A Brief History of PTSD.
Frank Parkinson
1st August 08
Introduction.
Stress, trauma and Post-Traumatic-Stress have been around as long as there have been people on earth. Stress is a normal part of living. It enables us to stand up for what we believe and to protect ourselves and those we love but, if the stress goes beyond our ability to cope, it can lead to distress and eventual breakdown. We all experience stress and need to have strategies for coping. A ‘Prayer for the Stressed’ sums this up:
“Lord, when I am having a bad day, Getting angry with people winding me up, Help me to remember that it takes 24 muscles to frown but only 5 muscles to smile”.
This appeared on the wall of an army sergeant’s office, but he had added these words underneath:
“But only 4 to stretch out my arm and smack someone in the mouth!”
Some believe that those who suffer from stress must either be weak or have some kind of personality disorder. “What happened to the good old British stiff-upper-lip?” Is trauma a modern invention and disease? Well, the answer is, “No”. Shakespeare knew about stress and trauma. In Henry 4th Part 1, Act 2, Scene 11,Hotspur’s wife is talking about him while he sleeps and says, “In thy faint slumbers I by thee have watch’d, and heard thee murmur tales of iron wars; and thus hath so bestirr’d thee in thy sleep that beads of sweat have stood upon thy brow, andin thy face strange motions have appear’d, such as we see when men restrain their breath”.She alsomentions relationship and sexual problems. Charles Dickens, involved in a train crash in 1868, said afterwards “I have sudden vague rushes of terror even when riding in a Hansom-cab, which are perfectly unreasonable but quite insurmountable”. These are both early examples of what we could call ‘Post-Traumatic Stress’.
In the1860s American Civil War, soldiers who suffered emotionally after battle were often diagnosed with “Soldiers’ Heart” and ‘Nostalgia’. ‘Soldiers’ Heart’ was still used in the First World War with such terms as’Shell-shock’, ‘Neurasthenia’,’Hysteria’, ‘War Neurosis’ and, sometimes, ‘Cowardice’. The word ‘Hysteria’ comes from the Greek word for ‘womb’ and could suggest that a man is ‘behaving like a woman. God forbid! There seems little doubt that many who were executed, largely for desertion, were suffering from reactions which would now be labelled as Post-Traumatic Stress (P.T.S.) or even Post-Traumatic Stress Disorder (P.T.S.D.). During and after World War 1 much work was carried out by doctors and psychiatrists in treating ‘victims’ and special hospitals were opened for them but there was still an underlying belief in many that these ‘victims’ were malingerers. Treatment was varied, using sleep therapy, electric-shock treatment, rest and recuperation, exercise and, by some, the fairly new ‘talking therapy’ of Sigmund Freud. There has always been an attempt, and still is, to understand whether or not such psychological and physical reactions are caused by external events or if it is simply the fault of the sufferer who is either a degenerate or a mentally and physically weak individual. Is it the event or the individual? Concerns were, and still are today, largely centred on the words ‘Cause’ and ‘Compensation’. There were famous and influential people on both sides of the argument. In the First World War an army chaplain wrote home saying “No words can tell you how I feel - nor can words tell you of the horrors of clearing a battle-field. This battalion was left to do that and several men went off with shell-shock. I am certain that the shell-shock was caused, not just by the explosion of shells nearby, but by the sight, smell and horror of the battle-field in general. I felt awful”. In spite of this insight, therewas little use of the word ‘fear’, possibly because of a cultural belief that ‘realmen’ should not be frightened or admit to being afraid.
Combat Stress Reaction (CSR) was well known in World War 2 and in later conflicts but in spite of the fact that some 118,000 men were discharged from the British army in the first five years of the war, words such as ‘cowardice’ and ‘funking’ were used with the belief that ‘real men don’t break down when under stress’. This was typified by the use of the term ‘Lacking Moral Fibre’ in the R.A.F for air-crew who developed psychological problems. However, in World War 2, military psychiatrists were deployedbut there was still suspicion that they were bad for morale. There is a famous story about General Montgomery when a psychiatrist was posted to his Command. The psychiatrist was asked to report immediately to Montgomery but when he marched into Montgomery’s office the great man ignored him and kept on writing. He then looked up at the psychiatrist and said that he could leave. When the psychiatrist asked Montgomery why he had called him in,Montgomeryapparently replied, “I just wanted to see what a psychiatrist looked like!”
