Facing Past Trauma, Part VI: The History of the PTSD Diagnosis

John McManamy Health Guide
  • This is the sixth in our conversation on past trauma. Last week we looked at how PTSD can guide our understanding into how trauma may connect to bipolar. There is, however, one major catch: The PTSD diagnosis had its roots in the observable phenomenon of soldiers mentally falling apart from the horrors of combat, and society’s attitudes in how to treat these individuals. Needless to say, this severely colored how the diagnosis came to be applied to those who never experienced combat. A brief history:


    Seventeenth and eighteenth-century European physicians coined the term “nostalgia” to refer to battle-weary soldiers, a term that Union doctors applied - along with “soldier’s heart” and “exhausted heart” - to the widespread trauma among troops in the US Civil War. The Civil War was a precursor to the high-tech horrors and mass bloodbaths of twentieth-century warfare.  

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    The First World War marked the beginning of systematic debate on physical vs psychological stress. Doctors used the term “shell shock” to describe an apparent physical reaction to artillery fire. Later, it became evident that many of the afflicted had not been exposed to explosions, implying a psychological reaction.


    “Reaction” was the mindset of Freudian psychiatrists. “Combat fatigue” and “battle fatigue” were the best-known terms to come out of the Second World War, but it was “gross stress reaction” that entered the DSM-I of 1952. According to Nancy Andreasen of the University of Iowa, writing in the Sept 2011 Dialogues in Clinical Neuroscience, “its description emphasized that the disorder was a reaction to a great or unusual stressor that invoked overwhelming fear in a normal personality.” The catch was that the DSM regarded the disorder as transient and reversible, and that if symptoms persisted another diagnosis was to be given. Not surprisingly, “gross stress reaction” did not catch on, and the designation was dropped by the DSM-II of 1968.


    Coincidentally, 1968 was when fighting in Vietnam reached new levels of intensity, along with growing opposition to American involvement in the conflict. Soldiers faced the additional trauma of arriving home to hostile welcomes. During the seventies, as discussions for the DSM-III got underway, Vietnam veterans lobbied for the inclusion of a combat stress diagnosis. Wrapped up in the debate - a consideration that also applied to veterans from both World Wars - was the political hot potato of disability benefits. To keep things simple: Narrow criteria save governments a lot of money.


    As a direct result of the advocacy efforts of the Vietnam veterans, Robert Spitzer, the DSM-III task force chair, assigned Dr Andreasen the task of revisiting the gross stress disorder diagnosis. According to Dr Andreasen:


    The answer to the veterans' request was obvious to me: there is a well-established syndrome, defined by a characteristic set of physiological (autonomic) and cognitive and emotional symptoms, that occurs after exposure to severe physical and emotional stress. In fact, its scientific basis was as strong as that available for disorders such as depression or even schizophrenia.

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    Dr Andreasen, who began her career caring for severe burn victims, was guided by the emerging biological school of psychiatry, in particular the work of Han Selye, who in the 1950s coined the term “stress” and hypothesized its relationship to the HPA axis. Seyle, in turn, drew his inspiration from Walter Cannon, who in 1915 came up with “fight or flight.” Cannon also developed the concept of “homeostasis” to describe the body in a constant state of self-regulation in order to maintain a “steady state.”


    Chronic exposure to stress, needless to say, poses extreme challenges to the body and brain’s capacity to maintain a steady state. 


    In other words, a soldier with the classic thousand-yard stare wasn’t just faking it. The Vietnam vets pressed for the DSM diagnosis of “post-Vietnam-syndrome,” but Dr Andreasen felt that major trauma did not simply confine itself one particular war, much less the battlefield. Accordingly, PTSD (post traumatic stress disorder) entered the DSM-III of 1980, with the threshold that the precipitating stressor had to be “outside the range of normal human experience,” such as combat or rape (but not an everyday experience such as an auto accident). 


    The PTSD diagnosis, according to Dr Andreasen, immediately became too popular and applied too widely, but “the genie was out of the bottle.” For instance, what to make of an adult who describes having been abused as a child? How do you connect cause to an effect that may be decades apart?  


    The DSM-III-R of 1987 and DSM-IV of 1994 further broadened the criteria. The current threshold reads, in part: “involves a threat to the physical integrity of self or others.” The DSM-5, due out next year, largely sticks to the 1994 script.


    In an editorial in the 2004 American Journal of Psychiatry, Dr Andreasen argues that the diagnosis should be reeled in. According to Dr Andreasen:


    Giving the same diagnosis to death camp survivors and someone who has been in a motor vehicle accident diminishes the magnitude of the stressor and the significance of PTSD.


    Do you detect a fatal flaw in Dr Andreasen’s logic? Death camp survivors - most notably the Italian writer Primo Levi -  also experienced severe depression. In 1987, Levi fell victim to suicide. According to Nobel Laureate Elie Weisel, "Primo Levi died at Auschwitz forty years earlier."


    So, would giving the depression diagnosis to a person who can’t get out of bed in the morning or finds herself crying a lot in the company of others diminish the death camp hells that Primo Levi went through? Of course not.


    To put it another way: Would we deny treatment to someone who cannot function based on the criteria that they did not endure combat or a death camp - or a civilian experience that equates to one or the other? Of course not.


    So why the absurdity in limiting the PTSD diagnosis? Simple, really. Depression and bipolar and other illnesses had their origins in everyday life. PTSD came out of the heat of combat. It is an historical anomaly, but hardly a biological fact. The great biological psychiatrist Dr Andreasen (whom I tremendously admire) temporarily lost sight of that.

Published On: July 07, 2012