Shell Shock: The Response of UK Neurology.

The neurological and psychological manifestations of trauma, confinement, and terror became apparent throughout Europe as soldiers were evacuated from the trenches of the Western Front. The response in the UK evolved as a result of the experience of medical staff embedded with the troops in base hospitals and the philosophy of those treating returned soldiers in specialist establishment. There were widely disparate approaches to the management encompassing simple supportive care, a psychanalytic approach and radical electric shock therapy. The latter was partially driven by the Queen Square experience in the UK but was also concurrently widely pursued throughout Europe. With experience, care was increasingly undertaken close to the front lines using a philosophy of immediacy and expectation of recovery. Post-war analysis was startlingly unsympathetic, yet the experiences and management of shell shock have guided psychiatric and medical understanding of functional illness and post-traumatic stress over the subsequent century. In this historical review, we have sought to present features of the UK response to the neurological manifestations of trauma, the way in which these changed as the war proceeded and the political and medical response in the aftermath of war.

Functional neurology after the Second World War: The beginnings of neurology on screen (III).

Treatment of functional symptoms has a long history, and interventions were often used in soldiers returning from battle. On the 75th anniversary of the end of the Second World War, I review the portrayal of neurology in documentary film. Two documentaries were released in 1946 and 1948 (Let There Be Light and Shades of Gray, respectively), which showed a number of soldiers with functional neurology including paralysis, stuttering, muteness, and amnesia. The films showed successful treatments with hypnosis and sodium amytal by psychoanalytic psychiatrists. These documentaries link neurology with psychiatry and are remarkable examples of functional neurology and its treatment on screen.

Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart.

Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.

[Delayed Onset of PTSD - A Problem for Diagnosis and Litigation - with Special Reference to Political Imprisonment in the GDR]. / Der "verzögerte Beginn" einer Posttraumatischen Belastungsstörung (PTBS) ­ ein diagnostisches und gutachterliches Problem mit Bezug zur politischen Inhaftierung in der DDR.

More often than is generally assumed: according to 2 metaanalyses, an average of about 25% of all cases of PTSD are not definitively diagnosed with post-traumatic stress disorder (PTSD) until 6 months or more after their trauma. Its prevalence varies widely depending on the given population. Delayed onset PTSD is diagnosed in military personnel much more often than in the civilian population (38,2 vs. 15,3%) . The divergence in PTSD's prevalence numbers is attributed to differences in its definition, methodology, and target population, as well as the type of trauma. The longer the observation period, the more likely it is that the PTSD diagnosis will be delayed. Several influencing factors have been identified for its emergence and persistence. Some experts insist that "bridge symptoms" be defined when patients are diagnosed as suffering from delayed onset PTSD. Although frequent, they are not necessarily present. We discuss an example thereof provided by political prisoners in the former GDR exhibiting different courses of PTSD as well as its delayed-manifestation subtype.

We need to talk about Epizelus: 'PTSD' and the ancient world.

In the pursuit to offer validity and lineage to the modern diagnosis of post-traumatic stress disorder (PTSD), non-historical scholars often remove ancient episodes from their social context and retrospectively diagnose them based on our modern diagnostic criteria. This approach reinforces our pre-existing ideas, and form a confirmation bias that does not help to grow our understanding of these injuries. As this article argues, the use of ancient precedents would offer greater benefit to the psychological and medical profession when used to ask new questions rather than reiterate old answers. This article addresses the use of ancient history in the psychological disciplines, especially concerning the topic of post-traumatic stress, and its earlier categorisation as shell shock. Before assessing the non-historical scholarship for the use of ancient precedents, this article sets out the historical debate around the topic and the methodological issues involved in using PTSD as a model with which to examine the ancient world. After which, the use of ancient history by psychological and medical researchers examining PTSD will be assessed. In turn, it will be shown how the removal of historical context has allowed misunderstandings of the original texts and for historical errors to permeate. The story of Epizelus, a man who went blind in battle without incurring any injury, will be used as a case study to show how ancient history has been misused, and vital parts of his life story have been ignored because they do not fit the modern diagnostic model. In particular this article will show how ancient episodes have been used to justify modern ideas and modern understanding, and propose new therapies, without the necessary historical due diligence.