In the USA, towards the end of the war, an incident in Boston, the Cocoanut Grove Nightclub Fire, resulted in psychiatrists discovering symptoms which were not unlike those who suffered from Combat Stress Reaction. However, even after the Vietnam War there was still scepticism about trauma, some continuing to believe that it was due to weakness in individuals. The US Congress’saw no reason why they should provide facilities for the many hundreds of Vietnam Veterans (‘Vets’) who were suffering psychological problems. In any case ‘combat stress’ was not included in the psychiatric manuals. However, some began to recognise that the reactions of suffering Vets were similar to those of people from incidents of rape, serious traffic accidents, natural disasters, air crashes and the like. Eventually, in 1980, a new term, ‘Post-Traumatic Stress Disorder’ (P.T.S.D.) was included in the D.S.M – the ‘Diagnostical and Statistical Manual of Mental Disorders’ – the psychiatrists Bible. This stipulated the conditions necessary for diagnosing P.T.S.D. and the major symptoms. These included three basic groups of reactions:
Re-experiencing: (the intrusive symptoms) vivid and disturbing flash-backs to the event, re-living the experience through sensory impressions such as sights, sounds and smells, intense dreams and nightmares and distress at exposure to reminders.
Avoidance Behaviour: avoiding people, places and anything or anyone reminding them of the event, isolation from others, an inability to recall major aspects of the event, not talking about it, withdrawal from family life and work, an inability to express love and affection and little sense of a future.
Arousal: difficulty falling or staying asleep, intense irritability, difficulty in concentrating, outbursts of anger and violence, hyper-vigilance and an exaggerated startle-response.
These reactions often devastated and destroyed a person’s life and some claim that more Vietnam Vets committed suicide after the war than were killed in the war.
After the Falklands’ War the MOD denied the existence of P.T.S.D. with the claim that ‘acknowledging psychological problems would damage fighting spirit and be bad for morale and recruitment’and that psychological problems were the responsibility of the individual and civilian agencies. However a Royal Navy psychiatrist was reported as discovering that 1 in 8 veterans had psychiatric problems. He was not alone!
‘Gulf War Syndrome’, a term, coined by the media, emerged largely after the second Gulf War. Sufferers claimed that their symptoms were the result of a huge cocktail of drugs and chemicals used in the war: enriched uranium shells; vaccines against bacteriological and chemical warfare; anti-nerve-agent tablets (NAPS); organophosphate pesticide sprays and Iraqi nerve agents. Some claimed that these caused various illnesses such as motor-neurone disease, headaches, heart and other problems and even cancer, and laid people open to infection and caused neurological and physical damage. Others claimed that there was no such syndrome. In a court case against the MOD by over 300 ex-service personnelin 2003 the judge ruled that the MOD had no duty to identify sufferers so as to be able to treat them and that ‘the onus was on the individual to make known their suffering even when they were not trained to do so’. Crown and Combat Immunity applied to training, deployment, and peace-keeping operations and‘when two or more members of the Armed Forces of the Crown are engaged in the course of hostilities, one is under no duty to care in tort to another soldier...a soldier does not owe a fellow soldier a duty of care’.He also dismissed the evidence of a chaplain, who had suggested before the first Gulf War that soldiers be given psychological preparation, education, some kind of assessment and aftercare andsaid, it‘was meaningless because Chaplains did not carry a responsibility for the health of soldiers’.The claimants lost the case! So much for the centralmilitary belief that “Welfare is a function of command”!
There was still concern about ‘blame’. In the USA, post-Vietnam, 15% of all combatants were diagnosed with P.T.S.D. and research suggested that 60% of these had similar backgrounds with some of the following: dysfunctional families; frequent truancy from school; often in trouble with the police and involved in petty crime; early sexual experience and use of drugs; inability to relate successfully to peers or the opposite sex; poor educational achievement and a history of previous psychological problems. However, this does not account for the other 40% who did not have such backgrounds.
Treatment during the First World War has already been mentioned and from this war and World War 2 there emerged a system of treatment which eventually became known as the ‘I.P.E.’ system -changing the letters around it is also known as the ‘P.I.E.’ system.
I - Immediacy: symptoms should be recognised as soon as possible and the individual removed from the stressor and offered help and support.
P - Proximity: the importance of keeping the person as near to his comrades as possible - in the army, in the Regimental Aid Post,near the front-line, where he would probably know the Regimental medical officer, chaplain and medical orderlies – and not putting him in hospital because this would suggest that he was ‘ill’ and became a ‘patient in pyjamas’.
E - Expectation: reactions have to be seen by all as ‘normal’ and the condition one of being ‘temporarily indisposed’. “Given time you will recover”. With physical comfort, reassurance and support the soldier would fairly soon be back on duty with his comrades. And in many cases this worked. ‘Crisis Intervention Theory’ in the USA, post-World War 2, suggested the same things as the PIE system in helping people: be proactive, do not turn people into patients but let them know that their reactions are natural and normal and offer them reassurance, comfort and support.Apparently this ‘PIE’ system has been rediscovered in recent years by the MOD.
