The Evolution of PTSD

War What is it good for? Absolutely nothing War, it aint nothing but a heartbreak
professes Edwin Starr in his anti-Vietnam War song War. While arguments can be made that
war does indeed accomplish strategic trade or territorial goals, in 2016 war is more commonly
associated with civilian casualties, increasing national debt, and Post Traumatic Stress Disorder
(PTSD). The physical trauma of war is fairly easy to comprehend: sharp objects cut limbs, hot
objects burn skin, and heavy objects crush bones. The emotional trauma of war is less tangible,
and thus not as easy to identify. However, increasingly large amounts of scientific evidence
suggest that a wide variety of traumas have negative impacts on the human brain. In accordance
with this increasing scientific understanding, changing cultural attitudes towards trauma-induced
psychological disorders has given rise to the terminology surrounding Post Traumatic Stress
Disorder as it known today.
Understanding the stress disorder linked to witnessing a traumatic event is well beyond
the scope of this particular paper. The focus here is simply on the words utilized to describe the
very broad accumulation of symptoms as described by the American Psychiatric Association in
their 2013 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Within this paper, these symptoms will be referred to as Post Traumatic Stress Disorder (PTSD)
because this is the most widely accepted modern terminology for the conglomeration of
symptoms that meet the APAs defined diagnostic criteria. Commonly accepted exposure triggers
include directly experiencing the traumatic event, witnessing the traumatic event in person,
learning that the traumatic event occurred to a close family member/close friend, or experiencing
first-hand repeated or extreme exposure to adverse details of the traumatic event (exposure
through media, pictures, television, etc is often excluded) (American). These disturbances,
regardless of their trigger, cause clinically significant distress or impairment in the individuals
social interactions, capacity to work or other important areas of functioning, but these must not
be the result of other medical conditions, or substance abuse, though PTSD is often linked to
these things (American). Those who experience PTSD, especially combat related PTSD, often
re-experience the traumatic event through flashbacks or in dreams, or go out of their way to
avoid anything that would trigger memories of the traumatic event. Feelings of survivors guilt
are incredibly common, as are increased amounts of aggression, self-destructive or reckless

behavior, hypervigilance, sleep disturbances, and associated problems that last for longer than
one month (American). This paper focuses almost exclusively on the concept of PTSD in Britain
and the United States, as these are English speaking countries with similar values and medical
practices. The concept of PTSD had international counterparts in other languages, this broader
application and examination is, again, outside of the realms of this paper.
While having a set criteria for this set of symptoms is relatively new, the evidence of
some of these symptoms have been apparent for thousands of years. Scholars argue that several
characters in various Greek or Roman myths likely suffered from what we now classify as
PTSD, such as Achilles in Homers Iliad, who was changed by his war experience, and seemed
to present PTSD-type symptoms following his return home (Greaves). The danger in these
circumstances is that Achilles is a fictional character in a story that has since been translated
several times from its original ancient Greek. However scholars argue that even if modern-day
psychiatrists cannot label Achilles as having PTSD, they can assume that his characters
reactions were likely based on individuals Homer had witnessed following their return home
from battle. Similarly, in Shakespeares Romeo and Juliet, Mercutio when describing Queen
Mab, the dream fairy, says that:
Sometime she driveth oer a soldiers neck,
And then dreams he of cutting foreign throats
Of breaches, ambuscadoes, Spanish blades,
Of healths five fathom deep; and then anon
Drums in his ear, at which he starts and wakes,
This dream experience is similar to the flashback-style dreams commonly associated with PTSD,
in which the patient relives the trauma experienced, as seems to be the case here (I.iv.82-86).
These very specific descriptions of soldiers re-living distressing dreams of the battlefield are
much too common to completely dismiss, but there was no term to describe this particular
phenomenon. Indeed, several authors throughout the years have tried and failed to capture this
post-war phenomenon that seemed to plague some soldiers, but not others. Following both the
American Civil War (1861-1865) and the Franco-Prussian War (1870-1871), medical
professionals attempted to explain the problems of military veterans following their return home
from combat. Some of the more prominent descriptors of these symptoms include soldiers
heart or irritable heart, along with Da Costas Syndrome which encompassed symptoms

