**2. History of posttraumatic stress disorder**

Posttraumatic stress disorder was not officially recognized as psychological disorder until the Diagnostic Statistical Manual -III, which was published in 1980 (American Psychiatric Association, 1980; Lasiuk & Hegadoren, 2006). Posttraumatic stress disorder was known by an array of different labels previous to 1980, such as combat neurosis, railway spine, shell shock, soldier's heart, and stress response syndrome. Although it has been speculated that posttraumatic stress disorder has existed in all trauma stricken populations throughout history,the occurrence has been documented primarily in soldiers who experienced combat related trauma. (Jones et. al., 2003; Lasiuk & Hegadoren, 2006). One exception to this pattern is the historical concept of hysteria. Hysteria has also received much attention, but the symptoms associated with this term have evolved throughout history and therefore the term can only be loosely associated with posttraumatic stress disorder. This chapter will make reference to numerous historical figures that noted the similarities of hysteria to the symptoms that they were observing, but it must be noted that this concept is loosely defined.

#### **2.1 Railway spine, soldiers' heart, and hysteria**

Another non-military population who exhibited posttraumatic stress disorder-like symptoms is seen in the documentation of a phenomenon called *railway spine*. This is the

Combat Related Posttraumatic Stress Disorder –

(Sloggett, 1916 as cited in Jones et. al., 2007).

**2.2 World War I – Shell shock** 

History, Prevalence, Etiology, Treatment, and Comorbidity 27

A British military psychologist named Charles Samuel Myers was the first to use the term *shell shock* in medical literature (Myers, 1915 as cited in van der Kolk, 2007). Previous to his writings, the term was used in reference to British soldiers during World War I who had been exposed to a detonation or explosion, but had not sustained a visible head injury (Jones et. al., 2007). Some of the symptoms soldiers exhibited included tremors, dizziness, increased sensitivity to noise, headaches, difficulty concentrating, and amnesia (Turner, 1915 as cited in Jones et. al., 2007). Frederick Mott, a British neuropathologist suggested that shell shock impacted the tissue in the brain and spinal chord and could be fatal in extreme cases (Mott, 1917 as cited in Jones et. al., 2007). He also believed that some of the symptoms could be attributed to the gases that soldiers were exposed to during an explosion and that the gases could cause damage to the central nervous system (Mott, 1919 as cited in Jones et. al., 2007). Myers later conducted research on shell shock and suggested that the disorder may also result from psychological distress. He believed this because many of the soldiers who showed symptoms that were consistent with those of shell shock, had not been anywhere near an explosion (van der Kolk, 2007). The British Army was compelled to accept Myers' hypothesis because it enabled them to force soldiers to return to combat since the problem was psychological and they were not physically injured (Jones et. al., 2007). Subsequently the army declared two subtypes of shell shock, those who had been exposed to an explosion and those who were said to suffer from "nervousness" due to their anxiety about combat

By 1917, shell shock was said to have accounted for one in seven discharges from the British Army (Salmon, 1917 as cited in Jones et. al., 2007). Many doctors at the time believed that having shell shock was synonymous to being a coward (van der Kolk, 2007). Since numerous soldiers sought pensions for the effects of shell shock, the British Army became much more conservative with the diagnosis (Jones et. al., 2007). They intended that only the soldiers who were actually exposed to an explosion receive the diagnosis. Consequently, soldiers who were still serving and were dismissed from their duties for symptoms that resembled shell shock were said to be "not yet diagnosed nervous" (Jones et. al., 2007). Of those soldiers, individuals that did not have visible wounds and did not recover from their symptoms were labelled as "neurasthenic" (Jones et. al., 2007). Soon after the United State

