Combat Stress & Warriors: A Historical Perspective

By Robert J. Caffrey, M.A.

I. Introduction

Our modern study of trauma’s impact on the mind and body represents the continuation of an inquiry that is, in many ways, as old as recorded history itself. The categorization of trauma disorders, however, has never been exclusively the province of scientific understanding. A study of this history demonstrates that, like almost all aspects of human experience, trauma’s definition, symptomatology, and treatment are socially and culturally, as well as scientifically, constructed. This reality should inform our present day investigation into the scientific “truth” underpinning trauma, its symptomology, and treatment.

II. Modern Posttraumatic Stress Disorder Defined

Posttraumatic Stress Disorder (PTSD) is characterized by potentially disabling symptoms, which are behavioral and emotional and occur in a proportion of those individuals exposed to severe psychological trauma such as sexual abuse, combat, or natural disorders (Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR: American Psychiatric Association, 2000). PTSD is a relatively new diagnosis, appearing for the first time in the psychiatric diagnostic lexicon in 1980 (Foy, Ruzek, Glynn, Riney & Gusman, 2002). The disorder is triggered by exposure to a traumatic event outside the realm of normal experience, creating a symptom cluster (Foy et al., 2002, Schnurr et al., 2003, Schnurr et a. 2007)

Exposure to the precipitating event results in the creation of both core and secondary PTSD symptoms. Core symptoms are generally (a) re-experiencing of the trauma (“flashbacks”); (b) avoidance of triggers that remind the sufferer of the event; and (c) hyperarousal (“constant vigilance”) (Kutter, Wolf & McKeever, 2004, p. 160).

Secondary symptoms can include depression, anxiety, violence, anger, sleep disturbance and physical health problems. Veterans suffering from PTSD also demonstrate co-morbidity in alcohol and drug use (Schnurr et al., 2007, Schnurr et al, 2003).

III. PTSD in the Age of Heroes

The devastating physiological consequences experienced by warriors in the aftermath of life and death struggles have been chronicled since the dawn of written narrative. The Epic of Gilgamesh, one of the first pieces of literature extant and dating back to the third millennium Mesopotamian kingdom of Sumer, details the adventures of the Sumerian king, Gilgamesh, and his warrior companion, Enkidu (Birmes, Hatton, Brunet & Schmitt, 2003). The parallel between Gilgamesh’s post-combat experience and those of modern veterans with the “numbing” and “dissociative” aspects of the modern PTSD diagnosis is striking. On witnessing Enkidu’s death in battle, Gilgamesh is beset by recurrent and intrusive recollections of his friend’s death. A once proud and valiant warrior, Gilgamesh is haunted by these dreams and wanders numb through his kingdom, rendered incapable of regaining his once unassailable martial prowess.

Likewise, in Homer’s Iliad (850 B.C.), the immortal Greek hero, Achilles, is tormented by recurrent nightmares of battle, the death of his companion, Patroclus, and visits in his dreams from the hundreds of men slain by him in combat (Shay, 1994). The impact of these recurrent traumatic dreams and fragmented sleep, which are today recognized symptoms of PTSD, devastated even the great Achilles.

Although severe in their nature, in these ancient societies posttraumatic symptoms experienced by warriors seemed to be recognized as part of their lot in life (Shays, 1994).

IV. “Railway Spine”, “Nostalgia,” and the conceptualization of PTSD in the Victorian Age

In the late nineteenth century, the medical community began to study and record the fright symptoms experienced by victims of railway crashes who had suffered minor or no physical injury at the time of the incident (Micale & Lerner, 2001). Ultimately labeled “railway spine,” the disorder included symptoms such as sleep disturbance, nightmares about collisions, tinnitus, fear of railway travel and chronic pain (Cohen & Quintner, 1996). Interestingly, the legal dispute over whether these individuals should be paid compensation for these nonphysical injuries played almost as much of a role in this syndrome’s analysis as did scientific observation.

Railroad company doctors attempted to establish that these psychic disorders could not be the responsibility of the railroad companies as they reflected ephemeral injuries to the mind and not physical insult to the body (Harrington, 2001, Caplan, 2001). A theory was advanced by expert witnesses representing the injured claimants, however, that the excessive violence of these accidents resulted in such psychic shock to the nervous system that delayed psychological response was a predictable result (Caplan, 2001).

