Tuesday, October 18, 2016

History of the stress disorder

        By Alma Dzib-Goodin, Linda Sanders & Daniel Yelizarov

Trauma, Post Traumatic Stress Disorders or Complex trauma  are  terms related with the history of neurotic disorders, defined in the seventeenth and eighteenth centuries. During the second half of the nineteenth century with the increased emphasis on pathological anatomy and an anatomical-clinical medicine, the term and concept of neurosis became unpopular in Britain and disappeared from the medical writings (Trimble, 1985).

Later, Rigler introduced the term compensation neurosis, in 1879 following an increase in invalidism reported after the railway accidents with the introduction of compensation laws in Prussia in 1871. Such injuries were seen frequently in patients, victims of a violent shock on railway collision so Erichsen proposed the term concussion of the spine and it was recognized as clinical entity (Trimble, 1985).

During the First World War, the conscription of a mass civilian army, which in turn was subjected to the emotional pressures of trench warfare, led to an epidemic of post-trauma illness, termed shell shock. At first an organic explanation was proposed: a microscopic cerebral hemorrhage caused by either the concussive or the toxic effects of an exploding shell. When it became clear that many servicemen with the symptoms of shell shock had not been close to an explosion and some not even exposed to combat, other explanations were considered. 

The intense stress of battle, or its immediate prospect, was identified as causal factors. Rivers, who was the medically trained anthropologist who treated soldiers at Craiglockhart, believed that the disorder resulted from a failure of repression. Regular soldiers, he argued, had far greater time to build up an effective mechanism to control their fear and to master the conflict between duty and self-preservation. Conscripts, who had not been able to establish these protective defenses, succumbed to the pressures of the battlefield more readily. These ideas led post-war military planners to believe that the problem of war-related psychological injury was largely preventable. The Southborough Committee, set up in 1920 to investigate the nature of shell shock, concluded that well-led, highly trained units with high morale would be virtually immune from post-trauma illness (Jones, Wessely, 2006; Gerson, Carlier, 1992).

In an effort to prevent the epidemic of shell shock seen between 1914 and 1918 both, the civil and military authorities outlawed the term in 1939, and announced that no war pensions would be awarded for psychiatric war injuries  (the so called Horder committee leaded by EG. Horder). Henceforth, soldiers traumatized by the stress of combat were to be diagnosed as suffering from exhaustion and retained within the force.

However, the emergence of psychiatric casualties after Dunkirk, among seasoned troops in the Western Desert and, later, the modest performance of units in Normandy that had proved highly effective in North Africa and Italy, demonstrated that post- trauma illness was not entirely preventable. Neither the public nor parliament was at ease with the ban on psychiatric discharges or pensions. It was gradually accepted that even elite soldiers exposed to intense or protracted stress could cease to function, and it was expressed that every man has his breaking point. Furthermore, statistics recorded by doctors for internal assessment showed forward units had returned only 20–30% of troops to combat units, though around 70% were retained in the forces in base or non-combatant roles. Treatment was not as effective as clinicians in the First World War had claimed. (Jones, Wessely, 2006; Gerson, Carlier, 1992).

With this background, the phenomenon of nervous shock began to be noticed an it was changes for survivors syndrome after the Second World War, referring to the long-term psychological sequel of survivors from Nazi persecution or more simply to survival of other extreme situations (Trimble, 1985).

In the aftermath of the Second World War, US military psychiatrists undertook a number of retrospective analyses to discover how troops performed in battle and to assess the incidence of psychiatric casualties. In the light of this work, the US Army deployed specialist psychiatric teams during the Korean War. Thanks this, DSM-I, published during this conflict in 1952, contained the new category gross stress reaction, though no operational definition was provided  (Trimble, 1985; Jones, Wessely, 2006).

It described the extreme behavioral responses of normal individuals to exceptional stressors such as war or natural catastrophes. Published in 1968 while the Vietnam War was in progress, DSM-II introduced the term transient situational disturbance. This included all acute reactions (even brief psychotic episodes) to stressful exposures. Central, however, to both the DSM-I and DSM-II formulations was the concept that these reactions would be short-lived (Jones, Wessely, 2006; Gerson, Carlier, 1992).

During the 1970s a paradigm shift occurred in the way that psychological trauma was conceived and managed. Until then, it was argued that individuals without a family history of mental illness or other evidence of predisposition, if exposed to a traumatic event, might develop acute psychological distress, but would then go on to recover naturally with no long-term effects, rather like a self-healing wound. The discovery of a so-called delayed stress syndrome during the Vietnam War seemed to show that healthy soldiers subjected to stress could suffer chronic, adverse effects that were not apparent at the time of their exposure. The terrifying event, until then regarded merely as a trigger, assumed a crucial importance in the genesis and description of psychiatric breakdown (Jones, Wessely, 2006).