Following World War I, many psychiatrists attempted to translate the clinical skills they gained during the war to working with the general public. Although the majority of psychiatrists were unsuccessful in impacting the field, Abram Kardiner was able to incite some changes (van der Kolk, 2007). Kardiner was one of Freud's students, and after treating veterans of World War I he tried to develop a theory on *war neurosis* that fit with psychoanalysis. Many of the symptoms that he made note of to characterize war neurosis are still highly relevant to the diagnostic criteria that we use for posttraumatic stress disorder today. Kardiner documented on symptoms that he labelled as "physioneurosis," which is nearly synonymous to the current symptom of physiological hyper-arousal (Kardiner, 1941 as cited in van der Kolk, 2007). He also made note of many of the reexperiencing and numbing or avoidant symptoms of posttraumatic stress disorder. Some of the symptoms which he acknowledged include irritability or proneness to anger, becoming withdrawn or detached, and individuals feeling as if they were re-experiencing the trauma when triggered by a neutral stimuli (Kardiner, 1941 as cited in van der Kolk, 2007). He continued to conceptualize war neurosis based upon psychoanalytic theories and he

entered World War I, similar symptoms were observed in American soldiers.

first time where a cluster of symptoms that resembled posttraumatic stress disorder was documented on within medical literature. Railway spine was observed in London in the late 1700's in railway passengers and workers who were in train crashes (Lasiuk & Hegadoren, 2006; Micale, 1990; Ray, 2008). They experienced the physical effects of the crash such as whiplash, but more importantly they were said to have born the psychological effects of the trauma from the crash. Some of the symptoms of railway spine that resemble posttraumatic stress disorder include: nightmares about the crash, avoiding trains as a means of transportation, and difficulty sleeping. At the time, these symptoms were seen by some as being consistent with hysteria, which was believed to more commonly occur in females.

Since some of the individuals who suffered from railway spine believed that the railway companies should be legally liable for their passenger's and worker's well being, there was much debate as to whether a train crash could cause chronic psychological impairment (Lasiuk & Hegadoren, 2006). At the time, some believed that the individuals were faking their symptoms in order to receive financial gain from the railway companies. Others believed that the symptoms were legitimate which inspired a debate about what caused the symptoms. An English surgeon named John Eric Erichsen believed that hysteria should not be associated with railway spine and that its cause was rooted in an organic illness (Lasiuk & Hegadoren, 2006; Erichsen, 1866 & 1886 as cited in van der Kolk, 2007). Another English surgeon, Herbert Page opposed Erichsen's belief and argued that fear could be a sufficient cause for the symptoms (Lasiuk & Hegadoren, 2006; van der Kolk, 2007). Herman Oppenheim argued that railway spine could result from slight molecular changes in the central nervous system and renamed it *traumatic neurosis* (Lasiuk & Hegadoren, 2006; Oppenheim, 1889 as cited in van der Kolk, 2007). This is the first time where the title of the disorder implies that trauma is implicated in the development of the disorder. Kraepelin later used the term traumatic neurosis in reference to a reaction that was seen in those who survived through accidents or other disasters (Kraepelin, 1899 as cited in Ray, 2008).

During the late 1800's, many theorists became interested in the etiology of hysteria. Individuals such as Charcot and Janet contended that an individual must experience trauma in order to develop hysteria-like symptoms (Ray, 2008). Both individuals also agreed that hysteria was not solely a female disorder and pointed out many male populations that experienced symptoms that mimicked hysteria. One population Janet highlighted was males who had suffered from railway spine. Janet developed the term *neurasthenia* which encompassed a number of reactions to emotional trauma (Ray, 2008). Neurasthenia included symptoms such as headaches, fatigue, sleep issues, and emotional and somatization disorders.

Disorders that are similar to combat related posttraumatic stress disorder emerged once again during the Boer, Crimean, and American Civil Wars (Ray, 2008). Terms such as *soldiers' heart* and *DaCosta syndrome* were developed to describe symptoms that were frequently seen in soldiers after being exposed to combat situations. Some of the symptoms associated with soldiers' heart included "extreme fatigue, tremors, dyspnea, palpitations, [and] sweating" (Ray, 2008, p. 218). The central focus when providing a soldiers' heart diagnosis was the abnormality of the soldier's heartbeat. Little attention was paid to their emotional response to the trauma. Since soldiers were expected to be courageous, when a soldier showed any kind of fatigue they were only briefly sent to the back of the battle lines, so that they could recoup (Ray, 2008). After they received some time in the back, they were believed to have recovered and were sent back to the front lines. As a result, soldiers were likely exposed to multiple traumas during war.

