SHELLEY ANNE C.

MARTINEZ
EARLY HISTORY
1678: Swiss military Physicians identify
‘Nostalgia’
 a condition characterized by melancholy,
incessant thinking of home, disturbed sleep or
insomnia, weakness, loss of appetite, anxiety,
cardiac palpitations, stupor, and fever
1700s: Dominique Jean Larrey,
a prominent French surgeon,
described the disorder as
having three stages:
1)heightened excitement and
imagination
2)period of fever and
prominent gastrointestinal
symptoms, and
3)frustration and depression
1855: Government Hospital for
the Insane was established in
Washington, DC.
Its role expanded during the
Civil War years when many
soldiers were left with
psychological wounds which
physicians were unsure of how
to treat.
1861-1865
U.S. military physicians document
the stresses of Civil War soldiers.
1871
Jacob Mendez Da Costa, a
cardiologist in the US, published a
study about “irritable heart” or
“soldier’s heart.” He observed that
afflicted soldiers differed in their
higher blood pressure and heart
rate.
1905
PTSD, then known as “battle shock,” was
regarded as a legitimate medical condition by
the Russian Army.
 The psychological distress of soldiers was
attributed to concussions caused by the
impact of shells; this impact was believed to
disrupt the brain and cause “shell shock” (
Bentley, 2005).
 Shell shock was characterized by “the dazed,
disoriented state many soldiers experienced
during combat or shortly thereafter” (
Scott, 1990, p. 296).
 1918: Scholars Smith and Pear advocated for
the term “war strain” instead of “shell
shock” and for treatment of soldiers’
emotional symptoms. The disturbances are
characterized by instability and exaggeration
of emotion rather than by ineffective or
impaired reason.
Cont…
The trigger for war strain was considered to be intense emotional
arousal and the subsequent suppression of sympathy for others, as
well as fear(Smith & Pear, 1918). 
Resulting symptoms were believed to include:

“loss of memory, insomnia, terrifying dreams, pains, emotional

instability, diminution of self-confidence and self-control, attacks of
unconsciousness or of changed consciousness sometimes accompanied
by convulsive movements resembling those characteristic of epileptic
fits, incapacity to understand any but the simplest matters,
obsessive thoughts, usually of the gloomiest and most painful kind,
even in some cases hallucinations and incipient delusions…[These
symptoms] make life for some of their victims a veritable hell” (Smith &
Pear, 1918, pp. 12-13).
 1919: Freud’s colleagues, Sandor Ferenczi, Karl
Abraham, Ernst Simmel, and Earnest Jones,
published a book about his theory of “war
neurosis” entitled “Psycho-Analysis and War
Neurosis” and Freud wrote the introduction.
 Freud explained his conceptualization of war
neuroses as brought about by conflicts between
soldiers’ “war egos” and “peace egos.”
 1920: Freud submitted a
memorandum entitled
“Memorandum on the Electrical
Treatment of War Neurotics” to
the Austrian War Ministry about
the rumored brutal treatment of
psychologically wounded
soldiers.

 Freud attested that war neurosis

had psychical causes that were
best treated with psychoanalysis
rather than electrical shock
treatment. 
 By the end of WWI:
 Psychiatrists believe that what was known as
“shell shock” was the result of emotional
problems rather than physical injury of the brain.
 Soldiers who were “weak” are believed to be
predisposed to this condition.
 Thus, the primary aim was the use of psychiatric
testing to screen our those believed would sustain
psychological casualties in war.
 1939-1945: Terminology changed from war
neurosis to “combat exhaustion” or “battle
fatigue” during WWII, and U.S. Army
adopted the official slogan, “Every man has 
his breaking point.”
 1945: Due to a shortage of psychiatrists, U.S.
Army created a training video for
unspecialized medical officers for the
treatment of combat exhaustion, including
administration of sodium pentothal (or other
barbiturates) and suggestive therapy (to help
soldiers recover from psychosomatic physical
complaints).
 1947: The U.S. Army released a documentary,
entitled Shades of Gray, about the causes and
treatment of mental illness during WWII.
 This documentary indicates the consensus at
that time that no one is immune to mental
illness, and that environmental factors play a
large role in the development of psychological
problems.
 Combat exhaustion was thought to encompass
such symptoms as hypervigilance, paranoia,
depression, loss of memory, and conversion.
 1946: The National Mental Health Act was
passed, which provided for the expansion of
mental health facilities, including Veterans
Affairs (VA) centers that would treat mental
health problems in veterans.
 1952: Creation of the first diagnostic manual
(DSM-I) by the American Psychiatric Association
(APA). The manual included the diagnosis for
“Gross stress reaction.”
 
