Thin Red Line of Heroes and Diagnosing Posttraumatic Stress Disorder Since 1914

In defining and diagnosing posttraumatic stress disorder (PTSD), the roots of contemporary psychiatry have drawn heavily from lessons learned from four major conflicts in the twentieth century: the First World War (WWI), the Second World War (WWII), the Vietnam War, and the ongoing Iraq and Afghanistan Wars. In conjunction with the eternal politicization of war, the advent of mass-produced munitions and explosives in modern warfare resulted in injuries that have created Two U.S. military police officers mourning the death of an Iraqi girl in Balad, a mental health epidemic Iraq in June 2003. Iraq War Collection, Associated Press Archives. in militaries. Physicians and psychologists alike have continually battled to observe, diagnose, and treat the conditions associated with modern warfare. From WWI to Iraq and Afghanistan, the formalization of PTSD into a mental diagnosis evolved from political and societal pressure towards addressing the mental and physical trauma experienced by soldiers. In the First World War, the combination of revolutionized military technology and outdated military tactics proved disastrous as the estimated twenty million military casualties created a psychiatric nightmare. At the end of 1914, British military psychiatrists and psychologists began observing an abnormal mish mash of mental and physical symptoms never diagnosed in conjunction before—perceptual abnormalities such as loss of sight and hearing, tremors, fatigue, confusion, nightmares, and headaches. The initial cause of these symptoms was widely speculated to be attributed to cowardice, malingering, a lack of masculinity, moral strength, in their personal character, or as an externalized reaction towards physical injuries.1 In Britain, the term “shell shock” appeared extensively throughout 1915 and well into the 1930s thanks to the widespread publicity and attention it received due to the overwhelming casualties of war. Numerous British psychiatrists believed shell shock was a physical head injury “initially conceived as a neurological lesion, a form of commotio cerebri, [or] the result of powerful compressive forces” due to relentless artillery barrages, mortar attacks, devastating mine explosions, and red-hot shrapnel.2 These theories, however, puzzled psychiatrists as the 1916 Battle of the Somme had produced a significant spike in “numbers of soldiers who had been close to a detonation without receiving a head wound” whose symptoms could not be linked to physical injury.3 On the other hand, consulting psychologists such as Charles Myers in the British Expeditionary Force (BEF) observed “many shell-shocked soldiers [who] had been nowhere near an explosion had identical symptoms to those who had been in close proximity to an explosion.”4 This led psychologists to theorize that shell-shock was primarily a psychological condition.5

Wounded British and German soldiers move to a British dressing station during the Somme Offensive. Photo taken on 19 July 1916. Ernst Brooks. Battle of the Somme, July-November 1916. Collection of the First World War, IWM Q 800, Imperial War Museum, London, UK. Fair use.

With America joining the Entente powers in 1917, American physician Thomas W. Salmon modified Charles Myers’s widely utilized five-principle treatment plan for soldiers suffering from mental and emotional anguish: immediacy, proximity, expectancy, simplicity, and centrality.6 The purpose of Salmon’s modified treatment was to treat soldiers as soon and as close as possible to the frontline with persuasive expectations for recovery through “rest and recuperation” in a systematic manner.7 British and French military physicians noticed that soldiers within this treatment method were “benefiting from the emotional support of their comrades [and] had a high likelihood of return to their unit [in comparison to] those who were evacuated who often showed a poor prognosis with chronic symptoms that ultimately led to a discharge from the military.”8

The diagnosis of shell shock was a controversial phenomenon and alternative treatment methodologies were equally controversial as “doctors tried many therapies [such as] hypnosis, drugs, psychotherapy, electroshock, and discipline,” all of which were unsuccessful.9 On the extreme end, unsympathetic military psychiatrists “treated shellshocked soldiers as cowardly malingerers [who] deserved to be shot for treason”10 and by mid-1917, “electroshock and disciplinary therapies that emphasized fast, brutal, and shaming techniques” were widely utilized to keep soldiers in combat.11 British soldiers who failed to undergo successful treatment and reintegration into active service would be labelled as “undesirable soldiers”; they could be excluded from post-war pension plans and compensation despite their mental and physical injuries sustained.12 By 1917, the inhumane treatment of British and American soldiers discharged due to physical or mental injuries (or both) had become synonymous with the horrors of the war. Moreover, the military and public perception of soldiers diagnosed with shell shock was based on the belief that they were no longer “soldiers” regardless of whether they suffered physical injuries in addition to their psychological injuries. In 1919, it was estimated that over “10 percent of British battle casualties were categorized as some form of shell shock or neurasthenia [or] one seventh of all discharges from the British army”13 while “psychological cases constituted about 40 percent of all hospitalized veterans in the American army.”14 The reality of aerial combat, poison gas, and suicidal attacks had soldiers leaving the front shattered with mental injuries varying from facial tics to an inability to speak. In sum, PTSD was still an unformalized diagnosis at the end of WWI and although shell shock was understood “as a psychological reaction to war, as a type of concussion, or as a physiological response to prolonged fear,”15 doctors found it “difficult to distinguish between the effects of a mild head injury and an exceptionally stressful experience” until the end of the Second World War.16