#### **2.2 World War I – Shell shock**

26 Post Traumatic Stress Disorders in a Global Context

first time where a cluster of symptoms that resembled posttraumatic stress disorder was documented on within medical literature. Railway spine was observed in London in the late 1700's in railway passengers and workers who were in train crashes (Lasiuk & Hegadoren, 2006; Micale, 1990; Ray, 2008). They experienced the physical effects of the crash such as whiplash, but more importantly they were said to have born the psychological effects of the trauma from the crash. Some of the symptoms of railway spine that resemble posttraumatic stress disorder include: nightmares about the crash, avoiding trains as a means of transportation, and difficulty sleeping. At the time, these symptoms were seen by some as being consistent with hysteria, which was believed to more commonly occur in females. Since some of the individuals who suffered from railway spine believed that the railway companies should be legally liable for their passenger's and worker's well being, there was much debate as to whether a train crash could cause chronic psychological impairment (Lasiuk & Hegadoren, 2006). At the time, some believed that the individuals were faking their symptoms in order to receive financial gain from the railway companies. Others believed that the symptoms were legitimate which inspired a debate about what caused the symptoms. An English surgeon named John Eric Erichsen believed that hysteria should not be associated with railway spine and that its cause was rooted in an organic illness (Lasiuk & Hegadoren, 2006; Erichsen, 1866 & 1886 as cited in van der Kolk, 2007). Another English surgeon, Herbert Page opposed Erichsen's belief and argued that fear could be a sufficient cause for the symptoms (Lasiuk & Hegadoren, 2006; van der Kolk, 2007). Herman Oppenheim argued that railway spine could result from slight molecular changes in the central nervous system and renamed it *traumatic neurosis* (Lasiuk & Hegadoren, 2006; Oppenheim, 1889 as cited in van der Kolk, 2007). This is the first time where the title of the disorder implies that trauma is implicated in the development of the disorder. Kraepelin later used the term traumatic neurosis in reference to a reaction that was seen in those who

survived through accidents or other disasters (Kraepelin, 1899 as cited in Ray, 2008).

likely exposed to multiple traumas during war.

During the late 1800's, many theorists became interested in the etiology of hysteria. Individuals such as Charcot and Janet contended that an individual must experience trauma in order to develop hysteria-like symptoms (Ray, 2008). Both individuals also agreed that hysteria was not solely a female disorder and pointed out many male populations that experienced symptoms that mimicked hysteria. One population Janet highlighted was males who had suffered from railway spine. Janet developed the term *neurasthenia* which encompassed a number of reactions to emotional trauma (Ray, 2008). Neurasthenia included symptoms such as headaches, fatigue, sleep issues, and emotional and somatization disorders. Disorders that are similar to combat related posttraumatic stress disorder emerged once again during the Boer, Crimean, and American Civil Wars (Ray, 2008). Terms such as *soldiers' heart* and *DaCosta syndrome* were developed to describe symptoms that were frequently seen in soldiers after being exposed to combat situations. Some of the symptoms associated with soldiers' heart included "extreme fatigue, tremors, dyspnea, palpitations, [and] sweating" (Ray, 2008, p. 218). The central focus when providing a soldiers' heart diagnosis was the abnormality of the soldier's heartbeat. Little attention was paid to their emotional response to the trauma. Since soldiers were expected to be courageous, when a soldier showed any kind of fatigue they were only briefly sent to the back of the battle lines, so that they could recoup (Ray, 2008). After they received some time in the back, they were believed to have recovered and were sent back to the front lines. As a result, soldiers were A British military psychologist named Charles Samuel Myers was the first to use the term *shell shock* in medical literature (Myers, 1915 as cited in van der Kolk, 2007). Previous to his writings, the term was used in reference to British soldiers during World War I who had been exposed to a detonation or explosion, but had not sustained a visible head injury (Jones et. al., 2007). Some of the symptoms soldiers exhibited included tremors, dizziness, increased sensitivity to noise, headaches, difficulty concentrating, and amnesia (Turner, 1915 as cited in Jones et. al., 2007). Frederick Mott, a British neuropathologist suggested that shell shock impacted the tissue in the brain and spinal chord and could be fatal in extreme cases (Mott, 1917 as cited in Jones et. al., 2007). He also believed that some of the symptoms could be attributed to the gases that soldiers were exposed to during an explosion and that the gases could cause damage to the central nervous system (Mott, 1919 as cited in Jones et. al., 2007). Myers later conducted research on shell shock and suggested that the disorder may also result from psychological distress. He believed this because many of the soldiers who showed symptoms that were consistent with those of shell shock, had not been anywhere near an explosion (van der Kolk, 2007). The British Army was compelled to accept Myers' hypothesis because it enabled them to force soldiers to return to combat since the problem was psychological and they were not physically injured (Jones et. al., 2007). Subsequently the army declared two subtypes of shell shock, those who had been exposed to an explosion and those who were said to suffer from "nervousness" due to their anxiety about combat (Sloggett, 1916 as cited in Jones et. al., 2007).

