PTSD: A Short History

Johns Hopkins Biographies of Disease

by Allan V. Horwitz

A comprehensive history of PTSD. Post-traumatic stress disorder—and its predecessor diagnoses, including soldier’s heart, railroad spine, and shell shock—was recognized as a psychiatric disorder in the latter part of the nineteenth century. The psychic impacts of train crashes, wars, and sexual shocks among children first drew psychiatric attention. Later, enormous numbers of soldiers suffering from battlefield traumas returned from the world wars. It was not until the 1980s that PTSD became a formal diagnosis, in part to recognize the intense psychic suffering of Vietnam War veterans and women with trauma-related personality disorders. PTSD now occupies a dominant place in not only the mental health professions but also major social institutions and mainstream culture, making it the signature mental disorder of the early twenty-first century. In PTSD , Allan V. Horwitz traces the fluctuations in definitions of and responses to traumatic psychic conditions. Arguing that PTSD, perhaps more than any other diagnostic category, is a lens for showing major historical changes in conceptions of mental illness, he surveys the conditions most likely to produce traumas, the results of those traumas, and how to evaluate the claims of trauma victims. Illuminating a number of central issues about psychic disturbances more generally—including the relative importance of external stressors and internal vulnerabilities in causing mental illness, the benefits and costs of mental illness labels, and the influence of gender on expressions of mental disturbance— PTSD is a compact yet comprehensive survey. The book will appeal to diverse audiences, including the educated public, students across the psychological and social sciences, and trauma victims who are interested in socio-historical approaches to their condition. Praise for Allan V. Horwitz’s A Short History "The definitive overview of the history of anxiety."— Bulletin of the History of Medicine "A lucid, erudite and brisk intellectual history driven by a clear and persuasive central argument."— Social History of Medicine "An enlightening tour of anxiety, set at a sensible pace, with an exceptional scholar and writer leading the way."— Library Journal

Genres: Psychology, Nonfiction, History, Mental Health, Audiobook, War

256 pages, Paperback

Published September 3, 2018

Reviews

[Julian Meynell · Rating 3 out of 5]

In many ways I like this book. It's well researched. It covers off the major historical moments in the history of PTSD as an illness. It is readable. It is informative about the history. I enjoyed it. Furthermore, I would read other books by the author. A book on the history of PTSD is probably the hardest topic within the history of mental illness. That being said I am going to mercilessly and brutally critique it.

PTSD is a political illness and consequently any history of PTSD is necessarily a political history as well as a history of psychiatry. This book is partially aware of that and as such is partially a success and partially a failure.

PTSD of course stands for Post Traumatic Stress Disorder and for the Stress Disorder to exist it must be Post a Trauma. As such the traumatic event must exist and must be traumatic. For all those who have PTSD from traumas caused by humans, you have to recognize first, that humans do that sort of thing and second, that the practice is so traumatic that it causes mental illness. These twin observsations are necessarily political.

Horowitz does not clearly see this necessity and therefore attempts an apolitical and purely scientific and sociological approach that consequently partially fails. You cannot really tell the history of the early part of the scientific revolution, without thoroughly understanding its political nature. Galileo, Bruno, Bacon, Descartes and so on were involved in a political enterprise as well as a scientific one. The same goes for mental illness and especially PTSD. Horowitz has awareness of this in the past, but as we move closer to the present he becomes almost wilfully naive. For instance, on page 139 Horowitz says;

"By the twenty-first century, the 150-year contention between those who associated PTSD with malingering or flawed character and those who saw it as the consequence of overpowering traumatic events was over: the medicalization of PTSD was complete. Regardless of whether the condition resulted from exposure to traumas or from vulnerability among those who were exposed, PTSD victims were not cowards, Shirley's or fortune hunters; they suffered from an illness that deserved compassion, treatment, and often, financial compensation."

Really? I first came into the system when my PTSD caught up with me in 2011. Towards the end of that year, I started to become aware that my symptoms were PTSD. They were instead attributed to many other things, including depression and anxiety, which to be fair I also have. But also to having a flawed character and being a malingerer. I have been called a liar many many times. One psychiatrist going so far as to claim that my central trauma was "so extreme that no one would ever do it". I have been, in addition, diagnosed with bipolar disorder, drug addiction, paranoia and psychosis and these are just the diagnoses that I know about. God knows what else I was diagnosed with. Psychiatrist have gone so far as to refuse to talk to people who could confirm my nightmares.

I've been unsuccessfully prosecuted twice for reasons related directly to the denial. Rendered homeless twice, denied medical treatment uncountable times, proscribed medications that were harmful, refused help for suicidal ideation and rendered permanently disabled. For a period of two years, I abandoned even claiming or describing my PTSD symptoms. (I found that I could get treatment for depression and anxiety if I did not talk about my PTSD symptoms or my worst traumatic events.)

