From "Irritable Heart" to "Shellshock": How Post-Traumatic Stress Became a DiseaseS

When people have suffered a violent or horrifying experience, the trauma can follow them around for years — and we call that Post-Traumatic Stress Disorder (PTSD). From soldiers to accident victims to rape survivors, tons of people have found themselves haunted by their terrible experiences.

But PTSD didn't enter our vocabulary until 1980, when it was added to the DSM-III. Before that, there were many terms for the condition, and many people wrote about it, including Dickens and Shakespeare. How did people describe PTSD before 1980, and how did it come to be recognized as a syndrome, separate from grief or regular depression? Here's the secret history of trauma and recovery.

Top image: World War I soldier receives treatment from the "Bergonic chair for giving general electric treatment for psychological effect, in psycho-neurotic cases." Via Otis Archive/Flickr.


Early reports

Many ancient religious texts talk about the terrible aftermath of trauma — including the Book of Job, in which Job appears to be suffering from mental disturbance after his horrible experiences. And the Mahabharata describes the combat-related stress of warriors in the Mahabharat War.

The Greek historian Herotodus writes a lot about PTSD, according to a presentation by Mylea Charvat to the Veterans Administration. One soldier, fighting in the battle of Marathon in 490 BC, reportedly went blind after the man standing next to him was killed, even though the blinded soldier "was wounded in no part of his body." Also, Herotodus records that the Spartan leader Leonidas — yes, the guy from 300 — dismissed his men from combat because he realized they were mentally exhausted from too much fighting.

Also, some experts think the Iliad is describing PTSD when Homer says Ajax went mad under Athena's spell, slaughtering a herd of sheep that he thought were the enemy, and then killing himself.

Shakespeare writes a pretty dead-on description of PTSD in Henry IV Part 2, as Michael R. Trimble points out in Trauma and its Wake Vol. 1. Lady Percy observes Harry Percy having terrible nightmares in which he murmurs "tale of iron wars," and talks to his "bounding steed." And when he's awake, Harry is like a ghost. She says to him:

Tell me, sweet lord, what is't that takes from thee
Thy stomach, pleasure, and thy golden sleep?
Why dost thou bend thine eyes upon the earth,
And start so often when thou sit'st alone?
Why hast thou lost the fresh blood in thy cheeks,
And given my treasures and my rights of thee
To thick-eyed musing and cursed melancholy?

There's also that speech in Macbeth, where he asks, "Canst thou not minister to a mind diseased/Pluck from the memory a rooted sorrow?"

Likewise, Trimble notes, Samuel Pepys describes his trauma after the Great Fire of London, which left him with "dreams of the fire and the falling down of houses." He had a hard time sleeping due to his "great terrors of fire," and actually considered suicide.

From "Irritable Heart" to "Shellshock": How Post-Traumatic Stress Became a Disease

Charles Dickens writes about being "curiously weak... as if I were recovering from a long illness," after a traumatizing railway accident in which the front of the train plunged off a bridge under repair and 10 people died, with another 49 injured. Dickens wrote in letters to people: "I begin to feel it more in my head. I sleep well and eat well; but I write half a dozen notes, and turn faint and sick... I am getting right, though still low in pulse and very nervous." Dickens also writes about being unable to travel by rail, because he keeps getting the feeling that the train carriage is tipping over on one side, which is "inexpressibly distressing." Dickens was never as prolific after this incident, and he died on the fifth anniversary of the train crash.

But it's also true that PTSD wasn't fully recognized until around 100 years ago — and there are a few factors, including: 1) the rise of modern psychology, 2) modern warfare, with all of its huge explosions and ever-more-efficient killing machines, and 3) the rise of things like worker's compensation and lawsuits, making people more likely to report when they've been traumatized after an incident. So what did people call this condition in the past?