By 1917, shell shock was said to have accounted for one in seven discharges from the British Army (Salmon, 1917 as cited in Jones et. al., 2007). Many doctors at the time believed that having shell shock was synonymous to being a coward (van der Kolk, 2007). Since numerous soldiers sought pensions for the effects of shell shock, the British Army became much more conservative with the diagnosis (Jones et. al., 2007). They intended that only the soldiers who were actually exposed to an explosion receive the diagnosis. Consequently, soldiers who were still serving and were dismissed from their duties for symptoms that resembled shell shock were said to be "not yet diagnosed nervous" (Jones et. al., 2007). Of those soldiers, individuals that did not have visible wounds and did not recover from their symptoms were labelled as "neurasthenic" (Jones et. al., 2007). Soon after the United State entered World War I, similar symptoms were observed in American soldiers.

Following World War I, many psychiatrists attempted to translate the clinical skills they gained during the war to working with the general public. Although the majority of psychiatrists were unsuccessful in impacting the field, Abram Kardiner was able to incite some changes (van der Kolk, 2007). Kardiner was one of Freud's students, and after treating veterans of World War I he tried to develop a theory on *war neurosis* that fit with psychoanalysis. Many of the symptoms that he made note of to characterize war neurosis are still highly relevant to the diagnostic criteria that we use for posttraumatic stress disorder today. Kardiner documented on symptoms that he labelled as "physioneurosis," which is nearly synonymous to the current symptom of physiological hyper-arousal (Kardiner, 1941 as cited in van der Kolk, 2007). He also made note of many of the reexperiencing and numbing or avoidant symptoms of posttraumatic stress disorder. Some of the symptoms which he acknowledged include irritability or proneness to anger, becoming withdrawn or detached, and individuals feeling as if they were re-experiencing the trauma when triggered by a neutral stimuli (Kardiner, 1941 as cited in van der Kolk, 2007). He continued to conceptualize war neurosis based upon psychoanalytic theories and he

Combat Related Posttraumatic Stress Disorder –

follow today in the revised version.

aspects of the trauma.

**2.5 Current definition of posttraumatic stress disorder** 

**2.6 Potential diagnostic statistical manual – v changes** 

evaluate or treat the disorder (Frueh et. al., 2010).

Manual – V can be seen in the table below (figure 1).

History, Prevalence, Etiology, Treatment, and Comorbidity 29

marked distress and fear, helplessness, or horror (American Psychiatric Association, 1987 as cited in Lasiuk & Hegadoren, 2006). Civilian populations such as those who suffered child abuse, sexual abuse, and intimate partner violence were also included under the diagnosis. Extreme changes were made in the diagnostic criteria of posttraumatic stress disorder in the Diagnostic Statistical Manual – IV, which closely resembles the diagnostic criteria that we

Posttraumatic stress disorder is currently defined by the Diagnostic Statistical Manual – IV Text Revision as an anxiety disorder resulting from exposure to a traumatic event involving personal or secondary threat to life or wellbeing and causing intense fear, helplessness, or horror (American Psychiatric Association, 2000). Posttraumatic stress disorder is characterized by physiological hyper-arousal, avoidance of stimuli that would provoke anxiety or general emotional numbing, and recurrence of psychologically re-experiencing