including rapid pulse, anxiety, and trouble breathing (Friedman), but no true criteria were ever
officially established to define individuals suffering from this combination of symptoms. At
about this same time, the industrial revolution took hold across Europe and North America, and
evidence began to emerge that these symptoms of distress following a traumatic incident were
not exclusive to soldiers experiencing combat. As large factory machines grew in prominence,
and train travel became the norm, accidents occurred that left their victims with more than
physical wounds. The mental distresses were thought to be brought about by the disruption of the
cerebral fluids, and thus railway spine became the diagnosis for some victims (Friedman). The
lack of consistent language and concrete definition reveal how individuals in English speaking
societies before 1900 did not find the combination of these symptoms important enough to
classify them and name them specifically. This phenomenon would change following what was
then accepted as the bloodiest war in history, the Great War - also known as World War I.
With the advent of tanks, machine guns, trench warfare, and mustard gas, World War I
(1914-1918) was the bloodiest war on record, leading to a whole new slew of psychological
problems as a result of this violent and deadly warfare. During the World War I period, as
French, English, and American doctors were often working together to save the lives of their
soldiers, they came to the first tentative agreement about how to classify the psychological
trauma of war as either shell shock or war neurosis. The French described this phenomenon
as choc commotionnel and choc traumatique whilst their German enemies classified these
war-related neuroses symptoms as kriegshyterie, granatkontusion (shell concussion) and
granatexplosionslhmung (exploding-shell paralysis) (Jones). Within the British military,
soldiers who presented with symptoms of shell shock were often discouraged from being
properly diagnosed in an effort to limit the number of cases, and thus assuage the British public
about the safety of their soldiers (Crocq). The treatment of this war neurosis often involved
keeping the soldiers close to the front lines and within the confines of the military hierarchy, as
soldiers were then able to recover with the help of their comrades, and return more quickly to the
front lines. Unfortunately, the cultural attitudes towards those who experienced shell shock was
less than sympathetic, both within the military and amongst civilians, making the transition to
civilian life even more difficult for the veterans once they finally returned home. Suffering from
shell shock was often perceived as a weakness of the mind, and soldiers experiencing this for
extended periods of time were sent home in disgrace (Bourke). Part of this stigma against

psychological trauma was spurred by the widely held belief that some soldiers were pretending
to have war neurosis in order to be sent home with a nice pension and no actual physical
sacrifice, which may have been true in a limited number of cases, but was likely not true for
most. Falling in line with this train of logic, the United Kingdom made the distinction between
true and false war neurosis, in which those suffering from false neurosis were simply
doing so for the pension benefits and were thus not granted them (Jones). Similarly, in 1926, the
German government decided to refuse pensions to veterans suffering from psychological
disorders for many of the same reasons. This governmental and societal distrust concerning the
effects of war traumas on the minds of soldiers would plague veterans across the Western world
through both World Wars and well beyond. The lack of sympathy for non-tangible wounds
continues to this day, and highlights humans distrust of things they cannot see.
World War I was the war to end all wars, or so the world hoped, but this was far from
true, as was revealed by the outbreak of World War II in 1939 and the re-emergence of PTSDtype disorders. Unlike previous wars, World War II (1939-1945) was not confined to the
battlefield, and the effects of total war on the populations of France, Russia, Germany, the United
Kingdom, and others will likely never be completely understood. However, the prevalence of
death camps combined with the bombings of London and other major cities exposed civilians to
the trauma of warfare like never before, and many of the survivors of these tragedies were
analyzed in the decades following the tragedy revealing that they had developed PTSD. During
the war, though, the trauma of civilians was still unrecognized, leaving military leaders and
politicians to attempt to handle the prevalence of shell shock amongst their soldiers. In July of
1939, as the war was breaking out, the Royal British physician and a host of other individuals
known as the Horder Committee decided that an official acknowledgement of war neurosis
opened a route to discharge from the forces and the prospect of financial compensation, leading
the British government to announce that no pensions would be awarded for psychiatric war
injuries (Jones), as was seen in WWI. This meant that soldiers who experienced PTSD-type
symptoms were diagnosed with exhaustion and kept in the military forces. The British
government at this point was desperate to maintain a large military force against the numerically
superior Nazi forces, but eventually gave into public opinion and pressure from doctors, Trade
Unions and other social pressures to abandon its embargo on war pensions for psychological
disorders in June 1941 (Jones). However, there was still the overarching stigma that those who

were susceptible to war neurosis were the psychopathic, the damaged, defective or
constitutionally unstable indicating that military doctors believed the preexisting mental state of
the soldier, not the trauma he experienced on the battlefield, was responsible for sending him into
a shell shocked state (Jones). This idea was somewhat abandoned in 1943, as more evidence
emerged from in-depth studies of British aircrews and elite army units revealed that all
servicemen, however carefully selected, well-trained or led, had a breaking point, an
observation that was quickly confirmed through a number of post-war analyses of WWII
soldiers. Between the huge amount of civilians exposed to the horrors of war, the viciousness of
the war in general, and the growing acceptance of psychiatry as an actual field of science, the
Western Anglo-Saxon world saw war neurosis grow as a normal reaction to combat stress
situations. To be sure, there were caveats, but ultimately the shift towards acknowledging that all
people exposed to traumatic, war-like events could experience war neurosis was one of the
largest movements towards todays interpretation of PTSD. While the language around the
concept did not change at this time, the principles surrounding the term did change and become
applicable to a larger portion of the population.
One of the most interesting phenomenon surrounding the usage of war neurosis, shell
shock, and even civilian based terms such as railway spine, is that during times of peace these
words tended to fall out of use. When the American Psychiatric Association published their first
volume of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952, they
included the category of gross stress reaction, defined as a stress syndrome that is a response
to an exceptional physical or mental stress, such as a natural catastrophe or battle (Andreasen).
When a revised edition (DSM-II) was published in 1968, however, this diagnosis was abandoned
without explanation or replacement by another such disorder. The Korean War was not nearly as
traumatic as either of the World Wars had been, and the years of peace likely drove the disorder
from the minds of psychiatrists, as the concept of events triggering a stress reaction was not
nearly as prevalent as it is today. Similarly, talks of war neurosis and shell shock were all but
forgotten between the two World Wars, only to make a vicious reappearance when it was
experienced at home and on the battlefield. The Vietnam War acted as a game changer in many
respects, and is often cited as the turning point towards placing the concept of PTSD into the
everyday vocabulary of discussing traumatic events.

