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 included paralysis, contrac- coined the term neurasthenia or nervous exhaustion tions, disordered gait, tremors, and shaking. to cover nonspecific emotional disorders, fatigue, Neurasthenia symptoms included lassitude, fatigue, insomnia, headache, hypochondriasis, and mel- weariness, headaches, and particularly vivid and ancholia. Neurasthenia was common in the early terrifying dreams. Another symptom described by 1900s and was recognized to occur after emotional Mott in detail for the first time was a startle reflex. trauma (Kinzie & Goetz, 1996). In 1926, the U.S. Army reported that no new Freud (1896/1962) described early childhood psychiatric syndrome was found in World War l. sexual trauma in the Aetiology of Hysteria. He Even the Russian literature (Ronchevsky, 1944) recognized that traumatic repetitive dreams brought listed no unique syndromes. the patient back to prior situations and accidents The Traumatic Neuroses of War by Kardiner, which were in conflict with his pleasure principle White, and French {1941} and War Stress and because unpleasurable subjects were recollected and Neurotic lllness by Kardiner (1947) are seminal worked over in ttrc mind. Attempts by Freud to psychological works on the evolution of PTSD, explain this was felt by critics to be inadequate. The Kardiner included the most extensive follow-up of rejection of his theory led him to minimize the patients from World War l. He developed the external events and concentrate on premorbid pro- concept of "physioneurosis" which indicated bodily blems, such as intrapsychic conflict (Miller, 1997). involvement. Kardiner differentiated the normal Traumatic neurosis was used by Kraepelin action syndrome from its alteration through trauma (189912002) to describe reactions to accidents and in terms of the symptomology (Lamprecht & Sack, other disasters. The early searches for an etiology, 2002). Symptoms included features such as fixation first in the organic area and then in the intrapsychic on the trauma, constriction of personality function- conflicts, greatly influenced subsequent research to ing, and atypical dream life. In most cases, the the detriment of other approaches to knowledge organic etiology became untenable, and the syn- development. One effect of the separation between dromes were forced into the existing nomenclature neurology and psychiatry was the insistence that of traumatic hysteria or traumatic neurasthenia disorders were either functional (which became (Kinzie & Goetz, 1996). synonymous with psychological) or organic in ll nature. Thus, the concept of an interaction became World War lost (Trimble, 1981). At the onset of War World ll, the skeptics regarded shell shock 0r war neurosis as a hetero- World War I geneous group with many factors involved includ- Ferenczi, Abraham, Simmel, and Jones (1921) ing malingering as well as psychogenic (Turnbull, studied World War I combat stress reactions and 1998a). Brill (1943) commented on the many terms applied Freud's then current theories about uncon- used to describe the affected soldiers such as exhaustion neurosis, shell shock, fright neurosis, was psychological or organic. The recognition that and asthenia. Although the reactions were caused there was an interaction between the psychological by fear, shock, and physical strain, they were also and neurophysiologic was not clearly identified found in nonservice men and in men never exposed until post-War World ll. to shelling in warfare. As the events of World War ll unfolded, psycho- Post-World War ll analytic concepts undenruent modifications, and Krystal (1969) edited the groundbreaking work multiple analytic concepts were used to interpret Massive Psychic Trauma, which looked at "con- war-related neurosis. These theoretical concepts centration camp syndrome" of Nazi Germany's represented an attempt to explain the multiple concentration camp survivors after World War ll, symptoms seen in war neurosis in terms of an Psychological Aspects of Stress edited by Harry S. intrapsychic model, which downplayed the role of Abram (1970) is cited frequently in the trauma the trauma itself. literature as a mqjor contribution in the evolution of As the war continued, more American, British, PTSD. Abram examined the human response to and Canadian studies began to describe and name stressful events including psychological reactions to syndromes found among armed services personnel life-threatening illness, concentration camps, emet- such as acute exhaustion, war fatigue, war neurosis, gency situations, combat, and the stresses of outer and old soldier's syndrome. The sheer volume of space. As