Understanding PTSD E-Book

Austin Mardon

• Herausgeber: Packt Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 308

Veröffentlichungsjahr: 2024

Beschreibung

Understanding PTSD offers a comprehensive exploration of Post-Traumatic Stress Disorder (PTSD), tracing its history, debunking common myths, and examining its complex nature. The book begins with a personal narrative to ground the reader, before delving into the origins and evolution of PTSD, particularly during wartime. It addresses widespread misconceptions, emphasizing that PTSD affects diverse populations, not just soldiers. The assessment methods and criteria are discussed, alongside the brain's response to various traumas.
Key chapters explore the potential causes of PTSD, including genetic, environmental, and psychological factors. The book also covers the dangers associated with PTSD, various types of PTSD, and symptoms. It provides insights into how PTSD manifests in different age groups and reviews the most effective treatments, such as cognitive therapy and medication.
Further chapters discuss comorbidities like depression and substance abuse, the gaps in current knowledge, and ongoing research. The public's perception of PTSD, its portrayal in the media, and the impact on families are also examined. The book concludes with practical advice on supporting individuals with PTSD and a detailed directory of resources available in North America, Europe, and India.

Leseprobe

UNDERSTANDINGPTSD

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UNDERSTANDINGPTSD

Austin Mardon, PhD

MERCURY LEARNINGAND INFORMATION

Boston, Massachusetts

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ToMy beloved spouse

CONTENTS

Introduction: A College Student’s Story

Chapter 1: The History of Psychotraumatology

PTSD in Historical Texts

Evolving Terms During Battle

PTSD in the World Wars

References

Chapter 2: PTSD Myths

Only the Weak Get PTSD

It Is All in Your Head

Everyone Who Has Experienced Trauma Should be Affected

Treatment Does Not Work

Only Soldiers or People in War Zones Get PTSD

People Should Be Able to Move on After Trauma

People with PTSD Cannot Function Normally

PTSD Always Happens Directly After the Trauma

PTSD Victims Will Never Get Better

PTSD Sufferers Are Unstable and Violent

PTSD Sufferers Aren’t Victims

References

Chapter 3: How to Assess

Structured Interviews

Structured Clinical Interview

PTSD Symptom Scale Interview (PSS-I and PSS-I-5)

Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

Clinician-Administered PTSD Scale for Children and Adolescents

Self-Reports

PTSD Checklist for DSM-5 (PCL-5)

Distressing Event Questionnaire

Criteria for PTSD

References

Chapter 4: How the Brain Copes with Different Types of Trauma

References

Chapter 5: Potential Causes of PTSD

Risk Factors

Genetics

Neurobiology and the Brain Structure

Psychological Factors

Environmental Factors

Traumatic Experiences

Car Accidents

Sexual Assault

Combat

Mass Conflict and Displacement

Medical Illness

Childhood Trauma

References

Chapter 6: The Dangers of PTSD

Patient Experience with PTSD

References

Chapter 7: Different Types of PTSD

Childhood Trauma Survivors

Sexual Assault Survivors

War Survivors

Abuse Survivors

References

Chapter 8: The Physiological, Psychological, and Behavioral Response to Trauma and PTSD

References

Chapter 9: Symptoms of PTSD

Reexperiencing Symptoms

Avoidance Symptoms

Hyperarousal

Startle Response

References

Chapter 10: PTSD in Different Age Groups

References

Chapter 11: Treatments

Cognitive Therapy

Complementary and Alternative Methods (CAM)

Physical Activity

Nutrition and Diet

Breathing Relaxation

Hypnosis

Animal Therapy

Medications

References

Chapter 12: Other Risks (Comorbidity)

Depression

Substance Abuse

Suicidal Thoughts and Behaviors

References

Chapter 13: What Is Still Unknown?

