Evolution of Posttraumatic Stress Disorder and Future Directions Susan L. Ray The knowledge that trauma can cause long-term physiological and psychologi- cal problems has been recognized for centuries.Today, such sufferingwould be classified as the characteristic symptoms of posttraumatic stress disorder (PTSD). Nurses in all practice settings are increasingly caring for individuals suffering from military trauma, natural disasters, and interpersonal violence such as childhood sexual, physical, and emotional abuse, intimate partner vio- lence, and collectiveviolence.This article discusses howthe diagnosis of PTSD evolved over the course of h istory, I i m itations of the PTSD d iagnostic category, and additional diagnostic categories fortrauma. lmplications for nursing prac- tice and future directions for research are explored. RAUMA WAS A confusing concept that trayal of th€mis ("what is right") by a commander, originally meant physical trauma or organic the living feeling dead themselves, and berserk-like damage to the central nervous system. Trauma rage (Shay, 1994). came from the ancient Greek word "trauma." which In fiction and poetry one can also find examples meant to "wound" or "pierce," which was used to of how to cope with traumatization such as in Oliver refer to the bodily wounds or iryjury suffered by Twist by Charles Dickens, the story of a boy who soldiers from the piercing of their armor (Spiers & came to terms with the early death of his parents. Harrington, 2001). In its later usage, particularly in Pepys (1703/2001) described the extended sensory medical and psychiatric literature, trauma was imprint following exposure and the flashback understood as a wound inflicted upon the mind, recollection of the Great Fire of London in 1666 rather than upon the body (Caruth, 1996). People's evoked by an insignificant trigger. He wrote, "How responses to psychological trauma might be under- strange that to this very day I cannot sleep at night stood as a result of "piercing" through their without great fear of being overcome by fire. Last protective mental defenses (Spiers & Harrington, night, I was awake until almost two o'clock in the 2001, p. 213). morning, because I could not stop thinking about Throughout history, the suffering of human the fire" (p. 81), beings to situations of extreme adversity has always ln 1865, Charles Dickens described suffering been regarded with great interest and curiosity. The from symptoms of anxiety, memory and concentra- knowledge that trauma can cause long-term physio- logical and psychological problems has been From the The University of Western Ontario, London, recognized for centuries. Homer's lliad contained Ontario. Canada. Address reprint requests to Susan L. Ray, RN, PhD, powerful descriptions of soldiers' reactions to war Faculty of Health Sciences, The University of Western traumatization and stresses such as withdrawal, Ontario, HSA #32, London, Ontario, Canada NOA 5C1. griel and feelings of guilt toward fallen comrades E-mail address: [email protected] n 2008 Elsevier Inc. All rights reserved. (Fagles, 1990). Homer's epic emphasized three 0883-941 7/1 801 -0005$34.00/0 common events of heavy, continuous combat, be- doi: 1 0.1 01 6,1j.apnu.2007.08.005 tion problems, irritabi I ity, hyperarousal, disturbed preting the role of trauma itself became the biggest sleep, sudden alarm, nightmares, dissociation, and problem in understanding posttrauma syndromes. multiple somatic complaints following his involve- Although the exogenous causation stood in the ment in a train crash (Turnbull, 1998a). Such foreground of the railway traumas, the psycho- suffering throughout history and over the course analytic view placed endogenous factors in the of many wars was known variously as soldiers' foreground, thus deemphasizing external reality heart, battle fatigue, shell shock, combat neurosis, (Lamprecht & Sack, 2002), combat exhaustion, and even pseudocombat fatigue (Shay, leea). The Boet Crimean, and American CivilWar Today, such suffering would be classified as the During the early 1800s, military doctors diag- characteristic symptoms of Post Traumatic Stress nosed soldiers with exhaustion following the stress Disorder (PTSD). The purpose of this article will be of battle. This exhaustion was characterized by to discuss how the diagnosis of PTSD evolved over mental shutdown due to individual or group trauma. the course of history, limitations of the PTSD Like today, soldiers during the 1800s were not diagnostic category, and the need for additional supposed to be afraid or show any fear in the heat of diagnostic categories for trauma. lmplications for battle. The only treatment for this exhaustion was to nursing practice and future directions for research bring the afflicted