follow-up information on concentration observations by well-known psychiatrists gave camp victims became increasingly available; a clinical validity to these findings (Lamprecht & chronic syndrome was described by many authors Sack. 2002). with a high degree of agreement on symptoms with Cannon (1932) defined the fighting and escaping both physical and psychological factors. principles in both the psychological and physiolo- Selye and Fortier ('1950) introduced the "General gical sense as a person's reaction to impending Adaptation Syndrome" with the three phases of danger and the principal of homeostasis. Saul alarm, resistance, and exhaustion. As a result, the (1945) identified traumatic war experiences with term stress entered everyday language. Selye the term combatfatigue and incorporated Cannon's (1974) introduced the concept of heterostasis, fight-fl ight reaction. thereby indicating the existence of an area between ln 1942, the Coconut Grove fire provided the maintaining a normal equilibrium and succumbing first modern clinical descriptions of reaction to to physical and mental breakdown. Once again the noncombatant trauma. Lindemann (1944) found external environment was discovered as the insti- psychological grief among survivors characterized gator of threat and danger. Burgess and Holstrom by overactivity, expansiveness, some psychoso- (1974) described "Rape Trauma Syndrome" noting matic symptoms, irritability, avoidance of social that the flashbacks and nightmares resembled the relationships, and hosti I ity. traumatic neuroses of war. Grinker and Spiegel (1945), two American The first concession to a unique syndrome was psychiatrists in the Army Air Force, wrote about published by the American Psychiatric Association what happens to soldiers who break under the stress (APA; 1952) in the first edition of its Diagnostic of modern warfare. Sixty-five case histories were and Statistical Manual of Mental Disorders (DSM- included as illustrative material with a description of l) which coincided with the Korean War. The various therapies used to treat the psychological DSM-I called what is now known as PTSD casualties of combat. The most interesting aspects "Stress Response Syndrome" caused by gross stress were the etiology of the psychoneuroses or war reaction under the category of transient situational neuroses stated first in psychological terms and then personality disorder. in terms of neurophysiology. Some of the symptoms The inclusion of Stress Response Syndrome included passive dependent states, guilt and depres- recognized that some reactions could occur in sion, aggressive and hostile reactions, and psycho- normal persons at times of extreme physical and tic-like states. emotional stress. However, it was specified that the To summarize, during the 1gth century and into reactions were reversible and that the ego should the mid-20th century, there was an ongoing debate return to normal under treatment. This Freudian as to whether the etiology of traumatic disorders view became even harder to maintain with the follow-up studies from World War ll and the Criterion 42 required that the person responded to increasing data from concentration camp victims the event with intense fear, helplessness, or horror. (Bradford & Bradford, 1947). However, this In the current DSM-IV-TR (APA, 2000), PTSD information did not influence DSM-Il (APA, 1968) remained in the anxiety disorder category. Pre- in which the only comparable diagnosis given was sently, the necessary conditions for any definition situational adjustment reaction of adult life. of trauma involves a threat to either one's life or physical integrity or that of another; the threat is The Vietnam War and PTSD often accompanied by real assaults, damage, or The Vietnam War and the work by Horowitz death (Krystal, 1969; van der Kolk, 1987). The (1976) influenced the authors of the DSM-lll (APA, hallmark symptoms for the diagnosis of PTSD are 1980) to recognize a century ofclinical observation intrusiveness or reexperiencing the trauma, hyper- and to include PTSD in the official nomenclature. arousal, and avoidance such as dissociation (Table 1 The suffering of many veterans confirmed by long- DSM-lV-TR criteria). term follow-up documented the severe impairments The literature on Vietnam veterans and PTSD is of chronic cases. Horowitz made a mqjor contribu- vas! studies of veterans have been essential in tion when he successfully argued that an expectable developing and extending the concept of PTSD predictable sequence of symptoms follow abnor- (Knox & Price, 1996; Kulka et al., 1990; Shay, mally stressful life events. Horowitz organized post- 