References

Chapter 14: Current and Future Research

Treatment

Written Exposure Therapy (WET)

Exposure Therapy

Pharmacological Treatments

Susceptibility

Conclusion

References

Chapter 15: The General Public’s Knowledge About PTSD

Social Attitudes Toward Men and Women with PTSD

Myths About PTSD

References

Chapter 16: How PTSD Is Portrayed in Media

Portrayal of War Veterans with PTSD

Portrayal of Sexual Assault Victims with PTSD

References

Chapter 17: PTSD and the Family

Withdrawal and Disconnection

Sympathy

Conflict and Anger

Guilt

Avoidance

Depression

Stresses for the Primary Caregiver

References

Chapter 18: Recovery and How to Support Someone with PTSD

PTSD Recovery and Treatments

How to Support Someone with PTSD

References

Chapter 19: Epilogue

Chapter 20: PTSD Resources in North America, Europe, and India

Canada

Books

Worksheets

Online Resources

Workbooks

Directory of Resources

British Columbia

Alberta

Saskatchewan

Manitoba

Ontario

Quebec

Nova Scotia

Prince Edward Island

New Brunswick

Newfoundland

Yukon

Northwest Territories

Nunavut

United States

Web Sites

App

Books

Helplines

Videos

Europe

Sweden

Denmark

Norway

Finland

Iceland

Lithuania

Estonia

Latvia

Greenland

Ireland

United Kingdom

India

Web Sites

Videos

Books

Helplines

Appendix: Potential Pharmacological Treatments for Posttraumatic Stress Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs)

Mechanism of Action

Combination with Other Treatments

Effectiveness

Administration Guidelines

Additional Considerations

Example of SSRI

Fluoxetine

Prazosin

Mechanism of Action

Effectiveness in PTSD Treatment

Combination with Other Treatments

Administration Guidelines

Additional Considerations

Antidepressant Medications

Mechanism of Action

Effectiveness in PTSD Treatment

Combination with Other Treatments

Administration Guidelines

Additional Considerations

Examples of Antidepressant Medications

Sertraline

Tricyclic Antidepressants

Novel Antipsychotics

Mechanism of Action

Effectiveness in PTSD Treatment

Combination with Other Treatments

Administration Guidelines

Additional Considerations

Monoamine Oxidase Inhibitors (MAOI)

Lithium

Anticonvulsants

Benzodiazepines

Index

INTRODUCTION:A COLLEGE STUDENT’S STORY

Samantha was an above average student; ambitious and driven to succeed in every aspect of her life. She discovered that in order to succeed she had to have a loving and secure relationship with those closest to her. At the time, Samantha’s closest connections were with her parents, younger sister, and brother, as well as her long-term boyfriend. Throughout high school she would often volunteer her time at local nonprofit organizations as well as help out at homeless shelters around her immediate location. After graduation, Samantha prepared to depart for university; she was full of excitement and passion for what lay ahead of her. Despite her sadness at leaving those she loved behind; she told her loved ones that she would stay connected by writing letters and calling as often as possible to try and make the time pass between them smoother and quicker.

When Samantha started school, she immediately expressed extraordinary interest in her psychology course. Her textbooks were full of theories and explanations on learning, emotions, and memory that she seemed to never want to put down. Samantha would spend hours in the library and in her dorm reading and analyzing her books, absorbing all the information she could in a small amount of time.

It was a five-block walk from Samantha’s dorm to the library. One night she left the library just before closing time around 1 o’clock in the morning. On this night in particular, she was in a rush to get home so she decided that she could save some time if she would cut through the back alley behind a few buildings before returning onto the path to her dorm.

As she took this shortcut through the back alley, a dark shape came alive from the shadows and a man’s bulky and strong figure seemed to block all the space in front of her. Samantha tried to run, but there was no escaping the menacing figure before her. He was too strong, and she couldn’t injure him in any way; he simply overpowered her, leaving her feeling helpless with no hope, alone, and surrounded by darkness. The assailant took a strong hold of her, covered her mouth, and whispered in her ear, “Don’t make a sound, or this will end worse than it started.” The man released his hold on her face and smacked her across her mouth, proceeding to rape her and then he let her drop to the cold hard cement when he was done. Samantha lay crumpled on the ground with no understanding of time or space, only that all she felt was fear and a sense of being lost. All she could think was that his breath smelled like caramel.

Samantha felt like she had become damaged goods after that night; her philosophy of human nature had forever changed, and she could no longer believe the theories that she once read from her beloved textbooks. Not only was her body scratched and altered, but so was her identity. After that night, Samantha’s sense of trust was taken from her, that night where she felt uncertain and lost in a world she now viewed as dangerous and full of terror.