soldiers to the rear for a while, into the study of trauma will be explored. and then they would be sent back to the battle. Through extreme and often-repeated stress, the THE EVOLUTION OF PTSD soldiers became fatigued as part of their body's Trimble (1981) discussed case studies of railway natural shock reaction. accident survivors of the 1700s with a history of Disordered action of the heart or valvular head i4jury. He explored the biological components diseases of the heart were documented in the Boer which produce PTSD symptoms and equated the War, and subsequent reports and death certificates term with postconcussion syndrome. According to indicated a functional disorder (Jones & Wessely, Trimble, the English surgeon Erichsen attributed 2001). Myers (1870) coined the term soldiers' heart conspicuous psychol ogica I abnormal ities fol I owi ng to describe a disorder that included extreme fatigue, railway accidents to microtraumas of the spinal tremors, dyspnea, palpitations, sweating, and some- cord, which then led to the concept of the "railroad times complete syncope among soldiers in combat. spine syndrome." This original connection drawn Da Costa (1871), an army surgeon in the American by Erichsen was later contradicted by the surgeon Civil War, found "irritability of the heart," "effort Page (1885) who objected to the phrase "concus- syndrome," and "Da Costa syndrome" among Civil sion of the spine." Page argued that i$uries to the War and Crimean combat veterans. He described spinal cord were unlikely and that fright, fear, and the frequent involvement of the heart as an almost alarm contributed to the disorder. He introduced the constant symptom of traumatic neurosis, with only concepts of "nerve shock" and "functional dis- a few instances of serious cardiac disease (Lam- orders." Although Page stated that nervous shock is precht & Sack, 2002). lnstances ofsudden paralysis psychological in origin, it resulted in physiologic or loss of sensation were identified as traumatic malfunctioning of the nervous system. Putnam hysterical neurosis (Ramsay, 1 990). (1883) contended that many of these cases such as The late 1gth century: Traumatic railroad spine syndrome could be identified as hysteria, and neurosis hysterical neuroses. Oppenheim first coined the neurasthenia. term traumatic neurosis and placed the main seat of Healy (1993) explored the history of PTSD and the disturbance in the cerebrum (Lampreeht & the questions raised by Freud and Janet as to Sack, 2002). The term trauma, which until then had whether hysteria was precipitated by environmental been used exclusively in surgery, was thus events. Hysteria, melancholia, and hypochondria introduced into psychiatry (Kinzie & Goetz, 1996). were the major types of neurosis described in the These early descriptions, based on clinical late 1gth century. At the salpetriere in Paris, observations attempted to base a new syndrome Charcot and Janet pointed out the importance of on assumed pathology of the spinal cord or heart traumatic experience for the origin of hysteria or disease with limited phenomenological data. Inter- dissociative symptoms. Although hysteria had been considered an affliction of women, Charcot, as well scious conflict, rather than his original idea about as Briquet, described several cases ofworking-class trauma. Bailey, Williams, and Kamora (1929) men, most of whose hysteria (conversion symp- published a definitive work on neuropsychiatry in toms) followed work-related accidents. Charcot World War I which referred throughout to Freudian demonstrated that paralysis could result from psychology as a theoretical construct for their data. hypnotic suggestion and initially deduced that Da Costa's work on effort syndrome became a there was a latent flaw in the nervous system popular diagnosis during the war (Turnbull, 1998b). (although he could not demonstrate it anatomically), The largest number of psychiaric cases in the Janet agreed that some of the hysteria, such as war involved neurosis, including neurasthenia or that seen following railroad accidents, was a form "shell shock," which was coined by Myers (1915), of neurosis but also noted that the shock could be a British military psychiatrist. imaginary. Hysterical symptoms included paralysis, Mott (1919) gave one of the best descriptions of contractions, disordered gait, tremors, and shaking. the mqjor forms of war neurosis, hysteria, and Janet was the first to systematically study dissocia- neurasthenia. He wrote that physical shock and tion as a critical process in the reaction to horrifying conditions could cause fear, which in ovenruhelming stress and subsequent symptoms turn produced an intense effect on the mind. (van der Kolk & van der Hart, 1989). Beard (1869) Hysterical symptoms