Psychological trauma was recognized by the early Greeks as both a source, and a consequence of great mental distress. Indeed, the English word ‘trauma’ derives from the ancient Greek word τραῦμα which means simply: ‘wound’. And so the fore fathers of medicine, working from a diagnostic system that remarkably, is recognizable and functional to us some 3,000 years later, understood that the traumatized individual was in a fundamental way, wounded. Asclepiades of Bithynia was perhaps the first physician to discern the importance of the humane treatment of the psychologically traumatized individual. Bitterly opposed to Hippocrates whose name and methods still form the basis of medical ethics and practice today, Asclepiades could in a sense be regarded as the first historical figure recognisable to us as a psychotherapist. His motto cito tuto jucunde (swiftly, safely, sweetly) was based on the principle of the restoration of mental and emotional harmony to the distressed individual. He refered to this state of mental wellbeing as the ‘psychogenic equilibrium’. Many of his treatments (like that of Hippocrates of whom he was so critical) were based around the use of hot baths, massages, soft music and the liberal prescription of wine.
Moving from the ancient world through to the modern, the first real movement towards the understanding of trauma as a neuropsychological phenomenon can be traced to the late 19th century. It emerged from the work of a number of key individuals at the time (including Freud and Janet) but the key contribution was primarily from the work of French neurologist Jean Martin Charcot, a physician working with traumatized women in the Salpêtrière hospital in Paris. Charcot’s main area of practice, study and research was a condition known then as hysteria, a commonly diagnosed condition believed to occur only in women. Charcots’ records of hysterical symptoms included sudden unexplained episodes of sudden paralysis, amnesia, sensory loss, and convulsions. The prevailing medical theory of the time was that since all of the patients with hysteria were women, the symptoms were thought to originate in the uterus.
It is worth remembering today that until Charcot, the common treatment for hysteria was a hysterectomy. Charcot was the first to understand that the origin of hysterical symptoms was not in the womb but in the nervous system. He was the first to observe and note that traumatic events could induce a “hypnotic state” — the first accurate observation and descriptions of the dissociative state we now know to be one of the main symptomatic hallmarks of psychological trauma. He seems to have known intuitively that the vacant hypnotic “thousand-yard” gaze of his female patients was somehow the end result of the brain having endured an unbearable experience that forced the changes he observed and recorded accurately.
Building on the work of Charcot, Janet and others, the twentieth century saw the conceptualisation of psychological trauma through the horrific wars fought throughout it. “Shell shock”, the first term to appear in the modern medical lexicon was used by the British to describe soldiers that after periods of constant artillery bombardment would develop symptoms that at one extreme gave the appearance of the individual being “mentally vacant” (held by some that it was the observation of this state of “mental vacancy” after these soldiers returned home that the origins of the phrase “the lights are on but no one’s at home” arose). At the other extreme were symptoms of panic, terror, nightmares, flashbacks. It was commonly said of these men that they “never came home from the war”. It is a cruel irony that this is, if viewed from a neuropsychological perspective, actually true. With the second world war, the term was changed to “battle fatigue” and in the Korean war, “operational exhaustion”. These terms were in essence all describing the same constellations of symptoms that Charcot first categorized and recorded.
It was however, the Vietnam war, combined with large social movements during the 1960s such as the civil rights movement, women’s liberation and others that really made the push in scientific research towards an eventual diagnosis: post-traumatic stress disorder (PTSD for short). The inclusion of PTSD in the DSM III published in 1980 meant that for the first time, the medical profession (and society by extension) recognized the profoundly debilitating after effects that plagued war veterans exposed to the horrors of combat and that these after effects could be ongoing for months or even years after the war had ended. A simple diagnostic system consisted of 3 broad categories of symptoms:
- Re-experiencing: the traumatized individual in some way continually re-experiences the events indicating that there was a qualitative difference in these individuals’ memory systems.
- Numbing: methods that these individuals would use to avoid their emotional and psychological distress
- Hyperarousal: a heightened and uncomfortable state characterized by high levels of anxiety, physiological arousal, hypervigilance, and symptoms characteristic (as we now know) of an overactivated sympathetic nervous system.
Over the last 35 years, the diagnostic criteria for PTSD has been changed and refined to the one that we now have in the DSM 5 (published in 2013). But even as our understanding increases and our diagnostic tests and criterion become more refined and advanced, there remains at the heart the same individual that Asclepiades saw over 3,000 years ago, the individual who is wounded.