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.

CSR 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.

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.