As theorized by John Erichsen, both the subsequent physical symptoms and fright syndromes were attributable to the “same mechanical and organic etiology, the consequence of the molecular generation of a shaken nervous system” (Birmes, et al, 2003 at p.23). For Erichson, the psychological symptoms were, thus, attributable to organic causes and warranted the same compensation as visible, physical injuries (Cohen & Quintner, 1996).

Others such as Britain’s Dr. Herbert Page and Germany’s Hermann Oppenheim, who were less impacted not by issues of legal compensability, claimed that the fear created by the event, as opposed to direct injury to the spine and nervous system, caused the traumatic symptomology (Harrington, 2001, Lerner, 2001). Oppenheim renamed the syndrome “traumatic neurosis” and asserted that both the emotional and physical aspects were primarily caused by “the psychic” (Lerner, 2001 at p.83).

Herbert Page suggested that the sequale to railway spine were ultimately the result of nervous shock and, thus, constituted a form of “hysteria” (Cohen & Quintter, 1996). Although “hysteria” had traditionally been viewed as a disorder that was limited to women, Page’s writing strongly influenced the theoretical analysis of hysteria’s principal expert, Jean-Martin Charcot (Micale, 2001). Charcot ultimately broadened and further refined his theories of hysteria in men to include classical hysteria (grande hysteria) and a posttraumatic form (petite hysteria) (Micale, 2001). Charcot would ultimately theorize that nervous shocks and the trauma causing symptoms in the body were always managed by the psyche, finally and ultimately expressed due to an individual’s hereditary make up (Micale, 2001).

The attempt to establish the locus of traumatic symptomology as the result of insult to the nervous system or the mind continued into the American Civil War. During the Civil War, a condition known as “nostalgia” with symptoms of lethargy, fits of hysteria, withdrawal and numbing, and extreme emotionality was documented in both Northern and Southern soldiers (Birmes, et al., 2003). The impact of “nostalgia” in particular, and the trauma of the war on its veterans in general, were devastating. Two-thirds of those committed to Northern insane asylums after the civil war were veterans (Dean, Jr., 1997). By way of example, virtually all of the 291 veterans in the Indiana State Asylum demonstrated classic symptoms of PTSD, most often expressed in an irrational fear of death and resultant paranoia against almost anyone aside from the veteran himself (Dean, Jr. 1997).

In terms of its etiology, “nostalgia” was often considered to be the psychic consequence of the undue stress placed upon a soldier’s heart by military duties and physical exertion during wartime (Dean, Jr., 1997). In addition to emphasizing an organic, as opposed to psychic causation, the physicians documenting nostalgia ultimately included within its ambit virtually all mental disorders related to battle. Although seemingly contradicting the physical insult causation theories underpinning “railway spine”, this “scientific” decision allowed almost all Northern Civil War veterans with mental disorders to receive a government pension. As a scientific construct, “nostalgia” appears to have been rendered more malleable due to societal concerns favoring compensating veterans, while “railway spine” was restricted by societal pressure to limit railroad companies’ responsibility to pay damages to accident victims.

V. “Shell shock”, “Battle Fatigue,” and the formal creation of “Post Traumatic Stress Disorder”

Combat veterans of World War I demonstrated a syndrome known as “shell shock”, which lent itself to further integration and categorization of posttraumatic symptoms (Birmes, et al., 2003) The theories about its cause, however, once again reflected the “either-or” body/mind duality that had been seen in the studies of railway spine (Shephard, 2001). Likewise, its recognition and treatment also varied based upon social and cultural factors related to the status of its victims and their caregivers (Holmes, 1985).

“Shell shock” was originally defined as damage to the central nervous system that demonstrated no objective physical injuries (Shephard, 2001). Despite the lack of physical injury, “shell shock” sufferers demonstrated classic PTSD symptoms such as exaggerated startle response, traumatic dreams, stupor, irritability, or trembling (Birmes, et al. 2003). The pervasiveness of the disorder was significant, totaling an estimated 40% of Britain’s battle casualties (Herman, 1992).

Some military psychiatrists, such as Lewis Yealland, viewed the disorder as caused by damage to the nervous system resulting from the percussive impact of artillery shells (Herman, 1992). As such, the nervous system needed to be rebalanced and symptoms such as paralysis, sensory loss, or mutism were treated by electric shock (Leese, 2001). Those displaying these syndromes that could not substantiate their exposure to actual, severe artillery bombardment to the satisfaction of their superior officers were often shamed, punished, or executed as malingerers (Shephard, 2001). In this respect, British and commonwealth enlisted soldiers of lower socioeconomic status were often more likely to face punitive treatment for “shell shock” than were their officers (Russel, 1919).

