Tuesday , October 19 2021

From the shell-shock in PTSD, a century of invisible war trauma Kingman Daily Miner


After the World War, some veterans returned injured, but not with obvious bodily injuries. On the contrary, their symptoms were similar to those previously associated with hysterical women – most commonly amnesia or some kind of paralysis or inability to communicate without clear physical cause.

English physician Charles Myers, who wrote the first book on shell shock in 1915, considers that these symptoms actually came from physical injury. He argues that repeated exposure to shocking explosions caused brain trauma that resulted in this strange grouping of symptoms. But once tested, his case did not last. There were many veterans who were not exposed to the shocking explosions of the trench warfare, for example, who were still experiencing shell shock symptoms. (And surely all the veterans who had seen this kind of fight returned with symptoms.)

We now know that what these battle veterans face is likely what we now call post-traumatic stress disorder or PTSD. We are now better able to recognize it and the treatments have progressed, of course, but we do not yet have a full understanding of what PTSD is.

The medical community and society in general are accustomed to seeking the simplest cause and treatment for any illness. This results in a system where symptoms are discovered and cataloged and then combined with treatments to relieve them. Although this method works in many cases, over the past 100 years, PTSD has resisted.

We are three scholars in the humanities who have individually studied PTSD – the context through which people understand it, the ways in which researchers are investigating it, the therapies that the medical community plans to do for it. Through our research, each of us has seen how the medical model alone fails to respond adequately to the ever-changing nature of PTSD.

What is missing is a coherent explanation of the trauma that allows us to explain the different ways in which his symptoms have manifested over time and can differ in different people.

Unnatural effects of the Great War

As soon as it became clear that everyone suffering from shock after World War I had suffered brain damage, the British Medical Journal provided alternative non-natural explanations for its prevalence.

Poor moral and flawed education is one of the most important, if not the most important, causal factors: also that shell-shock was a "captive" grievance. – (The British Medical Journal, 1922)

The Shell shock came from being considered a legitimate bodily injury as a sign of weakness in the battalion and soldiers inside. An historian estimates that at least 20 percent of men developed a shell shock, although the numbers are dark because of the physician's reluctance at that time to be a British brand with a psychological diagnosis that could affect disability compensation.

The soldiers were heroic and powerful. When they came home, unable to talk, walk or remember, without the natural cause of these weaknesses, the only possible explanation was personal weakness. Methods of treatment were based on the idea that the soldier who had entered the war as a hero now behaved as a coward and had to move away from him.

Lewis Yealland, a British clinical practitioner, described in 1918 "Hysterical Warfare Disorder" the kind of brutal healing resulting from shell shock thinking as a personal failure. After nine months of unsuccessful treatment of patient A1, including electric crashes in the neck, cigarettes coming out of his tongue and hot plates placed on the back of his throat, Yealland was boasting to tell the patient: "You will not let that the room until you're talking like you do not, not before … you have to behave like the hero I expect you to be. "

Yealland bled to say to the patient, "You will not leave this room until you talk like yourself, no, not before … you have to behave like the hero I expect you to be."

Yealland then put an electric shock on his throat so powerful that he sent the patient to roll back by removing the battery from the machine. Without a doubt, Yealland pulled the patient down to avoid the battery problem and continued to shock for an hour, so patient A1 finally whispered "Ah." After another hour the patient began to shout and whisper: "I want a drink of water."

Yealland reported this encounter triumphant – the discovery meant his theory was correct and his method worked. Shell shock was a male illness and not a disease that came from witnessing, submitting and participating in incredible violence.

Evolution away from the shell shock

The next wave of the wound study came when World War II saw another influx of soldiers experiencing similar symptoms.

It was Abram Kardiner, a clinical practitioner who worked in the United States Veterans Office of Psychiatry, who rethinked the battle injury in a much more striking light. In his book's influence, "The traumatic perils of war," Karder judged that these symptoms came from psychological injuries rather than a flawed character of a soldier.

Work from other physicians after the Second World War and the Korean War suggests that post-war symptoms could last. Diachronic studies have shown that symptoms could remain anywhere from six to twenty years if they disappeared at all. These studies returned some legitimacy to the concept of the traumatic struggle that had been stripped down after the First World War.