Samantha’s grades suffered; she could not find the motivation to study the things that she once believed in with no reservations. She no longer had a relationship with her family members, and she lost her boyfriend in the process. After that night, Samantha could not communicate about her daily activities and experiences. She could not share her story of what happened that night to those she cared about, and she could no longer relate to those around her. Samantha became haunted and terrorized by every shadow. In every dark corner and alley, she saw the same menacing figure from that night. She was so frightened that she no longer left her room at night, regardless of whether others would be accompanying her. She became so obsessed with her attacker that she soon found excuses to not leave her room in the daylight. She began to hide from the world around her, and she only felt safe in her own room. Even then, at night the attacker would return to her in her dreams, where she believed he had come to finish the job he started in that dark alley. To this day the smell of caramel makes her curl into the fetal position and wait for the memory to end.

Samantha is suffering from posttraumatic stress disorder (PTSD).

As you can see from Samantha’s story, posttraumatic stress disorder is not as cut and dry as the media and other modern resources have made it out to be. In most cases, society has been led to believe PTSD is only experienced by war veterans or those exposed to war zone areas. Unfortunately, this is not the truth. Posttraumatic stress disorder, better known as PTSD, can be experienced by anyone that has been exposed to a traumatic event, regardless of where it took place. Trauma has been defined in regard to this condition as anything that causes an individual to feel fear, stress, anxiety, or loss of control.

It is important to understand that this book has not been written for an academic audience, rather that it has been specifically designed for the general population. This means that a lot of the technical jargon has been removed when explaining what PTSD is and how it affects individuals. It was important for the author to try and explain PTSD in a way that could be understood by everyone. This is essential, because in many cases when people try to explain mental disorders and conditions, people end up being more confused than before they read the explanation. This does more harm than good because people ignore the explanations they do not understand, and they instead simply pick out the information that they can understand. In an attempt to clarify PTSD, the authors of this book took a simplistic approach to explaining PTSD. Each of the chapters has been broken down into subsections, where these smaller sections of the chapters take the time to explain in nontechnical words what each of the elements are.

Before we dive into the book, it is important to try and get a feel for what PTSD is. As you know, this condition and its symptoms are brought on by a traumatic event. In most cases where PTSD has been developed within an individual, they surround themselves in the belief that it is either their fault or that it was the fault of someone else. In the case of Samantha, it is extremely likely that she will blame herself for being in the situation. It is also possible that those around her will also blame her and say that nothing would have happened had she not put herself in harm’s way in the first place. This is an extremely common scenario that tends to play out when people acknowledge that they are now suffering from PTSD.

Another quite common situation is that when people feel shame or guilt, they will not seek help from anyone, be it a professional or someone they are close to. In cases where people do not try and get help, the symptoms of PTSD begin to take over the individual’s life. This causes them to pull away from those that are trying to help them through whatever it is that they are feeling. The individual then puts up a wall between themself and those around them.

The barrier acts as their protection against the feelings associated with PTSD. This is the wall that many individuals hide behind to avoid talking about their trauma and “forgetting” the trauma ever occurred. Unfortunately, by ignoring the trauma and the associated symptoms, their condition worsens.

The goal for this book is to educate those who don’t know much about PTSD. By educating individuals on PTSD, it is not only about learning about a disorder, but it is about teaching people how to adjust to life with PTSD. This book will help those not only directly affected by PTSD but those being affected indirectly.

One major cause for individuals avoiding help is shame. Victims feel shame because they now have to live with this condition, and the shame that the media has led them to believe that they are flawed and that it is why they are now living with a condition. In many cases the media has stated that PTSD is caused by an individual either being crazy or even weak-minded. Fortunately, as society becomes more informed of PTSD and by understanding their circumstances, these individuals will hopefully be more inclined to seek help from those around them as well as from professional resources if needed. Reading a book like this is the first step in a victim’s attempt to help their situation.

Another goal of this book is to educate those around a victim of PTSD. It is vital that the victim personally understands what they are going through. But it is of equal importance for bystanders to understand the truth behind the disorder. When those around the victim acknowledge what is going on, they can then take specific steps to help them work through their issues. It also gives the victim a confidant without having to go public with their PTSD. It allows them to take the first step in admitting that there is something wrong.

Before you read more of this book, it’s important to know that PTSD is an overwhelmingly difficult disorder to deal with. Nonetheless, it is not an impossible task to learn to deal with, and even defeat, symptoms associated with PTSD. If you are someone that has PTSD and you are reading this book, remember that things will get better, but not without working to make things better. For those reading this book who are witnesses to someone dealing with PTSD, you have to support the sufferer of PTSD in whatever they do, as long as it is not harming them. It is vital to be there for them, let them know that everything is going to be alright, and that you will be there for them no matter what.

