Posttraumatic Stress: Historical context

1. Posttraumatic Stress: Historical context • German neurologist, Herman Oppenheim (1889) was the first to use the term traumatic neurosis. He proposed that functional problems in the soldiers he examined were produced by subtle molecular changes in the central nervous system. • The frequent occurrence of cardiovascular symptoms in soldiers, and others who experienced accidents or other trauma, started a long tradition of associating posttraumatic problems with such diagnoses as cardiac neurosis and soldiers heart (DaCosta, 1871; Myers, 1870).

2. Dr. J. DaCosta described the ‘irritable heart’ in American Civil War soldiers, which included physical symptoms such as palpitations, chest pain which greatly increased on exertion, rapid pulse, shortness of breath, and gastrointestinal symptoms, especially diarrhea. DaCosta listed nervous symptoms, which included headaches dizziness, disturbed sleep, jerking movements during sleep and unpleasant dreams, although he placed very little emphasis on emotional sequelae (Kinzie & Goetz, 1996).

3. WW1 This link between the effects of soldiers’ war experience and circulatory system deficits continued during World War I (WWI), when soldiers were diagnosed with disorderly action of the heart or neurocirulatory asthenia (Merskey, 1991). I It was reported that 80,000 men were discharged from the army in WWI due to soldier’s heart, or effort syndrome as it became known (Culpin, 1930).

4. Charles Samuel Myers (1915), a British psychiatrist was the first to use the term shell shock in the medical literature. Shell shock was believed to be related to factors such as molecular commotion in the brain, yet physicians were further challenged by the fact that even soldiers who had not experienced direct shell fire also suffered from the same constellation of symptoms, including anxiety and sleep disturbance.

5. WWII • During World War II (WWII), doctors found it extremely difficult to distinguish shell shock from cowardice, especially since ascribing an organic origin to traumatic neuroses was particularly important in combat soldiers. • Despite this diagnostic dilemma, more than 200 British soldiers were executed for cowardice during WWII, and an astounding 20,000 more were condemned to death for cowardice, but were never executed (van derKolk et al., 1996). • The tragedy of collective professional denial of the suffering of these men and women remains a crucial turning point in the history of trauma in psychiatric medicine.

6. Trauma as ‘Real’: A long Battle One of the most prominent features throughout the history of the field of trauma is the debate about whether or not post-war or post-disaster effects were organic, as discussed above, or whether there was a nervous or hysterical component, or even if there may be some combination of both.

7. As early as 1859, the French psychiatrist Briquet started to make the first connections between the symptoms of hysteria, including somatization and childhood histories of trauma. Briquet reported specific traumatic origins as the cause of their illnesses in 381 of the 501 patients that he studied (van derKolk et al., 1996). • Along with the first documentation in the literature of sexual abuse of children (Briquet, 1859) came the beginning of a long tradition of disbelieving that continues to this day with the debate about false memory syndrome, where childhood memories of abuse are considered false memories, perhaps induced by the therapist.

8. When Sigmund Freud visited Charcot at the Salpetriere at the end of 1885, he adopted many of Charcots ideas, including the notion that hysterical attacks were the recurrence of a traumatic psychical state which the patient has experienced earlier (van derKolk et al., 1996). • Freud (1925/1959) later recanted this belief and instead stated….

9. “I believed these stories [of childhood sexual trauma] and consequently supposed that I had discovered the roots of the subsequent neurosis in these experiences of sexual seduction in childhood. If the reader feels inclined to shake his head at my credulity, I cannot altogether blame him...I was at last obliged to recognize that these scenes of seduction had never taken place, and that they were only fantasies which my patients had made up. “ (p. 34)

10. Believing Trauma’s origins… • Pierre Janet (1889) was also inspired by Charcots work to continue investigation of processes involved in the transformation of traumatic experiences into psychopathology, and the notion of dissociation. Janet spent his life making meticulous clinical observations on hundreds of patients with a wide variety of seemingly unrelated symptoms. • Based on his observations, he described the syndrome of hysteria in which the primary mode of adaptation is the dissociation of feelings or memories related to frightening experiences, which results in a narrowing of consciousness. Janets work on sensory perception, mental integration, memory storage and trauma anticipated many of our current understandings of human response to overwhelming trauma (van derKolk & van derHart, 1989).

11. The Viet Nam War….where everything changed

13. “In the Vietnam war, the lessons of WWI and WWII were forgotten yet again, and this time with the active assistance of the mental health profession. The unpopularity of the war, the fact that a good proportion of the soldiers who fought it were from lower socioeconomic strata while better off youngsters managed to evade the draft, and the acknowledged participation of some of the soldiers in shameful atrocities all rebounded on the trauma victims. “(Solomon, 1995, p. 272)

14. In 1968, just as large numbers of soldiers were beginning to return from Asia, the American Psychiatric Association (APA) completely and inexplicably removed stress reactions from its second edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-II (1968). • The first edition of the manual, DSM-I (1952), contained the diagnostic category ‘gross stress reaction’ and referred to combat as an example of possible causes (Solomon, 1995). The removal of stress reactions from the DSM-II had a profound effect on the attitudes and clinical judgment of mental health professionals who, as in current day clinical practice, tend to rely heavily on the diagnostic categories in the DSM. • One of the most problematic consequences of this reliance on diagnostic categories is that there is a tendency to believe that the categories themselves are somehow conclusive and representative of objective reality, rather than a historical reflection of ever changing societal beliefs and attitudes toward what constitutes mental illness.