Are Drugs Always the Proper Solution to Therapeutic Dilemmas? Non-drug Approaches to the Post-traumatic Stress "Waking Corpse" Syndrome.

Jules Cotard (1840-1889), a Parisian neurologist, described a syndrome of delirium negations which was later named after him. Some physicians in antiquity and medieval times, especially in Asia, have noticed this syndrome and categorized it as a symptom of melancholy. They have presented it as a "walking corpse syndrome", inflicting most probably veteran soldiers after suffering during ferocious battles, presenting the first cases of a post war traumatic stress disorder. Philotimus (3rd-2nd century BC) was the first to record it around 3rd century BC, and proposed a simple but pioneering treatment, by just putting a lead hat on the men's heads. Although various combined treatment strategies were proposed by modern psychiatry including pharmaceutical, electroconvulsive therapy, behavioural therapy and supportive psychotherapy, it seems that in antiquity a simple external intervention of supportive therapy was the main concept of confrontation, while drug administration was to be avoided.

Posttraumatic stress symptoms in people exposed to the 2017 earthquakes in Mexico.

This is the first study to produce a reliable valid measure of the symptoms of Posttraumatic Stress Disorders (PTSD) in Mexico, which has a high incidence of disasters, and has not had a measurement of PTSD frequency in the population. The objective was to analyze the prevalence of PTSD symptoms in persons who experienced the 2017 earthquakes in Mexico. A probabilistic sample of 1539 participants from Mexico City, the State of Mexico, Chiapas, Puebla, Morelos and Oaxaca during November and December of 2017 was screened using the Davidson Trauma Scale (DTS) for symptoms of post-traumatic stress. The prevalence of PTSD symptoms was 34.6%, with greater effects on the inhabitants of Oaxaca, Morelos and Puebla, women, indigenous people and people who experienced damage to their homes (p = 0.001). The DTS had a moderate negative correlation with the RS-14 and a Cronbach's alpha coefficient of 0.957. The confirmatory factor analysis generated four factors that explain 50% of the variance, compatible with a Dysphoria model. We can conclude that one in three people exposed to earthquakes had symptoms of post-traumatic stress.

Charles Darwin's (1809-1882) illness - the role of post-traumatic stress disorder.

During most of his adult life, in counterpoint to his fame in describing the theory of evolution, Charles Darwin was chronically ill. He consulted many doctors with only limited and temporary success. His symptoms were many and varied. His doctors favoured dyspepsia or suppressed gout as the diagnosis. The Water Cure was only effective initially. Many diagnoses have been proposed by physicians since then. Perhaps he suffered from post-traumatic stress disorder (PTSD), not instead of but as well as other physical problems. His symptoms match with criteria for PTSD. Traumatic episodes from his life are considered in this paper: his mother's painful, sudden death from an acute abdominal event when he was eight; his reaction to seeing operations without anaesthetic; the deaths of three of his children, including his beloved daughter, Annie, aged ten; and being overwhelmed by his chronic, unrelenting symptoms. Trauma had not been conceptualised as a diagnosis in Darwin's time. Rather, hysteria and, in war, irritable heart were names given to what is now called PTSD.

"Not Only with Thy Hands, But Also with Thy Minds": Salvaging Psychologically Damaged Soldiers in the Second World War.

