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By Natalie Hughes.

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PTSD symptoms were first noted by Swiss military physicians in 1678. They named it Nostalgia. These symptoms included: Melancholy, Excessive thoughts of home, disturbed sleep or insomnia, weakness, loss of appetite, anxiety, palpitations, stupor, and fever (Bentley, 2005). Around the same time, German, French and Spanish doctors were also creating terms for the same symptoms. (Bentley, 2005).

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By the 1700s a prominent French surgeon, Dominique Jean Larrey, described the disorder as having three stages: Heightened excitement and imagination. Periods of fever and gastrointestinal symptoms. Frustration and depression Shortly afterwards, military physicians in the United States began documenting the same kind of symptoms from Civil War soldiers. Jacob Mendez Da Costa, a cardiologist, described this constellation of symptoms as Soldiers Heart, or Irritable Heart. The sharp increase in PTSD symptoms in service personnel during the Civil War years has been attributed to the arrival of modern warfare, the horrifying results of which left many soldiers with psychological wounds which physicians were unsure of how to treat (Bentley, 2005).

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Unfortunately, soldiers who suffered from PTSD during these times were often seen as weak. Robert C. Wood, the USA Assistant Surgeon General in 1864, was known to have stated: It is by lack of discipline, confidence, and respect that many a young soldier has become discouraged and made to feel the bitter pangs of homesickness, which is usually the first sign of more serious ailments The belief that soldiers suffering from PTSD were merely weak or malingerers remained in the public sentiment for years to come. However, elsewhere the disorder was beginning to gain some legitimacy. By 1905, PTSD, then known as Battle Shock, was regarded as a legitimate medical condition by the Russian Army.

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In WWI, it was believed that the psychological distress of soldiers was due to concussions caused by the impact of shells. This impact was believed to disrupt the brain and cause Shell Shock. Shell shock was characterized by a dazed, disoriented state that many soldiers experienced during or after combat. However, even soldiers who were not exposed to exploding shells were experiencing similar symptoms (Scott, 1990). Therefore it was once again assumed that soldiers who experienced these symptoms were cowardly and weak. Treatment was brief, consisting only of a few days R&R before the soldier was expected to return to duty. Because 65% of shell-shocked soldiers ultimately returned to the front lines, treatment was considered a success.

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Meanwhile, some scholars were questioning the term, shell shock,. For example, Smith and Pear (1918) preferred the term, war strain. These scholars also disagreed with the common misconception of the time that the condition resulted in shock, Instead they believed that this was a trauma related condition brought on by such things as: Witnessing a mine explosion Being temporarily buried alive in the dug-out, The sight and sound of injured or dead comrades, or other appalling experiences which finally incapacitate him for active duty.

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The authors go on to suggest that the trigger for war strain was considered to be intense emotional arousal and the suppression of emotion, as well as fear (Smith & Pear, 1918). Resulting symptoms were believed to include: Memory loss. Insomnia. Nightmares. Pains. Emotional instability. Loss of self-confidence and self-control. Convulsions. Obsessive thoughts, usually of the darkest and most painful kind, even in some cases hallucinations and delusions.

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Another stress theory that arose during this time was war neurosis, proposed by Sigmund Freud. Freud did not write a great deal about the topic, but his colleagues did. Sandor Ferenczi, Karl Abraham, Ernst Simmel, and Earnest Jones, published a book entitled, Psycho-Analysis and the War Neuroses (1919). Freud wrote the introduction to this book. In the following passage, Freud explains his belief that war neuroses was brought about by conflicts between soldiers war egos and peace egos: The war neuroses differed from the ordinary neuroses of peace time through particular peculiarities, so were to be regarded as traumatic neuroses. He believed their existence had been made possible because of an ego- conflict. The conflict took place between the old ego of peace time and the new war-ego of the soldier, and it became acute as soon as the peace-ego was faced with the danger of being killed through the risky undertakings of his newly formed parasitical double. Basically, the old ego protected itself from the danger to life by flight into the traumatic neurosis in defending itself against the new ego which it recognized as threatening its life. (Ferenczi, Abraham, Simmel, & Jones, 1919, pp. 2-3).

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Freud also believed that war neurosis was best treated by the cathartic method of psychoanalysis. After the war, Freud was called upon by the Austrian War Ministry to give his opinion about the rumoured brutal treatment of psychologically wounded soldiers by Army Doctors. In 1920, he submitted a memorandum entitled, Memorandum on the Electrical Treatment of War Neurotics. Consistent with the views expressed in the introduction to Psycho-Analysis and War Neuroses (Ferenczi et al., 1919), Freud confirmed that war neurosis had physical causes that were best treated with psychoanalysis rather than electrical shock treatment.

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By the end of WWI, psychiatrists began to believe that what had been known as Shell Shock was the result of emotional problems rather than physical injury of the brain. Although this was a step forward in the understanding and treatment of PTSD, psychiatrists continued to believe that soldiers who were weak were predisposed to the condition (Bentley, 2005). So, their primary aim was to use psychiatric testing to screen out those they believed would sustain psychological casualties in war (Bentley, 2005). There also continued to be doubts among some military professionals about the legitimacy of the condition.