It is apparent that the definition of posttraumatic stress disorder has evolved throughout the years. As such, it is to be expected that the Diagnostic Statistical Manual criteria will continue to be adapted as we learn more about the disorder. Some of the proposed changes for the Diagnostic Statistical Manual - V criteria will be presented in this section. Currently, none of the changes presented here have been officially accepted. Upon publication of the Diagnostic Statistical Manual - V, readers should reevaluate the proposed changes that have been presented in this chapter. It is not expected that the current proposal will severely alter the prevalence rates of posttraumatic stress disorder or severely impact how clinicians

The Diagnostic Statistical Manuel – IV – TR criterion for posttraumatic stress disorder specifies three symptom clusters: re-experiencing, avoidance or emotional numbing, and hyperarousal (American Psychiatric Association, 2000). These symptoms arise from primary or secondary exposure to a traumatic event that evokes feelings of extreme horror, fear, or helplessness. Re-experiencing is described as having nightmares, intrusive memories, feeling as if the event were reoccurring, and experiencing psychological and/or physiological distress when encountering internal or external reminders of the trauma. Avoidance or emotional numbing is defined as trying to avoid thoughts or feelings about the trauma, trying to avoid people or places that serve as reminders of the trauma, impaired memory for the trauma, feeling detached from others, having a sense of a foreshortened future, restricted affect, and anhedonia. Finally, hyper-arousal is defined as difficulty sleeping, irritability or anger, difficulty concentrating, hyper-vigilance, and exhibiting an exaggerated startle response. In order to receive a diagnosis of posttraumatic stress disorder, an individual must exhibit one re-experiencing symptom, three avoidance or emotional numbing symptoms, and two hyper-arousal symptoms. The symptoms must be present for over one month following the traumatic event and must cause impaired functioning or distress. If the symptoms have been apparent for less than three months the posttraumatic stress disorder is labeled as acute, but if present for over three months, the label is then changed to chronic posttraumatic stress disorder. The criteria for the Diagnostic Statistical Manual – IV – TR (current edition) and the proposed changes for the Diagnostic Statistical

believed that those with the disorder were fixated on the trauma (Kardiner, 1941 as cited in van der Kolk, 2007). Despite psychiatrists working extensively with those with shell shock, much of the public was still sceptical of the diagnosis and believed soldiers were malingering (Ray, 2008).

### **2.3 World War II – Combat neurosis**

During World War II, numerous names developed for what was previously labeled as shell shock even though each label was describing a very similar set of symptoms (Ray, 2008). Although having numerous names for one disorder could potentially result in confusion, it was seen as positive growth because it showed that multiple clinicians and researchers were coming to the same conclusion, that combat neurosis was a valid diagnosis. A new population of individuals suffering from similar symptoms – those who had survived the Nazi concentration camps, also expanded the professional understanding of combat neurosis. Observing concentration camp survivors brought Harry Abram to expand the concept of combat neurosis to a number of other trauma stricken populations which included: those under stress and those experiencing a life-threatening illness or an emergency situation (Abram, 1970 as cited in Ray, 2008). In his description, he suggested that the syndrome was comprised of both physical and psychological factors. An equal integration of both components was a novel argument because all past theories had put the primary emphasis on only one aspect without realizing the interplay between both components (Ray, 2008).

#### **2.4 The diagnostic statistical manual, vietnam war, and posttraumatic stress disorder**

In 1952, the first Diagnostic Statistical Manual included a diagnosis known as *stress response syndrome* (American Psychiatric Association, 1952 as cited in Lamprecht & Sack, 2002). The diagnosis was conceptualized as transient personality characteristic and was considered to be a normal reaction to extreme stress. Furthermore, with treatment, the symptoms were believed to subside once the ego regained balance (Lamprecht & Sack, 2002). The belief that people commonly recover from the syndrome was maintained despite multiple case examples to the contrary. The second Diagnostic Statistical Manual retained a very similar definition of stress response syndrome despite evidence demonstrating the need for adjustments (American Psychological Association, 1968 as cited in Lamprecht & Sack, 2002). It became a common belief among professionals that everyone had a breaking point, and that stress response syndrome was a normal response to an extreme stressor (Lamprecht & Sack, 2002).

