Post-Traumatic Stress Disorder: A Historical Perspective of an Evolving Diagnosis
1Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, MD
2University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, MD
Article series summary: This is the first article in a continuing series on posttraumatic stress disorder (PTSD). Subsequent articles will discuss the prevalence of PTSD; its risk factors; how to identify the signs and symptoms of PTSD, particularly in the elderly; and how to treat elderly persons who have a PTSD diagnosis, with a focus on biological, pharmacological, and psychological techniques.
Abstract: Post-traumatic stress disorder (PTSD) has been reported for thousands of years. Although the condition has been predominantly associated with veterans, we now know that any traumatic event can result in PTSD. In this article, the first in a series on PTSD, the authors outline some of the earliest accounts of PTSD in the literature and review how the condition is diagnosed today. They also discuss the latest criteria for making the diagnosis, which were recently published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Key words: Post-traumatic stress disorder, anxiety disorders, avoidance, traumatic experiences, Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-5.
Post-traumatic stress disorder (PTSD) is a severe condition that may develop after a person is personally exposed to or witnesses one or more traumatic events, such as a serious injury, sexual assault, or the threat of death. Because such events have occurred since the beginning of time, PTSD has been reported through the ages, but has gone by different names, from shell shock, to operational fatigue, to gross stress reaction, amongst many others. Although PTSD is most commonly recognized to affect military personnel returning from war, the condition can affect anyone, including the elderly. In this article, we examine some of the many accounts of PTSD that have been reported in the literature, review how PTSD is diagnosed today, and discuss recent changes to its diagnostic criteria, as outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published in May 2013. This article puts PTSD in historical context, setting the foundation for the next articles in this series on PTSD.
PTSD Through the Ages
The Epic of Gilgamesh,1 which dates back to between 1500 BCE and 1000 BCE, making it one of the oldest stories ever written, describes a King in Babylon named Gilgamesh who was not only distraught, but also terrified after surviving a violent encounter that led to the death of his closest friend, Enkidu. It was said that following this event, Gilgamesh had an inability to sleep, was angry, had terrifying memories, and had a sense of a foreshortened future. These are all characteristics of what we now recognize to be PTSD.
Alexander the Great, who lived between 356 BCE and 323 BCE, was also thought to develop symptoms of PTSD following years of stress and exposure to violence.2 When Alexander the Great was 20 years old, his father was assassinated (336 BCE), and he was involved in 10 years of bloody hand-to-hand combat receiving several near-fatal wounds while witnessing many of his peers and soldiers killed. Alexander was noted to experience changes in personality affecting his judgment and began killing the leaders of his army during his drinking bouts. He was also described as being pathologically suspicious.
Samuel Pepys, who lived in London during the Great Fire of London in 1666, recalled the terror and frustration of individuals who were unable to protect their possessions or stop the fire. He wrote in his diary, “a most horrid, malicious, blood fire. So great was our fear, it was enough to put us out of our wits.”3 He also described how witnessing the fire caused him to experience sleep disturbances even 6 months after the event. Based on our review of the historical accounts of PTSD, Pepys’ report may be one of the first to document a non-attack-related event leading to PTSD. Most accounts of PTSD in the early literature describe the condition as occurring after a military strike or altercation.
Captain James Cook, who lived between 1728 and 1779, was also thought to develop PTSD following years of stressful travel in the Pacific, where he experienced cannibalism, shipwreck, and epidemics, among other challenges.2 On his third and final voyage, it was noted that he exhibited a change in personality and became cruel, irritable, and profane. Cook’s leadership also came into question, as his poor judgment put his men’s lives at risk and eventually cost him his own life after he unnecessarily provoked native warriors. Cook’s dramatic change in personality mimics that of Alexander the Great’s, despite facing very different traumatic events.
Dominique Jean Larrey, a French surgeon who is commonly known as “the father of modern military surgery” for his many innovations treating injured soldiers during the Napoleonic Wars (1803-1815),4 also observed the condition among the many soldier he treated. He better defined the disorder we now refer to as PTSD, and he reported three distinct stages to this condition: the first was characterized by heightened excitement and imagination; the second by a period of fever and gastrointestinal symptoms; and the third by a feeling of frustration and depression.2 Many of these symptoms are still associated with PTSD today.
