Marines at Dong Ha, Operation Hastings, Vietnam, July 1966.
How long has PTSD been around? Is the response to trauma outlined in our current PTSD diagnosis something that has long happened to a subset of people facing trauma? Or did our current concept of PTSD rise from cultural and medical concerns and definitions peculiar to a particular time in history?
This question is debated fiercely. Some — particularly those committed to the current diagnostic and treatment construct — argue that PTSD is just another name for a timeless affliction going back to Homer’s time. Others, including many who feel the PTSD diagnosis is baggy, too elastic, and wildly overextended, argue that while trauma is real, “PTSD” is a diagnostic construct — a categorial convenience — that can sometimes help and sometimes hinder our response to those who are distressed following troubling events.
In a fine post from the weekend, Vaughan Bell reviews two highly important studies supporting the idea that our current concept of PTSD describes a reaction that simply wasn’t seen in eras before the Vietnam War. I’m passing on a few snips here:
It was originally called ‘post-Vietnam syndrome’ and was promoted by anti-war psychiatrists who felt that the Vietnam war was having a unique effect on the mental health of American soldiers, but the concept was demilitarised and turned into a civilian diagnosis concerning the chronic effects of trauma.
Since then there has been a popular belief that PTSD has been experienced throughout history but simply wasn’t properly recognised. Previous labels, it is claimed, like ‘shell shock’ or ‘combat fatigue’, were just early descriptions of the same universal reaction.
But until now, few studies have systematically looked for PTSD or post-trauma reactions in the older historical record. Two recent studies have done exactly this, however, and found no evidence for a historical syndrome equivalent to PTSD.
A study just published in the Journal of Anxiety Disorders looked at the extensive medical records for soldiers in the American Civil War, whose mortality rate was about 50-80 greater than modern soldiers fighting in Iraq and Afghanistan.
In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.
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Taking an even longer view, a study published in Stress and Health looked at historical accounts of traumatic experiences from antiquity to the 16th century.
The researchers found that although psychological trauma has been recognised throughout history, with difficult events potentially leading to mental disorder in some, there were no consistent effects that resembled the classic PTSD syndrome.
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The concept of PTSD is clearly grounded in a particular time and culture, but even from a modern diagnostic perspective it is important to recognise that we tend to over-focus on PTSD as the outcome of horrendous events.
Perhaps the best scientific paper yet published on the diversity of trauma was anarticle authored by George Bonanno and colleagues in 2011. You can read the full-text online as a pdf.If
It notes that the single most common outcome after a traumatic event is recovery without intervention, and for those who do remain affected, depression and substance abuse problems are equally, if not more likely, than a diagnosis of posttraumatic stress disorder.
Read the whole thing at A very modern trauma « Mind Hacks. And for continual high-quality stimulation sensitive to this time and culture, follow Vaughan Bell on Twitter. Seriously, even if the post above (and/or my stance on PTSD) irk you, follow and read Bell, who’s one of our sharpest, most wide-ranging, and funny observers of psychiatry and culture.
For more context, see my Scientific American feature, which has quite a rowdy comment thread; if you hit a paywall there, see the open-access version here on Neuron culture; and for the deeper pool, or if you’re wondering, “Where do these people get the idea PTSD is overdiagnosed? Where are the studies?”, see my annotated list of sources and links.
Image: Marines at Dong Ha, Vietnam, July 1966, Operation Hastings. From National Archives, via Wikipedia.
According to Achilles in Vietnam, by Jonathan Shay, the Iliad sings of
the PTSD of Achilles. Put far too simplistically, his commander
cheated him, his buddy was killed, and he went berserk.
It seems kind of ridiculous to conclude that the trauma humans experience today is any different than those of 200,000 years ago when Homo Sapiens first evolved. Don’t all humans experience the same emotions today? Considering that war and violence have been a part of the human experience, one would think PTSD existed for millenia, it’s just that no one knew how to talk about it – perhaps due what we now know are the coping skills of “dissociation” – separating oneself from the traumatic even in order to function in other parts of one’s life. The study of psychology didn’t exist until the 1900s with Freud’s pioneering theories and research. I think it’s this unresolved trauma which keeps some political leaders and their nations locked into the belief system that uber-defense/military systems and hoarding hundreds of millions of dollars are the way to cope with overwhelming fears of scarcity
It’s not a matter of what we experience but how we define and respond to it. We’ve suffered colds for millenia, but our explanation of what causes them and our ideas about how to prevent and treat them have changed many times. Likewise with responses to stressful events.
