In 1972 I was living in a shabby brownstone near Dupont Circle in Washington, D.C., a sketchy neighbourhood back then. One morning as I was about to leave for my physiology class at George Washington University, I heard a hard knock on my apartment door. I opened it to find two young men staring straight at me with intense black eyes. I immediately recognized them as neighbourhood toughs who often hung out on the street.
Without a word, they pushed me back into my apartment. The taller man pointed a large black pistol at me and growled, “Give us all your money!” My brain froze, like a computer encountering a file too large to open.
“Hey! I said where is your goddamn money? ” he shouted, pressing the muzzle of the gun to my forehead.
“I don’t have anything,” I stammered. Wrong answer. The shorter man punched me in the face. The taller one smacked me on the side of my head with the gun. They shoved me into a chair. The shorter man began rummaging through my pockets while the taller man went into my bedroom and began yanking out drawers and ransacking closets. After a few minutes of searching, they cursed with frustration; apart from the television, a stereo, and 30 dollars in my wallet, they weren’t finding anything of value . . . but they hadn’t checked my dresser.
Tucked away in the top drawer beneath a stack of underwear was a jewelry box containing my grandfather’s Patek Philippe watch. I couldn’t imagine losing it. He had given it to me before he died as a gift to his firstborn grandchild, and it was my most treasured possession.
“What else do you got? We know you got more!” the taller man shouted as he waved the gun in front of my face.
Then, a peculiar thing happened. My churning fear abruptly dissipated. My mind became calm and alert, even hyperalert. Time seemed to slow down. Clear thoughts formed in my mind, like orderly commands from air traffic control: “Obey and comply. Do what you need to do to avoid getting shot.” Somehow, I believed that if I just kept my cool, I would escape with my life — and possibly the jewelry box, too.
“I don’t have anything,” I said calmly. “Take whatever you want, but I’m just a student, I don’t have anything.”
“What about your roommate?” the intruder spat, motioning toward the other bedroom. My roommate, a law student, was away at class.
“I don’t think he has much, but take everything . . . anything you want.” The taller man looked at me quizzically and tapped the gun against my shoulder a few times as if thinking. The two thugs looked at each other, then one abruptly yanked the thin gold chain off my neck. They hoisted up the television, stereo, and clock radio, and casually ambled out the front door.
At the time, the home invasion was the scariest experience of my life. You might expect that it shook me up, giving me nightmares or driving me to obsess about my personal safety. Surprisingly, no. After filing a useless report with the D.C. police, I went right on with my life. I didn’t move to a new neighbourhood. I didn’t have bad dreams. I didn’t ruminate over the intrusion.
Twelve years later, another dramatic event produced a very different reaction. I was living in an apartment on the 15th floor of a high-rise in Manhattan with my wife and 3-year-old son. It was early October and I needed to remove the heavy air conditioner unit from my son’s bedroom window and store it for the winter.
The unit was supported on the outside by a bracket screwed into the wall. I raised the window that pressed down onto the top of the air conditioner so I could lift the unit off the windowsill — a terrible mistake. The moment I lifted the window, the weight of the air conditioner tore the bracket from the outside wall.
The air conditioner began to tumble away from the building toward the usually busy sidewalk 15 floors below. The machine seemed to hurtle down through the sky in a kind of cinematic slow motion. I could do nothing but uselessly shriek, “Watch out!”
“Holy s–t!” the doorman yelped as he frantically leapt away. Miraculously, the air conditioner smashed onto the pavement, not people. Pedestrians on both sides of the street all whipped their heads in unison toward the crashing sound of impact, but, thankfully, nobody was hurt.
I had escaped a high-stakes situation once again — but this time I was shaken to the depths of my being. I couldn’t stop thinking about how stupid I was, how close I had come to hurting someone and ruining my life. I lost my appetite. I had trouble sleeping, and when I did I was plagued by graphic nightmares in which I painfully relived the air conditioner’s fateful plunge.
During the day I could not stop ruminating over the incident, playing it over and over in my mind like a video loop, each time re-experiencing my terror with vivid intensity. Even now, decades later, I can viscerally recall the fear and helplessness of those moments with little effort.
These are all classic symptoms of one of the most unusual and controversial of mental illnesses: post-traumatic stress disorder (PTSD). One thing that sets PTSD apart from just about every other mental illness is that its origin is clear-cut and unequivocal: PTSD is caused by traumatic experience.