During the American Civil War (1861-1865), soldiers commonly exhibited symptoms that we now attribute to PTSD, including unexplained tremors, self-inflicted wounds, nostalgia (eg, a wish to return home), heart palpitations, and even paralysis.5 It was not unheard of to have soldiers return home and collapse with emotional distress after a period of time, despite demonstrating no symptoms prior to departure from the battlefront. These psychological problems were so common that the War Department started screening recruits in an attempt to identify those who were more susceptible to psychiatric issues. By 1863, there was a public outcry for intervention and the first military hospital was opened to deal with Civil War soldiers suffering from psychiatric illness. The most common diagnosis was nostalgia. Following the war, this hospital was closed and a system of domiciles were opened, the first located in present-day Augusta, Maine (VA Maine Healthcare System—Togus), and admitted soldiers with medical and mental disorders.
Jacob Mendez DaCosta, an observant clinician who lived between 1833 and 1900, was the first to actually recognize that the constellation of symptoms experienced by survivors of life-threatening injuries and other traumatic events was a distinct disorder.6 DaCosta noted that many American Civil War soldiers experienced chest pains, palpitations, breathlessness, and extreme fatigue with or without physical exertion following their injuries, despite having no physical abnormalities to account for these symptoms, and he described these findings in 1871 in his seminal paper, “On Irritable Heart; A Clinical Study of a Form of Functional Cardiac Disorder and Its Consequences.” Shortly thereafter, these symptoms were labeled DaCosta’s syndrome, and also became known as soldier’s heart because of their cardiac nature. Although DeCosta’s findings specifically involved soldiers, he noted in his paper that these findings are “equally interesting to the civil practitioner.”6 DeCosta’s report linking cardiovascular problems with traumatic events has been supported by other more recent reports in the medical literature. For example, in 1990 a form of cardiomyopathy known as takotsubo cardiomyopathy was identified in persons who have undergone a significant traumatic event.7 In addition, cardiac arrhythmias have been linked to excess circulating levels of catecholamines.8 As these more recent findings show, psychological stressors can lead to adverse physical effects, including with regard to cardiovascular health, and this is likely an area that will become increasingly understood over time as diagnostic modalities continue to improve.
During World War I (WWI; 1914-1918), of the approximate 2 million soldiers sent overseas to fight, hundreds of thousands were killed in action or wounded. In addition, thousands of soldiers were taken out of combat for showing physical and psychological symptoms, including crying, stupor, mutism, and confusion, that interfered with their ability to fight. Although military officials considered these men to be malingerers or cowards, military physicians believed these symptoms represented a neurological condition, which commonly became referred to as shell shock.9 It was thought that the large caliber artillery had something to do with the higher rate of soldiers being affected, but even soldiers who were not exposed to exploding shells manifested these symptoms, which led to debate over the use of the term, which was often applied to physical injuries, psychological conditions, and even when there was a perceived lack of moral fiber. The deep psychological turmoil caused by war was not widely recognized or accepted, as evidenced by 306 shell-shocked British soldiers being executed for what was considered cowardice.10 It was only in 2006 that these soldiers were posthumously granted a pardon.10 During WWI, Sigmund Freud proposed his own stress theory for the psychological effects experienced by the soldiers, which he referred to as war neurosis.11Although he did not write much about the condition, he postulated that it resulted from an inner conflict between a soldier’s “war ego” and “peace ego” and that it was best remedied through psychoanalysis,11 an approach to treatment that we will discuss in a subsequent article in this series on PTSD.
World War II (WWII; 1939-1945) brought with it an even greater degree of horror and impact, which extended to civilians. Unlike during WWI, when fear and anxiety were mostly confined to the trenches, feelings of uneasiness became pervasive in everyday life. Nevertheless, in an attempt to avoid another shell shock epidemic during WWII, British authorities banned use of the term shell shock.12 In the United States, the main effort to reduce WWII psychological casualties was to use psychological testing to weed out men predisposed to break down during combat, a tactic that led to more than 5 million men being rejected for military service.5The military was not prepared to deal with the magnitude of psychiatric issues it encountered during the war, and disorders such as anxiety and neurasthenia were frequently used to describe the end result, with the latter considered to be a syndrome associated with chronic fatigue, weakness, memory disturbance, and generalized body aches and pains. Individuals described having troubling nightmares that caused them to relive terrifying battle experiences and noted episodes of unexplained fear, startled reactions, and feelings of guilt. No one really understood why this was happening. One famous example illustrating this lack of understanding involves US Army General George Patton’s visit to a hospital in Sicily in 1943.13 During his visit, he slapped several hospitalized military personnel in the face because he believed them to be cowards. He ultimately had to apologize for this behavior, particularly once his actions became public knowledge, but he also had many staunch supporters.13 Ultimately, approximately 800,000 soldiers saw direct combat during WWII, 37.5% of who were characterized as having a war-related psychiatric problem that required discharge from service for at least a period of time.5 Battle fatigue and combat fatigue were popular terms used to describe this phenomenon.
