Sunday, April 26, 2015

"Soldier's Heart" and "Shell Shock": Past Names for PTSD


PTSD is a relatively new diagnosis, but Post-Traumatic Stress Disorder has been observed throughout decades of warfare. Here, tracing the history and our growing understanding of how the disorder affects soldiers is Matthew Friedman, executive director of the VA's National Center for PTSD. These excerpts are from extended FRONTLINE interviews.

Dr. Matthew Friedman
Exec. Dir., VA National Center for Post-Traumatic Stress Disorder

…Can you talk about the term "Soldier's Heart" and how it connects to our understanding today about what is PTSD?

The term "Soldier's Heart" was first coined in the post-Civil War era when people were looking at these veterans returning from Civil War combat and trying to understand why they had been changed, because there was general recognition that they had been changed, and that many of those changes were not for the good. [And back then] there were two different models trying to explain this. One was a psychological model, and the other model was a physiological model.

Soldier's Heart comes from the physiological model, the observations that people's cardiovascular system in terms of their heart dynamics, their blood pressure, a pulse rate, seemed to be altered. We can now incorporate that under the PTSD construct, but starting with Soldier's Heart, Irritable Heart ... it was [Jacob Mendez] Da Costa, who I believe was a 19th-century cardiologist, who made these observations.

Then, in World War I, another physical explanation was shell shock, the notion being that being close to the big guns pounding out the artillery on both sides of the barbed wire in the trench warfare was somehow disrupting neuronal connections, so nerves were actually affected. Combat exhaustion, combat fatigue -- all of these are physical types of manifestations. Following the Gulf War, some people felt that the unexplained medical symptoms [were] on a continuum going back to Soldier's Heart, as you've asked.

The parallel trajectory is about the psychological models. And in the Civil War, it was very interesting; the psychological model was nostalgia. The notion was that a Vermonter who found himself with Sherman marching through Georgia who exhibited psychological symptoms was doing so because he was nostalgic for being back in Vermont. Being in this alien Georgia terrain was somehow psychologically so disconcerting that he was having these kinds of symptoms. So this was another model under the influence of the Freudian psychoanalytic school. This got transformed into notions of traumatic neurosis and on and on.

And what's really interesting about PTSD is that it incorporates both the physical manifestations -- and certainly our research has shown that people with PTSD have alterations in their physiology and even are at risk for medical problems as well as psychological problems -- and it incorporates, of course, the psychological symptoms. The first person who really discovered this was an American psychoanalyst [Abraham Kardiner] working with World War I veterans. ... And what he observed, in addition to the psychological distress that they were manifesting and that he was diagnosing as traumatic neurosis -- which was the term that was used for these symptoms in those days -- he also noticed that they were physiologically altered. Particularly he noticed that they were very jumpy, that unexpected loud noises would produce in them a startled reaction …

Tell me about the breakthrough concerning understanding how the mind and body connect.

Well, you know, this mind-body dualism that has infected medical thinking for centuries, since Descartes, if you will, is the notion that what happens in the mind doesn't affect the body. And hopefully everybody now recognizes that we're talking about the brain, and the brain is a part of the body. And it also is the part of the body that produces the phenomenology that we also talk about as mind.

And I'd say in the last 10, maybe 15 years, there has been extraordinary progress. And I'm proud to say that the National Center for PTSD has been at the forefront of this progress, showing that people with PTSD have alterations in certain structures of the brain. And they have alterations in how the brain processes information, particularly how it processes information perceived to be dangerous or information that might be reminiscent of a tour in Iraq or of other traumatic situations. So this really is becoming much clearer now in terms of why both the body and the brain are affected in people with PTSD and other post-traumatic problems.


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