This essay breaks new ground in exploring the tensions in female nursing during the Second World War as the mental health needs of the injured were increasingly acknowledged. Advances in weaponry and transportation meant that the Second World War was a truly global war with mobile troops and enhanced capacity to maim and kill. A critical mass of female nursing sisters was posted to provide care for physical trauma, yet the nature of this uniquely modern war also required nurses to provide psychological support for troops readying for return to action. Most nursing sisters of the British Army had little or no mental health training, but there were trained male mental health nurses available. Publications of broadcasts by the Matron-in-Chief of the British Army Nursing Service detail the belief that the female nurse was the officer in charge of the ward when the patients had physical needs. However, that the nursing sister held this position when the patients' requirements were of a psychological nature was at times tested and contested. Through personal testimony and contemporary accounts in the nursing and medical press, this essay investigates how female nursing staff negotiated their position as the expert by the psychologically damaged combatants' bedside. The essay identifies the resourcefulness of nurses to ensure access to all patient groups and also their determination to move the boundaries of their professional work to support soldiers in need.

Dissociation debates: everything you know is wrong.

Controversy about dissociation and the dissociative disorders (DD) has existed since the beginning of modern psychiatry and psychology. Even among professionals, beliefs about dissociation/DD often are not based on the scientific literature. Multiple lines of evidence support a powerful relationship between dissociation/DD and psychological trauma, especially cumulative and/or early life trauma. Skeptics counter that dissociation produces fantasies of trauma, and that DD are artefactual conditions produced by iatrogenesis and/or socio-cultural factors. Almost no research or clinical data support this view. DD are common in general and clinical populations and represent a major underserved population with a substantial risk for suicidal and self-destructive behavior. Prospective treatment outcome studies of severely ill DD patients show significant improvement in symptoms including suicidal/self-destructive behaviors, with reductions in treatment cost. A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.

La controversia acerca de la disociación y de los trastornos disociativos (TD) ha existido desde el inicio de la psiquiatría y de la psicología modernas. Incluso entre los profesionales, las creencias sobre la disociación / TD a menudo no se basan en la literatura científica. Múltiples líneas de evidencia apoyan una relación poderosa entre disociación / TD y trauma psicológico, especialmente el trauma acumulativo y / o el que ocurre en la infancia. En oposición, los escépticos plantean que la disociación produce fantasías de trauma y que los TD constituyen condiciones artificiales producidas por la iatrogénesis y / o por factores socioculturales. Casi ninguna investigación o datos clínicos apoyan esta opinión. Los TD son comunes tanto en poblaciones generales como clínicas y representan un importante grupo desatendido que tiene un alto riesgo de comportamiento suicida y de conductas autodestructivas. Los estudios prospectivos de resultados del tratamiento de pacientes con TD grave muestran una mejoría significativa en los síntomas, incluídos los comportamientos suicidas / autodestructivos, con reducciones en el costo del tratamiento. Se requiere de un gran esfuerzo de salud pública para aumentar la conciencia acerca de la disociación / TD, incluyendo los esfuerzos educacionales en todos los programas de capacitación en salud mental y un mayor financiamiento para la investigación.

Les controverses au sujet de la dissociation et des troubles dissociatifs (TD) existent depuis les débuts de la psychologie et de la psychiatrie modernes. Même parmi les professionnels, les croyances au sujet de la dissociation et des TD sont rarement fondées sur la littérature scientifique. De nombreuses sources de données appuient la thèse d'une relation forte entre dissociation, TD et traumatisme psychologique, surtout quand celui-ci est cumulatif et/ou survenu dans l'enfance. Pour les sceptiques, la dissociation génère des traumatismes fictifs et les TD sont des maladies artificielles provoquées par des facteurs iatrogènes et/ou socioculturels. Pratiquement aucune donnée clinique ou de recherche ne vient conforter cette thèse. Les TD sont répandus dans la population générale et la population clinique, et touchent un nombre important de sujets sous-médicalisés pour lesquels le risque de suicide et de comportement auto-destructeur est élevé. Des études prospectives de résultats cliniques sur des patients sévèrement atteints de TD montrent une amélioration significative des symptômes, dont les comportements suicidaires et auto-destructeurs, avec une diminution des coûts de traitement. Un effort majeur de santé publique est nécessaire pour augmenter la vigilance sur la dissociation et les TD, y compris des efforts d'éducation dans tous les programmes de formation sur la santé mentale ainsi qu'une augmentation des fonds destinés à la recherche.