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WWII differed from previous wars due to its use of bigger weapons and bombs, which placed soldiers at greater risk. Additionally, soldiers were placed into smaller combat groups, which reduced the social interaction which may have previously been psychologically soothing for the soldiers. (Marlowe, 2000). WII took a tremendous psychological toll on soldiers, despite the extensive use of psychiatric screening for selection (Marlowe, 2000). Medical personnel were puzzled that although over one million soldiers were screened out for psychological reasons, there continued to be staggering numbers of psychiatric casualties in war. In fact, even soldiers who had fought bravely on previous tours were being affected (Scott, 1990). Overall, 25% of casualties were caused by war trauma, and this rate increased to 50% for soldiers engaged in long, intense fighting (PBS, 2003). In fact, so many soldiers were affected that psychiatrists were confronted with the reality that psychological weakness had little to do with subsequent distress in combat. As a result of this they changed the terminology from combat neurosis to combat exhaustion, or battle fatigue (Bentley, 2005). Reflecting the consensus that all soldiers were vulnerable to battle fatigue due to their environments, the U.S. Army adopted the official slogan, Every man has his breaking point (Magee, 2006).

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In 1947, the U.S. Army released a documentary, entitled Shades of Gray, about the causes and treatment of mental illness during WWII. This documentary indicated the consensus at that time that no one was immune to mental illness, and that environmental factors play a large role in the development of psychological problems. Combat exhaustion was thought to involve such symptoms as hypervigilance, paranoia, depression, loss of memory, and conversion. During WWII, treatments changed again. They included extended rest in safe areas, administering sodium pentothal (or other barbiturates) to induce repressed battlefield experiences, and even giving alcohol to soldiers.

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Although psychiatrists were advancing in their understanding of war trauma, combat exhaustion was not universally accepted. General George Patton was notable in his lack of sympathy for the psychological afflictions of soldiers. He is said to have slapped two soldiers who were recuperating in a military hospital while yelling to a medical officer, Dont admit this yellow bastard. Theres nothing the matter with him. I wont have the hospitals cluttered up with these sons of bitches who havent got the guts to fight (Magee, 2006). President Roosevelt received thousands of letters about the incident, most of which indicated support for Patton. Ultimately, though, Patton was reprimanded, ordered to apologize, and relieved of command of the Seventh Army (Magee, 2006).

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After WWII, medical professionals started considering the biological factors involved in the soldiers psychological distress. A disease based model was proposed and psychiatric medications became more common (Marlowe, 2000). Unfortunately, this view of PTSD led to a great deal of stigmatization, because if biological factors were the sole cause of the development of these symptoms, then afflicted soldiers could be considered as physiologically weak or constitutionally disordered (Marlowe, 2000). Another explanation relating to biology was that psychological problems arose in early childhood, and that psychological problems were converted into physical symptoms, manifesting themselves in such a variety of diseases such as ulcers, arthritis, dermatitis, and hyperthyroidism (Marlowe, 2000).

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As psychology became more integrated with medicine, it became clear that PTSD was far more complex than the medical model or psychosomatic explanations would indicate.

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By the time of the Vietnam War measures were being taken to try and lessen the psychological impact of war on soldiers. From the very beginning of the war, the military provided each battalion with medical personnel trained to treat psychological problems (Scott, 1990). At first, these measures seemed very successful, as very few psychological casualties were reported. However, as the war continued, and public outcry about the legitimacy of the war led to even greater stigmatisation of soldiers, cases of combat fatigue increased. Estimates are varied, but the figures below give an indication of findings: 15.2% of male and 8.5% of female Vietnam veterans had PTSD 20 years after the war 11.1% of male and 7.8% of female Vietnam veterans had partial PTSD 20 years after the war 30.9% of male and 26.9% of female Vietnam veterans had PTSD at some time in their lives.

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Despite the enormous psychological toll of Vietnam on soldiers, they received no heros welcome when they returned from war, and often had to face homecoming alone, or alongside a few other soldiers who had shared their experiences and could offer social support. They were often met with hostile demonstrations by anti-war activists. American society offered little acceptance of Vietnam veterans even years after the war (Marlowe, 2000). The harsh treatment of Vietnam soldiers, especially given their psychological afflictions gave rise to our current beliefs about PTSD. Pettera, Johnson, and Zimmer (1969) referred to Vietnam combat reaction as a more extreme form of combat fatigue which was mostly seen in soldiers nearing the end of their tours, and would likely have long-term consequences (Marlowe, 2000). They provided a comprehensive description of the symptoms of Vietnam combat soldiers.