The Vietnam War (American involvement 1961-1975) was a different war than any
others that Western powers had fought before, and as such, ushered in a new way to define the
psychological traumas associated with it. Vicious guerilla-style warfare characterized the
Vietnam War, and while the treatment of acute combat fatigue had apparently been well
managed by military psychiatrists, after they returned home servicemen presented with what
appeared to be a range of delayed or chronic symptoms that would eventually become PTSD
(Jones). Another defining characteristic of this war was the anti-war sentiment taken up
throughout the country, with protests, riots, songs like Starrs War, and demonstrations against
the violence American soldiers were committing in the jungles of Vietnam. Indeed, this disorder
was defined thoroughly and painstakingly the 1970s largely due to the political opposition many
mental-health professionals held against the Vietnam War. DSM-III, published in 1980, reflected
the work that these anti-war mental-health professionals had conducted, and defined the PTSD
that is known and diagnosed today. As public opinion shifted away from war and combat, the
publics interest in quantifying the detriment to soldiers psyches that combat produced increased
exponentially. Unfortunately, the community that PTSD most widely applies to, those in the
armed forces, still reject PTSD as an acceptable excuse to leave combat situations, and often fail
to reach out and seek help for their mental trauma (Friedman).
The exact definition of PTSD is still hotly contested, with several military leaders
pushing to rename the disorder posttraumatic stress injury, a description they say is more in line
with the language of troops and would reduce stigma as they currently believe the word
disorder makes soldiers who are experiencing PTSD symptoms reluctant to ask for help
(American). This statement, more so than anything described in this paper, reveals the true power
of words on a soldiers willingness to seek help for what is now commonly accepted as a
reasonable reaction to war. Honestly, it is nigh on impossible to know whether or not the shift in
language from disorder to injury would truly change how PTSD is perceived in the United
States military, and trying to assess this is well beyond the scope of this paper. What is of note is
that as PTSD became more widely accepted throughout American society, psychiatrists found
new circumstances under which PTSD could be triggered. Beyond bombings, beheadings, and
the brute violence of war, now sexual assaults, terrible car crashes, near-drownings, and a whole
host of other events are now considered traumatizing enough to trigger PTSD. The widening of
this diagnosis beyond simply combat-induced trauma correlates with societys acceptance of it,

but its increased prevalence has also raised alarm bells, leading to questions of the validity of
PTSDs existence (Andreasen). The counter argument to such claims is to highlight the ways in
which warfare and everyday life are both much more complex than they were even 100 years
ago, and that the stressors our ancestors brains adapted to are vastly different from the stressors
of modern day life. Either way, the overwhelming majority of the English-speaking scientific
community believe that PTSD is a disorder that impairs the lives of the victim, and should be
treated to improve the individuals quality of life.
Science and medical technologies have advanced tremendously over the past 150 years,
and so has the understanding of the human mind, especially in how it relates to traumatic
incidents. Shell shock, war neurosis and railway spine have specific usages, but no clear
criteria defining their application, and they have thus become terms of the past. Post Traumatic
Stress Disorder, however, captures the clinical nature of this particular ailment, indicating that
this is a medical condition that has been researched, defined, and can be treated with some
amount of success. As understanding of the far-reaching effects of mental trauma grows, perhaps
PTSD will receive yet another name. In 2016, however, PTSD is the most succinct and versatile
explanation for the effects of mental trauma - a term that has been moulded, rearranged, and
somewhat redefined as humans further understand their own minds. Perhaps one day the whole
world will sing Edwin Starrs War together in harmony, and recognize that violence is not the
answer to the worlds problems. Unfortunately, this will likely not happen within the foreseeable
future, and even if war was expunged, other traumas in our everyday lives can cause mental
trauma and the symptoms associated with its presence. Under these circumstances, PTSD is
likely a concept that will continue for easily the next 100 years.

Citations
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Bourke, Joanna. Shell Shock During World War One. BBC. BBC, 10 March 2011. Web. 5
March 2016.
Crocq, Marc-Antoine, and Louis Crocq. From Shell Shock and War Neurosis to Posttraumatic
Stress Disorder: A History of Psychotraumatology. Dialogues in Clinical Neuroscience
2.1 (2000): 47-55. Print.
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