175 Years of Progress in PTSD Therapeutics: Learning From the Past.

Traumatic stressors have always been a part of the human experience. What is now referred to as posttraumatic stress disorder (PTSD) was first studied in the context of military trauma during the Civil War and World War I but most extensively in World War II. Much of what we know about the medical and psychological management of PTSD has its origins in military psychiatric approaches, and a review of these practices reveals important tenets that should be applied in current treatment for both military and nonmilitary PTSD. These practices include intervention as soon as possible after the traumatic exposure, provision for a safe and supportive therapeutic milieu designed for an individual's relatively rapid return to his or her responsibilities and normal activities, and using a combination of pharmacotherapy and psychotherapy (especially exposure to the traumatic memory). A review of current guidelines for treatment of PTSD reveals that few treatments are endorsed with great certainty, owing in large part to a paucity of clinical trials, particularly of pharmacotherapy. This shortcoming must be addressed to enable translation of promising discoveries in the neuroscience of fear into the therapeutic advances patients need and deserve. [AJP at 175: Remembering Our Past As We Envision Our Future March 1947: Psychiatric Experience in the War, 1941-1946 Brig. General William C. Menninger "Another observation which can be made as a result of our experience, is that if intensive treatment was provided early, in an environment in which the expectation of recovery prevailed, remarkable results were obtained." (Am J Psychiatry 1947; 103:577-586 )].

Healing a Sick World: Psychiatric Medicine and the Atomic Age.

The onset of nuclear warfare in Hiroshima and Nagasaki had far-reaching implications for the world of medicine. The study of the A-bomb and its implications led to the launching of new fields and avenues of research, most notably in genetics and radiation studies. Far less understood and under-studied was the impact of nuclear research on psychiatric medicine. Psychological research, however, was a major focus of post-war military and civilian research into the bomb. This research and the perceived revolutionary impact of atomic energy and warfare on society, this paper argues, played an important role in the global development of post-war psychiatry. Focusing on psychiatrists in North America, Japan and the United Nations, this paper examines the reaction of the profession to the nuclear age from the early post-war period to the mid 1960s. The way psychiatric medicine related to atomic issues, I argue, shifted significantly between the immediate post-war period and the 1960s. While the early post-war psychiatrists sought to help society deal with and adjust to the new nuclear reality, later psychiatrists moved towards a more radical position that sought to resist the establishment's efforts to normalise the bomb and nuclear energy. This shift had important consequences for research into the psychological trauma suffered by victims of nuclear warfare, which, ultimately, together with other research into the impact of war and systematic violence, led to our current understanding of Post-Traumatic Stress Disorder (PTSD).

The relationship between the First World War and neurology: 100 years of "Shell Shock".

The First World War was a global war, beginning on 28 July 1914, until 11 November 1918. Soon after the beginning of the war, there was an "epidemic" of neurological conversion symptoms. Soldiers on both sides started to present in large numbers with neurological symptoms, such as dizziness, tremor, paraplegia, tinnitus, amnesia, weakness, headache and mutism of psychosomatic origin. This condition was known as shell shock, or "war neurosis". Because medically unexplained symptoms remain a major challenge, and considering the close relationship of symptoms described in shell shock with clinical neurology, we should study their history in order to improve future care.

The relationship between the First World War and neurology: 100 years of "Shell Shock" / A relação entre a Primeira Guerra Mundial e a neurologia: 100 anos do "Shell Shock"

ABSTRACT The First World War was a global war, beginning on 28 July 1914, until 11 November 1918. Soon after the beginning of the war, there was an “epidemic” of neurological conversion symptoms. Soldiers on both sides started to present in large numbers with neurological symptoms, such as dizziness, tremor, paraplegia, tinnitus, amnesia, weakness, headache and mutism of psychosomatic origin. This condition was known as shell shock, or “war neurosis”. Because medically unexplained symptoms remain a major challenge, and considering the close relationship of symptoms described in shell shock with clinical neurology, we should study their history in order to improve future care.

