As we approach the 101st anniversary of the Great War armistice, it is always worth contemplating the fate of those soldiers shot for ‘cowardice’ or ‘desertion’ who were in fact suffering from post- traumatic stress disorder (PTSD) and who were blameless in their misery. Although ‘shellshock’ was a term in common use at that time there was next to no understanding as to the basics of the condition or how to treat it, and as recently as the Vietnam War we were still using terms such as ‘combat stress reaction’ even though the first recorded reports of it date back the best part of 4,000 years when Egyptian physicians wrote about ‘hysterical reactions’ to acute trauma. It was only in the 1980s that the term PTSD came into common usage.
PTSD is a psychological and physical condition caused by severely distressing events such as military combat, serious accidents, terrorist attacks and personal assault. One in two of us experience significant trauma at some point in our lives, and of those around one in five go on to develop PTSD. It is more common in certain groups of people such as firefighters, war prisoners, rape victims and car crash survivors, and unfortunately symptoms may worsen over time. (I once saw a patient who admitted to me – for the first time to anyone – his symptoms seventy years after witnessing his friends torpedoed and drowning in the Arctic convoys of the Second World War, but have also treated members of the armed forces who fought in combat arenas such as Korea, the Falklands, both Gulf wars and Afghanistan).
It can happen at any age, with over a third of people with PTSD developing the condition as a result of someone close to them suddenly dying and the more disturbing the experience, the greater the chances of PTSD occurring.
Although it remains unclear why, factors such as being female, coming from a poorly educated and low income background, and being part of an ethnic minority all appear to increase the risk of PTSD developing.
Symptoms typically develop immediately or within three months of a traumatic event but on occasion may begin many years afterwards. Sufferers relive the trauma with nightmares and flashbacks, and hyper-arousal may also occur, where there are problems with sleeping and concentrating, irritability and being easily startled. They often have other mental health problems, feel isolated and detached from life and can become depressed, withdrawn and dependent on alcohol or other drugs.
PTSD is still treatable years after the initial traumatic event but unfortunately evidence still suggests that two thirds of people with the condition sit and suffer in silence, and do not receive any professional help at all. Treatment starts with a detailed medical evaluation of the symptoms then a plan is tailored to that individual’s needs. This typically consists of psychotherapy, medication, or a combination of the two.
Psychotherapy includes cognitive behavioural therapy (CBT) to help change patterns of negative thinking and sometimes a process called eye movement desensitisation and reprocessing (EMDR) whereby whilst thinking of the traumatic event you follow someone’s moving finger with your eyes. It is unclear why this should work but does appear to help reduce the upset these memories cause in some people. Medication involves selective serotonin reuptake inhibitors (SSRIs) in many cases.
However, no drug is yet approved to prevent someone developing PTSD in the event of them being exposed to significant trauma, and there is no treatment that is able to erase all memories of a traumatic episode. Although every PTSD sufferer varies in their response to treatment, one saving grace here is that around two thirds of people with the condition eventually get better over time.
Wilfred Owen, the greatest poet of the First War and himself hospitalised with ‘neurasthenia’ – another term for shellshock – in 1917, wrote in his poem ‘Mental Cases’ the line ‘Always they must see these things and hear them’ about his fellow soldiers. It is our duty not only to remember them but also to continue to do all we can for those who suffer today.