Freud pursued the theory of traumatic memories further during the early years of his practice by exploring the sexual histories of his patients (Herman, 1992). Repeatedly, he heard accounts of childhood sexual abuse, rape, and assault. As he listened to the stories, he developed the thesis that “in every case of hysteria there are one or more occurrences of premature sexual experience” (Freud, 1896/1962, p. 203). Unfortunately, the publication of his paper did not lead to further research or validation; instead, it ended the line of understanding and inquiry. Faced with the dilemma of accepting the frequency and reality of these occurrences and Victorian society’s disbelief regarding the existence of such reported childhood assaults, Freud repudiated his clients’ feelings of victimization (Herman, 1992). He subsequently recanted his earlier formulations because he found himself ostracized in his profession and concluded that the reported childhood sexual abuse never took place at all but, instead, was a result of the patients’ fantasy lives (van der Kolk, 2007). Thus, real-life trauma was ignored in favor of the theory of fantasy. This dramatic reversal set back the understanding and treatment of trauma and invalidated the reality of many women’s and children’s experiences until the later part of the twentieth century, even as it became the basis for his later theories on psychoanalysis. The disbelief of victimization would not be challenged until the women’s movement in the mid-twentieth century (Herman, 1992). The field of trauma inquiry was then dormant until the aftermath of World War I and Abram Kardiner’s formulation of the concept of traumatic neurosis in response to treating U.S. war veterans (van der Kolk, 2007). Kardiner noted the presence of postcombat heightened vigilance, hypersensitivity to perceived environmental threat, and a lowered threshold of emotional stability. He also noted what he called the “pathological traumatic syndrome,” which included fixation on the trauma, an altered sense of self in relation to the world, chronic irritability, startle reactions, a distressing and atypical dream life, and explosive aggressive reactions (Kardiner, as cited in van der Kolk, 2007, p. 57). Kardiner recognized, as had Janet and Freud, that a person acts as if the trauma is still occurring and engages in protective reactions when a present-day event triggers a recollection of the original trauma. Kardiner’s work was forgotten until after World War II, when postcombat trauma treatment had to be rediscovered. A number of pioneers in the field of psychiatry, including Roy Gringer, Herbert Spiegel, and Walter Menninger, became active in the treatment of what was called shell shock, war trauma, or combat neurosis. Also, for the first time, military psychiatrists tried to remove the stigma of combat stress reactions. They recognized that these reactions were not a pathological state and that any person could break down under similar stressors (van der Kolk, 2007). The depathologizing of trauma reactions was the first step on the way to our modern-day formulation of PTSD. Kardiner Posttraumatic Stress Disorder as a Diagnostic Category In 1980, the American Psychiatric Association (APA) added PTSD to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980). The fifth edition of the DSM (DSM-5) placed the diagnosis in a new category—trauma- and stressor-related disorders (APA, 2013), and the newest text revision (DSM-5-TR; APA 2022) made only a slight adjustment to reduce redundancy in the qualifying event criteria for children. Because of this limited change, this course will continue to reference the DSM-5 throughout, as it is the foundational reference for its current categorization. The creation of this diagnostic category in the manual’s most recent edition further distinguished trauma reactions from other disorders associated with disturbances in mood and anxiety. For a condition in this category to be diagnosed, exposure to a traumatic or stressful event is required. According to the DSM-5, PTSD is a constellation of symptoms accompanied by clinically significant impairment or distress that occurs after
and Spiegel (1947) observed that the strongest protection against overwhelming terror seemed to be the relationships between the combat soldiers and their leaders. Early on, this relational connection was recognized as being crucial in the treatment of psychological breakdowns as well as in their prevention. Thus, one of the earliest approaches to treating combat soldiers was to get them back to the front line and back with their fellow soldiers and leader as quickly as possible after a physical or emotional injury. The principles of frontline psychiatry led to more research on the protective factors of morale, group cohesion, leadership, and training (van der Kolk, 2007). The war experiences led to group treatment approaches being further investigated, with Walter Menninger in the U.S. and William Bion and his colleagues at the Tavistock Clinic in Britain heading up some of the important research (van der Kolk, 2007). After World War II, an additional independent line of inquiry emerged with the treatment and study of the long-term effects of survivors of the Holocaust and other war-related traumas. Henry Krystal (1968, 1978, 1988) studied the long-term effects of massive traumatization in concentration camp survivors and found that one of the core effects was a “giving up” and acceptance of the inevitability of pain and death. (This reaction is similar to Seligman’s findings in his learned helplessness studies some years later under laboratory conditions.) This shutting down of the life force is part of the numbing cluster of symptoms that will be discussed later. The Vietnam War led to the formation of what were called “rap groups” for returning veterans, where stories were told and retold and the support of peers, who had been through similar experiences, helped to provide healing. These groups became one of the prototypes for subsequent group trauma treatment approaches that began in the 1980s (van der Kolk, 2007). At about the same time, Ann Burgess and Linda Holmstrom (1974) first described rape trauma syndrome in their 1972 study of the effects of rape. They noted similarities in the flashbacks, nightmares, insomnia, startle responses, and dissociative or numbing symptoms of rape survivors and combat soldiers. Burgess and Holmstrom’s investigation and Lenore Walker’s (1979) investigation and definition of what she called “battered woman syndrome” led to a reaffirmation of the initial truths regarding the reality of domestic and sexual violence that had been discovered almost a century earlier through the pioneering efforts of Charcot, Janet, Freud, and Breuer. In 1992, Judith Herman wrote about the effects of the women’s movement and described women’s consciousness-raising groups as providing many of the same benefits that rap groups provided for veterans: Intimacy, confidentiality, the acceptance of and bearing witness to the horrors of the traumatic events, and the experience of being believed by peers when society at large did not want to hear, acknowledge, or believe in the veracity of the reports. exposure to a traumatic event. The DSM-5 identifies four types of exposure to a traumatic event: Directly experiencing the traumatic event, witnessing the traumatic event in person, learning about the traumatic event of a close family member or friend, and experiencing firsthand the repeated or extreme exposure to details of the traumatic event (APA, 2013). The historical emergence of this diagnostic categorization has led to the major advantage of depathologizing the victims’ and survivors’ responses to their experiences. It reflects an understanding that any person who experiences similar life events will be likely to have similar distressing and disorganizing reactions and responses. The classification of PTSD as a disorder has supported efforts aimed at removing the stigma given to the psychological and physiological effects of trauma by describing the constellation of PTSD responses as normative responses to the life experiences that generated them, as opposed to being generated by some internal pathology within the individual.
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Book Code: PYFL4024
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