15. The results of the removal of ‘stress reactions’ from the DSM in the late 1960s echoed in the experiences of trauma survivors for over a century: the seemingly relentless tendency of mental health professionals to disbelieve trauma stories and/or discount the possibility of traumatization, and thus attribute suffering to inherent personality weakness or pre-existing psychiatric illness.

16. Finally, after over a century of controversy, the third edition of the DSM (1980) included a detailed diagnostic guide for posttraumatic stress disorder (PTSD). In the DSM-III diagnosis, we finally begin to see the historical antecedents (Briquet, 1850; Charcot, 1887; Janet, 1889; Stierlin, 1911) of contemporary trauma literature. DSM-III criteria for PTSD included: • (1) exposure to a trauma; (2) re-experiencing the trauma in the form of dreams, flashbacks, intrusive memories, or unrest at being in situations that are reminiscent of the trauma; (3) avoidance behavior or a numbing of emotions and reduced interest in others and the outside world; and (4) physiological hyperarousal, as evidenced by insomnia, agitation, irritability or outbursts of rage.

17. Women, children and trauma… • The women’s movement, the civil rights movement…. Opening up discussion about the political and social context of trauma…

18. From 2000 to the end of 2006, the total of all U.S. military and law enforcement deaths—including accidents and suicides—was 4,588. The combined total of all Canadian military and law enforcement deaths in that period was 101. In that same seven years more than 8,000 women in the U.S. were shot, stabbed, strangled, burned, or beaten to death by the intimate males in their lives. .. While in Canada, over 500 women—five times more than Canadian soldiers and police officers—were killed by their current or former male partners. Even adding in all the victims of 9/11 to the U.S. law enforcement and military total, it’s still less than the number of women killed. (Vallee, 2007, Abstract)

19. PTSD: What are some of the characteristics? • Event(s) is persistently re-experienced… • There is persistent avoidance of stimuli associated with the trauma… • There are persistent experiences of increased arousal… • (also see DSM definition in text, p. 238)

20. PTSD: An introduction to trauma work • Therapeutic boundaries in the context of trauma work: • Containment • Believing • The wounded healer • The road to healing • Beginning with the fundamentals • Consciousness raising • Working with trauma material (maybe…)

21. Therapeutic containment in the context of trauma work Refers to the clinician’s therapeutic work in helping the client maintain their own boundaries regarding emotional and spiritual safety, especially in terms of processing trauma material, stories, memories. Does not mean silencing the client. • First: Therapeutic communication skills: listening (being there, mindfulness…), empathy… • Assessing the context of your interaction: • Is it relatively short term? (e.g. hours, days: the emergency department). • Is it medium term? (e.g. days, weeks: prenatal care • Is it long term (e.g weeks, years: long term cardiac care follow-up) • Knowing when to refer and having a thorough knowledge of referral options in your geographic area

22. Believing the trauma story, stories • Acknowledging societal silencing of trauma stories (e.g. historical denial of PTSD related to soldiers’ experiences in war; current lack of court and media attention to trauma perpetrators) • ‘Stopping the bus’: trauma survivors may feel safe to tell you their story in many different contexts (e.g. childbirth, addictions treatment, nursing home care). This is a time when clinicians take the time to acknowledge the story, yet help client maintain boundaries…

23. The wounded healer • The wounded healer is a clinician who has not had the opportunity ,or is not yet ready, to process their own trauma histories • The wounded healer may inadvertently cause further spiritual or emotional damage for the trauma survivor • As nurses and healers, it is important for us to do our own internal work…a tough sell in the context of biomedical dominance in the health fields

24. The road to healing from the perspective of the trauma survivor (Bass and Davis, 2009) • First: Healing is possible • Taking stock • Effects: Recognizing the damage • Honoring what you did to survive • The healing process • The decision to heal • The emergency stage • Remembering • Believing it happened • Breaking the silence • Understanding that it was not your fault

25. The healing process (cont’d) • Grieving and mourning • Anger • Forgiveness? • Spirituality • Resolution and moving on • The road to healing: More implications for nursing care(in addition to containment, believing, the wounded healer, beginning with fundamentals of self care) • Consciousness raising with the client and ourselves(e.g societal context of violence in working with women who have been, or are, in abusive relationships; societal context of war, as in Viet Nam war or war in Iraq; e.g. societal context in child abuse)