A paradigm shift in the conceptualization of psychological trauma in the 20th century

doi:10.1016/j.janxdis.2006.09.009

Journal of Anxiety Disorders

Volume 21, Issue 2, 2007, Pages 164-175

https://doi.org/10.1016/j.janxdis.2006.09.009 Get rights and content

Abstract

The inclusion of posttraumatic stress disorder (PTSD) in DSM-III in 1980 represented a paradigm shift in the conceptualisation of post-trauma illness. Hitherto, a normal psychological reaction to a terrifying event was considered short-term and reversible. Long-term effects, characterized as “traumatic neurosis”, were regarded as abnormal. Enduring symptoms were explained in terms of hereditary predisposition, early maladaptive experiences or a pre-existing psychiatric disorder. The event served merely as a trigger to something that existed or was waiting to emerge. Secondary gain, the benefits often but not solely financial that a person derived as a result of being ill, was considered the principal cause of any observed failure to recover. The recognition of PTSD reflected a diversion from the role of the group, in particular the “herd instinct”, towards a greater appreciation of the individual's experience. From being the responsibility of the subject, traumatic illness became an external imposition and possibly a universal response to a terrifying and unexpected event. This shift from predisposition to the characteristics of the event itself reduced guilt and blame, while the undermining of secondary gain made it easier to award financial compensation.

Section snippets

The conception of psychological trauma in the early 20th century

During the 19th century, with the exception of psycho-analytical literature, the word “trauma” generally referred to an open wound or violent rupture to the surface of the skin; it carried no psychological connotations. If, for example, a soldier broke down on campaign, he was deemed either to have succumbed to major mental illness, such as melancholia or dementia praecox, or to be suffering from the side effects of climate or disease (Jones & Wessely, 2005). The idea that a soldier of

Shell shock

The commitment of mass armies to a prolonged conflict of attrition almost guaranteed a steady stream of psychiatric casualties during World War One. A variety of terms were used by the various combatant nations: “shell shock” in the UK, “choc commotionnel” and “choc traumatique” in France, while German doctors referred to “kriegshyterie”, “granatkontusion” (shell concussion) and “granatexplosionslähmung” (exploding-shell paralysis).

At first, doctors in the UK proposed an organic explanation:

Prisoners-of-war and combat wounded

Evidence gathered in Germany about prisoners-of-war appeared to confirm that it was not combat itself but the personality of the soldier that was the determining factor in any form of war neurosis. Reports that they rarely exhibited hysterical symptoms suggested a functional basis for these disorders grounded in wishes and desires (Lerner, 2003). Only soldiers in the front line had need of such symptoms to give them cause for hospitalization and a possible claim for compensation. In 1920,

World War Two and psychological trauma

Meeting in July 1939 in an effort to prevent another epidemic of shell shock, the Horder Committee decided that an official acknowledgement of war neurosis opened a route to discharge from the forces and the prospect of financial compensation. As a result, the British government announced that no pensions would be awarded for psychiatric war injuries (Shephard, 1999). Henceforth, soldiers traumatized by the stress of combat were to be diagnosed as suffering from “exhaustion” and retained within

Post-1945

The Korean War (1950–1953) led to no major innovation in the conception or treatment of psychiatric battle casualties, which continued to be regarded as varieties of “war neurosis”. DSM-I, published in 1952, contained the new category “gross stress reaction”, though no operational definition was provided. It described the extreme behavioural responses of normal individuals to exceptional stressors such as war or natural catastrophes. Although the main causal factor was an overwhelming

PTSD defined

Codified in DSM-III (1980), PTSD was originally termed “post-Vietnam syndrome” or “delayed-stress syndrome”, having first been identified in veterans who had returned to the US. The treatment of acute combat fatigue had apparently been well managed by military psychiatrists attached to combat divisions. However, servicemen who had returned to civilian life presented with what appeared to be a range of delayed or chronic symptoms. Mental-health professionals, who were politically opposed to the

Secondary gain

Secondary gain was a major concern of both clinicians and government planners largely because it was seen as playing a major part in preventing patients from getting well and thereby increasing the cost of disability pensions and other forms of financial compensation (Ross, 1966). In July 1939, when setting parameters for psychiatric casualties from the impending conflict, the Horder Committee decided that no awards should be made for psychoneurosis because “the pension itself may become such a

Group versus individual

In the first half of the 20th century, theories of breakdown were framed in terms of the group rather than the individual. Soldiers were analysed not as single entities but as part of a hierarchical and structured organization. Hence, when the 1922 Southborough Committee attempted to prevent future episodes of shell shock, it made recommendations that referred to units rather than individuals. Training was to be designed to consolidate “the sense of collective responsibility and efficiency by

Discussion

Since its formal recognition in 1980, PTSD has become a high-profile and politically sensitive psychiatric disorder (Vedantam, 2005). However, its international acceptance was not rapid or without controversy. It was slow to catch on in the UK where the disorder was initially considered specific to the US and Vietnam veterans. A study of Post-traumatic neurosis by Trimble (1981) never once mentioned the Vietnam War or PTSD. Similarly, the Oxford Textbook of Psychiatry, first published in 1983

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