Now, here is a provocative question for persons with a special interest in posttraumatic stress disorder (PTSD). How long has the disorder existed?
Some psychiatric historians would argue that it goes back to the Great Fire of London in the 17th century or even to ancient Greece. A new study, however, reported in the February British Journal of Psychiatry makes the case that at least one PTSD symptom—the PTSD flashback—is a modern construct.
The study implies that PTSD flashbacks were virtually nonexistent before the 20th century and became increasingly common as the century moved on. And the reason, the study’s investigators suspect, may be because people were exposed to an increasing number of film flashbacks and intrusive television images as the 20th century progressed, and such exposure in turn influenced their expression of psychological distress.
A PTSD flashback is an involuntary, visual rerun or visual replay of a traumatic incident that occurs in a waking state. The first time that such a phenomenon was officially recognized as a PTSD symptom was in 1987, in DSM-III-R. But just because it was not officially recognized until 1987 does not mean that it did not exist earlier. So Edgar Jones, Ph.D., a reader in history of medicine and psychiatry at Guy’s, King’s, and St. Thomas’s School of Medicine in London; Ian Palmer, M.D., a professor of military psychiatry with the Royal Defence Medical College in Gosport, England; Kenneth Hyams, M.D., a consultant to the U.S. Department of Veteran Affairs in Washington, D.C., and several other investigators collaborated on a study to find out.
They used as their subjects 1,856 British soldiers who had served in any one of seven wars over a 137-year period, starting with the Victorian Campaigns of 1854 to 1895 and working up to the Persian Gulf War of 1991, and who had been awarded pensions for combat disorders. Some of these disorders appeared to be blatantly physical, for example, rheumatism; others seemed to be psychological, such as "shellshock." But all of the soldiers, the researchers reasoned, had been exposed to the horrors of war and were at risk for PTSD. What’s more, all of soldiers’ pension files contained detailed information about their medical conditions. So these files would reveal whether they had experienced PTSD flashbacks, the investigators believed.
First the researchers scrutinized the pension file for each veteran to determine whether he had experienced PTSD flashbacks or not. For instance, Thomas H., a veteran who had served during World War I and who had been diagnosed for shellshock, reported sometimes awakening at night, seeing somebody standing in the room, and feeling terrified that the person might knock him down or kill him. These visual experiences appear to have ended after Thomas received outpatient psychotherapy in 1921. Since Thomas’s pension file indicated that he had no delusions and was rational, the investigators concluded that he had indeed been experiencing PTSD flashbacks.
In contrast, Charles T., another veteran who had served during World War I, was described in his pension file as "always thinking of the past" and with a memory "too good for past events." The researchers decided that these ideas and images had been under Charles’s rational control and did not constitute PTSD flashbacks.
Then the investigators determined how many veterans who had fought in each of the seven wars had experienced PTSD flashbacks. The answer was none (0 percent) for the 28 Victorian Campaign veterans; none (0 percent) for the 400 Boer War veterans; three (0.5 percent) for the 640 World War I veterans; five (1.4 percent) for the 367 World War II veterans; and 36 (9 percent) for the 400 Persian Gulf War veterans. Thus, an increasingly greater percentage of veterans appeared to have experienced PTSD flashbacks from 1854 to the present. When the proportion of veterans experiencing PTSD flashbacks after the Persian Gulf War was compared with the percentage found in veterans from earlier conflicts, the difference in each case was statistically significant.
Thus, it looks as though flashbacks are a modern PTSD symptom, Jones and his team concluded, becoming increasingly prevalent as the 20th century advanced. If that is the case, they reasoned, then it may be because people were exposed to an increasing onslaught of film flashbacks and intrusive television images as the 20th century marched on. Or as they asserted in their study report: "Our findings imply that the psychopathology of trauma is not static and that culture has an impact on the expression of distressing memories."
As tantalizing as these results and speculations are, "the study has a lot of problems," Randall Marshall, M.D., director of trauma studies at the New York State Psychiatric Institute, told Psychiatric News. Matthew Friedman, M.D., executive director of the National Center for Posttraumatic Stress Disorder in White River Junction, Vt., concurred.
Both Marshall and Friedman pointed out that years ago PTSD flashbacks were not recognized diagnostically by physicians, and certainly no structured psychological assessments for PTSD flashbacks were available as in today’s psychiatric studies. So no wonder that physicians did not inquire about flashbacks, veterans did not report them, and Jones and his colleagues found no evidence of them.
And no, Friedman does not believe, as Jones and his coworkers do, that if veterans of yore had had PTSD flashbacks, they would have voluntarily talked about it. The reason?
"Even today PTSD patients don’t talk spontaneously about flashbacks," he said. "You have to ask for them. They can be frightening. People can feel that they are losing their minds. The material itself may be very painful to bring up."
Friedman also observed that Jones and his coworkers used only compensation-seeking veterans as their subjects. So there may have been many British veterans in the past who experienced PTSD, and perhaps PTSD flashbacks, yet who were not included in the study.
All these salvos aside, though, both Marshall and Friedman agreed with Jones and his team on one point: Culture can influence PTSD symptoms. In fact, an intriguing new field of research is investigating how culture can affect the symptoms of some mental disorders other than PTSD, Marshall pointed out.
The study was financed by the U.S. Army Research and Material Command and the U.S. Department of Defense.
An abstract of the study, "Flashbacks and Posttraumatic Stress Disorder: The Genesis of a 20th-Century Diagnosis," is posted on the Web at http://bjp.rcpsych.org/cgi/content/abstract/182/2/158. ▪
Br J Psychiatry2003182158