Medical Matters: Psychiatric legacies of the horrors of war

“The real horrors of war were

to be seen in the hospitals,

not on the battlefield." Lieut John Glubb, 1917

The 100th anniversary of the first World War was marked this month by a series of papers in The Lancet. Among the topics was World War 1 and the birth of military psychiatry, which looked in some detail at shellshock and its relationship to what we now call post traumatic stress disorder (PTSD).

Unprecedented in terms of its scale and the suffering experienced by combatants, some three-quarters of a million British soldiers alone died in the Great War. Psychiatric casualties, which were known at the time by various labels including shellshock, disordered action of the heart, and neurasthenia, may have accounted for a quarter of combat- related hospital admissions.

The term shellshock was coined by psychiatrist Charles Myers in 1915. At the time the sudden increase in troops who were shivering and crying involuntarily was thought to be because soldiers were reacting to the loud explosions of new kinds of ammunition and bombs, or to the air pressure from explosions.

Myers identified a constellation of physical symptoms, including exhaustion, palpitations, shortness of breath, tremor, joint and muscle pain, dizziness and headache. Victims of shellshock also developed nightmares, persistent anxiety and difficulty sleeping. However, throughout the first World War, soldiers with shellshock were shot for cowardice, reflecting widespread scepticism among generals about the existence of the condition.

The authors of The Lancet paper, from King's College London, do not agree with the view that the Great War ushered in an era of psychological enlightenment. Despite the recommendations made after the war, including the training of military psychiatrists and a more careful selection of recruits, it wasn't until the end of the second World War that it was accepted that every man had his breaking point.

American psychiatrists estimates of when this point was reached varied between 100 days and a full year of battle exposure.

As one expert noted, “Instead of interpreting mental breakdown as the more or less inevitable result of predisposition, military psychiatrists now viewed it as resulting from the extraordinary stress of warfare on normal, well-adjusted soldiers.”

The Vietnam War was a significant trigger in linking PTSD and shellshock. Our knowledge of the neurobiology of PTSD has been helped by advances in neuro-imaging and neurophysiology. An almond-shaped structure in the brain called the amygdala receives information about external stimuli which, in turn, triggers emotional responses including our “fight or flight” response. Other areas of the brain – the hippocampus and medial prefrontal cortex – influence the response of the amygdala in determining the final fear reaction.

A current theory is that PTSD represents a failure of medial prefrontal and anterior cingulate networks to regulate the activity of the amygdala, which results in hyper-reactivity to threat. This causes a spike in stress hormones; it has been suggested that this initial surge of chemicals may be associated with the consolidation of traumatic memories.

The Lancet authors maintain that while shellshock had some features in common with PTSD, it was not the same disorder. "Responses to terrifying events or protracted exposure to stress during World War 1 were far more varied than the constellation of symptoms associated with PTSD.

“Some soldiers and veterans presented with disordered action of the heart, which was characterised by chest pain, palpitations and shortness of breath, but with no sign of cardiac disease; others had photophobia and had to wear dark glasses for the remainder of their lives, but did not have detectable optic lesions,” they note.

One conclusion is that PTSD and shellshock are both the same and different. Shellshock, while the intellectual forerunner to PTSD, was specific to the experiences of combat whereas PTSD has more wide-ranging causes. And at least now no one gets shot for either condition.

mhouston@irishtimes.com

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