot who maintained that these cases were only forms of hysteria, neurasthenia, or hystero-neurasthenia. This was a first glimpse of what would later be known as the unconscious. The Russian-Japanese war was marked by the siege of Port Arthur and the naval battle of Tsushima. It was probably during this conflict that post-battle psychiatric symptoms were recognized for the first time as such by both doctors and military command.
Russian psychiatrists - notably Avtocratov, who was in charge of a bed psychiatric clearing hospital at Harbin in Manchuria - are credited with being the first to develop forward psychiatric treatment. This approach may have been a response to the difficulty of evacuating casualties over huge distances at a time when the Trans-Siberian Railway was not yet completed. Whatever the initial reason, forward treatment worked, and would again be confirmed as the best method during succeeding conflicts.
The number of Russian psychiatric casualties was much larger than expected in and in and the Red Cross Society of Russia was asked to assist. This dubious distinction is also, to a lesser degree, shared by the American Civil War. Psychiatric casualties were reported very early in the war, in numbers that no-one had anticipated. The big artillery battles of December From then on, that number grew at a constantly increasing rate.
At first, these soldiers were hospitalized with the others Now, psychiatric patients make up by far the largest category in our armed forces The main causes are the fright and anxiety brought about by the explosion of enemy shells and mines, and seeing maimed or dead comrades The resulting symptoms are states of sudden muteness, deafness In the British military, patients presenting with various mental disorders resulting from combat stress were originally diagnosed as cases of shell shock, before this diagnosis was discouraged in an attempt to limit the number of cases.
It is not known when the term began to be used. These patients had been shocked by shells exploding in their immediate vicinity and presented with remarkably similar symptoms. As we shall see below, these patients might not have been evacuated to the peaceful surroundings of their home country had they sustained their wounds a year later. Indeed, the experience of the first war months and the unexpected large influx of psychiatric casualties led to a change in treatment approaches.
The evacuation of psychiatric casualties to the rear became less systematic as the experience of the remaining war years convinced psychiatrists that treatment should be carried out near the frontline, and that evacuation only led to chronic disability.
It was noticed that soldiers treated in a frontline hospital, benefiting from the emotional support of their comrades, had a high likelihood of returning to their unit, whereas those who were evacuated often showed a poor prognosis, with chronic symptoms that ultimately led to discharge from the military.
Also, it was discovered that prognosis was better if the convalescing soldiers remained in the setting of the military hierarchy, rather than in a more relaxed hospital environment. Thus, by the end of , evacuations became rare and patients were treated instead in forward centers, staffed by noncommissioned officers NCOs , within hearing distance of the frontline guns and with the expectation of prompt recovery.
Salmon, 12 chief consultant in psychiatry with the American Expeditionary Forces in France: immediacy, proximity, expectancy, simplicity, and centrality. Immediacy meant treating as early as possible, before acute stress was succeeded by a latent period that often heralded the development of chronic symptoms; proximity meant treating the patient near the frontline, within hearing distance of the battle din, instead of evacuating him to the peaceful atmosphere of the rear, which he would, understandably, never wish to leave; expectancy referred to the positive expectation of a prompt cure, which was instilled into the patient by means of a persuasive psychotherapy; simplicity was the use of simple treatment means such as rest, sleep, and a practical psychotherapy that avoided exploring civilian and childhood traumas; finally, centrality was a coherent organization to regulate the flow of psychiatric casualties from the forward area to the rear, and a coherent therapeutic doctrine adopted by all medical personnel.
Salmon's principles were disccwered independently and applied universally by all warring sides; only to be forgotten, and rediscovered again, during World War II. Among the many treatment applied to stress disorders, one was much used during WWI, and scarcely at all during WWII: the application of electrical current, also called faradization. This was probably because motor symptoms, such as tremor, paralysis, contractions, limping, or fixed postures, were common during WWI, and rare in WWII.
Faradization was criticized in post-war Austria; WagnerJauregg - a professor of psychiatry in Vienna who was awarded a Nobel prize in - was even accused of excessive cruelty in the administration of this treatment and had to appear before an investigation committee, in which Sigmund F'rcud had the more enviable role of testifying as an expert. Etiology was a controversial question that was reflected by the choice of terms: shell shock or war neurosis? Soma or psyche? The now obsolete term shell shock, harking back to the vent du boulet of the Napoleonic wars, implied a somatic etiology, such as microscopic brain lesions due to a vascular, meningeal, white or gray matter concussion.
Other diagnoses were also used to express the belief that the cause was more an emotional stressor, rather that a physical concussion. Such diagnoses were, for instance, war neurasthenia and war psychoneurosis, in France. Emil Kraepelin , without doubt one of the most influential psychiatrists of our times, wrote about his experience with war neuroses during WWI in his autobiography, published posthumously in German in 15 :.
We alienists all agreed that we should try to limit an excessively liberal granting of compensations which might lead to a sharp rise in the number of cases and claims Kraepelin's comments typify the controversies that raged at the time: i were the mental symptoms nothing more than malingering, with the clear objective of getting away from the frontline? Some British and Commonwealth soldiers were actually shot on the orders of military command and this number certainly included soldiers suffering from acute stress disorder who walked around dazed or confused and were accused of desertion or cowardice; ii Did posttraumatic symptoms have pathoanatomical explanations?