Of the 265 diagnoses in the latest edition of the DSM (the Diagnostic and Statistical Manual of Mental Illness, the official compendium of disorders that U.S. mental health professionals use), all are defined without any reference to causes, except for substance-use disorders and PTSD.
While drug addiction is obviously due to an effect of the environment — the repeated administration of a chemical substance inducing neural changes — PTSD is the result of a psychological reaction to an event that produces lasting changes to a person’s mental state and behaviour. Before the event, a person appears mentally healthy. After the event, he is mentally wounded.
What is it about traumatic events that produce such intense and lasting effects? Why does trauma occur in some people and not in others? And how do we account for its seemingly unpredictable incidence — after all, it seems rather counterintuitive that dropping an air conditioner elicited PTSD-like effects, while a violent home invasion did not.
The unique nature and curious history of PTSD make it one of the most fascinating of all mental disorders. The story of PTSD encapsulates everything we’ve learned so far about psychiatry’s tumultuous past: the history of diagnosis, the history of treatment, the discovery of the brain, the influence and rejection of psychoanalysis, and the slow evolution sof society’s attitude toward psychiatrists, from open derision to grudging respect.
PTSD also represents one of the first times that psychiatry has achieved a reasonable understanding of how a mental disorder actually forms in the brain, even if our understanding is not yet complete.
The belated unriddling of PTSD commenced in a setting that was extremely inhospitable to the practice of psychiatry but extremely conducive to the generation of PTSD: the battlefield.
In 1862, acting assistant surgeon Jacob Mendez Da Costa was treating Union soldiers at Turner’s Lane Hospital in Philadelphia, one of the largest military hospitals in the States. He had never seen such carnage, gaping bayonet wounds and ragged limbs blown off by cannon fire.
In addition to observing the visible injuries, as he slowly worked his way through the casualties of the Peninsular campaign, Da Costa noticed that many soldiers seemed to exhibit unusual heart problems, particularly “a prompt and persistent tachycardia” — medical jargon for a racing heartbeat.
For example, Da Costa described a 21-year-old private, William C. of the 140th New York Volunteers, who sought treatment after suffering from diarrhea for three months and “had his attention drawn to his heart by attacks of palpitation, pain in the cardiac region, and difficulty in breathing at night.”
By the war’s end, Da Costa had seen more than 400 soldiers who exhibited the same peculiar and anomalous heart troubles, including many soldiers who had suffered no physical battlefield injuries at all. Da Costa attributed the condition to an “overactive heart damaged by ill use.” He reported his observations in the 1867 publication by the United States Sanitary Commission and named this putative syndrome “irritable and exhausted soldier’s heart.”
Da Costa did not believe that the condition he had identified was in any way psychological, and no other Civil War physician made a connection between soldier’s heart and the mental stress of warfare. In the official records of soldiers who refused to return to the front lines despite a lack of physical injury, the most common designations were “insanity” and “nostalgia” — that is, homesickness.
As bloody as the Civil War was, it paled in comparison to the mechanized horrors of World War I, the Great War. Heavy artillery rained down death from miles away. Machine guns ripped through entire platoons in seconds. Toxic gas scalded the skin and scorched the lungs. Incidents of soldier’s heart increased dramatically and were anointed by British doctors with a new appellation: shell shock, based on the presumed link between the symptoms and the explosion of artillery shells.
Physicians observed that men suffering from shell shock not only exhibited the rapid heart rate first documented by Da Costa but also endured “profuse sweating, muscle tension, tremulousness, cramps, nausea, vomiting, diarrhea, and involuntary defecation and urination” — not to mention blood-curdling nightmares.
In the memorable book A War of Nerves, by Ben Shepherd, British physician William Rivers describes a shell-shocked lieutenant rescued from a French battlefield:
He had gone out to seek a fellow officer and found his body blown to pieces with head and limbs lying separated from his trunk.
From that time he had been haunted at night by the vision of his dead and mutilated friend. When he slept he had night-mares in which his friend appeared, sometimes as he had seen him mangled in the field, sometimes in the still more terrifying aspect of one whose limbs and features had been eaten away by leprosy. The mutilated or leprous officer of the dream would come nearer and nearer until the patient suddenly awoke pouring with sweat and in a state of utmost terror.
Other symptoms of shell shock read like a blizzard of neurological dysfunction: bizarre gaits, paralysis, stammering, deafness, muteness, shaking, seizure-like fits, hallucinations, night terrors, and twitching.
These traumatized soldiers were shown no sympathy by their superiors. Instead, shell-shocked soldiers were castigated as “gutless yellow-bellies” who couldn’t stand up to the manly rigours of war. They were often punished by their officers, and occasionally executed for cowardice or desertion.