Vietnam was another time to fight PTSD, because veterans began to support themselves in an unprecedented way. Beginning with a small course in New York in the summer of 1967, veterans themselves began to become activists for their own mental health care. They worked to redefine the "Vietnam Syndrome" not as a sign of weakness but as a normal response to the experience of atrocities. The public's own understanding of the war had begun to shift, as the massive television accounts of My Lai's massacre brought for the first time the horror of war in American lounges. The veterans' campaign helped PTSD be included in the third edition of the DSM-III Diagnostic and Statistical Manual of Psychiatric Disorders, the largest US diagnostic resource for psychiatrists and other clinical psychologists.

The authors of DSM-III deliberately avoid talking about the causes of mental disorders. Their aim was to develop a handbook that could be used by psychiatrists who followed radically different theories, including Freud's approaches and what is known as "biological psychiatry". These psychiatric teams would not agree on how to explain the disorders – and they came to agree on which patients had similar symptoms. Thus, the disorders defined by DSM-III, including PTSD, are based solely on symptom clusters, an approach that has been maintained since then.

This tendency toward agnosticism about the physiology of PTSD is also reflected in modern documented approaches to medicine. Modern medicine focuses on the use of clinical trials to prove that a treatment works, but it is skeptical about attempts to link the effectiveness of treatment to the biology that forms the basis of a disease.

Today's PTSD medicine

People can develop PTSD for a variety of reasons, not just in battle. Sexual attack, traumatic loss, terrible accident – anyone can lead to PTSD. The US Department of Veterans Affairs estimates that 13.8% of veterans returning from wars in Iraq and Afghanistan now have PTSD. For comparison, a veteran man of these wars is four times more likely to develop PTSD than a man in the civilian population. PTSD is at least partly at the root of an even more worrying statistic: More than 22 veterans commit suicide every day.

Treatments for PTSD today tend to be a mixed bag. Practically, when veterans seek PTSD treatment in the VA system, the policy demands that they be offered either exposure or mental therapy. Exposure therapies are based on the idea that the response to fear that causes many of the traumatic symptoms can be impaired through repeated exposure to the traumatic event. Cognitive therapies work on the development of personal treatment methods and slowly change the abusive or destructive thoughts that contribute to the symptoms (for example, the shame that one can feel when it does not successfully complete a mission or saves a partner). The most common treatment a veteran will likely receive will be psychopharmaceuticals – especially the class of medicines called SSRIs.

Sensitization therapies, based on the awareness of mental states, thoughts and emotions and their acceptance instead of trying to fight or remove them, is another option. There are also other alternative methods that are being studied, such as desensitization of eye movements and reprocessing, EMDR treatment, MDMA (Ecstasy) controlled treatments, virtual reality exposure, hypnosis and creative treatments. The army is funding a rich research on new technologies to deal with PTSD. These include neuro-technological innovations such as transcranial stimulation and neural chips as well as new drugs.

Several studies have shown that patients improve more when they have chosen their treatment. But even if they limit their choices to those supported by the weight of the National Center for PTSD, using the Center's help center decision-making, patients still weigh five options, each based on evidence but involves a different psychometric model of trauma and healing.

This buffet of treatment options allows us to overcome the lack of understanding why people experience trauma and respond to interventions so differently. It also relieves stress on psychometry to develop a complete PTSD model. We review the problem as a consumer issue instead of a scientific issue.

Thus, while World War II was for soldiers and punished for their weakness, in modern times the ideal veteran patient PTSD is a consumer of health care who has an obligation to play an active role in finding and optimizing his treatment.

As we are here with the strange benefit of backwardness that comes with 100 years of study of wound-related injuries, we must be careful to celebrate our progress. What is still missing is an explanation of why people have different reactions to trauma and why different reactions occur in different historical periods. For example, paraylsis and amnesia that described WWI shock incidents are now so rare that they do not appear as symptoms in the DSM entry for PTSD. We still do not know enough about how the military's experiences and perceptions about PTSD are shaped by the wider social and cultural aspects of trauma, war and gender. Although we have made incredible steps in the century since the World War I, PTSD remains a chameleon and requires our ongoing study.

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