Traumatic experiences are an aspect of human life. The psychological consequences of trauma, specifically due to war and conflict, have long been a point of interest in medicine and the scientific community. Early attempts at diagnosing psychological symptoms following military trauma date back to the early 1800s. The American Civil War and Prussian War veterans were one of the first to be diagnosed, laying down the foundation to an early understanding of combat trauma-related conditions.
The diagnosis for trauma-related conditions have been influenced throughout the years, most notably by major war events. In the aftermath of the first World War, symptoms of a traumatic disorder were diagnosed as “shell shock”, thought to be a reaction to experiencing artillery explosions. Treatment often varied from “hydrotherapy” or “electrotherapy” to a few days’ rest before returning to the war zone. For those with severe or chronic symptoms, treatments focused on daily activity to increase functioning, in hopes of returning them to productive civilian lives6. However, as time passed, thinking changed as more veterans, who were not exposed to artillery explosions, showed similar if not worse symptoms than “shell shock”.
By World War II, shell shock was diagnosed as Combat Stress Reaction or CSR. In the latter half of the war, military discharges were mostly due to the result of CSR in conjunction with “battle fatigue”. Such discharges were approached systematically, by treating those afflicted with CSR using principles of CIE (Proximity, Immediacy, and Expectancy). These principles became a focus of preventing stress and promoting recovery.
Fast forward to the years after World War II, CSR experienced various name changes and fluctuating definitions. In 1952, the American Psychiatric Association (APA) released the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), which described post-traumatic stress disorder (PTSD) as a ‘gross stress reaction’ 6. In the second edition of the DSM, PTSD was removed altogether despite growing evidence linking trauma exposure and psychiatric problems. As a result, PTSD-like conditions were inappropriately summarized as an “adjustment reaction to adult life” 6. However, several later editions of the DSM revised the criteria for PTSD symptoms. In the current DSM-5, PTSD is now in a new category of its own, called Trauma- and Stressor-Related Disorders. In this category, there is a clear distinction between combat related PTSD and various other types of PTSD caused by different traumatic experiences.
From the very first conception of trauma-related conditions, there are have been many evolving factors and stressors that were pivotal in molding the current definition of PTSD. From a historical perspective, a significant change in understanding was ushered in by the concept that the main cause of psychological symptoms was outside the individual rather than an inherent individual weakness. The key to understanding the change in scientific diagnosis of these conditions is to take into account the history of how certain stressors were conceptualized as ‘trauma” during wartime. In my research, I will explore how specific forces that became salient or evolved during and after every major war event, has helped to shift the definition or understanding of PTSD.
It is accepted in the scientific community that combat-related PTSD experienced by military veterans, include symptoms that may not be generalizable to civilian PTSD. With the current healthcare landscape, mental illness compensations are prioritized less very year. Therefore, addressing the pivotal stressors present during wartime is crucial for a better understanding of PTSD. Providing such a context would create more awareness for PTSD and ultimately a more accommodating mental healthcare system. Additionally, observing the pathway of PTSD conception could be useful in evaluating general treatment of other mental illnesses as well. For example, as aforementioned, the first treatment of trauma-related conditions was a couple days bed rest and hydration. It took decades later to upend that diagnosis for a more suitable treatment. Other mental illnesses with less background could benefit from studying the historical stressors and factors that define them currently as well.
Understanding these factors could also help provide a context as to how PTSD (and potentially other similar mental disorders) react to other social factors other than war and conflict. The distinction between combat-related and civilian PTSD is a hotbed for debate. But PTSD caused by other global events, such as economic depression, government corruption, or revolution, are less under the microscope. Understanding the historical stressors that led to the current concept of PTSD, could provide similar frameworks of understanding for other mental illnesses.
The concept of posttraumatic disorder has had a long history of evolution and consequently has become an important conversation in modern clinical psychology. PTSD is unique among psychiatric diagnoses because of the growing list of what is considered to be the traumatic stressor. Thus, the changes in definitions of PTSD occurred in conjunction with the pivotal traumatic stressors, relative to the state of peace or conflict at a certain time period. For example, in the 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), PTSD-like symptoms were defined as a “gross stress reaction”. But as years passed, the American Psychiatric Association omitted the disorder altogether in the second edition, during a time period of relative peace in America 2. When the DSM-III was released in 1987, the disorder made a reappearance as the Vietnam War veterans developed combat-trauma related symptoms.
During this time period, the scientific community considered a traumatic event to be a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions), and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events to be clearly different from the relatively less violent, or “ordinary”, stressors of a time period during peace, whether that be divorce, interpersonal disputes, and events of the like. As an aside, it is important to note that psychological responses to such ‘ordinary stressors’ would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD 2.
This evolution in conceptualizing trauma is one of the many key factors necessary to analyze the historical change in PTSD diagnosis. Other key features to be considered include the political and societal landscape of a certain time period, individual differences regarding the capacity to cope with traumatic stressors, and most importantly the healthcare policies that are contingent to the treatment and diagnosis of PTSD and other mental disorders. By pinpointing the specific forces that shaped the definition of PTSD, similar frameworks of analysis could be used to understand various other mental health disorders. In doing so, I believe that society would become more educated and proactive in erasing stigma, politicians would be more inclined to push for funding for healthcare, and ultimately, detailed healthcare policies would become more accommodating for those who are in need.