The first description of “wartime psychic trauma” in the medical literature was in a 1915 Lancet article written by two Cambridge University professors, psychologist Charles Myers and psychiatrist William Rivers. In the article, they adapted Freud’s new psychoanalytic theory to explain shell shock in terms of repressed memories from childhood that became unrepressed by war trauma, thereby producing neurotic conflicts that intruded upon conscious awareness.
To exorcise these neurotic memories, Rivers advocated the “power of the healer” (what Sigmund Freud called transference) to lead the patient to a more tolerable understanding of his experiences.
Freud himself testified as an expert witness in a trial of Austrian physicians accused of mistreating psychologically wounded soldiers, and concluded that shell shock was indeed a bona fide disorder, distinct from common neuroses, but that it could be treated with psychoanalysis. Soon, psychiatrists applied other treatments to shell-shocked soldiers, including hypnosis and hearty encouragement, reportedly with favourable results.
Still, there was nothing approaching consensus when it came to the nature or treatment of combat trauma.
While the horrors of the Great War were unprecedented, somehow World War II was even worse. Aerial bombardment, massive artillery, flamethrowers, grenades, claustrophobic submarines, and vicious landmines conspired with diabolical enhancements of World War I weaponry to produce even more frequent incidents of soldier’s heart, now dubbed battle fatigue, combat neurosis or combat exhaustion.
At first, the military believed that combat neurosis occurred only in cowards and psychological weaklings, and it began screening out recruits thought to possess deficiencies in their character; by these criteria over a million men were deemed unfit to fight because of perceived susceptibility to combat neurosis.
But the military brass was forced to revise its thinking when the psychological casualty rate was still 10 per cent of “mentally fit” soldiers. Moreover, some of these casualties were seasoned soldiers who had fought bravely.
The deluge of emotionally disabled soldiers compelled the military to reluctantly acknowledge the problem. In a startling reversal of attitude, the American army sought out the assistance of the shrinks who were just gaining prominence in civilian society.
At the start of World War I, there were no psychiatrists in the military. At the start of World War II, their presence in the American military was minimal: out of the 1,000 members of the Army Medical Corps in 1939, only 35 were so-called neuropsychiatrists, the military’s term for psychiatrists.
At the start of the war, the Office of the Surgeon General had two divisions: medicine and surgery. Now, because of need for more battlefield psychiatrists, a new division was added: neuropsychiatry. The first director of the new division was William C. Menninger, who would soon be assigned to produce the Medical 203, the direct forerunner of the DSM (whose editions are numbered 1 to 5, the most recent); he also became the first psychiatrist to hold the rank of brigadier general.
In 1943, 600 physicians from other specialties were trained in neuropsychiatry and 400 neuropsychiatrists were directly recruited into the army. By the war’s end, 2,400 army physicians had either been trained in neuropsychiatry or were neuropsychiatrists. A new role had been carved out for the psychiatrist: trauma physician.
Menninger’s Medical 203 included a detailed diagnosis of what was termed “combat exhaustion,” but instead of viewing the condition as a single disorder, the 203 broke it down into a variety of possible neuroses stemming from wartime stress, including “hysterical neuroses,” “anxiety neuroses,” and “reactive depression neuroses.” In 1945, the Department of Defense created a 50-minute film that trained military physicians in the nuances of combat exhaustion.
Despite its conspicuous psychoanalytic perspective, the training film takes a surprisingly progressive attitude toward the condition. It portrays a roomful of dubious military physicians who question the authenticity of combat exhaustion. One declares, “We’re going to be dealing with soldiers who are really shot up, we won’t have time to monkey around with guys like that.”
Then the instructor patiently explains to them that combat exhaustion can afflict even the most courageous and battle hardened of men and insists the condition is just as real and debilitating as a shrapnel wound.
Such a perspective was a striking turnaround for the military; it would have been simply unimaginable in World War I.
Even so, many officers still scoffed at the idea of combat exhaustion and continued to dismiss soldier’s heart as ordinary cowardice. During the Sicily campaign in 1943, General George Patton infamously visited wounded soldiers in an evacuation hospital when he came across a glassy-eyed soldier who didn’t have any visible injuries. He asked the man what was wrong.
“Combat exhaustion,” murmured the soldier.
Patton slapped him in the face and harangued him as a spineless malingerer. He issued an order that anyone who claimed they could not fight because of combat exhaustion should be court-martialed. To the military’s credit, Patton was reprimanded and ordered to apologize to the soldier by General Dwight D. Eisenhower.