The cases of war neurosis observed during WWI were indeed a challenge to psychoanalytical theories; it was simply unbelievable that all cases were caused by childhood traumas and it had to be admitted that psychological symptoms could be produced by recent traumas. Freud had postulated that dreams were a wish fulfillment. Not until , in an address at an international congress of psychoanalysts, did he allow one exception: the case of traumatic dreams, dreams that recall recent accidents or childhood traumas.
And even this turned out to bc no real exception at all: Freud eventually understood traumatic dreams as fitting into his wish-fulfillment theory of dreams in that they embodied the wish to master the trauma by working it through. Despite WWI, most armies were once again unprepared for the great number of psychiatric casualties and psychiatrists were often viewed as a useless burden, as exemplified by a memorandum addressed by Winston Churchill to the Lord President of the Council in December, , in the following terms I am sure it would be sensible to restrict as much as possible the work of these gentlemen [psychologists and psychiatrists] In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience.
The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters such as earthquakes, hurricanes, and volcano eruptions , and human-made disasters such as factory explosions, airplane crashes, and automobile accidents.
They considered traumatic events to be clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness, financial reverses, and the like. This dichotomization between traumatic and other stressors was based on the assumption that, although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.
PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic.
Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress. Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified.
Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat.
Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations.
Although there is currently a renewed interest in subjective aspects of traumatic exposure, it must be emphasized that events such as rape, torture, genocide, and severe war zone stress are experienced as traumatic events by nearly everyone. One important finding, which was not apparent when PTSD was first proposed as a diagnosis in , is that it is relatively common.
A fifth criterion concerned duration of symptoms; and, a sixth criterion stipulated that PTSD symptoms must cause significant distress or functional impairment.
The latest revision, the DSM-5 , has made a number of notable evidence-based revisions to PTSD diagnostic criteria, with both important conceptual and clinical implications 9. Such presentations are marked by negative cognitions and mood states as well as disruptive e. Furthermore, as a result of research-based changes to the diagnosis, PTSD is no longer categorized as an Anxiety Disorder. PTSD is now classified in a new category, Trauma- and Stressor-Related Disorders, in which the onset of every disorder has been preceded by exposure to a traumatic or otherwise adverse environmental event.
Other changes in diagnostic criteria will be described below. Indirect exposure includes learning about the violent or accidental death or perpetration of sexual violence to a loved one.
Exposure through electronic media e. On the other hand, repeated, indirect exposure usually as part of one's professional responsibilities to the gruesome and horrific consequences of a traumatic event e.
Before describing the B-E symptom clusters, it is important to understand that one new feature of DSM-5 is that all of these symptoms must have had their onset or been significantly exacerbated after exposure to the traumatic event.
The "B" or intrusive recollection criterion includes symptoms that are perhaps the most distinctive and readily identifiable symptoms of PTSD. For individuals with PTSD, the traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that retains its power to evoke panic, terror, dread, grief, or despair. These emotions manifest during intrusive daytime images of the event, traumatic nightmares, and vivid reenactments known as PTSD flashbacks which are dissociative episodes.
Furthermore, trauma-related stimuli that trigger recollections of the original event have the power to evoke mental images, emotional responses, and physiological reactions associated with the trauma. Researchers can use this phenomenon to reproduce PTSD symptoms in the laboratory by exposing affected individuals to auditory or visual trauma-related stimuli The "C" or avoidance criterion consists of behavioral strategies PTSD patients use in an attempt to reduce the likelihood that they will expose themselves to trauma-related stimuli.
PTSD patients also use these strategies in an attempt to minimize the intensity of their psychological response if they are exposed to such stimuli. Behavioral strategies include avoiding any thought or situation which is likely to elicit distressing traumatic memories. In its extreme manifestation, avoidance behavior may superficially resemble agoraphobia because the PTSD individual is afraid to leave the house for fear of confronting reminders of the traumatic event s.
Symptoms included in the "D" or negative cognitions and mood criterion reflect persistent alterations in beliefs or mood that have developed after exposure to the traumatic event.
People with PTSD often have erroneous cognitions about the causes or consequences of the traumatic event which leads them to blame themselves or others. A related erroneous appraisal is the common belief that one is inadequate, weak, or permanently changed for the worse since exposure to the traumatic event or that one's expectations about the future have been permanently altered because of the event e. In addition to negative appraisals about past, present and future, people with PTSD have a wide variety of negative emotional states such as anger, guilt, or shame.
Dissociative psychogenic amnesia is included in this symptom cluster and involves cutting off the conscious experience of trauma-based memories and feelings.
Treatments improved through the advent of group therapy and newly created psychotropic medications. Modern definitions of PTSD gained national spotlight in the s, as countless Vietnam veterans began experiencing a host of psychological problems, many persisting upon their return home.
Social movements in the s began to study Holocaust survivors, Vietnam veterans, and survivors of domestic abuse. This research was a pioneering force in drawing attention to the effects of trauma. These research and social efforts gave way to further understanding and the official description of PTSD in At that time, post-traumatic stress disorder was finally adopted into the Diagnostic and Statistical Manual of Mental Disorders DSM , considered the definitive text for diagnosis among those in the psychological professions.
In the s, new treatments for PTSD began to crop up. Eye-movement desensitization and reprocessing EMDR , newer generations of medications, and new approaches to therapy have all been continually developing in the last years.
If you or someone you love has experienced a trauma and would like to learn more about modern treatment and support, Black Bear Rehab can help.
Our dedicated team of treatment experts can help you and those you love get back to feeling good again, despite past traumas.
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