From shell shock to PTSD: proof of war's traumatic history

2015 marks several important First World War anniversaries: the centenary of the first use of poison gas in January; the centenary of the Gallipoli landings and the Armenian genocide in April. It is also 100 years since The Lancet published Charles S. Myers’ article, A Contribution to the Study of Shell Shock.

The study of shell shock

Myers' article is generally regarded as the first use of the term “shell shock” in medical literature. It was used as a descriptor for “three cases of loss of memory, vision, smell and taste” in British soldiers admitted to a military hospital in France.

While Myers presented these cases as evidence of the spectacular concussive effects of artillery on the Western Front, British medical opinion soon came to regard these symptoms as psychological in origin. The men presenting to medical officers with tics, tremors and palpitations, as well as more serious symptoms of “functional” blindness, paralysis and loss of speech, were not concussed – but nor were they necessarily cowards or malingerers.

Instead, these were men simply worn down by the unprecedented stresses of trench warfare – in particular, the effort required to push out of one’s mind the prospect of joining the ranks of the maimed or the corpses lying in no man’s land. Myers later wrote:

Even those who start with the strongest “nerves” are not immune from “shell shock”, if exposed to sufficiently often repeated, or to incessant, strain, or if subjected to severe enough shock.

For contemporaries and later for historians, shell shock came to encapsulate all the horror of this new form of industrialised warfare. As historian Jay Winter suggests, it moved “from a diagnosis into a metaphor”.

The effects of shell shock could linger. In his celebrated Good-Bye to All That, poet Robert Graves recounted returning to England trembling at strong smells (from fear of gas attacks) and loud noises. He judged that it took:

… some ten years for my blood to recover.

Developing a diagnosis

It is tempting to view shell shock as the unambiguous turning point in psychiatry’s history, popularising the idea that unconscious processes might produce symptoms that operate separately from moral qualities such as endurance and courage. However, scholarship over the last 15 years suggests that this position was far from widely accepted.

Shell-shocked soldiers were as likely to be subject to harsh “disciplinary” treatments, such as “faradism” – the application of alternating electric currents to stimulate paralysed limbs or target other physical symptoms – as they were to receive psychotherapy. The notion that many patients had some “predisposing” weakness – independent of their combat experiences – persisted throughout the interwar period and into the Second World War.

It wasn’t until the Vietnam War that this formulation was reversed, which in turn bridged the gap between combatant syndromes and the civilian sphere.

This development is only comprehensible as part of a broader political context. The notion that the Vietnam War exacted a form of psychic damage on American soldiers was championed by the anti-war activists of Vietnam Veterans Against the War (VVAW) and psychiatrists Chaim Shatan and Robert Jay Lifton. “Post-Vietnam syndrome”, Shatan wrote, was caused by the “unconsummated grief” of a brutal and brutalising war.

The VVAW’s advocacy was instrumental in securing official recognition for this condition. It was included in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as “Post-Traumatic Stress Disorder”.

PTSD’s inclusion in DMS-III legitimated the suffering of Vietnam veterans and held out the possibility of subsidised medical care and compensation. But the DSM-III definition of PTSD was significant in two additional ways.

First, it identified the disorder as a condition that could afflict soldiers and civilians alike – not a diagnosis exclusive to combat, like shell shock.

Second, it focused attention on the continuing effects of a traumatic experience, rather than on the personality and constitution of the patient.

The ramifications of these changes have been immense. PTSD and a broader field of “traumatology” are now entrenched in psychiatric and popular discourse. In Australia, we now assume that warfare is objectively traumatising, and that governments ought to provide medical and financial support for affected service personnel, even if a recent Four Corners program confirmed that this is not always the case.

How is PTSD viewed today?

Though PTSD has its origins in opposition to the Vietnam War, the politics of the condition are now largely ambivalent, with its significance shifting according to circumstance.

The titular character in American Sniper is shown to be suffering from some after-effects of combat.Warner Bros Pictures

This point is well illustrated by the film American Sniper, which demonstrates the possibility of two contrary positions. After his return to civilian life, SEAL sniper Chris Kyle (Bradley Cooper) is shown to be suffering from some characteristic after-effects of combat. He is startled at loud noises, sees scenes of combat on a blank TV and becomes enraged at a barking dog during a family barbecue. This leads his wife to call in assistance from a Veterans Administration psychiatrist.

On the one hand, we could view this evidence of psychological damage as an implicit critique of the Iraq war, serving the same function as the damaged Vietnam veteran in Hollywood cinema of the late 1970s and 1980s. But there is also a converse reaction that values this pain as a worthy sacrifice in the fight against the “savages” Kyle sees through his rifle scope. This reaction discounts entirely the damage done to civilian populations by years of occupation and mutually destructive fighting.

The potential for this second reading is perhaps greater in this particular film, which for the most part portrays Iraqis as marginal and malign figures.

Interestingly, the film also depicts Kyle as ambivalent in the face of his symptoms, with Kyle objecting to the psychiatrist’s suggestion that he may be suffering from the repercussions of multiple tours of duty. Yet he is depicted as a sympathetic support figure for other veterans suffering from physical and psychological injuries.

The real Chris Kyle was shot dead by one of these men, Eddie Ray Routh, in 2013. At trial, the accused’s lawyers pursued a defense of insanity, compounded by the inadequate care provided by veterans’ mental health services. Routh was found guilty of Kyle’s murder late last month.

In the 100 years since Myers’ article on shell shock, the psychological consequences of war remain as relevant as ever.

Elizabeth Roberts-Pedersen does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.