National PTSD Awareness Day
Every year, on June 27th, I’m reminded it’s National PTSD Awareness Day. Every year, I share that notice, sharing symptoms, my personal experience, and remind my friends that we should never be silent on our mental health issues. It’s a stigma that needs to go away.
We’ve learned a lot about PTSD in the last forty years. Initially we believed it was something only war veterans experienced, and that only officially acknowledged in the ’80s. Before that, we would call it ‘shell shock’ or some other term.
Later, in the 1990s and beyond, we began to realize PTSD — post-traumatic stress disorder — was something commonly experienced by people who were abused, a car accident, witnessing the death of someone, or some other traumatic event.
However, PTSD has a very long history. We began to first mark its affect and experience on military people during and after the Civil War. That was when we started to notice the impact war had upon people and how it transformed them.
Austrian physician, Josef Leopold, back in 1761, noted an event in soldiers that he termed ‘nostalgia’. In these soldiers, they remarked how they missed home, feeling sad, noted sleep problems and anxiety. These are, in fact, the first historically written symptoms of what we now to be post-traumatic stress disorder.
Fast-forward to the Civil War era. Jacob Mendez Da Costa, during a study he performed on Civil War veterans, noted something he called “Soldier’s Heart” or “Irritable Heart”. He believed it was a physical injury that caused rapid pulse and trouble breathing. He believed it was an overstimulation of the heart’s nervous system, and it acquired the term “Da Costa’s Syndrome”. He would have the soldiers return to battle after receivin a course of drugs to treat the symptoms.
He gained support for his diagnosis that it was a physical injury when rail travel became more commonplace — and rail accidents. Autopsies were performed on those who died from rail accidents had suggested injury to the central nervous symptoms. One famous survivor of a rail accident was Charles Dickens, who noted problems of sleeplessness and anxiety as a result of his trauma.
1919 was when we began to call veterans ‘shell shocked’, mainly because they survived explosions of artillery shells. Symptoms resulted in panic, sleep problems, and many others that mirrored what we know to be post-traumatic stress disorder today. Shell shock was believed to be hidden damage to the brain caused by the impact of big guns. That opinion changed when even soldiers who weren’t even near big guns developed symptoms as well. “War neuroses” became the new term.
In World War I, treatment varied among doctors. Some only assigned a few days’ rest. Others invested in hydrotherapy or electrotherapy, along with hypnosis. Some even believed just focusing on daily activities would be enough to have a patient return to civilian life.
After World War II, “War Neuroses” changed to “Combat Stress Reaction”, also known as battle fatigue. Given WWII lasted years, soldiers in the front line became fatigued and battle weary. However, a number of those in higher command, such as Patton, did not believe in battle fatigue. A great example of Combat Stress Reaction can be find in Red Badge of Courage.
Up to half of those discharged from battle in WWII were due to combat exhaustion. Treatment to Combat Stress Reaction was three-fold, called PIE: Proximity, Immediacy, Expectancy. Sufferers were to be treated immediately and encouraged to make complete recovery. During this time, the benefits of the military unit relationship and support became the main focus of treatment.
In 1952, the American Psychiatric Association (APA) developed the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I). Combat Stress Reaction was now known as Gross Stress Reaction (GSR). It was the first diagnosis proposed to treat people who were relatively ‘normal’, but had symptoms of trauma from disaster or war. The drawback was the assumption that it could be dealt with relatively quickly and resolved within half a year. If symptoms persisted after six months, a new diagnosis was made.
When DSM-II came out, it eliminated GSR despite growing evidence of traumatic exposure to psychiatric problems. Instead, DSM-II had “adjustment reaction to adult life” in its place. It was thoroughly insufficient to capture the severity of PTSD. In addition, the diagnosis only covered three life events: unwanted pregnancy with suicidal thoughts; fear attached to military combat; Ganser syndrome, which was limited to prisoners facing a death sentence.
After the Vietnam War, APA added PTSD to DSM-III in 1980. It also included research from Holocaust survivors, victims of sexual trauma, and others. This was when the link between war and trauma was firmly established.
The criteria for PTSD is constantly revised and added, in DMS-III (R), DSM-IV, and so on. Even DSM-V now reflects more research and acknowledging that trauma can be acquired not just in war, but any kind of traumatic experience. The most important finding though is this:
4 of every 100 American men (or 4%) and 10 out every 100 American women (or 10%) will be diagnosed with PTSD in their lifetime.
One of the most vital changes is that now PTSD stands in its own category and no longer considered an anxiety disorder. Oh, it is still associated with depression and anxiety, but not necessarily requiring them to be diagnosed. PTSD is now placed in Trauma- and Stressor-Related Disorder.
So what about Complex PTSD? It’s a fairly new diagnosis, established in 1988. Dr. Judith Herman of Harvard University suggested it be added, and included new symptoms to go along with it. Such symptoms include: behavioral difficulties such as aggressiveness or sexual acting out; emotional difficulties such as depression or panic; cognitive difficulties such as dissociation and pathological changes in personal identity; interpersonal difficulties such as issues holding a relationship; and somatization, resulting in numerous visits to the doctor.
Sometimes known as Disorders of Extreme Stress Not Otherwise Specified (DESNOS), Complex PTSD/DESNOS was not added as a separate diagnosis in DMS-IV due to disagreement on trial results. It was felt and believed that the symptoms matched PTSD and there was no need for a separate diagnosis for it in DSM-V.
However, I firmly believe there is a difference between Complex PTSD and PTSD. The reason being, Complex PTSD encompasses either a long duration of trauma or multiple experiences of trauma without treatment or respite. There is evidence that suggest the duration of trauma is most strongly linked to the concept of Complex PTSD.
During long-term trauma, the victim is in a state of captivity, be it physically or emotionally, or both. They are unable to get away, such as a child in an abusive family, prisoners of war, concentration camps, and so on. This puts the victim in a prolonged state of being, with their Fight or Flight stuck in a cyclical trap.
An individual who experienced prolonged trauma — be it months to years — and total control by another will develop comorbidities such as substance use, mood disorders, and personality disorders. They can also experience difficulties in emotional regulation, like persistent sadness or explosive anger. They can also forget traumatic events, relive them over and over, or have episodes of dissociation. They feel, often, helplessness, shame, guilt, and a sense of being completely different from other people.
Treatment for Complex PTSD can include Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have been show to benefit. Psychotherapies are shown to help. More recently, Eye movement desensitization and reprocessing (EMDR) has shown to be very successful in treating sufferers of C-PTSD and PTSD.
As time goes on, we learn more and more about the human brain. We discover that trauma can be damaging, to the point that it can change how our brains function as a whole. Trauma is horrific, be it a car accident, rape, war, or abuse.
It’s time to recognize it. It’s time to realize mental health disorders are no laughing matter or that all we have to do is “get over it”.
End the stigma.