 The DSM-I description of gross stress reaction
indicated that anyone exposed to trauma was
vulnerable to this disorder, even those without a
history of psychological problems. It also
described the disorder as a temporary reaction
which would be alleviated once the soldier was
removed from the stressful situation.
 1953: Harold Wolff proposed a
holistic model of stress based on an
evolutionary model.
 Man is further vulnerable… Since his adaptive
and protective capacities are limited, a man’s
response to many sorts of noxious agents and
threats may be similar, the form of the reaction
to any one agent depending more on the
individual’s nature and past experience than
upon the noxious agent evoking it. Moreover,
because of its magnitude and duration, the
adaptive-protective reaction may be far more
damaging to the individual than the effects of
noxious events per se.
1965: Each military battalion was provided
with officers trained to treat psychological
problems during the Vietnam war.
 1968: Gross stress reaction was
dropped from DSM-II for
unknown reasons. The APA
revised the title of the syndrome
to “transient situation
disturbances,” a label with a more
clearly negative term. Still, it was
not considered a disorder.
 1969: Pettera, Johnson, and Zimmer
conceptualized “Vietnam combat
reaction” as a more extreme form of combat
fatigue which was mostly seen in soldiers
nearing the end of their tours, and would
likely have long-term consequences
(Marlowe, 2000). 
 The Vietnam years did give rise to our current
conceptualization of PTSD.
 1972: Chaim Shatan, a psychiatrist and advocate
for Vietnam veterans, raised awareness about
the absence of a combat-related diagnosis in
DSM-II. He wrote about “post-Vietnam
syndrome” in the New York Times.
 1980: “Posttraumatic stress disorder” was added as
a mental disorder to DSM-III by the Task Force headed
by Nancy Andreasen.
 It also became the first disorder to include a
diagnostic criterion — a traumatic event — that was
entirely external to the individual and outside the
range of usual human experience. Examples of
traumatic events included rape, combat, accidents
and disasters. If the event was a “normal” one, such as
the loss of a job or divorce, the person’s reaction was
diagnosed as an adjustment disorder.
 1987: DSM-III-R dropped the requirement that stressors
be outside the range of normal human experience.
 2000: The DSM-IV-TR was released. The criteria was
broadened. It tightened the definition of a traumatic event
to something that is “extreme” and “life threatening.” It
also added several diagnostic specifiers, such as “acute,”
“chronic” and “delayed onset.”
 Intrusion, avoidance, and arousal symptoms are all present for
at least one month, and cause significant problems in
functioning.  The criteria indicate that the cause of the trauma is
outside of the individual, rather than the result of a weakness
inherent in the individual. The current criteria acknowledge
both psychological and biological components of the disorder.
 Notably, the DSM-IV-TR criteria indicate that
PTSD can arise even as a result of threat to the
physical integrity of another, leaving room for
“vicarious traumatization” or “secondary
traumatic stress.” That is, even individuals, such
as family members or helping professionals who
are exposed to the traumatic experiences of
others, can be susceptible to developing PTSD
symptoms themselves (Bride, Robinson, Yegidis,
& Figley, 2004).
 Treatment has evolved for this disorder and
used by the Veteran Affairs:
 Cognitive processing therapy
 Prolonged Exposure therapy