wow you have written many articles on this with no facts.wars are not the only thing that gives people PTSD. I guess its just the era huh? what about every horrible thing people have seen since the begining of time.rape,murder,arson,car accidents,plane crashes,crime, Why would you ever call PTSD a product of the times. And just FWI I am a marine vet 100 percent disabled PTSD. I dont work and I dont seek treatment. The va hasnt taken my disability. You really should find facts first or every article you write you look dumb to millions of people
No facts? Plenty of facts above and in the studies the post describes and links to. Many, many facts supporting my argument are in the list of references at the bottom of my main post about this, here:
http://www.wired.com/wiredscience/2012/03/the-ptsd-trap/?utm_source=Contextly&utm_medium=RelatedLinks&utm_campaign=Previous
“…our current concept of PTSD describes a reaction that simply wasn’t seen in eras before the Vietnam War.”
I think the First World War might have something to say about that. Ever heard of shell-shock? The specific mental illness we label PTSD might be a post-Vietnam construct, but the symptoms go all the way back to those first descriptions of utterly broken, yet often physically healthy men coming back from the trenches. Examine a context other than American wars (though the First World War did involve US troops from 1917) for a proper history of the disorder.
I’ve read the literature and most relevant histories — a couple hundred thousand words or more — and have seen what the studies here describe: The conceptual definition and response to reactions to trauma differed in those earlier conflicts or, to put it another way, PTSD, as defined in the post-Vietnam era, included conceptual elements that earlier definitions did not. As Bell’s quoted article above notes (citing the study), a huge emphasis on flashbacks and painful memories was perhaps the leading new element. That has proven both dangerous and ill-founded, since memories are highly malleable and can take on both remembered elements and emotional and cognitive signficance that did not come with the initial purported traumatizing incidence or earlier recalls.
This is not to say that some events don’t scar some people: That much was recognized before and is recognized now. But the post-Vietnam reworking of the combat-trauma concept has added elements that encourage misdiagnosis and overdiagnosis and often complicate recovery. Add the VA’s spectacularly dysfunctional disability program in the US, and you have the big baggy mess we now have.
I agree that the DSM IV’s diagnostic criteria may be somewhat skewed and loosely-defined, even to the point of only being a rough guide (as with so many of its definitions; ADHD or Schizophrenia in particular spring to mind). Like many things, especially in American psychiatry, the diagnosis assumed a political dimension that it shouldn’t have, but necessarily does due to the often controversial nature of mental illness in society. Your point about the emphasis on flashbacks and memory is well-made, as well.
I agree to a certain extent that the definitions could be tightened, but PTSD doesn’t just apply to combat trauma, it’s a diagnosis that applies to a broad range of traumas such as severe accidents or child abuse. People often have severe, long term reactions to awful events in which they were involved, and that should be reflected in the literature and psychiatric diagnoses. What’s needed right now, and unfortunately sorely lacking from the current DSM IV (we’ll see about the DSM V in 2013), is a scientifically rigorous, evidence-based approach written with flexibility and patients in mind, not attempting to push the agenda of its authors onto the way mental illness is diagnosed for decades to come. So yes, you are to a certain extent right about PTSD in the political, post-Vietnam American context, but I’ve yet to see much evidence for its wholesale redundancy, merely for a reconsidering of some of the aspects in the literature.
Thank you for the full and measured response, by the way. It’s appreciated, and I apologise for my slightly flippant tone initially.
No harm, no foul, and thanks for your gracious response.
I’m with you on almost everything you say here: We DO need a reworked diagnostic for PTSD, one more parsimonious and truer to the many findings that have been made since 1987 about memory’s inaccuracies, for instance. I’m not convinced it needs to be tossed; just sharply reworked.
And yes, it should recognize other areas. One of its problems is how erroneous assumptions from often erroneous findings and readings of combat trauma spread to PTSD as applied in other populations as well.
I don’t think it completely redundant. But it has become the reflexive diagnosis for most cases in which someone had a troublesome event and suffer mental distress; is too often assumed to be lifelong, rather than curable; and in the VA, collides with a disability system that seems designed to discourage healing rather than speed it.
A sad state.
I have PTSD, and it has nothing to do with war. Is that considered in the discussion, or is it acknowledged even though it is not the angle of the story?