Combat exhaustion turned out to be one of the few serious mental conditions that psychoanalytic treatment appeared to help. Psychoanalytical neuropsychiatrists encouraged traumatized soldiers to acknowledge their feelings and express them, rather than keeping them bottled up as military training and masculine self-discipline dictated.
They observed that soldiers who openly talked about their traumas tended to experience their battle fatigue less severely and recover faster. Today it is standard practice to provide empathic support to traumatized soldiers.
Military neuropsychiatrists’ apparent success in treating combat exhaustion with Freudian methods increased the self-confidence of military shrinks and motivated many to become proponents of psychoanalysis when they returned to civilian practice after the war, thereby aiding the Freudian conquest of American psychiatry.
Despite the small but meaningful advances in understanding the nature of psychological trauma, when World War II ended, psychiatry quickly lost interest. Combat exhaustion was not retained as a diagnosis but instead incorporated into a broad and vague category called “gross stress reaction” as part of DSM-I and then was omitted altogether from the DSM-II. Psychiatry’s attention did not return to the psychological effects of trauma until the national nightmare that was Vietnam.
The Vietnam War represented another major turning point in the American military’s relationship with psychiatry. Yet again, a new war somehow found ways of becoming even more horrific than its horrific predecessors — sheets of napalm fire rained down from the sky and sloughed the skin off children, familiar objects like pushcarts and boxes of candy became improvised explosive devices, captured American soldiers were tortured for years on end. The Vietnam War produced more cases of combat trauma than World War II. Why? Two opinions are commonly expressed.
One view is that the Greatest Generation was stronger and more stoic than the Baby Boomers who fought in Vietnam. They came of age during the Great Depression, when boys were taught to “keep a stiff upper lip” and “suck it up,” silently bearing their emotional pain.
But there’s another perspective I find more plausible. According to this explanation, veterans of World War II did sustain psychic consequences similar to those experienced by veterans of Vietnam, but society was simply not prepared to recognize the symptoms.
The Academy Award-winning 1946 film The Best Years of Our Lives portrayed the social readjustment challenges experienced by three servicemen returning from World War II. Each exhibits limited symptoms of PTSD. Fred is fired from his job after he loses his temper and hits a customer. Al has trouble relating to his wife and children; on his first night back from the war he wants to go to a bar to drink instead of staying home.
A little-known documentary produced by John Huston, the acclaimed director of The African Queen, and narrated by his father, Walter Huston, also depicted the psychological casualties of WWII. Let There Be Light follows 75 traumatized soldiers after they return home.
“Twenty per cent of our army casualties suffered psychoneurotic symptoms,” the narrator intones, “a sense of impending disaster, hopelessness, fear, and isolation.” The film was released in 1946 but was abruptly banned from distribution by the army on the purported grounds that it invaded the privacy of the soldiers involved. In reality, the army was worried about the film’s potentially demoralizing effects on recruitment.
Another reason proposed for the increased incidence of combat trauma in Vietnam was the ambiguous motivation behind the war. In World War II, America was preemptively attacked at Pearl Harbor and menaced by a genocidal maniac bent on world domination. Good and evil were sharply differentiated, and American soldiers went into combat to fight a well-defined enemy with clarity of purpose.
The Vietcong, in contrast, never threatened our country or people. They were ideological adversaries, merely advocating a system of government for their tiny, impoverished nation that was different from our own. Our government’s stated reason for fighting them was murky and shifting.
Ambiguity in a soldier’s motivation for killing an adversary seems to intensify feelings of guilt; it was easier to make peace with killing a genocidal Nazi storm trooper invading France than a Vietnamese farmer whose only crime was his preference for Communism.
When traumatized Vietnam veterans returned home, they were greeted by a hostile public and an almost complete absence of medical knowledge about their condition. Abandoned and scorned, these traumatized veterans found an unlikely champion for their cause.
Chaim Shatan was a Polish-born psychoanalyst who moved to New York City in 1949 and started a private practice. Shatan was a pacifist, and in 1967 he attended an antiwar rally where he met Robert Jay Lifton, a Yale psychiatrist who shared Shatan’s antiwar sentiments. The two men also discovered they shared something else in common: an interest in the psychological effects of war.
