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.  

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.