1994; Wagner, Wolfe, Rotnitsky, Proctor, & traumatic symptoms into intrusive effects and denial Erickson, 2000). lt is fair to say that much, if not or avoidance effects which had been originally most, of what is known today about normal described by Freud. The former are attempts to responses to catastrophic events, to fear, and to revive the trauma 0r to live through repetition of it. the threat of being killed have been learned from The negative reactions are attempts to avoid combat veterans. For the most part, the current memories or actions associated with the forgonen criteria for PTSD in the DSM-IV-TR (APA, 2000) fit trauma. This became the organizing topology of combat and peacekeeping-related trauma. How- DSM-Ill. The DSM-Ill focused on overt symptoms ever, the current diagnostic criteria only cover a to avoid dilemmas brought on by theoretical small section of the overall spectrum of frequently attempts at etiology. The inclusion of the diagnostic occurring psychic and psychosomatic symptoms criteria of PTSD in DSM-Ill and the World Health after traumatization (Friedhelm & Sack, 2002). Organization (1992) International Classification of LIMITATIONS OF THE PTSD Diseases and Related Health Problems. 1Oth DIAGNOSTIC Revision (lCD-10) was a step forward and helped CATEGORY many of those suffering from trauma. Many symptoms such as weakness, fatigue, and The revised DSM-Ill (DSM-Ill-R; APA, 1987) loss of will power mentioned early on and by many separated PTSD from the ordinary stressors (i.e., subsequent authors (Lamprecht & Sack, 2002) that divorce, failure, rqjection, and financial problems) have historically been related to trauma did not find that are characterized in DSM-lll as adjustment a place in the DSM-Ill-R (APA, 1987), the DSM-IV disorders. The stressor criterion for PTSD had to (APA, 1994), or the DSM-IV-TR (APA, 2000). be outside the range of usual human experience Headache was a common symptom reported in both (i.e., war, torture, rape, or natural disasters). The combat and concentration camp victims, as well as stressor criterion had to cause marked distress to multiple psychophysiological reactions, particu- almost everyone and induce intense fear, terror, larly gastrointestinal disturbances (Friedhelm & and helplessness. Sack, 2002) are not mentioned. In the DSM-lV (APA, 1994), the stressor criterion There are few descriptions of dissociative symp- contained both objective and subjective features. toms, except amnesia operating in PTSD. This fact Criterion A1 required that an individual must have is recognized by the limited dissociative symptoms experienced, witnessed, or been confronted with an required for the diagnosis of PTSD in DSM-IV-TR event or events that involved actual or threatened (APA, 2000). DSM-lV-TR (APA, 2000) reflects the death or serious injury or a threat to the physical ongoing ambivalence of psychiatry to maintain integrity of self or others. A1 may also be expressed dissociative disorders such as dissociative identity as disorganized and agitated behavior in children, disorder in a separate diagnostic group while still Table 1. DSM-IV-TR (APA, 2oOO) ADDITIONAL DIAGNOSTIC A. The person has been exposed to a traumatic event in which CATEGORIES FOR TRAUMA both of the following were present: The DSM-IV field trial studied 440 treatment- 1 . The person experienced, witnessed. orwas confronted withan event or events that involved actual or threatened death or seeking patients and 128 community residents and serious injury or a threat to the physical integrity ofselfor others. found that victims of prolonged interpersonal 2. The person's response involved intense fear, helplessness, or trauma, particularly early in life, had a high horror. incidence of problems with (a) regulation of affect B. The traumatic event is persistently reexperienced in one or and impulses, (b) memory and attention, (c) self- more of the following ways: perception, (d) interpersonal (e) 1 . Recurrent and intrusive distressing recollections ofthe event, relations, somati- including images, thoughts, or perceptions zation, and (0 systems of meaning (Roth, Newman, 2. Recurrent distressing dreams of the event Pelcovitz, van der Kolk, & Mandel, 1997). 