The Evolving Conception of PTSD

Perhaps more than any other diagnostic category, PTSD is a vehicle for showing major historical changes in conceptions of mental illness. Examining the social evolution of PTSD provides an especially good way of showing how valuations of psychiatric diagnoses sharply change in different historical periods. Diagnoses of mental illness have typically been associated with negative consequences such as stigma, fear, shame, and guilt. In contrast, the conception of  PTSD as being rooted in some external source can potentially cast blame and responsibility on an outer entity and so diminish the sufferer’s own accountability. Doing so brings issues of responsibility, blame, liability, and secondary gains into particularly sharp focus.

PTSD only became a consequential form of mental illness when trauma victims could hold a specific party responsible for providing damages. In the nineteenth century, “railway spine” brought to the fore issues of compensation that have persisted throughout the history of PTSD. Several decades later, conceptions of “shell-shock” emerged during World War I that led to vigorous debates over whether afflicted soldiers were cowards who were afraid of carrying out their duties or victims of overwhelming amounts of fear with which they were unable to cope. The evolution of PTSD thus involved constant tensions between, on the one hand, the notion that external events traumatize blameless victims, and, on the other hand, the focus on personal susceptibilities or suspicions of malingering.

The diagnosis of PTSD that emerged in the DSM-III in 1980 was historically anomalous. It clearly attributed the causes of this condition to “an event that is outside the range of usual human experience.” Moreover, it severed the emergence of PTSD from individual characteristics, stating that the generating traumatic event “would be markedly distressing to almost anyone.” One of the most prominent advocates of this diagnosis, Chaim Shatan, emphasized the purely external nature of the DSM-III diagnosis: “After such massive manmade stress, preexisting disorder is irrelevant. The specific stress itself constitutes the crucial predisposition.”

The current acceptance of post-traumatic stress disorder as a legitimate psychiatric diagnosis thoroughly contrasts with its contentious history. Before a purely stressor-related diagnosis emerged in the DSM-III the credibility of PTSD sufferers was highly contested. Because the damage inflicted by PTSD is internal, it is impossible to verify; self-reports provide the only evidence of traumatic psychic wounds. Coupled with the singular benefits of a PTSD diagnosis, the unconfirmable aspect of its symptoms traditionally led to deep suspicions over claims of enduring traumatic memories. From their inception, stressor-related conditions were deeply embedded in moral, as well as medical, contentions. For example, a British committee formed in 1939 to investigate the problem of pensions for shell-shocked veterans concluded: “There can be no doubt that in the overwhelming proportion of cases, these patients succumb to ‘shock’ because they get something out of it. To give them this reward is not ultimately a benefit to them because it encourages the weaker tendencies in their character.”

By clearly grounding symptoms in severe traumatic events, the DSM diagnosis guaranteed the credibility of victims and ruled out the need to examine any preexisting biological or psychological vulnerabilities that made individuals prone to develop mental illness. It also dispensed with the consideration of character weaknesses, cowardice in particular, in accounting for mental breakdowns. It created the expectation that dire and enduring psychological consequences will develop after stressful events. This belief stands in stark opposition to the resistance that traumatic diagnoses faced from both the medical establishment and the general culture for most of their history. Freud, for example, doubted the lingering impact of war trauma: “When war conditions ceased to operate, the greater number of the neurotic disturbances brought about by the war simultaneously vanished.” Most clinicians traditionally assumed that time-limited techniques, which provided “an atmosphere of rest and assurance,” would lead most psychic injuries to heal fairly quickly. Prominent psychiatrist Abram Kardiner, referring to the victims of an Italian earthquake, observed that “most recovered within a few weeks, almost none remaining after six months.” Many observers, however, singled out one striking exception to the tendency for traumatic states to naturally dissipate over short periods of time: the provision of compensation.  

The current PTSD diagnosis, as Didier Fassin and Richard Rechtman note, “identifies complaints as justified and causes as just.” It has had the effect of facilitating compensation for afflicted individuals. As earlier observers might have predicted, more than 99 percent of veterans receiving disability payments for PTSD from the Veterans Administration do not improve in the following year. Paradoxically, the compassion and caring that marks the therapeutic mentality that generated the DSM diagnosis might facilitate lifelong disability instead of recovery.

Allan V. Horwitz is a Board of Governors and Distinguished Professor of Sociology at Rutgers University. He is the author of PTSD: A Short History.