Many Names

According to psychologist Edward Tick, PTSD has had more than 80 names over the years. Here are just some of them:

Nostalgia This is the diagnosis given to Swiss soldiers in 1678 by Dr. Johannes Hofer. In 1761, Austrian physician Josef Leopold Auenbrugger wrote about the widely diagnosed condition of nostalgia in his book Inventum Novum, writing that soldiers "become sad, taciturn, listless, solitary, musing, full of sighs and moans. Finally, these cease to pay attention and become indifferent to everything which the maintenance of life requires of them. This disease is called nostalgia." French physicians in the Napoleonic wars believed soldiers were more likely to suffer nostalgia if they had come from a rural, rather than urban, background. They prescribed such cures as listening to music, regular exercise, and "useful instruction."

Homesickness Around the same time, German soldiers were calling the same condition heimweh, and the French called it "maladie du pays" — both terms basically mean "homesickness."

Estar Roto Spanish physicians came up with this term for PTSD, which means "to be broken."

Soldier's Heart
Internal medicine doctor Jacob Mendez da Costa studied Civil War veterans in the United States, and discovered that many of them suffered from chest-thumping (tachycardia), anxiety, and shortness of breath. He called this syndrome "Soldier's Heart" or "Irritable Heart." But it also came to be called "Da Costa Syndrome."

Neurasthenia/Hysteria
These classic Victorian descriptions for anybody who suffered from excessive neurosis or nervousness included many symptoms that would now be considered signs of PTSD, judging from James Beard's definitive text on neurasthenia, published in 1890.

From "Irritable Heart" to "Shellshock": How Post-Traumatic Stress Became a DiseaseS

Compensation Sickness or Railway Spine
As railroad travel became much more common in the late 19th century, so did railroad accidents — and psychologists started noticing a lot of cases of trauma among survivors of those accidents. (Just like Charles Dickens.) Psychologist CTJ Rigler coined the term "compensation neurosis" to describe these cases — with the "compensation" part referring to a new law that allowed people to sue for compensation for emotional suffering. Rigler believed people were more likely to report their traumatic symptoms — or possibly exaggerate them — if they were going to get paid. Victims of railway accidents were also referred to as having "Railway Spine," as if their spinal cords had suffered a concussion that caused them to be more nervous or tramautized afterwards.

Shell Shock
Dating from World War I, "shell shock" is probably the most famous term for PTSD. By December 1914, up to 10 percent of officers were suffering from shell shock, and 40 percent of casualties from the Battle of the Somme were shell-shocked.

Combat Exhaustion
That's what it started being called during World War II and the Korean War. People also called it "combat fatigue." The Army studied the problem, and decided that "unit cohesion" was a crucial factor in surviving this syndrome, and replacement soldiers were more prone to it because they were new to their units. And as Charvat notes, there's an ad in the September 17, 1945 issue of Life Magazine touting Wyeth Pharmaceuticals' products in treating both colic and "battle reaction and mental trauma."

Stress Response Syndrome
That's the term it was given in the DSM-I in 1952. And that's the condition that Vietnam War soldiers were diagnosed with. In the DSM-II this syndrome was lumped in with some others, in a new category called "situational disorders."


Clinical Debates

Once it was recognized as a medical condition, the nature of PTSD was still up for a lot of debate, including:

Was it physical or psychological?
The term "shell shock" sort of conjures an idea of someone's brain getting rattled inside its skull by exploding shells. And indeed, that's pretty close to what the term meant. Similarly, as we mentioned above, "railway spine" was based on the notion that railway accidents caused damage to the spinal cord, even if the patient appeared physically unharmed.

One of the first experts on "shell shock" was Frederick Walker Mott, who believed that explosions caused physical lesions on the brain, perhaps exacerbated by carbon monoxide or changes in atmospheric pressure. (Although Mott did believe that psychological trauma was part of the problem as well.) He writes in his landmark 1919 study:

From "Irritable Heart" to "Shellshock": How Post-Traumatic Stress Became a DiseaseS

Physical shock accompanied by horrifying circumstances, causing profound emotional shock and terror, which is contemplative fear, or fear continually revived by the imagination, has a much more intense and lasting effect on the mind than simple [physical] shock has. Thus a man under my care, who was naturally of a timorous disposition and always felt faint at the sight of blood, gave the following history. He belonged to a Highland regiment. He had only been in France a short time and was one of a company who were sent to repair the barbed wire entanglements in front of their trench when a great shell burst amidst them. He was hurled into the air and fell into a hole, out of which he scrambled to find his comrades lying dead and wounded around. He knew no more, and for a fortnight lay in a hospital in Boulogne. When admitted under my care he displayed a picture of abject terror, muttering continually, "no send back," "dead all round," moving his arms as if pointing to the terrible scene he had witnessed.