One important development in treatmentisthe use of Cognitive Behavioural Therapy. Part of this is a process encouraging people to look at theirexperiences and reactions using ‘Reframing’ techniques. During and after a traumatic event an individual can be overwhelmed by emotions and feelings, the facts of what happened can almost fade into the background and the normal ‘cognitive-emotive balance’ is challenged. Disturbance of this balance can contribute to the development of feelings such as self-blame, anger, loss of self-esteem, guilt , even survivor-guilt, and feelings of inadequacy and helplessness. Words and expressions such as “I could have, should have, ought to!” and the ‘If only syndrome’ can predominate and the individual takes almost total blame for what has happened, even when he or she is clearly blameless and could do nothing other than what they were able to do, or not do, at the time. Through ‘Reframing, the individual is encouraged and challenged to look at their experience from a different angle or point of view. The first Century Roman philosopher Epictetus said, “People are disturbed not so much by events as by the views which they take of them”. This approach can help someone to re-assess, understand and ‘reframe’ their experiences and help them to move towards and to restore a more positive cognitive-emotive balance.
Psychological Debriefing and Critical Incident Debriefing have been used following traumatic experiences such as war and combat and were used before the first Gulf War broke out with military personnel held hostage in Iraqand with the military Graves’ Registration Team. Much controversy has been caused by these, resulting in generally abandoning its use. Some researchers claimed that these techniques made people worse. However,the two most influential pieces of research have been shown not to be research into ‘proper’ Debriefing. Certain key protocols and rules laid down by the founders of these techniques,Dr Jeffrey Mitchell in the USA and Dr Atlé Dyregrov in Norway,were not observed: debriefers were not properly trained; sessions were too short or of limited time; debriefings were conducted at the wrong time and in the wrong place; debriefees generally experienced more traumatic events that those in the ‘control groups’. Also, the aims of Debriefing have been misrepresented. Debriefing was not designedas an anti-dote to the development of P.T.S.D. but to help people to cope better after incidents and to understand what has happened to them and how and why they have reacted. It also encourages a process of ‘normalising’ reactions and giving reassurance and information about resources for helping and referral, should they be needed. Debriefing should be one part of a much wider approach to trauma and Stress Management to include education, information giving and support to create‘a climate of acceptance, especially within organisations, of the normality of reactions’.
Treating P.T.S.D. however, is much more complex and usually involves treatment which can either be over a long period of time or from ‘in-house’ treatment as offered by ‘Combat Stress’, the Ex-Service’s Mental Welfare Society. Some of the techniques used in treatment, often used with other techniques listed are; Psychotherapy, Cognitive Behavioural Therapy and Reframing, various forms of personal and group Counselling or therapy,Defusing and Psychological Debriefing, medication and drugs, relaxation techniques, exercise and massage, diet, drawing and painting, Eye Movement Desensitising and Reprocessing (EMDR), recording personal stories and listening to them, exposure therapy, systematic desensitisation, flooding andthe use of cultural and religious resources including re-unions and memorial services. The Royal Marines have developed a system called ‘Trauma Risk Management’, or ‘TRiM’, which uses techniques of assessment and a form of defusing after return from deployment. This is being encouraged within the Armed Forces and isalso used by some civilian organisations.
P.T.S.D. is now accepted by most as a genuine psychiatric condition and not the result of personal weakness or inadequacy but there are still sceptics who blame the individual. They tend to see the desire for compensation as the driving force behind those who campaign. It is alleged that not many years ago, at the ArmyStaffCollege, a lecturer referred to P.T.S.D. as ‘compensationitis’. We are still left with the problems of stigma and of unhelpful attitudes, from some, towards those who develop physical or psychological problems plus a lack of appropriate resources and funding for treatment during and especially after leaving the Services. There are still those who will claim that certain reactions are signs of weakness or of some form of personality disorder and, especially, that if you do not cope you are not a ‘real man’.
Perhaps the clue to treatment is that, as far as possible, those who suffer are helped to integratetheir traumatic experiences into their lives. One image is that some sufferers are like people walking along ‘the road of life’ trying to leave their experiences and reactions at the roadside. However, such experiences can be seen as tied to us by an elastic rope and we try to dump them and leave them behind. As we walk away the rope stretches until eventually it reaches a point where the elastic reacts and these experiencesare brought from the past, hurtle into the present and hit us on the back of the head! It seems to be much healthier to grasp these experiences, face up to them, no matter how painful, and incorporate and integrate them into who and what we are.
One interesting development is the research taking place in trying to understand how the brain works and what processes take place in the brain of someone suffering from P.T.S.D.The hope is that understanding how organs in the brain like the amygdala, hippocampus, hypothalamus and the limbic system operate in processing information and experiences might help us to treat and help those who suffer. This research is still in its infancy but could lead to greater understanding of how and why people develop P.T.S.D. with positive results in terms of treatment and in the use of appropriate medication.