PTSD from Armistice Day to DSM-5

Although exposure to trauma has always been a part of the human condition, the evolution of what is now known as Posttraumatic Stress Disorder (PTSD) since the first Armistice Day, Nov. 11, 1918, is particularly fascinating. Armistice Day became Veterans Day in 1954 to honor all Veterans.

For Veterans Day, let’s reflect on how far we have come since the first Armistice Day in our understanding of this mental health problem.

In 1919, President Wilson proclaimed Nov. 11 as the first observance of Armistice Day, the day World War I ended. At that time, some symptoms of present-day PTSD were known as “shell shock” because they were seen as a reaction to the explosion of artillery shells. Its symptoms included panic and sleep problems, among others. Shell shock was first thought to be the result of hidden damage to the brain caused by the impact of the big guns. That changed when more soldiers who had not been near explosions also had its symptoms. Treatment was inconsistent. Soldiers often received only a few days’ rest before being returned to the war zone.

In World War II, the shell shock diagnosis was replaced by Combat Stress Reaction, also known as “battle fatigue.”  Today’s Combat and Operational Stress Reaction diagnosis reflects serious reactions to a high-stress or combat-related event.  COSR is a normal, brief reaction – less than 72 hours – from which complete recovery is expected.  A PTSD diagnosis, however, requires that its symptoms last at least a month.

Some American military leaders, such as Lt. Gen. George S. Patton, did not believe “battle fatigue” was real. During World War II, Patton slapped two soldiers who had been hospitalized for battle fatigue, which he considered to be cowardice. Gen. Dwight D. Eisenhower urged Patton to apologize to all involved, and he did.

About Face-veteransCSR at first was treated using the “PIE” principles – proximity, immediacy and expectancy – which required treating casualties without delay and making sure its sufferers expected complete recovery so they could return to the battlefront after rest. After the war, the PIE concepts were changed over time to become “BICEPS” – brevity, immediacy, centrality/contact, expectancy, proximity, and simplicity.

In 1952, the American Psychiatric Association produced the first Diagnostic and Statistical Manual of Mental Disorders, which included “gross stress reaction.” This first DSM proposed the diagnosis for people who were relatively normal, but had symptoms from experiences such as disaster or combat. A problem was that it was a passing reaction. If it didn’t resolve in six months, another diagnosis had to be made. Paradoxically, despite growing evidence that trauma exposure was associated with psychiatric problems, this diagnosis was eliminated in DSM-II.

In 1980, APA added PTSD to its DSM-III classification, which came from 1970s research involving returning Vietnam War Veterans and linkages between the trauma of war and those of civilian life. The PTSD diagnosis has filled an important gap in psychiatry in that its cause is outside the individual rather than a personal weakness.

The criteria for PTSD were revised in subsequent editions of the manual to reflect continuing research. One important finding, which was not clear at first, is that PTSD is relatively common. Recent data shows lifetime PTSD rates are 3.6 percent and 9.7 percent respectively among American men and women.

In the most recent edition, PTSD is no longer an anxiety disorder, because it is sometimes associated with other mood states – depression, for example – and with angry or reckless behavior rather than anxiety. PTSD is now in a new category, trauma and stressor-related disorders.

Today VA operates more than 200 specialized programs for the treatment of PTSD. In 2012, a total of 502,546 Veterans diagnosed with PTSD received treatment at VA medical centers and clinics.

VA is committed to provide the most effective, evidence-based care for PTSD. It has implemented major programs to ensure that VA clinicians receive training in state-of-the-art treatments for PTSD. As of the end of 2012, VA had trained more than 4,700 of its clinicians in the use of such treatments.PTSD  information widget

VA’s National Center for PTSD was created in 1989 by an act of Congress. We continue to be at the forefront of progress in the scientific understanding and treatment of PTSD.  In addition to improving upon existing treatments, we are researching effective new treatments. We are also developing new educational products such as PTSD Coach Online, which can help people build valuable coping skills. For more information on the National Center for PTSD, please visit our website.

Dr. Matthew J. Friedman is Executive Director of the U.S. Department of Veterans Affairs National Center for PTSD and professor of psychiatry and of pharmacology and toxicology at the Geisel School of Medicine at Dartmouth. He has worked with PTSD patients as a clinician and researcher for more than 35 years. Dr. Friedman has published extensively on stress and PTSD, biological psychiatry, psychopharmacology, and clinical outcome studies on depression, anxiety, schizophrenia, and chemical dependency. He has more than 200 publications, including 23 books and monographs.

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11 Comments to “PTSD from Armistice Day to DSM-5”

  1. Norman Decker, M.D. says:

    Helpful and comprehensive review. However there are biological and experiential factors worth mentioning. A history of early life extensive trauma increases vulnerability to major stressors such as combat. Resilience is diminished and frequency of diagnosable PTSD is greater in such individuals. Genetic predisposition also has an influence on vulnerability, resilience and illness frequency.