The denial of my PTSD was a slowly retreating tide, with at least one legal proceeding on my part against the police. It was not until 2018 that all opposition to my diagnosis ceased. The same year this book was published. By that time I had been retraumatized many times and my symptoms were much, much worse.

I don't want to talk about my original trauma, but I will mention a personal example of how politics still drives PTSD when it comes to my retraumatization. When I was first retraumatized by the police, it was prior to the Black Lives Matter movement. I was from a white, professional, middle class background and was naive about these things. I had more than one psychiatrist claim that the police never do anything wrong at that time.

Since then I have met several people who suffer from PTSD from police misconduct. I know enough to know that it is a frequent cause of PTSD in marginalized communities. Many mental health professionals that work with marginalized communities can tell you this. Yet if you were to look at the literature, you would not even know this exists. From my own experience, I know that this denial is not because PTSD is not a reliable indicator of police misconduct but precisely because it is.

Horwitz is right to see the overclaiming of PTSD in certain contexts. You can't get PTSD from a news report, although you certainly can be triggered by one. (Police misconduct stories certainly always cause me to have flashbacks). Also there is increasing confusion between having some negative psychological effects from traumatic events and full fledged PTSD. Horowitz addresses this in the book but in a way that felt incomplete.

Despite the fact that Horowitz often celebrates the fact that people with PTSD are no longer stigmatized as malingerers. He devotes a lot of the book to it. For instance, he quotes Psychiatrist Nancy Andreasen as saying "It is rare to find a psychiatric diagnosis that anyone likes to have, but PTSD seems to be one of them." Interestingly it is the only quote given three times in the book and is evidently the most important thing that anyone has ever said. Interestingly, while Andreasen is a very accomplished researcher, she does not work extensively with patients or specialize in PTSD.

A real problem with mental health is that much of the research is done in the USA. To anyone who lives outside of the United States, the distortions of research in an American context of litigation and private insurance are obvious. Part of my problem in both being diagnosed and being treated was caused by these distortions which are wholly irrelevant in my Canadian cultural context, yet poison the research for the globe. From my point of view, the problem is that there are billions riding on denying PTSD. For instance, the history taking practices in EMDR therapy are vicious and not in the best interest of the client. The practices make therapy fast and induce a high drop out rate, which can be used for insurance companies to deny further care. Consequently, they are very financially appealing to large American insurance corporations and have caused unnecessary complications for Canadian practitioners. At the end, PTSD is the worst disease in the world and only a fool would pretend to have it.

But from my perspective, PTSD is the easiest thing in the world to see. Watch the person sleep. Do they wake up in the middle of the night fighting for their life? Pop a balloon behind them. Take them to the same restaurant twice and once let them sit next to the wall and the second time have them sit in the open. Or take them to group therapy for PTSD and see what the other patients say to each other when no one is around. The problems are not with the illness, but with the societal implications. Horowitz can only see this where the implications are firmly in the past. I have been accused of malingering over PTSD claims many many times. I have never bee accused of malingering over depression even though the illness is much easier to fake. PTSD is a political illness.

Horowitz clearly sees and discusses how social factors and political movements have shaped our perceptions of PTSD. But he thinks that he can just float above this without taking a stand. Because of the inherent political nature of the illness this is impossible. For instance, you could not write a good short history of the Trump administration without taking a stand on say race, democracy, the economy and Covid. History is essentially normative and PTSD, as Horowitz is aware, is essentially a normative illness.

This means that their is a sort of fake neutrality to the book. For instance, in the chapter dealing with the Recovered Memory Movement, Horowitz writes as if there is no such thing as recovered memory. This is the now dominant view that has been driven by the American insurance industry. In fact, the evidence is clear that it is both possible to suggest fake memories and that actual memories can be repressed. There are plenty of clear well documented examples of both. Writing as if the psychological defense mechanism of repression doesn't exist (something that Horowitz doesn't quite say) is negligent.

Horowitz does say, and he says it a lot, that PTSD is a desirable diagnosis. This is not something that people who treat PTSD would ever say. He clearly thinks that PTSD is now a stigma free diagnosis and that the current situation is that the era of stigmatization is over and that there is a problem with it being over claimed. In a way that is true. But it is either in the context of veterans or people who are basically functional. It is simply not true for the majority of people who suffer from PTSD.

I had to fight for my PTSD diagnosis. I fought so I could get treatment. But I don't go around discussing it in general. You have to know me well before I mention it. That's purely because of the stigma. That stigma does not exist in certain contexts but it still does in others. If you don't believe me, go to any homeless shelter and announce at the top of your voice that PTSD is a stigma free illness and see how that goes. I have known many people with very serious PTSD. If it's serious enough everyone gets the stigma and the stigma you get is directly related to the specific trauma and how severe your illness is.