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Early symptoms included insomnia, anorexia or both. Later symptoms included: Insomnia Recurrent nightmares, which were usually a reliving of a severe psychic trauma (friends and colleagues severely injured, mutilated, or killed, the subject themselves wounded close to a vital organ, or perhaps their unit overrun by enemy with few survivors; anorexia progressing to nausea; and sometimes even watery diarrhoea. Depression, including guilt over not having saved his friends life or perhaps not having grieved enough for him, as well as shame for having broken down when others in his unit maintained emotional control severe anxiety, to such a degree as to make the soldier ineffective in combat. Soldiers experienced a deep fear of combat or the thought of it, and noticed increasing tremulousness beyond their control when in the field, especially if actual enemy contact was made. (Pettera, Johnson, and Zimmer, 1969, p. 675, as quoted in Marlowe, 2000)..

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Elements of this definition can be seen in the current diagnostic criteria for PTSD

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In the post-Vietnam period, it became clear that many soldiers were suffering severe psychological problems as a result of their traumatic exposure, yet psychiatrists were left without a diagnosis. Chaim Shatan, a psychiatrist and advocate for Vietnam veterans, raised awareness about the absence of a combat-stress diagnosis in the DSM. In 1972, he wrote an article for the New York Times calling it post-Vietnam syndrome,. He described it as an affliction that occurred 9-30 months after Vietnam combat (Scott, 1990). Shatan described the syndrome as delayed massive trauma and identified its themes as: guilt, rage, the feeling of being scapegoated, psychic numbing, and alienation (Scott, 1990, p. 301). Shatan expanded upon Freuds conceptualization of grief: Freud explained the role grief plays in helping the mourner let go of a missing part of life and acknowledging that it exists only in the memory. The so-called Post-Vietnam Syndrome confronts us with the unconsummated grief of soldiers and their impacted grief, in which a never-ending past deprives the present of meaning. Their sorrow is unspent, the grief of their wounds is untold, their guilt unresolved. Much of what passes for cynicism is really the veterans numbed apathy from an excess of bereavement and death (Shatan, 1973, as quoted in Scott, 1990, p. 301).

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Shatans piece in the New York Times gained a great deal of support for legitimising post-Vietnam syndrome in the DSM (Scott, 1990). Ultimately, this description became accepted and the condition was renamed Post Traumatic Stress Disorder. PTSD has remained a diagnosis in the DSM. The Diagnostic and Statistical Manual of Mental Disorders, In the United States the DSM serves as a universal authority for psychiatric diagnosis. In the most recent version the criteria for PTSD are defined as follows:

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Criteria A: Stressor The person has been exposed to a traumatic event in which the person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others, and their response involves intense fear, helplessness, or horror. Criteria B: Intrusive recollection The traumatic event is persistently re-experienced in at least one of the following ways: Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when having drunk alcohol. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Physical reactions upon exposure to internal or external triggers that symbolize or resemble an aspect of the traumatic event.

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Criteria C: Avoidance/Numbing Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections of the trauma Inability to recall an important aspect of the trauma Markedly diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (e.g., unable to have loving feelings) Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

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Criteria D: Hyper-arousal Persistent symptoms of increasing arousal (not present before the trauma), indicated by at least two of the following: Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hyper-vigilance Exaggerated startle response Criteria E: Duration Duration of the disturbance (symptoms in B, C, and D) is more than one month.

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Criteria F: Functional significance The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Our current understanding of PTSD is that intrusion, avoidance, and arousal symptoms are all present for at least one month, and cause significant problems in functioning. The introduction of these criteria was a great step forward in our understanding of PTSD, as the criteria indicate that the cause of the trauma is outside of the individual, rather than the result of a weakness in the individual (Friedman, 2007). Additionally, the current criteria acknowledge both psychological and biological components of the disorder.

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We also now believe that PTSD can arise as a result of threat to the physical integrity of another, So, even individuals, such as family members or helping professionals who are exposed to the traumatic experiences of others, can be susceptible to developing PTSD symptoms themselves (Bride, Robinson, Yegidis, & Figley, 2004).

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As our understanding of PTSD evolved, so has the treatments available. One of the main treatments used is Cognitive Behaviour Therapy. CBT involves educating patients about PTSD symptoms and cognitive changes in the areas of safety, trust, control, intimacy, and self esteem. PTSD sufferers are also helped to identify their negative, irrational thoughts, (NATs) and learn skills for challenging these beliefs Additionally, some medications, such as Zoloft (sertraline) and Paxil (paroxetine), have been approved for the treatment of PTSD, but are primarily used when therapy alone is ineffective (Friedman, 2007).

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Cognitive behavioural therapy (CBT) aims to help suffers manage their problems by changing how they think and act. Trauma-focused CBT uses a range of psychological treatment techniques to help the client come to terms with the traumatic event. For example, the therapist may ask the client to confront traumatic memories by thinking about the experience in detail. During this process the therapist will help with any distress felt, while identifying any unhelpful thoughts or misrepresentations about the experience. By doing this, the therapist can help the client gain control of fear and distress by changing the negative way of thinking The client may be encouraged to gradually restart any activities that have been avoided since the experience. It is the norm to have approximately 6-12 weekly sessions of CBT.

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