A Brief History of PTSD
Attention-Deficit/Hyperactivity Disorder (ADHD) and Post-traumatic Stress Disorder (PTSD) are two prominent diagnoses associated with myriad mental health symptoms. There can be many similarities in how the symptoms of the two distinct disorders present. In this second addition to my three-part series on ADHD and PTSD, the history of PTSD is explored through textual examples. The present article concludes with diagnostic criteria and considerations in the process of diagnosing PTSD.
Written by Trevor Holak, MA, LAC
A brief history of PTSD
It is interesting to consider that most people who have ever lived have not had access to the modern understanding of Post-traumatic Stress Disorder. Still, their brains were working with the same essential composition, during a time when the average person’s experience may have included more violence. Steven Pinker makes a strong argument in his book The Better Angels of Our Nature for the role of the “Civilizing Process”. During this process, it is argued that the average person has, over millennia, come to exhibit more inhibition over their impulses. With these considerations, it is difficult to understand how our ancestors and ancestral hominids would have been exempt from something like PTSD.
To find the earliest accounts of PTSD, a broader definition needs to be used. Post-traumatic Stress Disorder is a diagnosis for mental disorder according to the modern medical model of health and treatment. By looking for accounts of “a persistent and disruptive stress response developing after experiencing or observing an emotionally elevated or life threatening event”, a more inclusive search can begin.
The Greek historian Herodotus has been supported and scrutinized for seeming to embellish his reporting of human history. It is from Herodotus however, that there is evidence of a persistent and disruptive stress response developing after experiencing a life threatening event. At the Battle of Marathon in 490BCE, Epizelus, an Athenian Hoplite developed a permanent blindness after a near death experience that instead killed another Athenian beside him. Most importantly, it was reported that Epizelus sustained no physical injuries during the Battle of Marathon. If this story is true, it is the first known, and most widely accessible, written documentation of the somatic conversion of psychological trauma. Older but less available information seems to indicate that the Assyrian Dynasty of Mesopotamia also had a documented awareness of the afflictions brought to soldiers after battles. Soldiers reportedly experienced hearing whispers and seeing apparitions which were thought to be caused by the spirits of their enemies.
An early account of PTSD that is not associated with military violence is from a witness and survivor of The Great Fire of London. Samuel Pepys was a 17th century writer, whose diary has first-hand accounts of many significant historical events of his time. Pepys’ chronicle of the fire and the impact on the people of London is descriptive enough to put the reader there. In the days after understanding the extent of the fire and beginning to fear for his own safety and security, Pepys describes his pervasive melancholy mood and sense of powerlessness. As the fire continued relentlessly for days, it was hard not to keep watch on its progression. Sleep was disrupted and limited because of the need for vigilance. As the fire neared Pepys’ home, he evacuated his family and valuables and found it hard to remember the day of the week. While physically safe from threat of the fire, and almost a week removed from his initial entry about it, Samuel Pepys made note of his sleep difficulty and hyper-vigilance. The journal entries for some time after conclude with the writer’s acknowledgement of fear and sleep trouble associated with the fire. Samuel Pepys developed a disruptive stress response that persisted after surviving a life threatening event.
Much of the historical awareness of what would become known as PTSD has developed in relation to warfare and military violence. More contemporary examples come out of the American Civil War and World Wars during which “Soldier’s Irritable Heart” and “Shell Shock” were respectively reported and studied by physicians of these times. As technologies developed in warfare and in medicine, “psychiatric casualties (of war)” were treated for “Combat Neuroses” in World War II. The symptoms throughout history remained the same while the name changed with each new war.
It was with the development of the DSM-II just before 1970 that the psychiatric and medical fields had respect for similarities between civilian and veteran symptoms developed after psychological traumas. The diagnosis for “Transient Situational Disturbance” in the DSM-II marked the beginning of a consistent modern medical interpretation of Post-traumatic Stress Disorder. After briefly becoming defined as “Delayed Stress Response Syndrome” during the mid-late 1970s, Post-Traumatic Stress Disorder became a formal diagnosis with the DSM-III in 1980.
Today, research into PTSD and understanding for the development and experience of the disorder has only increased and improved. Now, entire programs and modalities are geared toward the diagnosis and treatment of PTSD for civilians and veterans. The understanding of psychological trauma has, like many psychomedical theories, shifted away from spiritual affliction toward a more empirical explanation rooted in neurobiology.
Diagnosing PTSD
A comprehensive diagnosis for PTSD can be reached by exploring personal historical information and completing diagnostic interviews. During interviews and historical information gathering, it is important to consider if there was a reported traumatic event, after which, symptoms began to develop. If symptoms were present before the event, it is possible there was a previous traumatic event or that the symptoms may be better explained by a pre-existing and separate condition.
The Diagnostic and Statistical Manual for Mental Disorders (DSM-5) established the diagnostic criteria for PTSD using 8 standard criteria and are included with considerations made in the DSM-5 below.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains: police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.)