  2. John Ensch says:

    It would be helpful if the VA used some sort of reasonable testing when a PTSD veteran comes for his disability final review. Instead of asking if the veteran is wanting to kill people. Which is what I was asked when I went to the Bay Pines VA for my final review.

  3. Can a veteran be diagnosed with two mental disorders, such as anxiety disorder (nos) and ptsd???

    Thanks

  4. Gerry H. says:

    Have you written any books on spousal PTSD? Have you ever considered spousal PTSD caused from the military mate with PTSD?

  5. Dr. Don Lynch says:

    Thank you Dr. Friedman for your historical overview of the PTSD diagnosis. Your readers might be interested to know that the documentation of many of the symptoms related to the disorder went back even before Armistice Day, all the way to the American Civil War. At that time, post traumatic stress-related symptoms were known in the military, colloquially, as “Soldier’s Heart”.
    Sincerely,
    Don

    Dr. Don Lynch
    Professor of Psychology
    Unity College

  6. Don says:

    I am deeply grateful that the VA, DSM, and the American public in general, have now identified and accepted the fact that PTSD is real, and that it is not a result of weakness, cowardice, or emotional instability, as has often been the case in the past.

    I served in Vietnam as a Casualty Officer from April, 1968 until February, 1969, when I was med-evaced from Camrahn Bay to Wilford Hall USAF Hospital. My initial diagnosis was “Psycho Neurotic Depressive Reaction”, whatever that means, and I was medically retired, then discharged.

    For a while, I seemed to be doing better, but the constant nightmares, the depression, the startle response, were all totally unnatural for me, and I began trying to escape the memories in alcohol and drugs. For those of us who have travelled that road, we know how that works. Finally, in 1981, while working for the VA, I met two counselors who worked at the local Vet Center, and they were the first to identify why I was acting and reacting the way I did.

    Through their intervention, a lot of Psychiatric help, and fellowship in both AA and NA, I have taken my life back, and have become a productive human being. The nightmares still occasionally wake me, and firecrackers scare the crap out of me, but that’s okay now, because I know why, and know that I do have some control over my reactions.

    I am in the process of devoting my time to taking 12 step meetings to our local VA Substance Abuse vets, as sort of a pay back for the guys who helped me. And besides, helping another alcoholic or drug addict assures me that I too have a chance at continued recovery.

    Thanks for this website, and all the information you provide.

    Don

  7. Michael J Hennessey says:

    Thank you!

    A good article. There is so much that has been discovered about Combat PTSD.
    I am fortunate that I had great people in and out of the Va when my problems became to much to bear.

    I am still here because of the number of people willing to walk with me through the fire and hold me up. Most of all my wife of 44 years.

    Michael

    • richard says:

      I have had this stuff since at least my first major infantry battle 11-29-68. I did 2 tours in Nam as an infantryman, with lots of fighting involved, lots of soldiers killed throughout that time.I walked around with this sfutff for at lease 30 years, before I was diagnosed in 1999 by VA at 30% and had to fight to get 50% for VA missing a critical point in my condition. I am still fighting to get rated for hiatal hernia and GERD secondary to PTSD, and staff doctors just think it is a joke becasue so many civilians have it.
      One more try at this rating before my time is up here on earth. VA has done some good for many but there is still alot more unfinished or ignored.
      VA needs advocates, not impediments for truly disabled vets, especially Viet nam vets who got nothing for a long, long time.

  8. Carl burgess says:

    Thank You for the article Dr.Matt Freeman. I’am a Vietnam Vet(Combat)).With PTSD. I been thru programs, however it created more problems!”1989″ When Va. National Center PTSD was created and added 4,700 clinicians, How many were Veterans? I had a hard time talking to the social workers about my problems. They were opening up Pandor’s box, Became to forceful,.44 years have gone by with Veterans coping on our own, Rejection from Govt,society and VA.Has deepen our problems.The programs needs Combat Veterans clinicians.So, we can relate.

  9. Jay Daniels says:

    Thank you for all the PTSD information in this article! I wasn’t aware of most of what you wrote. It looks like I have a lot of studying to do. That’s because my brother came home from Afghanistan in June with PTSD and he is having a tough time re-adjusting as well as getting help. He needs counseling but he says he doesn’t. He goes from angry to depressed and back to angry almost every day. The PTSD Coach site looks like a good resource to start with. Our family is really happy to see all the effort being put into helping vets who have PTSD. How do we get our loved ones into some kind of VA counseling service. I think that’s where we should start.

  10. Todd Saddler says:

    This all sucks. I wrote all this stuff and submit and it erased everything. I don’t fee; ;lile type ingain I ag