Image via Alistair Hobbs/Flickr.

But Charles Myers, who wrote about "shell shock" in a 1915 Lancet article, contended later that proximity to an explosion was not a key cause of the condition. Rather, these were cases where "the tolerable or controllable limits of horror, fear, anxiety, etc. are overstepped." In 1940, at last, Myers published his groundbreaking study of 2,000 cases of shell shock, and was able to identify many cases which did not directly involve explosions.

Another World War I researcher, Millais Culpin, described dissociative states that were linked to extreme terror. When he asked a soldier to close his eyes and describe his first experience of fighting, he "seemed to be living his experience over again with more than hallucinatory vividness, ducking as shells came over or trembling as he took refuge from them."

Meanwhile, as for "railroad spine," a surgeon named Herbert Page who worked for the London and North West Railway published a whole book in 1890 called Injuries of the Spine and Spinal Cord Without Apparent Mechanical Lesion, in which he contended these patients were really suffering from "nervous shock," not physical injury."

From "Irritable Heart" to "Shellshock": How Post-Traumatic Stress Became a DiseaseS

Was it short-term or long-term?
Starting after World War II, psychologists started classifying all of these cases of trauma, based on loads of notes that the Armed Forces had been collecting since 1933. There was just one trouble: the military shrinks were working on the assumption that all of these cases were "transitory" or "acute." Meaning that otherwise normal people would have a short-term problem, after they got back from combat, but that by its nature this wouldn't last long. Image via Kimadababe/Flickr

Because the psychological studies were based on the military data, which all made this assumption, psychologists also assumed that cases of PTSD would be short-term or temporary in nature.

After the Vietnam War, countless veterans were diagnosed with "stress response syndrome" — but the VA declared that if the problem lasted more than six months after the soldiers returned home, then it obviously was a pre-existing condition and had nothing to do with their wartime service. And thus, it was no longer covered.

It wasn't until DSM-III in 1980 and ICD-10 in 1992 that the clinical guidelines started to acknowledge that these problems could be chronic. And that this problem could be an "anxiety disorder" rather than a short-term adjustment. This change came in the wake of researchers working with a large number of Vietnam veterans — like World War II, the Vietnam War was a huge boost to PTSD research, and you could find a large number of people suffering from the same symptoms within the same city, so you had tons of ready data.

A big proponent of reclassifying PTSD as an anxiety disorder, rather than an adjustment disorder, was Boston University's David H. Barlow. He theorized that when people who have psychological and physiological vulnerability get exposed to a stressful event, they develop the belief that these stressful events are unpredictable and uncontrollable — and they will become fearful about the repetition of this stress. This leads to a cycle of "chronic overarousal" and "anxious apprehension." These, in turn, lead to people being excessively vigilant, with shortened attention spans, and the way people process information gets distorted.

In short, they have major stress as a result of a trauma they've experienced. Hence, PTSD.

Sources:
Trauma and its Wake: The Study and Treatment of Post-Traumatic Stress Disorder (Charles R. Figley, ed.)
War and the Soul: Healing Our Nation's Veterans from Post-Traumatic Stress Disorder by Edward Tick, PhD.
"Shell shock, Gordon Holmes and the Great War" by A.D. Macleod, Journal of the Royal Society of Medicine.
"History of Post-traumatic Stress Disorder in Combat," presentation by Mylea Charvat, MS to Veterans Administration
Posttraumatic Stress Disorder: Malady Or Myth? By Chris R. Brewin