This new concept of psychological trauma also saw the retreat into obscurity of secondary gain, the attention and rewards that a patient received as a consequence of suffering from a recognized disorder. Before the 1970s anyone who broke down and suffered long-term effects was considered constitutionally vulnerable or the product of a degenerate family; in either case, responsibility lay with the individual. Not everything, however, was attributed to pre-exposure predisposition – since it was also considered that secondary gain, which was often but not exclusively financial, could inhibit the process of recovery. After the admission of post-traumatic stress disorder (PTSD) to DSM-III in 1980, once this causation was attached to the event itself, and individual sufferers were largely absolved from blame or responsibility (Jones, Wessely, 2006).

The acceptance of PTSD by the American Psychiatric Association was in part a response to the anti-Vietnam War movement, which portrayed the veteran as a victim of an insane and unpopular war, but was also a product of a society that regarded the needs of the individual as paramount, in which rights triumphed over duties (Jones, Wessely, 2006).

This open a door to begin studies from different perspective to treat  patients and understand the implication of the effects of trauma, that so far still is in develop.


Gerson, BP., Carlier, IV. (1992) Post – traumatic stress disorder: the history of a recent concept. The British Journal of Psychiatry. 161(6) 742-748.
Jones, E., Wessely, S. (2006) Psychological trauma a historical perspective. Psychiatry 5(7) 218-220.
Trimble, MR. (1985) Post-traumatic stress disorder: history of a concept. In C. Figley. (1985) Trauma and its awake. Volume1. Brunner/Mazel psychosocial stress series. Bristol. USA.

What is Post traumatic Stress Disorder?

By Alma Dzib-Goodin, Linda Sanders and Daniel Yelizarov

Trauma is a very complex topic with many concepts associated, because traumatic events can take many forms, described by types, Type I is defined as a single incident trauma, such as a traumatic accident or a natural disaster, a terrorist attack, a single episode of abuse or assault, witnessing violence and, type II is referred as a complex or repetitive trauma, such as ongoing abuse, domestic violence, community violence, war or genocide (Courtois, and Ford, 2009).

The risk of exposure to trauma has been a part of the human condition since we evolved as a species. Attacks by saber tooth tigers or twenty-first century terrorists have probably produced similar psychological sequel in the survivors of such violence. Shakespeare's Henry IV appears to meet many, if not all, of the diagnostic criteria for Posttraumatic Stress Disorder (PTSD), as have other heroes and heroines throughout the world's literature (.Friedman, ND)

In 1980, the American Psychiatric Association (APA) added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of trauma (Friedman, ND). 

Moreover, trauma has no boundaries with regard to age, gender, socioeconomic status, race, ethnicity geography or sexual orientation. It is an almost universal experience of people with mental and substance use disorders (Hodges, Godbout, Briere, Lanktree, Gilbert, Taylor Kletzka. 2013). This is why is so important to understand its complexity.

Traumatic events are associated with adverse downstream effects on physical health, independent of PTSD and other mental disorders. Although the associations are modest they have public health implications due to the high prevalence of traumatic events and the range of common physical conditions affected. The effects of traumatic stress are a concern for all medical professionals and researchers, not just mental health specialists (Scott, Koennen, Aguilar-Gaxiola. Alonso, Angermeyer, Benjet, Bruffaerts, Caldas-de-Almeida, De Girolamo, Florescu, Iwata, Levinson, Lim Murphy, Omel, Posada-Villa, Kessler, 2013).

In this regard, the American Psychiatric Association (APA) has played an important role in defining trauma, however diagnostic criteria for traumatic stress disorders have been debated through several iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) with a category of Trauma- and Stressor-Related Disorders, across the life-span (Friendman, ND).

The current definition of a traumatic event in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5; American Psychiatric Association, 2013) may be too narrow to describe the myriad of difficult childhood experiences. Furthermore, youth may develop a distinct pattern of symptoms in relation to complex or multiple childhood trauma experiences (McDonald, Borntrager, Rostad, 2014).

In this version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) featured extensive changes to the posttraumatic stress disorder (PTSD) diagnosis. PTSD was moved out of the anxiety disorders into a new class of “trauma- and stressor-related disorders,” and the definition of what constitutes a traumatic experience was revised. Three new symptoms were added, existing ones were modified, and a new four-cluster organization and diagnostic algorithm were introduced. Finally, a new dissociative subtype was added to the diagnosis (Miller, Wolf, and Keane, 2014).

On the other hand, the World Health Organization (WHO) is responsible for developing the International Classification of Diseases, 11th version (ICD-11) has proposed two related diagnoses, posttraumatic stress disorder (PTSD) and complex PTSD.  The proposed distinction conforms to the ICD-11 goal of clinical utility by virtue of its relative simplicity in the classification structure, clear differences in conceptual organization and limited set of symptom features. In the proposed ICD-11 hierarchical classification structure, PTSD and complex PTSD are sibling disorders, meaning that the diagnoses follow from the parent category of traumatic stress disorders. The stressor acts as the gate, which allows consideration of a diagnosis of either PTSD or complex PTSD (Cloitre, Garvet, Brewin, Bryant and Maercker, 2013).