RESUMO A Primeira Guerra Mundial foi uma guerra global, iniciada em 28 de julho de 1914, até 11 de novembro de 1918. Logo após o início da guerra, exatamente há 100 anos, houve uma “epidemia” de sintomas neurológicos conversivos. Soldados de ambos os lados começaram a apresentar com frequência sintomas neurológicos, tais como: tontura, tremor, paraplegia, zumbido, amnésia, fraqueza, cefaleia e mutismo de origem psicossomática. Esta condição ficou conhecida como shell shock, ou “neurose de guerra”. Como muitos sintomas e doenças inexplicadas continuam sendo um grande desafio, e considerando a estreita relação dos sintomas descritos no shell shock com a neurologia clínica, torna-se importante estudar essa parte da história com o objetivo de entendermos e melhorarmos os cuidados aos pacientes.

Long-term psychological outcomes of flood survivors of hard-hit areas of the 1998 Dongting Lake flood in China: Prevalence and risk factors.

BACKGROUND: Although numerous studies have indicated that exposure to natural disasters may increase survivors' risk of post-traumatic stress disorder (PTSD) and anxiety, studies focusing on the long-term psychological outcomes of flood survivors are limited. Thus, this study aimed to estimate the prevalence of PTSD and anxiety among flood survivors 17 years after the 1998 Dongting Lake flood and to identify the risk factors for PTSD and anxiety. METHODS: This cross-sectional study was conducted in December 2015, 17 years after the 1998 Dongting Lake flood. Survivors in hard-hit areas of the flood disaster were enrolled in this study using a stratified, systematic random sampling method. Well qualified investigators conducted face-to-face interviews with participants using the PTSD Checklist-Civilian version, the Zung Self-Rating Anxiety Scale, the Chinese version of the Social Support Rating Scale and the Revised Eysenck Personality Questionnaire-Short Scale for Chinese to assess PTSD, anxiety, social support and personality traits, respectively. Logistic regression analyses were used to identify factors associated with PTSD and anxiety. RESULTS: A total of 325 participants were recruited in this study, and the prevalence of PTSD and anxiety was 9.5% and 9.2%, respectively. Multivariable logistic regression analyses indicated that female sex, experiencing at least three flood-related stressors, having a low level of social support, and having the trait of emotional instability were risk factors for long-term adverse psychological outcomes among flood survivors after the disaster. CONCLUSIONS: PTSD and anxiety were common long-term adverse psychological outcomes among flood survivors. Early and effective psychological interventions for flood survivors are needed to prevent the development of PTSD and anxiety in the long run after a flood, especially for individuals who are female, experience at least three flood-related stressors, have a low level of social support and have the trait of emotional instability.

Senseless Violence Against Central American Unaccompanied Minors: Historical Background and Call for Help.

The southwestern U.S. border has recently seen a significant increase in the number of unaccompanied children from Honduras, Guatemala, and El Salvador illegally crossing the Mexican border into the United States. Many of these children leave home to flee violence, starvation, impoverished living conditions, or other life-threatening situations. The treatment of acute stress, anxiety, and depression associated with traumatic events is crucial in helping these children address these negative psychological events they have experienced so that they can move forward with their lives. Untreated, traumatic events experienced by this population can develop into Post Traumatic Stress Disorder, a potentially life-changing and physically threatening psychological and medical issue. The United States needs to effectively address the serious matter of responding to mental health issues facing refugees from war-torn or impoverished nations so as to help them to successfully adjust to American systems. There is a need for researchers in the mental health field to focus efforts in designing, implementing, and evaluating methodologies that can help these children develop healthy strategies for living with a very difficult and complex past.