Furthermore, he is wrong in how he sees the relationship between PTSD and culture. Culture does play a role in how traumatic an event is. Horowitz is right when he explores the relationship between culture and trauma. How traumatic an event is is effected by how abnormal it seems, how much it violates social norms and so on. This Horowitz clearly sees.

But symptoms are absolutely not culturally determined. My symptoms preceded my awareness of the illness by years. That's most people in my opinion. Horowitz is misled by a focus on war where these symptoms are expected. Another thing that happened in my case was that I thought my flashbacks were unusual because they were so short. It turned out that I was misled by Hollywood movies. That's everyone in my experience and a good example of how symptoms are independent from cultural expectations.

As will now be obvious, part of my problem with this book is that it denies the reality of my own experience. It also denies the reality of the experience of those I have known with PTSD. It just feels off.

For instance, Horowitz seems to think that PTSD naturally reduces over time. For whatever it is worth he is entirely wrong about that. PTSD doesn't naturally do anything over time. Mine has gotten worse. I know people where it has gotten better, others where it is mixed. For instance, I know one person whose ability to work improved but who no longer has sex. In my experience the biggest determiner of outcomes is how violent the housing is of a person suffering from PTSD is. Horowitz feels like the kind of author who would never in a million years realize that that is a consideration. He is detached from the reality of the illness.

I think the main problems are two. First, there is a real and problematic divide between practitioners in mental health and researchers. Increasingly, the two fields are divided so that you get practitioners unaware of modern research and researchers who are removed from actual people who suffer the illnesses. I don't know what first hand knowledge Horowitz has of PTSD sufferers, but it wouldn't surprise me if it was very limited. This book reads like a history of France by an incredibly well informed and well read author who has never actually been to France.

Second, and this is my main point. In any history, even short ones, the author should interogate the subject matter. They should take a critical stance. In effect, the writing of history always must be a normative exercise. Horowitz never really says, what everyone else thinks about X is wrong. He doesn't go through this interrogative exercise. Instead he takes a lofty view of the kind that is passed off as how history is done in high school text books.

PTSD is, was and always will be a political illness. Far from being over diagnosed, it is resisted everywhere it raises awkward questions about society. Here is a list of causes of PTSD none of which are ever mentioned in the book and all of which do occur. Severe PTSD can be caused by domestic abuse, extreme psychological abuse (such as convincing your partner they are insane, or credible threats of murder), systemic violence caused by racism (I mean where people are for instance beaten because they are black), systemic violence against the LGBTQ community, police misconduct, prison inherently violent living arrangements of all kinds, and God knows what else. If you've got serious PTSD from one of these sources, good luck getting anyone to take it seriously no matter how close you might have come to death.

For instance, prisons are machines for the manufacture of PTSD, but this raises so many awkward questions about the justice system that there is a collective blindness and silence over a phenomenon more obvious than PTSD from war. PTSD, by its nature inherently raises awkward questions about society, and Horowitz is entirely wrong that it is over diagnosed. As long as society is potentially lethally unjust PTSD will remain political.

I would recommend this book to anyone very familiar with the lived realities of PTSD but not to anyone else. People unfamiliar with actual PTSD cases would be liable to pick up dangerous misconceptions from it. Those familiar with the illness can learn a lot about its history. In a weird way, I would like it if Horowitz tried again at some point in the future. Despite all my criticisms he is a clever man. But he should go to France first.

[Alex The Ninja Squirrel · Rating 2 out of 5]

I'll preface my review by stating that I was already familiar with the historical background of trauma (and the pseudoscience surrounding it) before reading this book, so my opinions about it might to some extent be colored by my not having gotten anything new/useful out of it. In any case, based on Horwitz's previous work and the glowing endorsement from Rosenberg, I was expecting him to provide a short overview of the historical background and then critique the dominance of contemporary psychiatric approaches to trauma (e.g., rigid diagnostic categories, the pathologization of trauma survivors). I was rather disappointed, however, to see how heavily he leaned towards directing suspicion at people reporting post-traumatic symptoms - to the extent that he feels the need to repeat over and over that any given individual could be faking for pecuniary gain and continuously downplay the continued presence of stigma (not to mention the way that deliberately riling up suspicion can contribute to stigma).