In 1952, the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published, and it included a disorder known as gross stress reaction, which was used to describe the psychological damage that mental healthcare professionals had observed in soldiers who had fought during WWII.14 The description of gross stress reaction indicated that anyone exposed to trauma was vulnerable to the disorder, even in the absence of any previous psychological problems. During this time, the Korean War (1950-1953) was also taking place. Of the approximately 200,000 soldiers who fought in this war, up to 25% were eventually found to have an associated psychiatric problem, and these soldiers were often labeled as having operational fatigue or operational exhaustion. The objective of using such euphemisms, which were devised by the military and not by psychiatrists, was to hide the neurotic nature of the illness from both the soldiers who developed it and from their officers, making the illness seem less severe.15
Although terms like operational exhaustion may have trivialized the psychological impact of war, by the time the United Stated became involved in the Vietnam War (1959-1975), the military recognized the importance of treating troops for psychological distress, rather than simply rejecting people deemed to be at high risk for developing psychological problems. As a result, a new plan to treat troops during the Vietnam War was implemented, which required each battalion to have staff with them who specialized in psychological conditions.16 Any soldier reporting or demonstrating psychological issues was required to speak with a psychological specialist before returning to the battlefield. This plan so significantly reduced the number of troops dismissed for psychological reasons that military leaders thought that they had found a cure for gross stress reaction. As a result, the DSM-II, which was published in 1968, changed its listing of gross stress reaction totransient situational disturbance, noting that “an overwhelming environmental stressor was needed to cause severe stress reactions in otherwise healthy individuals” and that the resultant stress reactions were temporary.16
By the 1970s, it was recognized that a similar stress response was not uncommon in individuals who were victims of abuse and rape, and that someone could develop these symptoms from either a one-time event or from chronic exposure to multiple types of traumatic events.16 It was also recognized that these effects may not be transient and can last for many years, if not an entire lifetime. As a result, when the DSM-III was published in 1980, it used the term posttraumatic stress disorder to describe the constellation of psychological symptoms that can occur after a traumatic event.16 Despite its legitimization, not everyone bought into PTSD being a real malady. Some claimed that symptoms of distress are a normal response to exposure to abuse and/or violence, whereas others were concerned that the diagnosis could be used to manipulate the system for self-gain, including financial benefit. Some people even went so far as to consider it a publicity stunt by feminist and veteran groups. Nevertheless, in 1987, the DSM-III-R reconfirmed PTSD as a real disorder. Its diagnostic criteria largely matched those outlined in the DSM-III and required the presence of symptoms from each of the three following symptom clusters after the occurrence of a profound traumatic event (ie, the event had to involve actual or threatened death or injury to the person or to those around him or her)17:
- Intrusive Recollections: Includes flashbacks in which the patient relives the traumatic event for minutes or even days at a time, has upsetting dreams about the traumatic event, or feels intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event. The patient must experience at least one event from this cluster.
- Arousal Symptoms: Includes marked arousal leading to insomnia, irritability, difficulty concentrating, hypervigilance, or a heightened startle response. Patient must experience at least two events from this cluster.
- Avoidance Symptoms: Includes actively avoiding thinking about or discussing traumatic events; avoiding activities or situations that arouse recollections of the event; being unable to recall an important aspect of the traumatic event (ie, psychogenic amnesia); displaying diminished interest in certain activities; feeling estrangement or detachment from others; being unable to have close relationships with other people; and having a sense of a foreshortened future with regard to career, marriage, or even life. The patient must experience at least three events from this cluster.
