The role of warfare and genocide in the history of PTSD, important contributions

Main theme: Psychiatry at war

 

Post-traumatic stress disorder (PTSD) appeared for the first time in the Diagnostic and Statistical Manual of nervous and mental disorders DSM-III 1980. At that time, some believed PTSD was unnecessary and a “political” diagnosis, because it came in the wake of the war in Vietnam as well as a government task force to study the situation of the Vietnam veterans in the USA. It just serves to illustrate that every war makes the consequences visible, while they might drown or become underrecognized when the causative links become difficult to perceive.



But of course, PTSD has always existed whether it was officially diagnosable or not. Descriptions of symptoms that would now be recognised as PTSD can be found in the literature. Homeros described the wrath of Achilles (the extraordinary potential for anger in veterans), Shakespeare lady Macbeth (who will never sleep again and constantly hallucinates her own atrocities), to mention a few. Even historical accounts can be found, of which Samuel Pepys’s diary is the well-known example, with a description of the great fire of London, and his subsequent period of hypervigilance, sleeplessness, and reactions to reminders.


World War I (WWI) was one of the first examples of a war that has left clear imprints in the medical literature, maybe since so many subjects were exposed to traumatic experiences of a new type because of the shelling, the trenches, biological warfare; all of it in the middle of Europe, where the doctors were French-, German- or English speaking, and there was international exchange for many years before the wars.


One of the prevalent diagnoses of the 19’th century was hysteria, and there was an interest in hypnosis. Most of us remember the well-known painting of Charcot on La Salpêtrière, demonstrating a female patient in arc-de-cercle, with many important figures of contemporary European neurology present, such as Sigmund Freud. Other persons who were present are Babinski (known for the reflex), and Pierre Janet, who was almost forgotten until Onno van der Hart discovered his writings. According to some, Janet understood hysteria (dissociation) better than most of his contemporaries, but since he destroyed most of his records and case descriptions before he died, he was almost forgotten. Among the disciples of Charcot was even the Swedish doctor Axel Munthe who wrote his doctoral dissertation with Charcot as supervisor.


At La Salpêtrière, an important diagnostic concern was how to distinguish between neurosyphilis and hysteria. Amongst the other doctors present at the famous painting, Janet was the one who was most interested in psychological trauma.


So, before WWI, hysteria and its causes were neurological issues because it was a diagnostic challenge to know for instance if a seizure was epileptic or functional (in which case it was called epileptoid). Often hysteria was treated by hypnosis, a treatment modality that has been forgotten to a large extent. The effects of some forms of hypnosis were ascribed to animal magnetism until Bernheim of the Nancy School could show that the single and necessary feature that could explain the effect of hypnosis was the use of suggestion during trance; a naturally occurring state. But until then, “electricity” had even played a part in some forms of hysteria, namely hysterical paresis. By using “Faradic stimulation” -electric currents – it could be demonstrated to patients that their muscles were able to contract, and thus they could be convinced to forget their symptoms.


These are just a few features of the time preceding WWI, that could have influenced medical thinking…


One of the features of WWI was as mentioned the advent of modern artillery, bombs of a hitherto unknown force, the fronts that stood still between trenches, and biological warfare with nerve gas. A new condition appeared when the bombings with unforeseen power and strong pressure waves caused physical damage in the form of cerebral concussion, as well as mass destruction with emotional traumas for the survivors, who might become buried in the trenches and dug out in the last moment. It was difficult for military physicians to diagnose the difference between a cerebral concussion and mental conditions related to the emotional impact of warfare.


W. H. R. Rivers


British physician, anthropologist, and researcher, who founded a laboratory for experimental psychology when he was a lecturer at Cambridge. He did service during the First World War as a psychiatrist at a military hospital, Craiglockhart in Scotland. There he took care of officers with so-called “shell shock” and returned to Cambridge after the war, where he had studied perception and consciousness. Rivers died of a sudden illness in 1922.


In a series of lectures in 1919 in Cambridge, and 1920 at Johns Hopkins in Baltimore, Rivers outlined some important biological principles regarding the nervous system, memory, and consciousness, as well as the reactions in animals and humans related to “the instincts of self-preservation” during danger. An important paper “The Repression of War Experience” is published in Lancet.