Proposed ICD-11 complex PTSD is a disorder that requires PTSD symptoms as defined above but also includes three additional features that reflect the impact that trauma can have on systems of self-organization, specifically problems in affective, self-concept, and relational domains. Unlike the PTSD symptoms in which reactions of fear or horror are tied to trauma-related stimuli, these three latter types of disturbances are pervasive and occur across various contexts and relationships regardless of proximity to traumatic reminders. This is because PTSD can occur in persons who experience fear, helplessness, or horror following threat of injury or death. It is characterized by the presence of three distinct, but co-occurring, symptom clusters. Re-experiencing symptoms describe spontaneous, often insuppressible intrusions of the traumatic memory in the form of images or nightmares that are accompanied by intense physiological distress (Yehuda, and LeDooux, 2007).

 A proposal for a second trauma-related disorder was first articulated by Herman (1992), who described the potential impact of prolonged traumatic stressors like torture, domestic violence, childhood abuse) on self-organization, independent of PTSD symptoms. This conceptualization of complex PTSD was operationalized under the name Disorders of Extreme Stress Not Otherwise Specified (DESNOS) for the DSM-IV field trials.

Herman’s stated hypothesis as to why this was the case (an omission which persists) however, until recently, complex PTSD couldn’t be included as part of the trauma spectrum because it does not fit neatly under the category of anxiety disorders. It might fit equally well under dissociative disorders, or somatization disorders, or even personality disorders. Complex trauma, and the challenges it poses to standard classification of PTSD, was lost within the subtypes. This remains a continuing problem not only for adequate conceptualization of complex trauma, but for widespread recognition and appropriate treatment of it, so this means that complex trauma can underlie a range of otherwise diverse presentations, which in turn receive diverse diagnoses that fail to account for the underlying trauma., and this point is critical precisely because of the breadth of responses generated by the comprehensive nature of complex trauma (Herman, 1981).

At this sense, it’s clear that understanding all diverse manifestations of complex trauma is crucial, both to recognition, and appropriate treatment of it. Yet such understanding is unassisted by the standard diagnostic categories which themselves fragment the pervasiveness and totality of the effects of complex trauma. Beyond the consequences for the child and family, these problems carry high costs for society. For example, a child who cannot learn may grow up to be an adult who cannot hold a job. A child with chronic physical problems may grow up to be a chronically ill adult. A child who grows up learning to hate herself may become an adult with an eating disorder or substance addiction.


American Psychiatric Association. (2013) Diagnostic and Statistical manual of mental disorders, (Fifth edition), Washington, D.C., USA.
Cloitre, M., Garvet, DW., Brewin, CR., Bryant, RA., and Maercker, A. (2013) Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. European Journal of  Psychotraumatology. 4, 10.3402/ejpt.v4i0.20706.
Courtois, CA., Ford, JD. (2009) Treating complex traumatic stress disorders: An evidence-based guide.The Guilford Press,  New York. USA.
Friedman, MJ. (ND)  PTSD history and overview: A brief history of the PTSD diagnosis. Available at:  PTSD: National Center for PTSD. http://www.ptsd.va.gov/professional/PTSD-overview/ptsd-overview.asp
Herman, J. (1981) Father  - daughter incest. Harvard University Press, Cambridge, MA.
Herman, JL. (1992) Trauma and recovery: The aftermath of violence from domestic violence to political terrorism.  Guilford Press, New York. USA.
Hodges, M.,  Godbout, N., Briere, J., Lanktree, C., Gilbert, A., Taylor Kletzka. N. (2013) Cumulative trauma and symptom complexity in children: A path analysis. Child Abuse & Neglect. 37(11) 891-898.
McDonald, MK., Borntrager, CF., Rostad, W. (2014) Measuring trauma: considerations for assessing complex and non-PTSD criterion a childhood trauma. Journal of Trauma & Dissociation.15(2) 184-203.
Miller, MW., Wolf, EJ., and Keane, TM. (2014) Posttraumatic stress disorder in DSM-5: New criteria and controversies. Clinical Psychology: Science and Practice. 21(3) 208-220.
Scott, KM., Koennen, KC., Aguilar-Gaxiola. S., Alonso, J., Angermeyer, MC., Benjet, C., Bruffaerts, R., Caldas-de-Almeida, JM.,  De Girolamo, G., Florescu,, S., Iwata, N., Levinson, D., Lim CCW., Murphy, S., Omel, J., Posada-Villa, J., Kessler, RC. (2013) Association between lifetime traumatic events and subsequent chronic  physical  conditions: a cross-national, cross-sectional study. Plos One. DOI: 10.1371/journal.pone.0080573
World Health Organization (2015) ICD11 Beta Draft. Available at: http://apps.who.int/classifications/icd11/browse/l-m/en
Yehuda, R., and LeDooux, J. (2007) Response variation following trauma: A translational neuroscience approach to understand PTSD. Neuron Review. DOI 10.1016/j.neuron.2007.09.006