CHAPTER 1

THE HISTORY OF PSYCHOTRAUMATOLOGY

Posttraumatic stress disorder (PTSD) is said to be a relatively new psychological disorder, but in actuality, PTSD has simply become a new title for a very old condition. Symptoms of PTSD can be identified going back as far as three thousand years ago, to the time of an Egyptian named Hori who once wrote about the fear and anxiety with descriptions of shaking and raised hair. It was believed that Hori wrote about these symptoms in regard to his experiences in past battles (“What Is PTSD?,” 2024). Although this description does not specifically fit the criteria for PTSD, it does have similar symptoms of what would be a part of a current medical explanation of PTSD.

Here are just a few of the titles or “nicknames” that have been given for PTSD over the years. Some of the more common names that most veterans know this condition is either Soldier’s Heart or Da Costa’s Syndrome. This was discovered and named by an internal medicine doctor by the name of Jacob Mendez, who studied Civil War veterans in the United States and identified that many of these soldiers were suffering from chest-thumping, anxiety, and shortness of breath.

PTSD IN HISTORICAL TEXTS

Long before PTSD was an official psychological diagnosis, it was still often able to be recognized. Soldiers or civilians alike, after witnessing the trauma of others or enduring their own, displayed a similar array of symptoms captured in centuries of poetry, art, official records, myths, and personal journals. People would display symptoms of injury, such as blindness, despite not being physically harmed, and would be wracked with nightmares or illusions of a previous traumatic experience.

One of the earliest known records of PTSD-like symptoms dates back to 1300–609 BC, when ancient Mesopotamians faced many wars. The citizens’ trauma manifested as difficulty sleeping, as well as invasive memories of the destruction they had witnessed. Observations by Herodotus note the psychological struggles of Epizelus after his time at war in 490 BC. Appian of Alexandria also described a veteran who burned down his own home with himself in it as a defense against the oncoming threat of battle against his village. Furthermore, Life of Marius by Plutarch tells of Caius Marius and his struggles with sleep, substance abuse, and flashbacks, which are comparable to currently known symptoms of PTSD (Shipp, 2022). While these instances cannot be confirmed to be the PTSD we know today, they do point to similar symptoms and experiences, which works to reveal how the illness, or forms of it, have been around for at least as long as humans could leave records for people to find.

Documentation of the Hundred Years’ War in England and France revealed how soldiers struggled with anxieties and nightmares related to their experiences in battle (“History of PTSD,” n.d.). Samuel Pepys (1633–1703) was an English naval administrator and member of Parliament whose valuable diary captured both key moments of upper-class life, and the Fire of London in 1666 (Bryant, 2024). He wrote about the fire in the time after it ended, where he included information about the struggles of survivors, as well as his own struggles, which included sleep riddled with recurring nightmares of the great fire which destroyed much of London (Bryant, 2024). Though no one took the time to diagnose and treat Pepys for PTSD, the repetitive nature of his nightmares are consistent with PTSD symptoms still experienced today. As such, his valuable account of life in seventeenth-century London works to further emphasize that PTSD is far older than its label would indicate.

Literature and art also capture a great historical interest in understanding the symptoms of PTSD. Soldiers having recurring nightmares of battles appear in tales such as Homer’s Iliad and the works of Shakespeare (Chicco and Tebala 2020; “History of PTSD,” n.d.). The Gisli Súrsson Saga, an Icelandic story estimated to have been written during the thirteenth century, recounts how the hero Gisli suffers from vivid nightmares of battle, so much so that he cannot safely rest alone and fears sleeping (Larson, 2021). In the epic poem The Epic of Gilgamesh, Gilgamesh himself endures flashbacks of the death of his close companion. He is wrought with questions about his own death and his guilt (de Villiers, 2020). The Bible clarifies that in some cases, this pattern of soldiers losing sleep or being permanently affected by battlefield trauma was recognized not just by diarists and poets but by military leaders. They also recognized the way that one soldier’s psychological symptoms may affect others. The Book of Deuteronomy in the Old Testament provides the advice of letting traumatized men go home, rather than risk the hearts of his comrades, as well as his own (Janzen, 2019. These examples combine to show the ubiquity of PTSD symptoms, revealing that they are so common they enter into stories and histories throughout time.