Rivers’ reflects on suppressed memories, based on a few case descriptions of himself and a patient with a phobia. “We can be confident that when an experience is suppressed on account of its unpleasant nature, it may take with it a vast mass of neutral experience which would have remained accessible to consciousness if it had not been associated with experience needing suppression” and is however easily accessible by hypnosis.


In association with memory, he points out that it is more noteworthy what people sometimes cannot forget, than forgetting things that are not useful any longer. He described perceptions in the subcortical systems, such as crude sensations, which when accessing higher cortical and combined with phylogenetically more recent sensations, will lose their overwhelming character. It reminds very much of PTSD where the sufferer is plagued by intrusions of seemingly fragmented memories, to which, when they develop into semantic memories, he can gain a distance. And eventually deal with new aspects of the experience (such as can be seen during a single EMDR session where the fear subsides, changes into anger, then sadness, etc.).


He further describes the reactions to danger in man and animals (pp 53-55). “I shall first describe the reactions to danger which can be objectively observed, and then attempt the more difficult task of connecting these with forms of emotion or other forms of conscious response”. He then outlines the following five chief forms of reaction to danger:


  • Flight. “Flight from danger is probably the earliest and most deeply seated of the various lines of behaviour by which animals react to conditions which threaten their existence or their integrity… Flight may be regarded as the development of the reaction of the repulsion from the noxious which is one of the fundamental modes of response to stimulation … repulsion from the harmful”.

  • Aggression. “The second danger instinct, …opposite of flight…. Since it will only come into play where the source of danger is another animal, this instinct must be later than that of flight…”

  • Manipulative Activity. “I have had great difficulty in finding a term for the mode of reaction to danger I have now to consider... The normal reaction of healthy man... whereby the danger can be overcome.

  • Immobility. “The mode of reaction now to be considered differs fundamentally from them in that it involves the complete cessation of movement, complete inhibition or suppression of the movements which would be brought into being by the instincts of flight and aggression, or by manipulation. The instinct which thus leads to the complete absence of movement seems to go very far back in the animal kingdom”...

  • Collapse. “This last form of reaction to danger is one that has greatly puzzled biologists. The reaction is usually accompanied by tremors or irregular movements which wholly deprive the reaction of any serviceable character it might possess………. I think we shall take a more natural view of the reaction by collapse if we regard it as a failure of the instinct of self-preservation taking place in animals when instinctive reactions to danger have been so overlaid by reactions of other kinds that, in the presence of excessive or unusual stimuli, the instinctive reactions fail. It is noteworthy that collapse with tremor seems to be especially characteristic of Man in whom all the different modes of reaction to danger found in the animal kingdom are present to some degree, but no one of them so specially developed as to an immediate and invariable mode of behaviour in the presence of danger.”


“While these reactions can be observed directly, the accompanying affects can be inferred with some certainty. Fear and flight seem to belong, as well as Anger and Aggression”. Manipulative activity, according to Rivers, is devoid of fear and pain sensitivity, an observation made by many others. “The complete suppression of pain and fear, even in the presence of imminent danger, may also take place when any form of serviceable activity is impossible”.


On collapse and immobility, he writes: “Though immobility and collapse resemble each other superficially, I suppose them to be poles so far apart as the accompanying affect is concerned. In dealing with collapse as a mode of reaction, I pointed to interference with flight or with some other form of serviceable activity as its most important conditions. In this obstruction to normal instinctive modes of reaction by which danger would be avoided, we have a satisfactory explanation of the excess of affect by which it is characterized...”


The terminology he used was aimed at clarifying some important notions. He used the term suppression to discern phenomena that seemingly disappear out of consciousness by natural processes, such as when more mature parts of the brain or nervous system take over from lower or older parts (as an example childhood amnesia; or when a severed nerve heals, transforming painful crude sensations to epicritic perception). He anchors the reactions to danger in phylogenesis and thus clarifies reactions that might easily be interpreted as simulation. For instance, social animals sometimes must act in unison, thus the phenomena of hysteria and hypnosis might have a phylogenetic explanation.