Patients in a neuro-psychological ward at Camp Sherman, Ohio in 1918. Failed “rest and recuperation” cases were sent back to the U.S. for treatment. First World War Collection, National Archives, Washington, DC. Fair use.

American psychiatric casualties being treated under Thomas W. Salmon’s modified version of Myers’s five-principle “rest and recuperation” treatment plan. Salmon’s modified treatment would continue to be used by Allied militaries throughout WWII. American Soldiers at a Field Hospital in France, 1918-1919. First World War Collection, National Archives, Washington, DC. Fair use.

When the world entered another global conflict in WWII, psychiatry built on lessons learned from WWI. The nature of the war had become increasingly unrestrained geographically, and psychiatrists and psychologists within the British, American, and Canadian militaries consistently found that soldiers “exposed to high-explosive blasts identified significant psychological ef apparent physical injury [with] reported symptoms for which no organic basis could be found.”17 Immense public backlash and politicization of veterans-related topics in the post-WWI era resulted in a shift in diagnosis and perceptions of mental and emotional anguish in soldiers in WWII. Gone were militaristic sentiments of execution from mental misdiagnoses and instead, slightly more humanistic approaches were implemented. As Britain faced invasion in 1940, former consulting psychologist Charles Myers of the BEF publicly detailed his psychological and humanistic theories for shell shock and its treatment in WWI; however, the British military and Parliament criticized his findings as unpatriotic and defeatist. Nevertheless, the straightforward principles of rest and recuperation introduced by Myers in 1915 had gradually been adopted during WWII by both the British and American armies as the prompt treatment of soldiers as close to the fighting as safely possible became a defining feature of stretching and utilizing manpower.18 Britain’s strained wartime economy forced British psychiatrists to halt studies on soldiers suffering from symptoms relating to PTSD. Despite these setbacks, military psychiatrists agreed that hypotheses of the causes of PTSD emphasizing hereditary dispositions, neurotic personalities, cowardice, or being inhibited physically or mentally, were not supported by sufficient evidence. treatments involving drugs, hypnosis, and persuasion with drug-facilitated remembering, and directive psychotherapy were gradually phased out due to moral and ethical concerns in the treatment of soldiers.20 These concerns inevitably forced Allied neuropsychiatrists to adopt pragmatic approaches in treatment methods by “retaining soldiers with shell shock in the armed forces and offering occupational therapy and vocational training based on aptitude test” as a way to return service personnel to purposeful activities to avoid public scrutiny. (ECT), magnetic seizure therapy (MST), and transcranial magnetic stimulation (TMS) showed limited effectiveness for soldiers recovering from symptoms of PTSD. However, these trials contributed to defining symptoms of PTSD outlined in the DSM-III in 1980 and the subsequent development of treatment methods within cognitive behavioural therapy (CBT). Educational psychology studies focusing on PTSD symptoms from WWII veterans have suggested that soldiers with a higher intelligence quotient (IQ) are less likely to develop PTSD or at least have reduced severity in PTSD symptoms following a traumatic experience.23 In 1970, further studies on American WWII veterans attributed genetic pre-dispositions for higher IQ as a major protective factor while also suggesting that soldiers’ access to education prior to military service could develop IQ and thus build resiliency in developing symptoms for PTSD or at least gain sophisticated verbal skills and greater awareness of personal trauma and memories for coping.24 Moreover, post-WWII longitudinal studies on relational qualities with fellow soldiers and the onset of PTSD symptoms due to combat exposure have suggested that “quality relationships with fellow soldiers may play a protective role against postwar PTSD symptoms, particularly at higher levels of combat exposure.” WWII and the complications of manpower shortages and logistical resources, soldiers suffering from mental anguish on any frontline simply had to continue fighting and allow themselves to repress or re-live their traumatic experiences at a later date. The theories and practices of psychiatry and psychology towards symptoms under PTSD remained in place until the end of the war and would lay the foundation for PTSD as a recognized mental diagnosis in the DSM-III following the conclusion of the Vietnam War.