3. Acting or feeling as if the traumatic event were recurring Complex PTSD (C-PTSD) or disorders of extreme (includes a sense of reliving the experience, illusions, stress not otherwise specified (DESNOS) attempted hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) to recognize the long-term psychological responses 4. Intense psychological distress at exposure to internal or of individuals exposed to prolonged periods of external cues that symbolize or resemble an aspect of the violence such as various forms of captivity, child- traumatic event hood physical or sexual abuse, domestic violence, 5. Physiological reactivity on exposure to internal or external and organized sexual exploitation (Roth et al., cues that symbolize or resemble an aspect of the traumatic event 1997; van der Kolk, Roth, Pelcovitz, Sunday, & C. Persistent avoidance of stimuli associated with the trauma Spinazzola, 2005). However, these profound psy- and numbing of general responsiveness (not present before chological alterations that occurred among indivi- the trauma), as indicated by three or more of the following: duals exposed to prolonged periods of captivity or 1. Efforts to avoid thoughts, feelings, or conversations total control by another such as hostages, prisoners associated with the trauma 2. Efforts to avoid activities, places, or people that arouse of war, concentration camp survivors, and survivors recollections of the trauma of long{erm interpersonal violence (Matussek, 3. Inability to recall an important aspect of the trauma 1975; Niederland, '1964) were not captured in 4. Markedly diminished interest or participation in significant PTSD as outlined by the DSM-IV-TR (APA, 2000). activities The DSM -IV-TR (APA, 2000) listed C-PTSD or 5. Feeling of detachment or estrangement from others 6. Restricted range of that affect (e.9., unable to have loving DESNOS not as a distinct diagnosis but under the feelings) rubric of "associated and descriptive features" of 7. Sense of a foreshortened future (e.9., does not expect to PTSD (p. 425). have a career, marriage, children, or normal lifespan) D. Persistent symptoms of increased arousal, not present before the trauma, as indicated by two or more of the following: DISCUSSION 1. Difficulty falling or staying asleep Many authors (Bracken, 2002; Gorman, 2001; 2. lrritability or outbursts of anger 3. Difficulty concentrating Lykes, 2000; Summerfield, 2004; Thomas & 4. Hypervigilance Bracken, 2004) have questioned the inadequacy 5. Exaggerated startle response of the PTSD diagnosis to explain trauma from E. Duration of the disturbance (symptoms in criteria B, C, and D) prolonged interpersonal violence and collective is more than 1 month violence such as terrorism, mass murders, mass F. The disturbance causes clinicatly significant distress or impairment in social, occupational, or other important areas torture, genocide, and ethnic cleansing that occurs of functioning. on a wide scale around the world. PTSD as a Acute: lf duration of symptoms is less than 3 months. universal concept has been applied to everyone Chronic: lf duration of symptoms is 3 months or more. With regardless of cultural, ethnic, religious background, delayed onset: lf onset of symptoms is at least 6 months after age, gender, or context. However, its universality the stressor. has been challenged because victims of violence Nore. Diagnostic criteria for PTSD. around the world are not homogeneous and do not necessarily fit into the individualistic PTSD acknowledging a close relationship between psy- category (Ehrenreich, 2003; Ozer & Weiss, 2004). chological trauma and dissociative symptoms (van Although some evidence of individual traumatiza- der Kolk, Herron, & Hostetler, 1994). tion is widespread, and many individuals may acknowledge symptoms of PTSD, symptom pre- time without resolution; individuals may require sentations rarely match (or are limited to) PTSD crisis intervention in order to return to their (Baron, Jensen, & deJong, 2004; Kagee, 20Aq. premorbid level of functioning and to foster the More commonly, traumatized individuals of long- development of additional coping skills (Dripchak term interpersonal violence seek help for regulation & Marvasti, 2007). of affect and impulsivity, somatic symptoms, When adolescents and adults present with relationship conflicts, and dissociative symptoms symptoms 0f pathology that are present for at least (Herman, 1997; Linehan, '1993). Local observers 3 months, more intensive therapeutic interventions perceived the primary consequences of collective are required such as cognitive-behavioral therapy, violence in non-Western societies and cultures to be eye movement desensitization and reprocessing, increased levels of interpersonal conflict, wide- and dialectical behavioral therapy. Play therapy is spread apathy, increased drug and alcohol use, used to reenact the traumatic experience for children marital breakdown. and violence directed at women from ages 3 to 11 years in order to arrive at a better and children (Baron et a'.,2004: Kagee, 2004). resolution of the conflict (Dripchak & Marvasti, The development of additional diagnostic 2004). Specialized