In addition to manifesting the requisite number of symptoms from each cluster, these symptoms had to occur for at least one month after the traumatic event and cause clinically significant distress or impairment in social, occupational, or other important areas of function.17
The DSM-III diagnostic criteria for PTSD set the foundation for making the diagnosis, and they received varying degrees of revisions in the DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), and DSM-5 (2013) as knowledge regarding the condition evolved. What follows is a review the latest PTSD criteria, as outlined in theDSM-IV and, most recently, in the newly published DSM-5.
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Current Definition of PTSD
For the past 20 years, healthcare providers have widely followed the diagnostic criteria of PTSD outlined in the DSM-IV. Per DSM-IV, an individual with PTSD must demonstrate two of the first four criteria as well as the fifth and sixth criteria listed below18,19:
- The individual should have a history of “exposure to a traumatic event in which the person experienced, witnessed, or confronted an event involving actual or threatened death, serious injury, or threat to the physical integrity of oneself or others” and “the person’s response involved intense fear, helplessness, or horror.” It should be noted that the event need not have been recent and may have occurred years or even decades earlier. The traumatic event must be 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; or acting or feeling as if the traumatic event were recurring with a sense of reliving the experience with illusions, hallucinations, and/or flashback episodes.
- The affected person should experience intense psychological distress when exposed to internal or external cues that symbolize or resemble an aspect of the traumatic event and exhibit some form of physiological response when exposed to these cues.
- The affected person should demonstrate persistent avoidance to stimuli associated with the trauma and a numbing of general responsiveness 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 or an amnesia of the events; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; restricted range of affect; a sense of a foreshortened future.
- The affected person should demonstrate persistent symptoms of increasing arousal that were not present prior to the trauma, as indicated by at least two of the following: difficulty falling or staying asleep; irritability or outburst of anger; difficulty concentrating; hypervigilance; an exaggerated startle response.
- The symptoms should be present for more than 1 month.
- There should be clinically significant distress or impairment in social, occupational, or other important areas of daily living.
If the patient’s symptoms persist for fewer than 3 months, he or she has acute PTSD, whereas symptoms lasting longer than 3 months are considered chronic PTSD. Delayed onset PTSD has been used to characterize PTSD that is associated with at least a 6-month interval between exposure to the stressor and symptom onset.20
In May 2013, the diagnosis of PTSD underwent several changes when the American Psychiatric Association released the DSM-5.21 Whereas the DSM-IV categorized PTSD as an anxiety disorder, the DSM-5 recognizes it under the category of trauma- and stressor-related disorders. The DSM-5 also more clearly defines what constitutes a traumatic event. The new diagnostic criteria identify the trigger to PTSD as exposure to an actual or threatened death, serious injury, or sexual violation. The exposure must result from one or more scenarios in which the individual directly experiences or witnesses the trauma; learns that the trauma occurred to close family members or friends; or experiences first-hand repeated or extreme exposure to aversive details of the trauma (eg, media). It also specifies that PTSD is not a result of another medical condition or attributable to use of medications or other substances. Sexual assault is considered a traumatic event, whether experienced or witnessed; and language in the DSM-IV stipulating an individual’s response to the traumatic event (intense fear, helplessness, and horror) has been eliminated because it was not deemed helpful in predicting the onset of PTSD.
Furthermore, the DSM-5 proposes four diagnostic “clusters” of behavioral symptoms of PTSD, compared with the three outlined in the DSM-IV and some of the earlier versions of the DSM. The new clusters include: re-experiencing, avoidance, negative cognitions and mood, and arousal. The number of symptoms that must be identified for the diagnosis depends on the cluster, and the criteria require the symptoms to persist for more than 1 month. The distinction between acute and chronic phases of PTSD has been eliminated. We suspect that these revisions will lead to an increase in the prevalence and incidence of PTSD in the general population, including older adults.
As this article demonstrates, our understanding of PTSD has come a long way, and what was once simply dismissed or thought to be nostalgia, cowardice, or a lack of moral fiber is now recognized as a legitimate diagnosis that requires intervention. It is also clear that PTSD is an evolving diagnosis, with the diagnostic criteria changing as our knowledge of the condition improves. Our next article in this series will examine the prevalence of PTSD, risk factors associated with PTSD, and how to recognize PTSD in elderly persons, a population for whom this diagnosis is often overlooked.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Steven R. Gambert, MD, University of Maryland Medical Center, N3E09, 22. S. Greene Street, Baltimore, MD 21201; firstname.lastname@example.org