Battle Fatigue and PTSD Diagnosis in the DSM-IV: A History of Post Traumatic Stress Disorder in the DSM

Post Traumatic Stress Disorder (PTSD) was first classified as a disorder in 1980 in the DSM-III, although versions of it were found in the earliest edition of the DSM. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is developed and revised periodically by the American Psychiatric Association and is used by mental health professionals to diagnose patients.

History of PTSD Diagnosis: Shell Shock and Battle Fatigue

References in writings dating back to the period before Christ can be found that reflect an understanding that trauma can affect an individual for years and years after the trauma has ended.

During the American Civil War what is now PTSD was referred to as “battle fatigue.” In the First World War it was known as “shell shock.” By the Second World War, soldiers who experienced symptoms of PTSD were judged as being weak. PTSD in that war was known as “combat neurosis,” or “traumatic neurosis” – names that reflect the stigma.

The DSM-I came out around the time of the Korean War. It included a condition called “gross stress reaction.” The DSM-II described a “transient situational disturbance.” During this time, medical and mental health professionals learned more about the condition and the stigma applied to the condition during World War II began to lift.

This was the first time it became understood that the symptoms were the body’s and the mind’s attempt to process the trauma: in other words, the disturbance was a function of normal bodily processes.

The DSM-III was in process after the Vietnam War. Critics of the diagnosis say that politics and anti-war sentiment influenced the formation of the PTSD diagnosis. This attitude is still prevalent, as some Iraq war veterans see PTSD as a Vietnam-era problem and have difficulty acknowledging their own symptoms.

At the same time as DSM-III was being developed, the women’s movement was speaking out about family violence and rape, and the traumas experienced by women and children. It began to be understood that not just war veterans but other trauma victims experienced the same or similar set of symptoms.

The cause of PTSD as described in the DSM-III includes a trauma beyond the range of normal that would be distressing for anyone who experienced it.

In DSM-IV a trauma is seen as an event that can cause death, serious injury or harm, but is not necessarily beyond the range of normal, as it is in DSM-III. The DSM-IV was revised (TR means "text revision") in 2000 and the revised version, known as DSM-IV TR is the manual that is currently in use. One of the changes redefined the concept of trauma in PTSD.

It is stipulated in DSM-IV TR that the event qualifies as a trauma if it inspires intense fear, helplessness or horror in the victim. This would include events not otherwise thought to cause PTSD. The reaction of the individual plays more of a role than the event itself.

The DSM-IV TR also added that the individual need not experience the event directly, but that witnessing it or being exposed in some other way, such as hearing about it, can also prompt the development of PTSD.

These changes reflect new understandings about trauma. For example, trauma response can be passed down through the generations, as is seen in children of holocaust survivors. Also, children who witness parental violence can have PTSD even if they are not the targets of the violence. Andt trauma can be relative depending on the reaction of the person experiencing it. Seemingly minor or “normal human events" can cause extreme trauma responses in some people, for example. Likewise, not all people exposed to war, for example, will develop PTSD.

It has long been known that trauma can cause negative psychiatric symptoms in an individual long after the trauma is over. Over time the understanding of this phenomena has evolved and changed, and it continues to do so. Once seen only as a war veteran’s problem, now it is understood that symptoms of PTSD can occur in many individuals in a variety of situations. DSM-V, due in May of 2012, will reflect the latest research on PTSD.

Jul 30, 2009 5:48 AM

Guest :

During the Civil War it was called "Soldier's Heart." Read Dr. Ed Tick's book "War and the Soul" for a very good explanation of the evolution of the terms.

Aug 14, 2009 4:31 PM

Guest :

By NO means should a victim of PTSD take SSRI's since these medications frequently make night terrors more vivid.
Also, some victims develop PTSD after having survived a series of extreme traumas with no permanent longterm effects. It may be that the old adage "what doesn't kill you makes you stronger" is folly; repeated extreme traumas can deplete one's resources to rebound, even in a personality that is quite strong and reliable. Also, if the trauma that breaks that person down is more personally important, and/or the victim is alone to deal with the repercussions of trauma, the damage may be permanent.
It doesn't make the victim more "likable" either, making the rebuilding of one's life and creating new relationships less and less likely - and leaving the victim even more alone - a vicious circle.
It is possible to reach a life alone, realistically hopeless.
There are no "mental health workers" who understand this.
There are no treatments but the kindness, commitment to a relationship, and ongoing encouragement. Those treatments do not exist in "professional" relationships.
There are no pills that stave off night- or day- terrors.
This is as normal reaction to horrific experience. It is not mental illness. But the person who cannot hide the terror is shunned, not protected, and there is no place to go, no one to call for those who never had substance abuse or acting out reactions, who kept trying to rebuild their lives, only to face the distaste and shunning of others to their lack of "helping themselves" and "not following advice."
Victims of PTSD can't survive and get through it alone.
And PTSD practically insures you are going to become alone.

Aug 15, 2009 8:25 AM

Lisa C. DeLuca :

The guest on Aug. 14th speaks compellingly about the plight of the person who is suffering with PTSD. The guest hints that unconditional love and acceptance is what ultimately heals people, or at least helps them get by the best they can, and this point is very valid. Though the guest may not have found this in a professional relationship, I have seen that such love and acceptance can often be found in a professional relationship, and also in surprising places. (I am speaking of human love, not romantic love.) I encourage anyone who feels isolated and alone and desperate to reach out for help in any way they can, even in the face of hopelessness, whether it's to helping professionals, teachers, neighbors, churches, friends or strangers. Feelings of hopelessness and defeat can certainly be justified, but hope can be re-born in an instant when that connection is made.