More progressive military physicians such as W.H. Rivers postulated that “shell shock” was a bona fide psychiatric condition resulting from intolerable traumatic stress of war, as opposed to evidence of either low moral character or neurological damage (Herman, 1992). Rivers promoted the use of Freud’s “talking therapy” and encouraged trauma victims to generate “oral and written narratives of their war experiences” (Herman, 1992). The acceptance and treatment or rejection of World War I veterans suffering from shell shock were also strongly influenced by culture. In the United States, the American Legion engaged in campaigns to both promote public sympathy and assist civilian psychiatrists in ensuring that the military establishment did not ignore veterans’ mental health issues (Cox, 2001). Alternatively, in Germany shell shock veterans were deemed “cowards, malingerers, and political subversives that had disguised themselves as psychiatric casualties” and “significantly contributed to the country’s defeat” (Matsumura, 2004, p. 806).

Although at the end of World War I the exact nature of the relationship between combat exposure and psychological trauma remained uncertain, the similar symptom clusters that had been formerly labeled as “hysteria’ and “war neurosis” were grouped together by a young American psychiatrist, Abram Kardiner, in what became known as “psychic trauma” (Herman, 1992, Shephard, 2001). One of the continuing issues in the study of psychic trauma was the theory that certain individuals were predisposed to become symptomatic. This, however, was often an issue of social class as opposed to science.

For the British, those who broke down were viewed by many as “constitutional neuropaths – people with hereditary or acquired weaknesses of the nervous system or lacking in the moral strength of character needed to honor their social obligations” (Shephard, 2001, p. 167). To prevent those so predisposed from serving during World War II, no less than 1.6 million men were rejected by the United States on the basis of psychiatric testing (Matsumura, 2004). The Japanese and German armies, on the other hand, essentially rejected pre-mobilization screening, determining that “war trauma” represented nothing more than cowardice or lack of discipline on the part of individual soldiers (Matsumura, 2004).

Despite the belief in predisposition, World War II experience once again demonstrated that any individual would succumb to trauma at some individual breaking point (Shephard, 2001). American scientific analysis began to focus upon social factors such as personality, unit morale, leadership, contact with home, and the political situation, as positively mediating a soldier’s capacity to manage combat trauma (Shephard, 2001). Despite efforts at “preventative” and “frontline psychiatry”, focusing upon immediate care before or shortly after the inception of traumatic symptoms, the U.S. ground forces alone lost 504,000 men permanently for psychiatric reasons, the equivalent of 50 combat divisions (Shephard, 2001). The impact of combat stress is even more apparent when it is considered that 80% of those succumbing to acute stress were eventually returned to duty within a week and a whopping 30% were returned to combat units (Herman, 1992).

Regardless of these results demonstrating that the severity of the impact of war trauma was undeniable, no systematic study on the impact of stress on veterans was undertaken after World War II (Herman, 1992). The modern systemization and categorization of PTSD, in fact, resulted from the confluence of the women’s movement and the Vietnam anti-war movement of the 1970s (Shephard, 2001, Herman, 1992). The discrete knowledge developed by those studying the effects of trauma in rape victims, Vietnam veterans, battered children and Holocaust survivors began to be integrated in the 1970s (Shephard, 2001). These forces, working together, influenced the third revision of the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) in which civilian and war trauma were subsumed under the new diagnosis of “Post Traumatic Stress Disorder”.

VI. Psychosocial factors affecting PTSD

Although the biological basis of the development of PTSD will be addressed in greater detail in this paper, studies indicate that other psychosocial factors may influence the development, intensity and chronicity of this complex constellation of symptoms. Studies of former POWs suggest that securely attached individuals, with a history of high quality caregiver-infant relationships, were less likely to develop PTSD symptoms than their less securely attached compatriots (Dieperink, Leskala, Thuras, & Engdahl, 2001).

Similarly, low cognitive function prior to exposure to trauma, which was determined to be a familial as opposed to individual trait by measuring the cognitive function of an identical twin not exposed to trauma, strongly influenced measured vulnerability to developing PTSD (Gilbertson, et al., 2006). Factors such as being of young age at the time of exposure to trauma and a previous trauma history (accidents, assaults, and natural disasters) were found to directly predict the development of PTSD and interact with high trauma exposure to exacerbate symptoms (King, King, Foy & Gudanowsky, 1996). Lower levels of education and minority status are also associated with increased risk of PTSD symptoms, although education and race present “a host of complex sociological processes that are difficult to tease apart when exploring the relationship between PTSD risk” (Orcutt, Erickson & Wolfe, 2004, p. 200) and factors such as educational attainment and race.