For example, Horwitz writes on pages 159-160, "Did the upsurge of PTSD diagnosis among veterans result from a genuine rise in the numbers of long-delayed conditions or from treatment-seekers who were deeply immersed in the culture of PTSD and who knew what responses were likely to obtain compensation? Unlike physical wounds, symptoms of PTSD are self-reported, invisible, and unverifiable. Mental health personnel historically believed that symptoms of PTSD are 'subjective, easily coached, and easily simulated.' According to one recent report, in online forums, 'veterans trade tips on how to behave in their disability evaluations. Common advice: Dress poorly and don’t shower, refuse to sit with your back to the door, and constantly scan the room.' The probability that patients will report traumatic symptoms that they have not in fact experienced is especially high when compensation is involved. Unlike other mental illnesses, a PTSD diagnosis can be a resource that entitles its bearers to obtain monetary and other benefits. Some observers claim that rising rates of PTSD among veterans are a product of a system that promotes disability" - before going on and on about how much money you can make from faking PTSD. The question also appears to involve a false dichotomy. I can think of many reasons why someone might take a long time before seeking psychological help, accommodations, and/or a diagnosis, such as being in denial due to the stigma of mental illness, trying to wing it on one's own and only admitting to needing help after struggling/experiencing failure, only seeking help after extended prompting from family and friends, etc. To be sure, there is legitimate controversy about the extent of PTSD among veterans, including questions related to measurement (e.g., Fisher, 2014), but Horwitz often comes across as biased if not downright hostile. On that note, he seems to assume (or at least imply) that if someone suffered from a pre-existing mental illness simply made worse by traumatic stressors, that fact would be sufficient to dismiss any claims to help, sympathy, and/or compensation. However, people can and do receive compensation for aggravation of existing physical injuries and/or when they suffer preexisting physical conditions - for example, some of the lawsuits in which plaintiffs were awarded damages for asbestos exposure involved known cigarette smokers, and the decision to start smoking cigarettes is of course a conscious choice. In the criminal justice context as well, when it comes to crimes against persons, there's a standard of taking the victim as they're found - for example, it does not matter if a blow to the head only killed a man because he had an unusually thin skull; the person who struck him would be just as guilty of murder.

Horwitz also seems to imply that more recent attempts to provide services and accommodations for trauma survivors, including veterans, has turned people into a bunch of wusses and whiners. While there's a point to be made about the need to foster resilience (e.g., encouraging people to believe they will make a full recovery) and avoid making pessimistic assumptions about how people will respond to stressful live events, there's also something odd about listening to academics and clinicians who have never been in mortal danger in their entire lives (as far as we know) essentially complaining that a soldier hasn't been bombed or shot at enough times to be allowed to experience panic attacks or nightmares about it.

On a more minor note, I noticed that he repeatedly quotes and in the Preface expresses gratitude towards Sally Satel and Paul McHugh, both of whom are prominent conservatives known for rather hostile or dismissive attitudes towards trauma survivors for apparently ideological reasons. Even ignoring McHugh's bigotry and dishonesty when it comes to the LGBTQ community (which, in all fairness, is perhaps not relevant here), McHugh is a right-wing Catholic who has long been invested in denying the extent of sexual abuse perpetrated by Catholic clergy, so it's not exactly surprising that he would want to reduce post-traumatic stress to either feigning or to pre-existing mental illness at most aggravated by disturbing events and at worst just latching onto trauma as an excuse. It's not as if Horwitz is unable to find serious researchers in trauma (e.g., Richard McNally, Allan Young) and memory (e.g., Elizabeth Loftus, Daniel Schacter) or historians of military psychiatry (e.g., Ben Shephard). To me, it very much feels like he decided to make his book a polemic against perceived excesses of sympathy or accommodations for experiencing post-traumatic symptoms, then just started digging for juicy quotes from clinicians who already agreed with him.

Still, the book has its merits. I think it can provide a useful "Short History" (as the title goes) for those not familiar with the history of understandings of trauma in psychiatry. There are a number of other books I would recommend instead, but this is the most concise but general one that I've found to date (whereas the others are a lot more specific to particular areas of psychiatric history).

[Killthehumans Savetheforest · Rating 4 out of 5]

Good. It seems that in addition to not reading the descriptions of books before I start, apparently now I'm not even finishing reading the title. But it worked out okay for once. I was looking for a biology book that could put the scaffolding into a proof/theory-based recovery strategy, but I'll never turn down a medical history.

I wonder how long it will take to stop imagining "killing a horse with a baseball bat". I have no recollection of what their point to that story was, and I don't remember the next 5 minutes.

[Anna · Rating 3 out of 5]

hopefully i finish my paper lmao

[Hilary Cockshaw · Rating 3 out of 5]

Audiobook

[Christina · Rating 4 out of 5]

❤️‍🔥 40 pages of research notes/annotations ❤️‍🔥

It was indeed a history book, on how PTSD came to be seen in society from WWI to time of publication.