History of Post-traumatic Stress Disorder in Combat

1
History of Post-traumatic Stress Disorder in
Combat

• Presented by
• Mylea Charvat, MS
• mcharvat_at_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

• Napoleons 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 Soldiers 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
  Soldiers 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 19151918. 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 Generals 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 Veterans 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 gt 4 weeks
  following the TE, last more than one month and
  cause significant distress

Re-experiencing gt1 Intrusive thoughts or memories Trauma related dreams Acting/feeling as though the trauma were reoccurring Emotional distress in response to triggers Physical Sx in response to triggers Avoidance gt3 Efforts to avoid trauma related thoughts or feelings Avoidance of people, places or activities that trigger reminders of trauma Memory loss for all or parts of the trauma Loss of interest in activities Feelings of estrangement from others Expectation of foreshortened future Hyperarousal gt2 Difficulty with sleep Irritability and anger Attention and Concentration problems Hypervigilence Exaggerated startle reaction