training in trauma for advanced categories such as C-PTSD or DESNOS, practice nurses in mental health is required for these although still a work in progress, attempted to i ntensive therapeutic interventions. capture the multidimensional nature of breakdown in the face of trauma from prolonged interperso- FUTURE DIRECTIONS FOR RESEARCH nal violence (van der Kolk et al., 2005). Future research into trauma needs to extend Additional diagnostic categories are needed to beyond the traditional preoccupation on PTSD as explain the multidimensional responses to inter- the sole outcome of traumatization and more personal and collective violence. closely attend to the full range of disordered psychological domains including disturbances in FOR PRACTICE IMPLICATIONS NURSING perceptions, information processing, affect regula- Nurses in a variety of practice settings such as tion, and personality development that are now psychiatry, pediatrics, maternal child, oncology, relegated to various other comorbidies. Further hospice, and addictions are increasingly caring for studies are needed in regard to C-PTSD or individuals suffering from military trauma, natural DESNOS as additional diagnoses into understand- disasters, interpersonal violence such as childhood ing the complexity of prolonged interpersonal sexual, physical, emotional abuse, intimate partner violence. PTSD is limited when called upon to violence, and collective violence. The nursing comprehend the responses of individual victims of profession has a significant role to play in working collective violence at the hands of others. To view with individuals from diverse cultural, ethnic, and these responses as simply a more severe form of the religious backgrounds who are suffering from response of victims to more encapsulated traumatic different types of trauma. Nurses need to recognize experiences such as a natural disaster or as unique responses to trauma due to these differences involving merely additional associated symptoms including age and gender. Nurses must be knowl- fails to capture the overall impact of these events edgeable about what is considered to be within a (Ehrenreich, 2003). To focus on the symptoms of normal range and what is considered more serious individuals rather than the impact of traumatic pathological symptoms. events on the collective experience of their Nurses must also understand the different levels communities and cultures minimizes the experience of intervention to help those suffering from trauma. of the victims. Thus, there is a pressing need for First-order interventions or "psychological first aid" research into understanding trauma from collective involve community prevention programs such as violence in communities and cultures from around connection to social supports, fundamental needs the world. such as food, rest, and safety, and resources for professional help (Slaikeu, 1990). lt is important CONCLUSION not to "pathologize" initial reactions and to focus on The diagnostic category of PTSD has evolved the individual's functionality (Shalev & Ursano, over the past two centuries. At present, there is a 2003). When symptoms occur for a longer period of need to understand trauma beyond the singular entity and limitations of PTSD. Further knowledge Da Costa, J. M. (1871). On irrirable heart: A clinical study of a and additional diagnostic categories in regard to form of cardiac disorder and its consequences. American Journal of the Clinical Sciences,61,17-52. various sources trauma such as prolonged of Dripchak, V. L. & Marvasti, J. A. (2004). Treatment approaches interpersonal violence and collective violence are for sexually abused children and adolescents: Play needed. Differences in responses to various forms therapy and cognitive behavioral therapy. In J. A. of trauma from diverse cultural, ethnic, and Marvasti (Ed.), Psychiatric treatment of victims and sur- religious backgrounds around the globe need to vivors of sexual traumar A neuro-bio-psychological app- roach (pp. 1 55-1 76). I llinois: Charles Thomas Publ ishers. be studied. Nurses in a variety of settings are in Dripchak, V. L. & Marvasti, J. A. (2007). The multi-dimensional unique positions both in practice and research to impact of terrorism on civilians: Treatment implications further our understanding of those suffering from for nurses. On the Edge: The Official Newsletter of the various forms of trauma from around the world. International Association of Forensic Nurses, 13(1), 5-8. Ehrenreich, J. H. (2003). Understanding PTSD: Forgetting REFERENCES "trauma". Journal of Social lssues, 3(1), 15-28. Abram, H. S. (1970). Psychological aspects of stress. Spring- Fagles, R. (1990). lliad/Homer. R. Fagles (Trans.). New York: field, lL: Thomas. Viking Penguin. American Psychiatric Association. (1952). Diagnostic and Ferenczi, S., Abraham, K., Simmel, E., & Jones, E. (1921). statistical manual of mental disorders (lst ed.) Washing- Psychoanalysis and the war neuroses. London: lnterna- ton, DC: Author. tional Psychoanalgical Press. American Psychiatric Association. (1968). Diagnostic and statis- Freud, S. (1 962). The aetiology of hysteria. (J. Strachey, Trans.) tical manual of mental disorders (2nd ed.) Washington, London: Hogarth Press (Original work published DC: Authu. 