When the world entered another global conflict in WWII, psychiatry built on lessons learned from WWI. The nature of the war had become increasingly unrestrained geographically, and psychiatrists and psychologists within the British, American, and Canadian militaries consistently found that soldiers “exposed to high-explosive blasts identified significant psychological effects [despite] survival without Immense public backlash and politicization of veterans-related topics in the post-WWI era resulted in a shift in diagnosis and perceptions of mental and emotional anguish in soldiers in WWII. Gone were militaristic sentiments of execution from mental misdiagnoses and instead, slightly more humanistic approaches were implemented. As Britain faced invasion in 1940, former consulting psychologist Charles Myers of the BEF publicly detailed his psychological and humanistic theories for shell shock and its treatment in WWI; however, the British military and Parliament criticized his findings as unpatriotic and defeatist. Nevertheless, the straightforward principles of rest and recuperation introduced by Myers in 1915 had mies as the prompt treatment of soldiers as close to the fighting as safely possible became a defining feature of stretching and Britain’s strained wartime economy forced British psychiatrists to halt studies on soldiers suffering from symptoms relating to PTSD. Despite these setbacks, military psychiatrists agreed that hypotheses of the causes of PTSD emphasizing hereditary dispositions, neurotic personalities, cowardice, or being inhibited physically or mentally, were not supported by sufficient evidence.19 Moreover, treatments involving drugs, hypnosis, and persuasion with drug-facilitated remembering, and directive psychotherapy were gradually phased out due to moral and ethical concerns in the treatment of These concerns inevitably forced Allied neuropsychiatrists to adopt pragmatic approaches in treatment methods by “retaining soldiers with shell shock in the armed forces and offering occupational therapy and vocational training based on aptitude test” as a way to return service personnel to purposeful activities to avoid public scrutiny.21 In addition, somatic treatments such as electroconvulsive therapy (ECT), magnetic seizure therapy (MST), and transcranial magnetic stimulation (TMS) showed limited effectiveness for soldiers recovering from symptoms of PTSD. However, these trials contributed to defining in 1980 and the subsequent development of treatment methods within cognitive behavioural therapy (CBT).22

Educational psychology studies focusing on PTSD symptoms from WWII veterans have suggested that soldiers with a higher intelligence quotient (IQ) are less likely to develop PTSD or at least have reduced In 1970, further studies on American WWII veterans attributed genetic pre-dispositions for higher IQ as a major protective factor while also suggesting that soldiers’ access to education prior to military service could develop IQ and thus build resiliency in developing symptoms for PTSD or at least gain sophisticated verbal skills and greater Moreover, post-WWII longitudinal studies on relational qualities with fellow soldiers and the onset of PTSD symptoms due to combat exposure have suggested that “quality relationships with fellow soldiers may play a protective role against postwar PTSD symptoms, particularly at higher levels of combat exposure.”25 Through the globalized nature of esources, soldiers suffering from mental anguish on any frontline simply had to continue fighting and allow themselves to repress or re-live their traumatic experiences at a later date. The theories and practices of psychiatry and psychology towards symptoms under PTSD remained in place until the end of the war and would lay the foundation for

U.S. Marines await evacuation of the wounded outside Da Nang, Vietnam on February 9, 1968. Vietnam War Collection, Associated Press Archives. Fair use. Under the umbrella of the Cold War, the psychiatric findings in defining PTSD through the Vietnam War were significant due to the significant emotional and mental distress of American servicemembers. In addition, later developments from the formation of the DSM-III to the Iraq and Afghanistan campaigns in early 2000s also contributed significantly in understanding and developing effective treatment methodologies for PTSD. The nature of combat within the Vietnam War—nonexistent battle lines, guerrilla attacks and tactics, and an often-indistinguishable enemy—was a newfound reality for American servicemembers. Although the Vietnam War is the second longest war in American history, American military psychiatrists estimated that psychological casualties were “ten times less than [those] in World War II” despite the brutality of the war.26 Although the number of psychological casualties was deemed minimal, many psychiatrists argued that the system of being in combat on Monday and being back in the US by Saturday, inevitably complicated the PTSD diagnoses due to the drastic shifts in environment.27 The socio-political fallout from the Vietnam War forced the American Psychiatric Association to formally define PTSD as a specific disorder that was more than a product of environmental stressors but also as a disorder that could emerge or persist many years following a traumatic experience.28 The conceptualization of a new disorder known as PTSD within the DSM-III29 formally recognized that, although soldiers experienced trauma externally, symptoms of PTSD could work “through present day memories of the past trauma that intruded into the present.”30

