The PTSD Diagnosis:

Past, Present, and Future

Judith L. Herman, M.D.

Part 1: Studies on Hysteria

(Late 19th Century)

Hysteria as a Traumatic Disorder

I therefore put forward the thesis that at

the bottom of every case of hysteria there are one or more occurrences of premature sexual experience… which belong to the earliest years of childhood but which can be reproduced through the work of psycho-analysis… I believe this is an important finding, the discovery of a caput Nili in neuropathology.

S. Freud, The Aetiology of Hysteria, 1896

Studies on Hysteria come to a halt

“I am as isolated as you could

wish me to be: The word has been given

out to abandon me, and a void is forming

around me.”

S. Freud, Letter to Wilhelm Fliess, 1896

Part 2: Studies on War

(20th Century)

World War I: Shell Shock

WWI: The Hysterical Neuroses of War

I was still mentally and nervously organized

for War. Shells used to come bursting on my bed at midnight, even though Nancy shared it with me; strangers in the daytime would assume the faces of friends who had been killed. When strong enough to climb the hill behind Harlech and visit my favorite country, I could not help seeing it as a prospective battlefield.

Robert Graves, Goodbye to All That, 1929

WW II:

The Traumatic Neuroses of War

[Traumatized soldiers] seem to suffer from chronic

stimulation of the sympathetic nervous system…

The emergency psychological reactions of anxiety

and…preparedness…have overlapped, and become

not episodic, but almost continuous…Eventually the

soldier is removed from the environment of stress..

…but the physiological phenomena persist, and are

now maladaptive to a life of safety and security.

---Roy Grinker and John Spiegel: Men Under Stress, 1945

Vietnam War:

“Post-Vietnam Syndrome”

…The real American casualties of the Vietnam War, at least in numbers, may well be those who see no psychiatrists and bear no psychiatric or medical labels yet are nonetheless plagued and diminished by numbed guilt…Their continuing struggle… may drive them to extreme acts of destruction and self-destruction—as in the many cases already reported…of seemingly purposeless violence, the significant number who stay on hard drugs or who...live in distraught withdrawal from fellow beings…Even a society bent on numbing cannot hide these casualties; we shall hear more and more of them bringing their bitter guilt and rage…back to a society already suffused with bitterness.

Robert Jay Lifton: Home from the War (1973)

Post-Vietnam: Official Recognition of Traumatic Disorders

• DSM-II (1968) Hysterical Neurosis Dissociative Type

Conversion Type

• DSM-III (1980) Post-Traumatic Stress Disorder

• DSM-IV (1994) PTSD + “associated features”

• DSM-V (2012) A Trauma Spectrum?

Diagnostic Criteria for

Posttraumatic Stress Disorder

(DSM-IV, 1994)

• The person has been exposed to a

traumatic event that involved actual or

threatened death or serious injury, or a

threat to the physical integrity of self or

others, and

• The person’s response involved intense

fear, helplessness, or horror.

Diagnostic Criteria for

Posttraumatic Stress Disorder (DSM-IV, 1994)

• The traumatic event is persistently

re-experienced in recurrent, intrusive images, thoughts, recollections, or dreams.

• Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness.

• Persistent symptoms of increased arousal (difficulty falling or staying asleep, difficulty concentrating, irritability, hypervigilance, exaggerated startle response.

Lifetime Exposure to Traumatic Events

Kessler, et al, 1995 (N=5877)

Type of Event Men (%) Women (%)

Saw Someone Seriously

Injured or Killed 36 15

Accident 25 14

Flood, Fire or Disaster 19 15

Threatened with Weapon,

Held Captive or Kidnapped 19 7

Physical Assault 11 7

Combat 6 0

Molestation 3 12

Rape 1 9

Any Event 61 51

Lifetime Prevalence of PTSD

(Kessler et al, 1995)

Men 5.0%

Women 10.4%

Total 7.8%

Part 3: Learning from Women

(Late 20th Century)

• First Speakout on Rape

(NY Radical Feminists,1971)

• “Rape Trauma Syndrome”

(Burgess & Holmstrom, 1973)

• The Battered Woman (Walker, 1979)

• Father-Daughter Incest (Herman, 1981)

Shame and PTSD (Andrews et al, 2000)

N=157

• Victims interviewed 1 & 6 mo. post crime

• Shame at 1 mo. predicted PTSD at 6 mo

• Content of shame responses: • Feelings of defeat (failure to take effective action)

• Feeling exposed in eyes of others

• Feeling ashamed of emotional reactions

• Feelings of humiliation

Part 5: Trauma in the 21st Century

Home Fires: American Veterans on

the Post-War Life Those of us with PTSD—I’m one of them—feel like

strangers here, carrying around a burden many people are unaware of or just can’t understand…. Throughout history, warriors have been taught not to speak of their emotional struggles. Earlier generations of American veterans mostly suffered in silence. That tradition can change. We can share our experiences…so that this generation of soldiers can let others know…without embarrassment or shame. So that when the worlds of the soldier and the civilian meet, they’ll come together, not collide.”

– Michael Jernigan. New York Times, October 26, 2009.

“Bringing the War Back Home”

Mental Health Disorders Among 103,788 US Veterans

Returning from Iraq and Afghanistan Seen at VA Facilities

(Seal et al, 2007)

• 25 % received mental health diagnoses

• 13 % were diagnosed with PTSD

Perceived Barriers to Seeking Mental Health

Services Among Soldiers and Marines (Hoge et al, 2004)

N= 731 respondents who met screening criteria for a mental disorder

• It would be too embarrassing (41%)

• It would harm my career (50%)

• Members of my unit might have less

confidence in me (59%)

• My unit leadership might treat me

differently (63%)

• I would be seen as weak (65%)

A “Mental Health Summit”

“Who is vulnerable? Everyone. Warriors

suffer from emotional injuries just as they

do physical ones….More veterans have

committed suicide since 2001 than have

been lost to combat deaths in Iraq and

Afghanistan”

-Erik Shinseki, Secretary of Veterans’

Affairs, October 25, 2009

Child Sexual Abuse: The role of race, class, and social ecology

Families are creatures of social systems, and the state of these systems is critical to family well-being and child safety. Rates of abuse fluctuate. We do not know the reasons…in all cases, but in some instances we do.

A 1996 study…in Harlem found that rates of childhood abuse were 3 times higher for men and 2.5 times higher for women than the national averages. Harlem was a poor neighborhood that had suffered from redlining, urban renewal, and planned shrinkage, leading to massive destruction of the area’s built environment and serial displacement of its population. This environmental upheaval had truncated social networks, disrupted family functioning, and added many social burdens to people with few resources.

– Mindy Thompson Fullilove, Toxic Sequelae of Child Sexual Abuse.

American Journal of Psychiatry 2009

Learning from Women

in the 21st Century Traditional patriarchy has slowly but systematically been

ruptured at different paces in various parts of the world. Applying a human rights perspective to violence has created a momentum for breaking the silence around violence, and for connecting the diverse struggles across the globe. Today, a life free of violence is increasingly accepted as an entitlement rather than merely a humanitarian concern….The agenda for the elimination of violence against women is not about victimization, but rather about the empowerment of women.

--Yakin Ertürk, 15 YEARS OF THE UNITED NATIONS SPECIAL RAPPORTEUR ON VIOLENCE AGAINST WOMEN (1994-2009)—A CRITICAL REVIEW