Repression, on the other hand, is the willful attempt to avoid thinking about something that causes fear or is disturbing in other ways. He pointed out that this was probably the reason for much illness; in a paper on war neurosis, he explains how soldiers are often taught to avoid thinking or talking about negative experiences. With “repression”, he is very close to avoidance. He explains that the cure for this (sleeplessness, nightmares, intrusive thoughts, etc) is to go through the war experiences “in every nut and bolt” in the psychotherapeutic treatment.


Charles S. Myers


Charles S. Myers was a colleague at Cambridge and took over the laboratory for experimental psychology after Rivers died. 1940, he wrote “Shell Shock in France 1914-1918, Based on a War Diary”.


Charles S. Myers was a physician and researcher in perception and experimental psychology, among others. During the first world war, he served as an army physician. His book on Shell Shock was published in 1940, and it is partly a detailed history of his experiences during the endeavours of setting up facilities for soldiers with mental symptoms during the war.


His book deals with multiple subjects at the same time. The war was in many ways a new type of warfare, with bombs and trenches. One important phenomenon was the shelling caused by very forceful artillery on the frontline. The vehement explosions caused much bodily damage. The unconscious wounded soldiers might well suffer from a cerebral concussion, and many persons with severe emotional shock ended up in army hospitals because they were at one time suspected of having a cerebral concussion.


Myers published a paper in 1915 where he interprets “shell shock” as a hysterical reaction to severe emotional trauma.


In his book from 1940, many case descriptions are used to convey what is going on in “Shell shock”. One example; “This man had been buried by a shell eight months before, and for the past six months had been employed on police duty in a large town. Of late he had been worrying over his sick wife, sleeping badly and dreaming often of the time when he was buried. He had been a total abstainer from alcohol for many years. During the past three months, he had had difficulty in speaking, at first only when excited; speech never affected before. He also began to have attacks of trembling which became gradually worse. Finally, he was admitted to hospital for general, uncontrollable, irregular muscular spasms. When he tried to speak, the masseter and temporal muscles underwent clonic contraction. He ate and swallowed well. Knee jerks much exaggerated. Pseudo-clonus of left ankle and knee. Tremor (especially in extension) and pseudo-ataxia of arms when trying to touch his nose with eyes shut, especially left side. Abdominal reflexes exaggerated. Generally diminished sensibility to touch and pain especially left side. On left side, visual field and visual acuity and hearing much reduced, and smell and taste lost. Pulse soft and rapid. Face flushed; hands warm. He was isolated from the other patients. By the aid of suggestion, the recollection of various scenes connecting with his burial was restored to him, many of which were previously irrevocable. Transient hysteric convulsions and considerable emotional excitement accompanied the revival of these memories; but with the return of the latter the spasms became less and less violent, the speech improved and the hemi-hypaestesia disappeared almost completely. He was successfully induced to face the previously suppressed memories with confidence and self-control and was sent to England to complete his recovery.”


Other descriptions are of the phase immediately after a severe emotional trauma, where neurological and autonomic symptoms are dominating until the patient recovers, sometimes through hypnosis to access the trauma and talk about it.


It was of course difficult to distinguish these cases from cases with brain concussions. Surely there must have been many cases that suffered from both brain concussion and severe emotional trauma.


Myers also cites cases where people with obvious shell shock were able to fight, with full access to their training and experience, despite severe mental symptoms, such as (hysterical) amnesia, mutism, or deafness.


In order to describe the dynamics of severe emotional trauma, Myers used the expression “apparently normal personality” and “emotional personality” previously described by Janet. Page 67: “But in the states of lighter stupor and in the states of excitement, depression and automatism just mentioned, the attention of the patient would appear to be concentrated on some narrow field, doubtless generally on the scene which produced his condition. While thus occupied, the stuporous patient lies in a more or less apathetic state, with occasional outbursts of hallucinatory delirium. At this stage, then, the normal personality is in abeyance. Even if it is capable of receiving impressions, it shows no signs of responding to them. The recent emotional experiences of the individual have the upper hand and determine his conduct: the normal has been replaced by what we may call the “emotional” personality.