EVOLVING TERMS DURING BATTLE

PTSD symptoms, especially on the battlefield, underwent centuries of medical misdiagnosis and general confusion from physicians. Soldiers with the disorder were often treated alongside, and confused with, cases of traumatic brain injury (TBI), as both had a lack of apparent physical injury and had similar symptoms. In time, psychotraumatology would split as a subspecialty from traumatology, but it would first endure a long series of ever-changing names, definitions, and euphemisms as militaries addressed this extremely common and debilitating disorder in their troops (Jongedijk et al., 2023).

Swiss doctor Johannes Hofer in his 1688 medical dissertation championed the next most notable name, nostalgia. This name survived until the end of the Seven Years War. Hofer classified the disorder as consisting of depression, angst, and both physical and mental exhaustion. Due to the increased interest in the soldier’s medical conditions, other medical sources began to argue that these symptoms of nostalgia were not in relation to an actual battlefield experience, but that it was in association with the soldier’s longing to return home, due to being apart from their loved ones for extended campaigns. French and German doctors took these soldiers classified with nostalgia and instead identified them as having homesickness. This then led to Spain creating their own way of identifying these individuals, where these same symptoms of PTSD became known as estar roto, which means “to be broken.” This new construct for PTSD lasted for another sixteen years throughout the length of the Napoleonic era (1799–1816).

As you can see there have been numerous names for PTSD. Interestingly, throughout the years, researchers only identified PTSD as being related to war soldiers. The written history of PTSD centered on the belief that only soldiers experienced a great enough trauma to suffer from PTSD. This has led contemporary society to continue to believe in the myth that only war veterans are affected by PTSD.

In the late 1700s, civilian PTSD appeared in great numbers for the first time, as a consequence of the Industrial Revolution. Due to increased mechanizations, disasters were at a scale and of a type rarely seen by civilians. Charles Dickens wrote about witnessing the death of people during a railway accident, which led to his phobia of traveling by train. In the late 1800s, the famous author Charles Dickens was involved in a railway accident in Staplehurst in Kent England. Dickens later wrote about his experiences and symptoms, claiming that he believed they were associated with the railway accident. He wrote in a letter explaining the horrifying scene he experienced, as well as stating that he did not feel himself, and believed this to be a result of the railway accident (Perdue, 2022). It was these instances that led to more social belief that PTSD could be caused by more than just killing or witnessing people being killed.

The railway accidents introduced the diagnoses “railway spine,” as some believed survivors suffered microscopic damage to the spine and brain. English surgeon John Eric Erichsen blamed this in particular on spinal concussions with the assertion that even in the absence of a fracture, physical damage from the accident caused inflammation in the spinal cord and subsequent psychological symptoms (Gasquoine, 2020). Due to the fact that PTSD was not in existence for anyone other than war soldiers, no one understood what Dickens was going through at the time. As we read about this today, we know that what he must have been feeling is a direct description of modern-day PTSD. Unfortunately, in the 1800s, people chose not to believe this theory of trauma that caused physical and mental ailments within individuals. After multiple railway accidents, people started to sue the companies stating that there was something unknown that started to happen to them after the accidents. Lawyers of the railways said the litigants were trying to get something from nothing, due to so many people discounting the effects of trauma. They stated that this supposed trauma only affected individuals with ulterior motives such as money, food, and shelter. Following the aftermath of this, people started considering the idea that PTSD symptoms could come from situations outside of the military world. Unfortunately, PTSD was left out of any sort of medical description not involving soldiers.

Meanwhile, battlefields still saw soldiers with trouble sleeping, anxiety, and a wish to return home. Austrian physician Josef Leopold called this ”nostalgia,” a term that would linger into the Civil War. The aforementioned French physician who treated the man with nightmares of drowning also treated patients during the French Revolution. He called this collection of familiar symptoms “cardiorespiratory neurosis” or “idiotism” (“History of PTSD,” n.d.; Zhou et al., 2021). During the French Revolution and the Napoleonic wars, “vent du boulet” (the wind of the ball) syndrome often explained why soldiers became inconsolable after being nearly hit by cannonballs (Jongedijk et al., 2023). Today, “sentir le vent du boulet” (literally “feeling the wind of the cannonball”) is a French idiom expressing relief at narrowly escaping danger (“Sentir le Vent du Boulet,” n.d.). Johann Wolfgang Goethe, German poet and survivor of the 1792 battle of Valmy, described soldiers who seemed to be catatonic after battle attacks. He refers to the experience of the battlefield as a hot and scary place, with a change in hue and feeling which gave the feeling that it was consumed in fire (Dollar, 2022). The struggles of Napoleonic soldiers prove the struggle to survive severe trauma and highlights yet another turn in society’s understanding of PTSD.