Eventually the prevalence of soldiers who suffered from the chronic effects of stress response syndrome following the Vietnam War became undeniable. Vietnam veterans lobbied for compensation from the government for the trauma that they suffered (Lasiuk & Hegadoren, 2006). This forced the American Psychiatric Association to reconsider their conceptualization of the disorder, and in 1980 the term *posttraumatic stress disorder* was officially adopted into the Diagnostic Statistical Manual - III (American Psychiatric Association, 1980). In this version, posttraumatic stress disorder was defined by its' overt symptoms so that the characterization was not biased to a particular theory (Ray, 2008). In the revision of the Diagnostic Statistical Manual – III, they further refined the criteria for posttraumatic stress disorder. A distinction was made between common life stressors and a traumatic event, which was considered outside of the realm of normal human experience. Posttraumatic stress disorder was defined as having experienced a traumatic event, causing

believed that those with the disorder were fixated on the trauma (Kardiner, 1941 as cited in van der Kolk, 2007). Despite psychiatrists working extensively with those with shell shock, much of the public was still sceptical of the diagnosis and believed soldiers were

During World War II, numerous names developed for what was previously labeled as shell shock even though each label was describing a very similar set of symptoms (Ray, 2008). Although having numerous names for one disorder could potentially result in confusion, it was seen as positive growth because it showed that multiple clinicians and researchers were coming to the same conclusion, that combat neurosis was a valid diagnosis. A new population of individuals suffering from similar symptoms – those who had survived the Nazi concentration camps, also expanded the professional understanding of combat neurosis. Observing concentration camp survivors brought Harry Abram to expand the concept of combat neurosis to a number of other trauma stricken populations which included: those under stress and those experiencing a life-threatening illness or an emergency situation (Abram, 1970 as cited in Ray, 2008). In his description, he suggested that the syndrome was comprised of both physical and psychological factors. An equal integration of both components was a novel argument because all past theories had put the primary emphasis on only one aspect without realizing the interplay between both

**2.4 The diagnostic statistical manual, vietnam war, and posttraumatic stress disorder**  In 1952, the first Diagnostic Statistical Manual included a diagnosis known as *stress response syndrome* (American Psychiatric Association, 1952 as cited in Lamprecht & Sack, 2002). The diagnosis was conceptualized as transient personality characteristic and was considered to be a normal reaction to extreme stress. Furthermore, with treatment, the symptoms were believed to subside once the ego regained balance (Lamprecht & Sack, 2002). The belief that people commonly recover from the syndrome was maintained despite multiple case examples to the contrary. The second Diagnostic Statistical Manual retained a very similar definition of stress response syndrome despite evidence demonstrating the need for adjustments (American Psychological Association, 1968 as cited in Lamprecht & Sack, 2002). It became a common belief among professionals that everyone had a breaking point, and that stress response syndrome was a normal response to an extreme stressor (Lamprecht &

Eventually the prevalence of soldiers who suffered from the chronic effects of stress response syndrome following the Vietnam War became undeniable. Vietnam veterans lobbied for compensation from the government for the trauma that they suffered (Lasiuk & Hegadoren, 2006). This forced the American Psychiatric Association to reconsider their conceptualization of the disorder, and in 1980 the term *posttraumatic stress disorder* was officially adopted into the Diagnostic Statistical Manual - III (American Psychiatric Association, 1980). In this version, posttraumatic stress disorder was defined by its' overt symptoms so that the characterization was not biased to a particular theory (Ray, 2008). In the revision of the Diagnostic Statistical Manual – III, they further refined the criteria for posttraumatic stress disorder. A distinction was made between common life stressors and a traumatic event, which was considered outside of the realm of normal human experience. Posttraumatic stress disorder was defined as having experienced a traumatic event, causing

malingering (Ray, 2008).

components (Ray, 2008).

Sack, 2002).

**2.3 World War II – Combat neurosis** 

marked distress and fear, helplessness, or horror (American Psychiatric Association, 1987 as cited in Lasiuk & Hegadoren, 2006). Civilian populations such as those who suffered child abuse, sexual abuse, and intimate partner violence were also included under the diagnosis. Extreme changes were made in the diagnostic criteria of posttraumatic stress disorder in the Diagnostic Statistical Manual – IV, which closely resembles the diagnostic criteria that we follow today in the revised version.