1896). American Psychiatric Association. (1980). Diagnostic and statis- Friedhelm, L. & Sack, M. (2002). Post{raumatic stress disorder

tical manual of mental disorders (3rd ed.) Washington, DC: revisited. American Psychosomatic Society, 64, 222-237 . Author. Gorman, W. (2001). Refugee survivors of torture: Trauma and American Psychiatric Association. (1987). Diagnostic and treatment. Professional Psychology: Research and Prac- statistical manual of mental disorders (3rd ed., revised). tice, 32,443-451. Washington, DC: Author. Grinker, R. R. & Spiegel, J. P. (1945). Man under stress. New American Psychiatric Association. (1994). Diagnostic and sta- York: Mccraw-Hill Book Company. tistical manual of mental disorders (4th ed.) Washington, Healy, D. (1993). lmages of trauma: From hysteria to post- DC: Author. traumatic stress disorder. London: Faber and Faber. American Psychiatric Association, (2000). Diagnostic and Herman, J. L. (1997). Trauma and recovery: The aftermath of statistical manual of mental disorders (4th ed., text violence from domestic abuse to political terror. New revision). Washington, D.C.: Author York: Basic Books. Bailey, P, Williams, F. E., & Kamora, P. O. (1929). Neuropsy- Horowitz, M. J. (1976). Stress response syndrome. New York. chiatry Vol. 10: The Medical Department of ttE United Jason-Aronson. States Army in the U/orld War. WashinEon, DC: Office of Jones, E. & Wessely, S. (2001). The origins of British military the Surgeon General, U.S. Army. psychiatry before the First World War. War and Society, Baron, N., Jensen, S. 8., & deJory, J. (2004). The mental health of 19, 91-108. refugees and internally displaced peoples. In J. Fairbanks, Kagee, A. (2004). Do South African former detainees experience M. Friedman, J. deJong, B. Green, S. Solomon (Eds.), post traumatic stress? Circumventing the demand Guidelines for Psychosocial Policy and Practice in Social characteristics of a psychological assessment. Transcul- and Humanitarian Crises: Report to the United Nations. turaf Psychiatry 4'1, 323-346. New York: United Nations, Kardiner, A. (1947). War ftress and neurotic illness. Washington: Beard, G. M. 0869). Neurasthenia or nervous exhaustion. Research Council. Boston Medical and Surgical Journal, 80, 217-221. Kardiner, A., White, B. V., & French, T. M. (1941). Thetrau- Bracken, P. (2002), Trauma: Culture, meaning and philosophy. matic neuroses of war. Washington: National Research London: Whurr Publishers. Council. Bradford, J. M. & Bradford, E. J. (1947). Neurosis in escaped Kinzie, J. D. & Goetz, R. R. 0996). A century of controversy prisoners of war. British Journal of Medical Psychology, surrounding posttraumatic stress-spectrum syndromes: 20,422-435. The impact on DSM-lll and DSM-IV. Journal of Brill, N. Q. (1943). War neurosis. Journal of Laboratory and Traumatic Stress, 9(2), 159-179. Clinical Medicine, 28, 489-498. Knox, J. & Price, D, H. (1996). Healing America's warriors: Burgess, A. W. & Holstrom, L. (1974). Rape trauma syndrome. Vet centers and the social contract. Retrieved December American Journal of Psychiatry, 147,887-892. 22, 2002, from http;//www.vietnamcsnter/events/ Cannon, W. B. (1932). The wisdom of the body. New York: 1 996Symposium/96papers/healing/htm. Norton Publishers. Kraepelin, E. (2002\. Lifetime editions of Kraepelin in English. Caruth, C. ('1996). Unclaimed experience: Trauma, narrative, London: Thoemmes Press (Original work published and history. Baltimore, MA: Hopkins University Press. 1 899). Krystal, H. (1969). Massive psychic trauma, New York: Saul, L. J. (1945). Psychological factors in combat fatigue with lntemational Universities Press. special reference to hostility and the nightmares. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Psychosomatic Medicine, 7 , 257 -272. Jordan, B. K., Marmar, C. R., etal. (1990). Trauma andthe Selye, H. (1974). Stress without distress. New York: Lippincott. Vietnam War generation. New York: Brunner/Mazel. Selye, H. & Fortier, C. (1950). Adaptive reaction to stress. Lamprecht, F. & Sack, M. (2002). Posftraumatic stress disorder Psychosomatic Medicine, 12, 1 49-157. revisited. Psychosomatic Medicine, M (2), 222-237 . Shalev, A. Y. & Ursano, R. J. (2003). Mapping the multi- Lindemann, E. (1 944). Sympomatology and management ofacute dimensional picture of acute responses to traumatic grief. American Journal of Psychiatry 101(9), 141-148. stress: From diagnosis to treatment planning. In R. Linehan, M. M. (1993). Cognitive-behavioral treatment of Orner & U. Schnyder (Eds.), Reconstructing early borderline personality disorder. New York: Guilford interventions after trauma. Oxford, England: Oxford Press. University Press. Lykes, M. B. (2000). Possible contributions of a psychology of Shay, J. (1994). Achilles in Vietnam: Combat trauma and the liberation: Whither health and human rights? Journal of undoing of character. New York: Maxwell McMillan Health Psychology, 5(3), 383-397. Intemational. Matussek, P. (1975). Internment and concentration camps and Slaikeu K.A. (Ed.). (1990), Crisis intervention: A handbook for their consequences. New York: Springer. practice and research. Boston: Allyn & Bacon. Miller, L. (1997). Freud and consciousness: The first one Spiers , T. & Hanington, G. (2001). A brief history of trauma. In hundred years of neuropsychodynamics in theory and T. Spiers (Ed.), Trauma: The practitioner's guide to cl inica I practice. Sem inars i n Neurology, 17 (2), 17 1 -17 7 . counseling (pp. 213-21). New York: Taylor & Francis Mott, F. w. (1919). war neuroses and shell shock. London: Group. Oxford University Press. Summerfield, D. (2004). Cross-cultural perspectives on the Myers, A, B. R. (1870). On the etiology and prevalence of diseases medicalisation of human suffering. In G. Rosen (Ed.), of the heart amorq soldiers. London: J. Churchill. Posttraumatic stress disorder: lssues and controversies Myers, C. S. (1915). A contribution to the study of shell shock. (pp. 1-15). New York: John Wiley. Lancet, 188, 316-320. Thomas, P. & Bracken, P. (2004). Critical psychiatry in practice. Niederland, W. G. (1964). Psychiatric disorders among persecu- Advances in Psychiatric Treatment, 10, 361 -370. tion victims: A contribution to the understanding of Trimble. M. R. (1981). Post-traumatic neurosis: From railway concentration camp pathology and its after effects. spine to the whiplash. New York: Wiley. Journal of Nervous and Mental Disorders, 1 39, 458-474. Turnbull, G. J. (1998). A review of post-traumatic stress disorder. Ozer, E. J. & Weiss, D. S. (2004). Who develops posttraumatic Part l: Historical development and classification. l4jury, stress disorden Current Directions in Psychological 2e(2), 87-91. Science, 1 3(4), '1 69-1 72. Turnbull, G. J. (199B). A review of post-traumatic stress disorder. Page, H. (1885). Injuries of the spine and spinal cord without Part ll: Treatment. ldury 29(3), 168-175. apparent mechanical lesion. In T,R. Trimble (Ed,), van der Kolk, B. A. 0987). Psychological trauma. Washington, Posttraumatic neurosis: From railroad spine to whiplash DC: American Psychiatric Press. (pp.29-37). London: J. Churchill. van der Kolk, B. A., Henon, N., & Hostetler, A. (1994). The Pepys, S. (1703/2001). The diary of Samuel Pepys. Toronto: history of trauma in psychiatry. Psychiatric Clinics of Random House. North America, 17(3), 583-600. Putnam, J. J. (1883), Recent investigations into the pathology of van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S.. & so-called concussion of the spine. Boston Medical Spinazzola, J. (2005). Disorders of extreme stress: The Surgical Journal, 109, 217 -220. empirical foundation of a complex adaptation to trauma. Ramsay, R. (1990). Invited review: Post-traumatic stress Journal of Traumatic Stress, 1B(5), 389-399. disorder; a new clinical entity? Journal of Psychosomatic van der Kolk, B. A. & van der Hart, O. (1989). Pierre Janet and Research, 34(4), 355-365. the breakdown in psychological trauma. American Ronchevsky, S. P (1944). Traumatic psychoneurosis: Problem of Journal of Psychiatry, 146, 1530-1540. psycho reactive states in time of war. Sovietskii Wagner, A. W, Wolfe, J., Rotnitsky, A., Proctor, S. P., & Vrachebnyi Zhurnal, 44, 359-366. Erickson, D. J. (2000). An investigation of the impact of Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B. A., & posttraumatic stress disorder on physical health. Journal Mandel, F. S. (1997). Complex PTSD in victims exposed of Traumatic Stress, '13(1), 41-55. to sexual and physical abuse results from the DSM-IV World Health Organization. (1992). The ICD-10 Classification field trial for posttraumatic stress disorder. Journal of of mental and behavioral disorders. World Health Traumatic Stress, 10, 539-555. Orqanization Publ ication: Geneva.