Gender has been reported to play a major role in the conditional risk of PTSD following trauma exposure (Orcutt, Erickson, & Wolfe, 2004). Although men have higher rates of trauma exposure, women have a higher risk of developing PTSD after exposure to trauma. Likewise, the literature suggests that the “duration of PTSD is longer in women than in men” (p.200). It has been suggested that women’s greater likelihood to have prior exposure to assaultive behavior may leave them more vulnerable to developing PTSD symptoms following additional trauma exposure (p. 200).

The effect of cumulative trauma over the lifespan appears to render individuals more susceptible to developing PTSD symptoms post exposure (Orcutt, Erickson & Wolfe, 2004). As recognized by many studies one of the strongest indicators of the likelihood of developing PTSD symptoms, is “the severity of traumatic exposure” (Koenen, Stellman, Stellman & Summer, Jr., 2003, p. 985) and its chronicity.

References

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Birmes, P., Hatton, L., Brunet, A. & Schmitt, L. (2003). Early historical literature of post-traumatic symptomatology. Stress and Health, 19, 17 – 26. Describes the historical evolution of the concept of psychological trauma and how this was relevant to establishing PTSD as a syndrome.

Caplan, E. (2001). Trains and Trauma in the American Gilded Age. In M.S. Micale & P. Lerner (Eds.), Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1870-1930 (pp. 280-306). New York: Cambridge University Press. Discusses the relationship between the development of concepts regarding trauma and compensation for victims of railway accidents in the nineteenth century.

Cohen, M.L., Quintner, J.L. (1996). The derailment of Railway Spine: A Timely lesson for post-traumatic fibromyalgia syndrome. Pain Reviews, 3, 181-202. Describes the ultimate rejection of “railway spine” as a valid scientific description of the multivariate injuries, physical and psychic, suffered by victims of railway accidents.

Cox, C. (2001). Invisible Wounds: The American Legion, Shell-shocked veterans, and American society, 1919-1924. In M.S. Micale & P. Lerner (Eds.), Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 19870-1930 (pp. 280-306). New York: Cambridge University Press. Discusses the political and educational efforts of the American Legion in assisting shell shocked veterans in post-World War I America.

Dean, E.T., Jr. (1997). Shook Over Hell: Post-traumatic Stress, Vietnam, and the Civil War. Cambridge: Harvard University Press. A study of the categorization, symptomatology and treatment of post-traumatic stress after the Vietnam and Civil wars.

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Gilbertson, M.W., Paulus, L.A., Williston, S.K., Gurvits, T.V., Lasko, N.B., Pitman, R.K., Orr, S.P. (2006). Neurocognitive function in monozygotic twins discordant for combat exposure: relationship to posttraumatic stress disorder. Journal of Abnormal Psychology, 115(3), 484-495. Discusses the evaluation of monozygotic twins for cognitive performance who were discordant for combat explosure and that specific domains of cognitive function may serve as premorbid risk factors for PTSD.

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Koenen, K.C., Stellman, J.M., Stellman, S.D., Sommer, Jr., J.F. (2003). Risk factors for course of posttraumatic stress disorder among American Legionnaires. Journal of Consulting and Clinical Psychology, 17(6), 980-986. Discusses impact of level of combat exposure, minority race, and early onset depression on the chronicity and severity of PTSD in 1,377 American Legionnaires who had served in Southeast Asia.

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Orcutt, H.K., Erickson, D.J. & Wolfe, J. (2004). The course of PTSD symptoms among Gulf War veterans: A Growth mixture modeling approach. Journal of Traumatic Stress, 17(3), 195-202. Discusses the socio-cultural factors such as gender, age, educational level, family stability, that affect the development and chronicity of PTSD symptoms in Gulf War veterans.

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Schnurr, P.P., Friedman, M.J., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., et. al. (2007, February). Cognitive behavioral therapy for post traumatic stress disorder in women: A randomized controlled trial. JAMA, 297(8), 820-830. Discusses the effectiveness of CBT for PTSD in female veterans based upon the results of a randomized, controlled trial.

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Shephard, B. (2000). A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century. Cambridge: Harvard University Press. Discusses the development and application of trauma theory and treatments for soldiers and veterans of World War I, World War II, the Korean War, Vietnam, and the first Gulf War, with special emphasis on the social and cultural factors affecting this process.