DSM-III criterion emphasized PTSD as a disorder that could emerge or persist many years following a traumatic experience beyond the confines of environmental stressors. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-III. 3rd ed., (Washington, DC, 1980), 238. In the 1986–1988 National Vietnam Veteran Readjustment Study on 3016 American veterans, researchers noted that “direct experience[es] of combat (killing or attempting to kill) was associated with increased risk of PTSD symptoms, even after accounting for the effects of witnessing combat trauma in fellow soldiers.”31 Moreover, this study further revealed that roughly twenty-five percent of Vietnam veterans who had been in theatre between 1964 and 1973 required some psychological help.32 Beyond that, eleven percent suffered with significant PTSD symptoms.33 The reality of the post-DSM-III classification reflected the political landscape and compartmentalization behind the treatment and rehabilitation of Vietnam veterans, particularly in the United States as the Department of Veterans Affairs estimated that roughly 30 percent, or 348,164 veterans who served in Vietnam from 1961–1975 had been categorized on disability rolls for PTSD.34

Concurrent studies for veterans of wars in Iraq and Afghanistan beginning in 2005 reported that “25 percent of more than 100 000 veterans who returned from these wars received some mental health diagnosis; 13 percent were diagnosed with PTSD.”35 The psychiatric lessons learned from Vietnam to Iraq and Afghanistan have utilized existing knowledge on co-morbid symptoms and diagnoses into the formal recognition of the PTSD diagnosis and the potential behavioural treatment options that have risen to prominence in recent years.

Formalization of PTSD as a mental disorder in the DSM-III in 1980 contributed to thousands of applications for disability roll, particularly from Vietnam and Gulf War veterans. Jamie L. Gradus, “PTSD: National Center for PTSD,” Epidemiology of PTSD, (2007): 1. https://www.ptsd.va.gov/ professional/treat/essentials/epidemiology.asp#three.

In the years since the Vietnam War and throughout the Iraq and Afghanistan conflicts, modern psychiatry and psychology have continually drawn on relatively new behavioural-based therapeutic interventions for treating PTSD. Eye movement desensitization and reprocessing therapy (EMDR) has been recognized as a phase-based approach in treating trauma and symptoms by dissociating while reconnecting the client in a safe and measured method to the images, emotions, self-thoughts, and body sensations associated with the trauma by which their cognitive perceptions of their trauma can be altered.36 Considerable research has been conducted on PTSD groups in civilian populations where “significant alterations in brain function with corresponding changes on symptom measures” have been achieved.37 Due to its humanistic and behavioural approach, EMDR has long been considered as having greater potential than traditional talk therapies.38 Prolonged exposure therapy (PE) is a Re-categorization of diagnostic criteria, symptoms and co-morbidity related to PTSD. cognitive behavioural treatment American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed., (Arlington, VA, 2013), 271-272. intervention aimed at re-shaping learned behaviours in response to situations, thoughts, or memories that are perceived as frightening or anxiety-provoking.39 Due to its phased and confrontational approach, PE has achieved significant treatment efficacy for those suffering primarily from PTSD’s second and third categories of intrusion and avoidance.40 The largest limitation of this approach is its dropout rate; PE can be confrontational and incredibly intense for some patients, especially considering the stigmatization of PTSD and therapeutic interventions for active and retired servicemembers. In addition, significant research is necessary for combat-related PTSD cases where comorbidity exists which may lead to lengthy and complicated treatment plans. Other modern treatment methods such as pharmacotherapy, have utilized selective serotonin reuptake inhibitors (SSRIs) as a primary treatment for PTSD. Unfortunately these have only shown short-term efficacy in suppressing symptoms of PTSD.41 Other medications such as painkillers and anti-depressants are also considered to be short-term solutions that should only be utilized in conjunction with other behavioural interventions as to minimize side-effects and complications for those with co-morbidity.42 The mental and emotional damage from Vietnam to Iraq and Afghanistan helped formulate the modern diagnosis of PTSD and the relatively recent therapeutic interventions.

David Furst. U.S. Soldier in Conversation with Local Iraqi. 2008. Iraq War Collection, Associated Press Archives. Fair use.

As war continues to make demands on soldiers, the distinctions between physical and psychological injury will continue. The unfortunate reality is that military service members of all branches will continue to fight battles far beyond the confines of conventional warfare. The complexities of diagnosing, treating, and living with PTSD for military servicemembers and societies, will forever be a controversial and confronting reality.

Psychology major; History minor