The Civil War brought the term ”irritable heart” to the forefront of social understanding. Soldiers reported rapid or irregular heartbeats, headaches, trouble sleeping, physical imbalance, anxiety, and a lack of concentration. There is no definitive proof whether irritable heart was truly a form of PTSD, or instead a related ”conversion disorder,” wherein psychological distress manifests as physical symptoms (Dollar, 2022; Mayo Clinic Staff, 2022). Regardless of possible alternatives, it is worth noting the similarities between the experiences of Civil War soldiers and soldiers today who suffer with PTSD.

The decades after the Civil War caused further confusion in understanding PTSD. This occurred as physicians struggled to match symptoms with their proposed diagnoses and parse its complexity from other syndromes such as TBI. Civil War army surgeon Jacob Mendez da Costa used the term ”soldier’s heart” to describe a link between severe trauma and an increased risk of cardiovascular disease. Occasionally, sufferers of a soldier’s heart would also experience paralysis or loss of sensation following the traumatic event (Bremner et al., 2020). French neurologist Jean-Martin Charcot proposed a concept of traumatic hysteria, adding that soldiers may be more likely to develop PTSD-like symptoms after a traumatic event depending on genetic factors. Charcot also noted the significance between past psychological traumas, disturbing dreams, and hysterical episodes (Bogousslavsky, 2020). In 1885, surgeon Henry Page reported that these symptoms were only psychological with no relation to spinal injury, and yet still caused the body’s nervous system to malfunction. His chosen terms were nervous shock and functional disorder. German physician Hermann Oppenheim was the first to use the term traumatic neurosis. Traumatic neurosis would later be connected to a set of recognizable and specific PTSD symptoms, such as the requirement of trauma, dissociation caused by the trauma, and the role of pathogens within lost memories (Jongedijk et al., 2023; “History of PTSD and Trauma Diagnoses,” n.d.). The idea that a person may be genetically predisposed to traumatic neurosis was later discarded. Unfortunately, Jean-Martin Charcot’s criticisms that Oppenheim was simply redefining hysteria and hysteria-related syndromes would not allow the term to truly permeate French psychiatry until Charcot’s death, showing the long battle to define the psychological effects of traumatic stressors. In 1889, American neurologist George Miller Beard classified under “neurasthenia” or “nervous exhaustion,” symptoms such as inability to sleep, lethargy, headaches, and depressive feelings. Anemia was also blamed during the turn of the century, at fault for syndromes called “disorderly action of the heart” and “irritability of the heart.” Morgan Fincuane brought railway spine to the battlefield after the Boer War, noting that much like railway accident survivors, soldiers with these syndromes had continuous, psychologically related nerve and muscle problems even after their wounds healed (“History of PTSD and Trauma Diagnoses,” n.d.). Despite the numerous names and considerations, it is clear that doctors and scientists have been exploring similar symptoms noted for soldiers and war survivors throughout history.

PTSD IN THE WORLD WARS

Regardless of the terms being used to diagnose the soldiers, most militaries across various wars would take affected soldiers away from the battlefield to treat them in an environment of relative peace and normalcy. During the Civil War, a psychiatric hospital was created to handle the increasing quantity of cases, but in time, they moved patients from the apparent death sentence of battlefield care to their homes. In 1904–1905 however, Charles S. Myers helped develop the idea of “forward psychiatric treatment,” which kept soldiers close to the front lines during treatment: this concept would evolve throughout World War I and II, until becoming standard practice in the modern day (Johnson, 2021). Forward treatment, or “forward psychiatry,” was specifically for stress-related issues. Surprisingly, soldiers who were treated within reach of both their comrades and the sounds of battle more reliably recovered from their symptoms. It appeared that remaining within the military hierarchy setting would stave off the chronic disability that evacuated patients developed. Forward treatment’s five principles were: immediacy (treating soldiers immediately, which may prevent chronic symptoms), proximity (treatment near the front line rather than an environment of quiet and peace), expectancy (communicating to the patient that recovery was imminent), simplicity (simple treatment such as rest), and centrality (all medical personnel following the same rules and ideals) (Zhou et al., 2021). For these soldiers, Forward treatment became an important feature of traumatic stress treatment which carried forward to future wars.