Also, psychotropic medications such as Zoloft

(sertraline) and Paxil (paroxetine) have been
approved by FDA
 2013: The DSM V was released in a massive
volume of 947 pages. PTSD is no longer
classified as an anxiety disorder. Instead, it is
included in a new chapter titled “Trauma- and
Stressor-Related Disorders.”
1. Criterion A: Exposure to Trauma
a. Subjective component to the definition of
trauma (Criterion A)
▪ Too inclusive in DSM-IV
▪ DSM-5 definition of trauma requires “actual or
immediate death, serious injury, or sexual violence.”
▪ DSM-5 clarified and narrowed the types of events that
qualify as “traumatic.”
 A DSM-IV/DSM-5 comparison study
conducted by Kilpatrick and colleagues using
highly structured self-report inventories
demonstrated that 60% of PTSD cases that
met DSM-IV but not proposed DSM-5 PTSD
criteria were excluded from the DSM-5
because the traumatic events involved only
non-violent deaths.
1. Criterion A: Exposure to Trauma
b. Need for a qualifying exposure to trauma
▪ DSM IV-TR did not specify whether witnessed exposures
had to be in person, or whether media reports could
constitute a witnessed exposure.
▪ DSM-5 clearly required the witnessing of trauma to
others to be “in person.”
1. Criterion A: Exposure to Trauma
Exposure through media is narrowed down in the
DSM-5.
  Using DSM-IV/-TR,
the nationwide
(US) incidence of
“probable PTSD”
related to the
disaster was thus
reported as 4% of
the population,
constituting an
estimated total
burden of 11 million
Media reports as trauma exposures in DSM-IV
cases.
1. Criterion A: Exposure to Trauma
c. Removal of subjective personal response to
trauma
 DSM-5 removed “intense fear, horror or
helplessness” added to criterion A in DSM-IV. The
personal response to trauma exposure, including
posttraumatic symptoms, needs to be separated
from the definition of trauma exposure for
conceptual clarity.
2. The Symptom Criteria
 Factor analytic research has demonstrated
substantial overlap of PTSD symptoms with
symptoms of other disorders (especially
depressive and anxiety disorders), inviting
criticism of the validity of PTSD as a distinct
disorder.
2. The Symptom Criteria
 Separation of avoidance symptoms (C) from
numbing symptoms (D)
▪ DSM-5 increased the number of symptom groups from 3 to 4
and the number of symptoms from 17 to 20. The DSM-5
symptom groups are intrusion, avoidance, negative alterations
in cognition and mood, and alterations in arousal and reactivity.

▪ With the reorganization, at least one avoidance symptom is

now required to meet diagnostic criteria in the DSM-5, in
contrast to DSM-IV/-TR which permitted a PTSD diagnosis
even if no avoidance symptoms were endorsed.
2. The Symptom Criteria
 Inclusion of reckless/self-destructive behavior
and negative emotional state
▪ Elsewhere it has been argued that inclusion of
reckless/self-destructive behavior, persistent
distorted cognitions, aggression toward others, and
emphasis on dissociation in DSM-5 have inserted
Cluster B personality features into PTSD, and that it
may reflect selection biases based on observations of
these features in specific subpopulations of PTSD,
such as patients receiving psychiatric treatment.
2. The Symptom Criteria
 Hoge and colleagues criticized that added
reckless/self-destructive behavior and negative
emotional state symptoms as non-specific to the
psychopathology of PTSD and the persistent distorted
cognitions symptom as over-pathologizing.
 History of PTSD. https://historyofptsd.wordpress.com.
Retrieved online [21 February 2018]

 Pai, A., Suris, A.M. & North, C.S. (2017). Posttraumatic

stress disorder in the DSM-5: Controversy, change and
conceptual considerations. Retrieved online from
www.mdpi.com/2076-328X/7/1/7/pdf [21 February 2018]