Gradually or suddenly an “apparently normal” personality usually returns – normal save for the lack of all memory of events directly connected with the shock, normal save for the manifestation of other (“somatic”) hysteric disorders indicative of mental dissociation. Now and again there occur alterations of the “emotional” and the ”apparently normal” personalities, the return of the former often being heralded by severe headache, dizziness or by a hysteric convulsion. On its return, the “apparently normal” personality may recall, as in a dream, the distressing experiences revived during the temporary intrusion of the “emotional” personality. The “emotional” personality may also return during sleep, the “functional” disorders of mutism, paralysis, contracture, etc., being then usually in abeyance. On waking, however, the “apparently normal” personality may have no recollection of the dream state and will at once resume his mutism, paralysis, etc.


The dissociated “emotional” personality is thus ever ready to appear on the scene, although its opportunities become fewer in the course of time...“


With the right treatment, importantly, and easy when early after the emotional trauma (p. 69): “When this re-integration has taken place, it becomes immediately obvious that the “apparently normal” personal differed widely in physical appearance and behaviour, as well as mentally, from the completely normal personality thus at least obtained… even the reflexes may change… and all hysterical symptoms are banished”...


Myers reported having had problems explaining this situation to his medical army superiors at the time, but in 1940 he wrote ”During the past twenty-five years, however, thanks to the work of Janet, Prince, Freud, Jung, Adler, Hart, Rows, Jones and many others, the neurologists’ method of treatment have been largely superseded by those of the psychotherapist”...


The scenario Myers describes in his book is the logistic problems - amid the chaos – of a spectrum of medical situations; the wounded, the normally occurring illnesses (somatic or psychic), the soldiers with severe emotional shock, and the malingerers.


Another important observation is that the number of soldiers who would suffer emotional strain was much higher than expected by the authorities, which caused much of the confusion. This is repeatedly mentioned by many later authors.


What Myers realized was that the soldiers with severe emotional shock might be efficiently helped close to the frontline, and could, under the right conditions, stay within the military discipline and carry out duties after a short time.


During the war, they were often mixed up with suspected malingerers and subjects unfit for service because of mental disorders. Thus, they even risked being executed for breaking martial law. Or evacuated to institutions for wounded soldiers and receiving a full pension for the rest of their lives.


Myers’s recommendation was to abolish the term “Shell shock”. He recommended the provision of special receiving centers both in army areas (abroad) and on the bases and spent much energy convincing the authorities of such an organisation. He outlines the psychotherapy that might help many cases.


Myers visited the French army to study how they organized their system of care. He comments that there were examples of soldiers with assumed hysterical paralysis treated with electric shocks, a routine he considered most doubtful. At the time, hysteria (and mental disorders generally) was treated by neurologists. The treatment “faradism” had been developed by neurologists to activate paralysed muscles. In hysterical paralysis, it could serve to convince the patient that the muscles could function and help them overcome the symptoms. But in the context of the military doctor, within a strongly asymmetric power relation, there was a temptation to increase the power of the current to get the desired result.


Myers seems to have fought to save many patients from martial court when they were suspected of malingering. He makes no secret about actual malingering but points out that most military doctors neither are qualified nor interested in mental diagnosis.


After the war he returned to Cambridge, lecturing and doing research. But his clinical experience and his suggestions for how to organize the health care during the war have made lasting contributions.


Abram Kardiner


Kardiner was a psychiatrist who grew up in New York. He published “Traumatic Neuroses of War” in 1941, with the express aim of presenting knowledge from previous wars, especially WWI. He had previous knowledge from a Veterans Administration hospital from 1922-1925, i.e. 5-8 years after the war that caused the traumatic experiences. This is obviously different from Rivers and especially Myers who have made their observations close to the events in time or space. Kardiner was a pupil of Freud, who had previously discussed “traumatic neurosis”.


