Historical Overview of Post Traumatic Stress Disorder by Judith Herman, MD

1. The PTSD Diagnosis: Past, Present, and Future
Judith L. Herman, M.D.

2. Part 1: Studies on Hysteria
(Late 19th Century)

3. Hysteria as a Traumatic Disorder
I therefore put forward the thesis that at
the bottom of every case of hysteria there are one or more occurrences of premature sexual experience… which belong to the earliest years of childhood but which can be reproduced through the work of psycho- analysis… I believe this is an important finding, the discovery of a caput Nili in neuropathology.
S. Freud, The Aetiology of Hysteria, 1896

4. Studies on Hysteria come to a halt
“I am as isolated as you could wish me to be: The word has been given out to abandon me, and a void is forming around me.”
S. Freud, Letter to Wilhelm Fliess, 1896

5. Part 2: Studies on War
(20th Century)

6. World War I: Shell Shock

7. WWI: The Hysterical Neuroses of War
I was still mentally and nervously organized for War. Shells used to come bursting on my bed at midnight, even though Nancy shared it with me; strangers in the daytime would assume the faces of friends who had been killed. When strong enough to climb the hill behind Harlech and visit my favorite country, I could not help seeing it as a prospective battlefield.
Robert Graves, Goodbye to All That, 1929

8. WW II: The Traumatic Neuroses of War
[Traumatized soldiers] seem to suffer from chronic stimulation of the sympathetic nervous system…
The emergency psychological reactions of anxiety and…preparedness…have overlapped, and become not episodic, but almost continuous…Eventually the soldier is removed from the environment of stress.. …but the physiological phenomena persist, and are now maladaptive to a life of safety and security.
---Roy Grinker and John Spiegel: Men Under Stress, 1945

9. Vietnam War: “Post-Vietnam Syndrome”
…The real American casualties of the Vietnam War, at least in numbers, may well be those who see no psychiatrists and bear no psychiatric or medical labels yet are nonetheless plagued and diminished by numbed guilt…Their continuing struggle… may drive them to extreme acts of destruction and self-destruction—as in the many cases already reported…of seemingly purposeless violence, the significant number who stay on hard drugs or who...live in distraught withdrawal from fellow beings…Even a society bent on numbing cannot hide these casualties; we shall hear more and more of them bringing their bitter guilt and rage…back to a society already suffused with bitterness.
Robert Jay Lifton: Home from the War (1973)

10. Post-Vietnam: Official Recognition of Traumatic Disorders
•DSM-II (1968) Hysterical Neurosis
Dissociative Type
Conversion Type
•DSM-III (1980) Post-Traumatic Stress Disorder
•DSM-IV (1994) PTSD + “associated features”
•DSM-V (2012) A Trauma Spectrum?

11. Diagnostic Criteria for Posttraumatic Stress Disorder (DSM-IV, 1994)
•The person has been exposed to a traumatic event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and
•The person’s response involved intense fear, helplessness, or horror.

12. Diagnostic Criteria for Posttraumatic Stress Disorder (DSM-IV, 1994)
•The traumatic event is persistently
re-experienced in recurrent, intrusive images, thoughts, recollections, or dreams.
•Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness.
•Persistent symptoms of increased arousal (difficulty falling or staying asleep, difficulty concentrating, irritability, hypervigilance, exaggerated startle response.

13. Lifetime Exposure to Traumatic Events Kessler, et al, 1995 (N=5877)
Type of Event
Men (%)
Women (%)
Saw Someone Seriously Injured or Killed
36
15
Accident
25
14
Flood, Fire or Disaster
19
15
Threatened with Weapon, Held Captive or Kidnapped
19
7
Physical Assault
11
7
Combat
6
0
Molestation
3
12
Rape
1
9
Any Event
61
51

14. Lifetime Prevalence of PTSD (Kessler et al, 1995)
Men
5.0%
Women
10.4%
Total
7.8%

15. Part 3: Learning from Women (Late 20th Century)
•First Speakout on Rape
(NY Radical Feminists,1971)
•“Rape Trauma Syndrome”
(Burgess & Holmstrom, 1973)
•The Battered Woman (Walker, 1979)
•Father-Daughter Incest (Herman, 1981)

20. Shame and PTSD (Andrews et al, 2000) N=157
•Victims interviewed 1 & 6 mo. post crime
•Shame at 1 mo. predicted PTSD at 6 mo
•Content of shame responses:
•Feelings of defeat (failure to take effective action)
•Feeling exposed in eyes of others
•Feeling ashamed of emotional reactions
•Feelings of humiliation

21. Part 5: Trauma in the 21st Century

22. Home Fires: American Veterans on the Post-War Life
Those of us with PTSD—I’m one of them—feel like strangers here, carrying around a burden many people are unaware of or just can’t understand…. Throughout history, warriors have been taught not to speak of their emotional struggles. Earlier generations of American veterans mostly suffered in silence. That tradition can change. We can share our experiences…so that this generation of soldiers can let others know…without embarrassment or shame. So that when the worlds of the soldier and the civilian meet, they’ll come together, not collide.”
–Michael Jernigan. New York Times, October 26, 2009.

23. “Bringing the War Back Home” Mental Health Disorders Among 103,788 US Veterans Returning from Iraq and Afghanistan Seen at VA Facilities (Seal et al, 2007)
•25 % received mental health diagnoses
•13 % were diagnosed with PTSD

24. Perceived Barriers to Seeking Mental Health Services Among Soldiers and Marines (Hoge et al, 2004) N= 731 respondents who met screening criteria for a mental disorder
•It would be too embarrassing (41%)
•It would harm my career (50%)
•Members of my unit might have less confidence in me (59%)
•My unit leadership might treat me differently (63%)
•I would be seen as weak (65%)

25. A “Mental Health Summit”
“Who is vulnerable? Everyone. Warriors suffer from emotional injuries just as they do physical ones….More veterans have committed suicide since 2001 than have been lost to combat deaths in Iraq and Afghanistan”
-Erik Shinseki, Secretary of Veterans’ Affairs, October 25, 2009

26. Child Sexual Abuse: The role of race, class, and social ecology
Families are creatures of social systems, and the state of these systems is critical to family well-being and child safety. Rates of abuse fluctuate. We do not know the reasons…in all cases, but in some instances we do.
A 1996 study…in Harlem found that rates of childhood abuse were 3 times higher for men and 2.5 times higher for women than the national averages. Harlem was a poor neighborhood that had suffered from redlining, urban renewal, and planned shrinkage, leading to massive destruction of the area’s built environment and serial displacement of its population. This environmental upheaval had truncated social networks, disrupted family functioning, and added many social burdens to people with few resources.
–Mindy Thompson Fullilove, Toxic Sequelae of Child Sexual Abuse.
American Journal of Psychiatry 2009

27. Learning from Women in the 21st Century
Traditional patriarchy has slowly but systematically been ruptured at different paces in various parts of the world. Applying a human rights perspective to violence has created a momentum for breaking the silence around violence, and for connecting the diverse struggles across the globe. Today, a life free of violence is increasingly accepted as an entitlement rather than merely a humanitarian concern….The agenda for the elimination of violence against women is not about victimization, but rather about the empowerment of women.
--Yakin Ertürk, 15 YEARS OF THE UNITED NATIONS SPECIAL RAPPORTEUR ON VIOLENCE AGAINST WOMEN (1994-2009)—A CRITICAL REVIEW