History of Post-traumatic Stress Disorder in Combat

1. History of Post-traumatic Stress Disorder in Combat Presented by Mylea Charvat, MS mcharvat@stanford.edu

2. PTSD in Ancient Literature • Though referred to by a number of different names, PTSD has been with us for as long as wars have been fought. • Herodotus, writing of the battle of Marathon in 490 BC, mentions an Athenian warrior who went blind when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body.” • Steven Bentley, “A Short History of PTSD: From Thermopylae to Hue, Soldiers Have Always Had A Disturbing Reaction To War The VVA Veteran, March/April 2005

3. PTSD in Ancient Literature • Herodotus also wrote of the Spartan commander Leonidas, who, at the battle of Thermopylae in 480 BC, dismissed his men from combat because he recognized they were mentally exhausted from previous battles.

4. PTSD in Ancient Literature • The Iliad makes a reference to what appears to be PTSD -- Ajax loses a duel, comes under a "spell" from Athena, slaughters a herd of sheep thinking they are the enemy, and then kills himself.

5. Evolution of PTSD • 1678 Swiss physician Johannes Hofer coins the term “nostalgia.” to describe symptoms seen in Swiss Troops. • Symptoms of “Nostalgia” • melancholy • incessant thinking of home • disturbed sleep or insomnia • loss of appetite • anxiety • cardiac palpitations

6. Napoleonic Era • French physicians recognized numerous factors important in producing nostalgia: • Cultural (rural vs urban conscripts) • Social (boredom vs rigorous activity) • Environmental (clement vs inclement weather) • Battle (victorious armies suffering fewer cases)

7. Napoleonic Era • Napoleon’s Chief Surgeon, prescribed a treatment for Nostalgia which consisted of: • Regular exercise • Listening to music • “Useful instruction”

8. The U.S. Civil War • The Union Army • 2,600 cases of insanity • 5,200 cases of nostalgia. • In addition many “insane” soldiers were simply discharged and left to find their own way home. • In 1864 the War Department ordered that such soldiers be transferred to the Government Hospital until their families could retrieve them. Franklin D. Jones, M.D., F.A.P.A, “Psychiatric Lessons of War in War Psychiatry, The Textbooks of Military Medicine, ed. Brigadier General Russ Zajtchuk, M.C., (Washington, DC: Office of The Surgeon General, Department of the Army, 1995),

9. The U.S. Civil War: Soldier’s Heart • 1871 Jacob Mendez Da Costa (internist) noted the following symptoms in soldiers: • Chest-thumping (tachycardia) • Anxiety • Breathlessness (hyper-arousal) • These symptoms were referred to first as Soldier’s Heart and later as Da Costa Syndrome.

10. Railway Spine • 1867 – following a series of deadly train accidents in Great Britain: • Railway spine was characterized by: • “…the manifestation of a variety of physical disorders in otherwise healthy and apparently uninjured railway accident victims.” Ralph Harrington, The Railway Accident: Trains, Trauma and Technological Crisis In Nineteenth Century Britain, in Traumatic Pasts: History and Trauma in the Modern Age ed. Mark S. Micale and Paul Lerner, Cambridge: Cambridge University Press.

11. World War I: “Shell Shock” • Symptoms of Shell Shock • Staring eyes • Violent tremors • Blue, cold extremities. • Unexplained deafness, blindness, or paralysis F. C. Hitchcock. Stand To: A Diary of the Trenches 1915–1918. London: Hurst & Blackett, 1937; report, Heath field, England: The Naval & Military Press, Ltd., 2001.

12. World War I: Treating Shell Shock • 1917: U.S. Army Surgeon General’s office creates comprehensive treatment program for shell shock • Placing psychiatrists in combat units • Treatment is Centered on: • Proximity (treating the soldier as close to the battle as possible) • Immediacy (treating the soldier as soon as possible) • Simplicity (providing simple treatment such as rest, a warm shower and food) • Expectancy (the expectation that the solider will return to fight after he has been treated)

13. World War II • Wyeth Pharmaceuticals placed this ad in Life Magazine on September 17, 1945, touting the benefits of their product in curing "battle reaction & mental trauma" caused by WWII...and colic

14. WWII: Combat Fatigue • Forward Treatment Employed. • Unit cohesion recognized as a factor in “resilience” to combat fatigue. • Understanding that intensity and duration of combat exposure increased risk for combat fatigue • Concurrently it was noted that “replacement” troops were more susceptible than “seasoned” Veterans – see unit cohesion.

15. DSM: 1952 • DSM-I • what we now know as PTSD was called "stress response syndrome" and was caused by "gross stress reaction".

16. Vietnam War • 1971 Marine Corps • Recruiting Poster

17. Vietnam War • 1968: Veteran’s Treated for “Stress Response Syndrome” • Informed that if their symptoms lasted more than 6 months after their return from Vietnam they had a "pre-existing" condition, making it a "transient situational disorder", and the problem was not considered service connected.

18. Vietnam War: DSM-II: 1968 • Trauma-related disorders were lumped together in a category titled "situational disorders". the jungles of Guadalcanal.

19. 1980 DSM-III: PTSD • Post-traumatic Stress disorder first introduced as a diagnosis • Placed under a sub-category of anxiety disorders

20. DSM-III PTSD Criteria • Essential feature: Characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. The original stressor is usually experienced with intense fear, terror, and/or helplessness. • The precipitating stressor must not be one which is usually well tolerated by most other members of the cultural group (e.g., death of a loved one, ordinary traffic accident).

21. Evolution of PTSD: DSM-III-R • Changes in DSM-III-R: • Specification of generic characteristics of traumatic stressors • Clearer organization of symptoms around three dimensions of stress response (re-experiencing, avoidance and numbing, and physiological arousal) • inclusion of symptoms specific to children, and specification of onset and duration of the disorder.

22. DSM-IV Criteria • Person Experiences Traumatic Event • Person Experiences Fear, Helplessness or Horror • The person experiences a combination of the following Sx which are still present > 4 weeks following the TE, last more than one month and cause significant distress