Kardiner presents 24 case reports, followed by an outline of the features of Traumatic Neurosis, which according to him must be the most prevalent neurosis globally, and – to avoid some mistakes from WWI – recommendations how to organise the military psychiatry regarding the massive traumata, also to the civil population, during the on-going WW2 and the upcoming American involvement.


Kardiner sums up the common features of his patients (p. 86):

  1. Fixation of the trauma – altered perception of self and of outer world.

  2. Typical dream life.

  3. Contraction of general level of functioning.

  4. Irritability.

  5. Proclivity to explosive aggressive reactions.

Even if he does not mention it explicitly in his description, there is ample description of re-experiencing and avoidance as well as numbing in his case reports. In the description of traumatic neurosis long after the causation, there are even many examples of “hysterical” and psychosomatic symptoms (p. 196). He uses the expression physioneurosis to convey what is typical. At the same time, the idea of malingering or compensation is never far away because of the poverty and lack of financial support.


Kardiner has many clinical examples, just one to show his ideas regarding treatment (p.103):


“The patient stated that he was a fearless soldier, never subject to anxiety states during the war. The traumatic event took him entirely by surprise, and at first sitting he remembered nothing but that, confined in a straitjacket, he woke up in a field hospital a long time afterward… After the first few sittings, the repetition mechanism was explained to him, and insofar as it was possible, he was directed to see that the spells were repetitions of the original traumatic event and that in his original reaction he also lost consciousness. Furthermore, he was told that all the auras he described were hallucinatory sensory reproductions of the experience immediately preceding the first loss of consciousness…. After the first sittings then, the patient’s reactions were extremely violent and distressing. This phenomenon has been observed by some other authors, who state, therefore, that such a practice of permitting them to recall the original trauma is wrong….” Kardiner explains that recalling traumatic events is crucial and a requirement for improvement. “Whereas the patient may complain and may appear, for the time being, to be somewhat aggravated in his illness, the release of this nuclear anxiety is the kernel of the therapy. One must not be alarmed by it. The patient’s immediate reaction was that he had seven spells within a week after his first visit to me, that he spent two sleepless nights, and that, although he had been having anxiety dreams for the past seven years, they did not compare in terror...”


At the end of the book, Kardiner mentions that it is not only important that military physicians are trained in psychiatry; the reason is also that traumatic neuroses are rarely seen during peacetime. Therefore, special training is necessary for all professions taking care of these cases.


Some contributions after WW2


After the war, new technology was accessible. Wenger (1948) studied physiological parameters and is credited with the first controlled investigations of the physiological responses associated with operational fatigue in WW2 flyers. He compared them to unexposed cadets, and further compared 225 operational fatigue pilots with 166 asymptomatic individuals who had recently returned from combat. The group with operational fatigue (PTSD) evidenced significantly higher skin conductance, diastolic blood pressure, shorter heart period, and lower finger temperature. Wenger also compared the fatigued pilots with anxiety patients and found distinct features in the operationally fatigued pilots.


In Norway, there was early on research on sequelae of the war. During the second world war, jews were deported to concentrations camps. Eitinger was a psychiatrist and concentration camp survivor who described their symptoms, pointing to the many somatic symptoms. In the US, Henry Krystal was one of the first during the sixties to write about the mental health of concentration camp survivors. Apart from what was already known he pointed to problems with affect regulation, alexithymia, somatization, and survivor guilt, as part of traumatic neurosis.


The war in Vietnam, prequel to PTSD


During and immediately after the war in Vietnam, military psychiatry considered it a great success by applying the principles of care that came out of the second world war. However, it dawned slowly upon the psychiatric world that there were significant problems amongst the veterans. The early studies showed that a significant proportion had problems with numbing, rage, fear, grief, blame, survivor mode functioning, etc.


Horowitz, who had studied subjects who had experienced single traumatic events, described the cycle between intrusion and avoidance. His Impact of Event Scale (IES) was probably the first scale used to measure PTSD. The documentation of the pervasive problems in many veterans from the war in Vietnam was a major incitement for the inclusion of criteria for PTSD in DSM-III 1980. However, it took time before WHO included the diagnosis in ICD-10.