Clinicians and scientists have long been concerned with the effects of violence and shocking events on the human mind. Important historical events and social movements, moreover, have affected how they view the effects of severely overwhelming experiences. Historical events that gained the attention of scientists were full-scale wars such as the American Civil War, the First World War, the Second World War (including the Holocaust), the Vietnam War, the Balkan Wars, and the recent conflicts in Iraq and Afghanistan. As for social movements, these include the women’s movement, migration flows, and changing attitudes to children’s rights. Even though shocking events have led to violence and the disruption of life since time immemorial, relatively speaking, scientific research on the effects of such disruptive life events is still in its nascence.
1.2.1. A brief history of PTSD
Different terms were used in the nineteenth century to describe severe physical and emotional reactions resulting from overwhelming events; for instance, railway spine was the diagnosis for symptoms occurring after a train accident, and traumatic neurosis referred to injuries to the head (Kleber & Brom, 1992). Originally the physical damage was thought to cause the symptoms, but Pierre Janet was the first to point to the psychological processes that were at work after the event. Van der Hart et al. (2000), who thoroughly reviewed Janet’s work, describe the processes of dissociation, memory fragmentation, and emotional fragmentation. The assumption was that traumatic experiences fragmented one’s consciousness, with the detachment of overwhelming emotions from consciousness serving as a coping mechanism that enabled the person to continue functioning. The therapeutic processing of deeply overwhelming experiences included the reintegration of unprocessed traumatic memories with normal consciousness.
The First World War confronted society with the severely emotionally and physically damaged soldiers who had suffered the horrors of the trenches. Their complaints were ascribed to shellshock, the term used to initially describe the physical damage caused by explosions, bombardments, and shrapnel. Gradually, however, psychological explanations for the intense emotional problems experienced by soldiers began to take form. Pat Barker’s Regeneration trilogy (1991), about the work of the psychiatrist Dr William Rivers and his colleagues, is illustrative of how trauma was conceptualized during the First World War (Shepard, 2000).
The Second World War confronted the world with such extreme horrors that new terms – such as concentration camp syndrome, survivor syndrome, and KZ syndrome (where the KZ refers to Konzentrationslager) – were coined to describe the consequences for psychological functioning caused by these traumas (Enning, 2009; Jongedijk et al., 1995). Soldiers experiencing traumatic reactions after the Second World War were considered to be suffering from combat fatigue, with terms such as traumatic neurosis, gross stress reaction, and adjustment reaction commonly used by the general public (Kleber & Brom, 1992). This was the first time the link between overwhelming experiences and stress was made.
In his exposition titled Stress Response Syndromes: PTSD, Grief and Adjustment Disorders, Horowitz (1997) makes explicit use of the new stress paradigm. Horowitz’s fundamental notion is that traumatized persons experience more stress than they can cope with or think they can cope with, calling this an issue of appraisal. Two fundamental tendencies help to normalize the overburden of stress, namely, reexperiencing and avoidance. Although notions regarding an individual’s capacity for resilience and endurance (stimulus barriers) had been addressed by Freud, they have recently gained new momentum because of the meaningfulness of the cognitive component included by Horowitz.
Dutch authors (Bastiaans, 1974; Blijham, 1984; Cohen, 1969; Hustinx, 1973; Musaph, 1973) have regularly addressed stress reactions in Holocaust survivors and in other groups of war-stricken people using various terms such as KZ syndrome, concentration camp syndrome and existential emotional stress syndrome while emphasizing the existential dimension of the violence. This dimension particularly affects a person’s ability to enter into and maintain relationships, and to give meaning to the violent events and to life in general; survivors also experience survivor’s guilt, which is guilt associated with surviving when others died.
The historical event that very well may have had the greatest bearing on defining PTSD as we know it today was the Vietnam soldiers’ homecoming to the USA. In retrospect, recovery was not so much a matter of dealing with what happened there during the war and its consequences but of facing up to the growing lack of social support at home for returning servicemen and servicewomen. By the end of the 1960s, US society was completely opposed to the deployment of soldiers to Vietnam, and returning soldiers could not count on much support; at times they were even publicly shamed.
PTSD, however, would have never been included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) had it not been for the pressure exerted by the women’s movement in general, including feminists, who demanded that victims of sexual violence and abuse – often young – be given the attention they needed (Herman, 1992).
1.2.2. PTSD
PTSD (Appendix 1) has carved out a place of its own in the DSM since the publication of DSM-III in 1980. It is the only diagnosis to have situational circumstances included as a criterion (that is, the criterion is external to the person). This has led to tremendous debate regarding the definition of and criteria for PTSD in subsequent versions of the DSM, as it is very difficult to reach consensus on which severe symptoms – reexperiencing the trauma, avoidance behaviour, and the hypervigilance – are required for a diagnosis of PTSD (APA, 2000).
A diagnosis of PTSD is only made when the traumatic events are intrusive or reexperienced, when the associated stimuli are persistently avoided, and when there are symptoms of increased arousal (hyperarousal or hypervigilance) that were not present prior to the event. Examples of in...