Nonetheless, the conflict of interest between military leaders and their soldiers, whose diagnoses were, throughout the wars, rife with controversy and accusations of cowardice, must be considered when describing the success of forward treatment. Among the contentious and contradictory discussions of PTSD in both soldiers and citizens, there were those who did not believe that symptoms of PTSD were actually medical. During the late 1800s in Prussia, new compensation laws for railway accidents appeared to infect many with “compensation neurosis,” who then applied for disability status. A study by a German psychiatrist, Bonhoeffer, in 1926 claimed nearly all soldiers with traumatic neurosis were simply seeking health insurance payouts, and as a result, Germany pulled their compensation for these veterans (“History of PTSD and Trauma Diagnoses,” n.d.). PTSD appeared to only be a manifestation of a “deficiency of character,” which resulted in the execution of many soldiers for desertion or other such supposed crimes (“Shot at Dawn,” 2021). This prompted a tangle of treatments, different diagnoses, and attempts by militaries and physicians to keep enough soldiers healthy while not losing too many of their numbers to these inscrutable disorders.

Soldiers were then said to suffer from shell shock, an umbrella term that today appears to cover a combination of PTSD and TBI. The term arose most frequently when soldiers were near, but untouched by, explosions. Of British military, there were over 250,000 soldiers who were diagnosed with shell shock (The National Archives, n.d.). Shell shock, and its eventual encapsulation of many psychological disorders, recognized serious and potentially treatable problems. Soldiers eventually became less nervous about revealing their symptoms only to be accused of a weakness of character. As cases skyrocketed, the military struggled to maintain both treatment and their fighting numbers. Unfortunately, the diagnosis “hysteria” returned as well as the idea that this was not caused by combat but instead by a preexisting personality disorder. Governments did not have to pay disability in such cases. British psychiatrists at times referred to these cases as simply stress-related and officially “not yet diagnosed, nervous,” and returned the soldiers to the field (Park et al., 2022). This would, of course, create a lot of ambiguity around the progressing understanding of PTSD.

World War II saw a great change in military and medical opinions of PTSD. Symptoms in survivors were extensively studied and psychiatrists introduced psychological assessments and screening tests in military applicants. Unfortunately, preexisting psychological conditions could not reliably predict the development of PTSD. Psychiatric casualties were better recognized, however, as was the importance of the stress of battle on a soldier’s risk of developing PTSD. Studies eventually provided data revealing that 20%–50% of discharges in the World War II military were considered to be psychiatric in nature (“History of PTSD and Trauma Diagnoses,” n.d.). A 1946 report concluded that psychiatric casualties were as common as gunshot casualties, and that the time in which a soldier achieved the highest level of efficacy was within his first ninety days at battle. It was also found that 98% of soldiers developed psychiatric symptoms of some kind after sixty days of battle (Gnam, 2023). The epidemic was clearly widespread and for many decades very difficult to track and understand, but this data became key in defining new regulations during later wars. Forward treatment returned to the forefront, with 50%-70% of those with psychiatric syndromes returning to duty (Gnam, 2023).

Traumatic neurosis was the popular term for civilian PTSD symptoms. In 1941, it was concluded that the aforementioned assortment of terms in the military were all the same syndrome under different monikers, promoting a consistency that was much needed within the field (“History of PTSD and Trauma Diagnoses,” n.d.). After the war, a Russian psychiatry textbook collected many of the terms under one umbrella: affective shock reactions. These were related to traumatic events such as war, natural disasters, or the ever-popular railway accidents, and manifest as psychological symptoms lasting either a few days or a few months (Zhou et al., 2021).

World War II also allowed the study of PTSD in civilians rather than only soldiers. Many civilians had lived under occupation of enemy forces, endured torture, or been imprisoned in concentration camps. Some experienced a decline in health over a long period of time. Among the longitudinal data, there were yet more terms such as concentration camp syndrome