Lifton had spent years contemplating the nature of the emotional trauma endured by Hiroshima victims (eventually publishing his insightful analysis in the book Survivors of Hiroshima). Then, in the late ’60s, he was introduced to a veteran who had been present at the My Lai Massacre, a notorious incident where American soldiers slaughtered hundreds of unarmed Vietnamese civilians. Through this veteran, Lifton became involved with a group of Vietnam veterans who regularly got together to share their experiences with one another. They called these meetings “rap sessions.”
“These men were hurting and isolated,” Lifton recounts. “They didn’t have anybody else to talk to. The Veterans Administration was providing very little support, and civilians, including friends and family, couldn’t really understand. The only people who could relate to their experiences were other vets.”
Around 1970, Lifton invited his new friend Shatan to attend a rap session in New York. These veterans had witnessed or participated in unimaginable atrocities — some had been ordered to shoot women and children and even babies — and they described these gruesome events in graphic detail. Shatan realized that these rap sessions held the potential to illuminate the psychological effects of combat trauma.
“We came to realize just how amazingly neglected the study of trauma was in psychiatry,” Lifton remembers. “There was no meaningful understanding of trauma. I mean, this was a time when German biological psychiatrists were contesting their country’s restitution payments to Holocaust survivors, because they claimed that there had to be a ‘preexisting tendency towards illness’ which was responsible for any pathogenic effects.”
Working in these unstructured, egalitarian, and decidedly antiwar rap sessions, Shatan meticulously assembled a clinical picture of wartime trauma, a picture quite different from the prevailing view. On May 6, 1972, he published an article in the New York Times in which he described his findings for the first time, and added his own appellation to the conditions previously described as soldier’s heart, shell shock, battle fatigue, and combat neurosis: “Post-Vietnam Syndrome.”
In the article, Shatan wrote that Post-Vietnam Syndrome manifested itself fully after a veteran returned from Asia. The soldier would experience “growing apathy, cynicism, alienation, depression, mistrust and expectation of betrayal, as well as an inability to concentrate, insomnia, nightmares, restlessness, rootlessness, and impatience with almost any job or course of study.” Shatan identified a heavy moral component to veterans’ suffering, including guilt, revulsion, and self- punishment.
Shatan’s new clinical syndrome immediately became fodder for the polarized politics over the Vietnam War. Supporters of the war denied that combat had any psychiatric effects on soldiers at all, while opponents of the war embraced Post-Vietnam Syndrome and insisted it would cripple the military and overwhelm hospitals, leading to a national medical crisis.
Hawkish psychiatrists retorted that the DSM-II did not even recognize combat exhaustion; the Nixon administration began harassing Shatan and Lifton as antiwar activists, and the FBI monitored their mail. Dovish psychiatrists responded by wildly exaggerating the consequences of Post-Vietnam Syndrome and the potential for violence in its victims, a conviction that soon turned into a caricature of demented danger.
A 1975 Baltimore Sun headline referred to returning Vietnam veterans as “Time Bombs.” Four months later, the prominent New York Times columnist Tom Wicker told the story of a Vietnam veteran who slept with a gun under his pillow and shot his wife during a nightmare: “This is only one example of the serious but largely unnoticed problem of Post-Vietnam Syndrome.”
The image of the Vietnam vet as a “trip-wire killer” was seized upon by Hollywood. In Martin Scorsese’s 1976 film Taxi Driver, Robert De Niro is unable to distinguish between the New York present and his Vietnam past, driving him to murder. In the 1978 film Coming Home, Bruce Dern plays a traumatized vet, unable to readjust after returning to the States, who threatens to kill his wife (Jane Fonda) and his wife’s new paramour, a paraplegic vet played by Jon Voight, before finally killing himself.
While the public came to believe that many returning veterans needed psychiatric care, most veterans found little solace in shrinks, who tried to goad their patients into finding the source of their anguish within themselves. The rap sessions, on the other hand, became a powerful source of comfort and healing. Hearing the experiences of other men who were going through the same thing helped vets to make sense of their own pain and suffering.
The Veterans Administration eventually recognized the therapeutic benefits of the rap sessions and reached out to Shatan and Lifton to emulate their methods on a wider scale.
Shatan concluded that Post-Vietnam Syndrome, as a particular form of psychological trauma, was a legitimate mental illness — and should be formally acknowledged as such. Although the Vietnam War was raging in the late ’60s as the DSM-II was being assembled, no diagnosis specific to psychological trauma, let alone combat trauma, was included.
As had been the case with DSM-I, trauma-related symptoms were classified under a broad diagnostic rubric, “adjustment reaction to adult life.” Veterans who had watched children bayoneted and comrades burned alive were understandably outraged when informed that they had “a problem in adult adjustment.