Posttraumatic Stress Disorder: A History and a Critique Nancy C. Andreasen, Annals of the New York Academy of Sciences Page 1 of 4

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Introduction

Although posttraumatic stress disorder (PTSD) is sometimes considered to be a relatively new diagnostic concept, given that it was first described using that name in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),¹ the concept of the disorder is considerably older. In order to understand where we are now, it is helpful to consider where we have been in the past. The disorder that we now know as PTSD has had a long and interesting history.

Historical antecedents to diagnostic manuals

Early descriptive accounts of stress-related disorders are often linked to the history of warfare. Stephen Crane’s introspective accounts of a youth’s reaction to the stress of a battle during the Civil War provides an early example. The Youth (Henry Fleming), the main character in The Red Badge of Courage, describes a range of anxiety symptoms that he experiences during combat.² The horrors of trench warfare during World War I, and their resultant psychological consequences, led to formulation of the concept of “shell shock,” initially thought to be a consequence of exposure to intense artillery. Subsequently clinicians realized that the symptoms were due to the stress of the combat experience.

Interest in shellshock waned as memories of World War I receded, but it was reawakened by the advent of World War II. As had happened previously, soldiers who were chronically exposed to combat experienced a syndrome characterized anxiety, intense autonomic arousal, reliving, and sensitivity to stimuli that are reminiscent of the original trauma.³ This syndrome was given a variety of different names: traumatic war neurosis, combat fatigue, battle stress, and gross stress reaction. When the war drew to its end, another type of stress was discovered: the experience of death camp survivors.⁴

In the pre-DSM era a literature also accumulated on psychiatric disorders that occurred as a consequence of exposure to noncombat injuries. Alexandra Adler wrote seminal papers on the psychological effects of stress in civilian settings, beginning with her work on the Cocoanut Grove fire, and described both the clinical picture and the epidemiology.5 She also compared the effects of stress reactions occurring as a consequence of head injuries with those that occurred because of psychological stress, thereby anticipating current discussions of the relationship between PTSD and traumatic brain injury (TBI) in the context of the conflicts in Iraq and Afghanistan.^6,7 Nemiah⁸ wrote about the effects of industrial accidents, and Hamburg et al.⁹ wrote about the effects of burn injuries. The descriptions of the syndromes occurring as a consequence of these diverse stressors were surprisingly similar.

During this time conceptual frameworks for understanding the effects of stress as a predisposing factor for mental illness also developed and matured. Two main positions were articulated. The first position (the “biological school”), represented by thinkers such as Selye, emphasized the role of physical mechanisms.¹⁰ Selye coined the term “stress” and hypothesized that it was mediated by the hypothalamic–pituitary–adrenal (HPA) axis. He described the general adaptation syndrome as a healthy response to stress, and he considered the traumatic neuroses to be a consequence of chronic or severe stress. The second position (the “psychological school”) had its roots in the psychodynamic tradition.¹¹ It emphasized the role of the unconscious, and of repressed memories and early childhood traumata. It led eventually to descriptions of mechanisms of defense and of their role in producing or preventing disease. These two conceptual frameworks set the stage for the history that was to follow.

Defining gross stress reaction

Because World War II brought together psychiatrists from all over the world and from all over the United States, it became clear that they could differ in training, conceptual framework, and in approaches to diagnosis and treatment. A consensus developed that some standardization was needed, and this challenge led to the creation of the first diagnostic manual, developed by the Veterans’ Administration. This provided an incentive to the American Psychiatric Association (APA) to develop its own manual: the first Diagnostic and Statistical Manual of the APA, or DSM-I, which appeared in 1952.¹² This manual included a category called gross stress reaction. It was defined as a stress syndrome that is a response to an exceptional physical or mental stress, such as a natural catastrophe or battle; it occurs in people who are otherwise normal; and it must subside in days to weeks; if it persists, another diagnosis should be made.

The first revision of this manual, DSM-II, was published in 1968.¹³ Without any explanation, the diagnosis of gross stress reaction was omitted. The most plausible explanation for the omission is that the concept was closely linked to warfare and combat, and DSM-II was written in a peaceful era. Consequently, between 1968 and 1980 no official diagnosis for stress disorders was available.

From the Annals of the New York Academy of Sciences, October 2010 issue. Used with permission.

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