In WWI, the psychological distress of soldiers was attributed to concussions caused by the impact of shells; this impact was believed to disrupt the brain and cause “shell shock” (Bentley, 2005). Shell shock was characterized by “the dazed, disoriented state many soldiers experienced during combat or shortly thereafter” (Scott, 1990, p. 296). However, even soldiers who were not exposed to exploding shells were experiencing similar symptoms (Scott, 1990). Thus, it was assumed that soldiers who experienced these symptoms were cowardly and weak. Treatment was brief, consisting only of a few days of comfort, with the “firm expectation that the soldier return to duty” (Scott, 1990, p. 296). Because 65% of shell-shocked soldiers ultimately returned to the front lines, treatment was considered a success (Scott, 1990).
Meanwhile, some scholars were questioning the term, ‘shell shock,’ almost as soon as it came into existence. For example, Smith and Pear (1918) preferred the term, ‘war strain’ to ‘shell shock’ because they believed the latter to be “a popular but inadequate title for all those mental effects of war experience which are sufficient to incapacitate a man from the performance of military duties” (pp. 1-2). These scholars also countered the common misconception of the time that the condition resulted in “shock,” described as lack of reason or lack of senses. Rather, they stated,
“Whatever may be the state of mind of the patient immediately after the mine explosion, the burial in the dug-out, the sight and sound of his lacerated comrades, or other appalling experiences which finally incapacitate him for service in the firing line, it is true to say that by the time of his arrival in a hospital in England, his reason and his senses are usually not lost but functioning with painful efficiency. His reason tells him quite correctly, and far too often for his personal comfort, that he had not given, or failed to carry out, a particular order, certain disastrous and memory-haunting results might not have happened. It tells him, quite convincingly, that in his present state he is not as other men are. Again, the patient reasons, quite logically, but often from false premises, that since he is showing certain symptoms which he has always been taught to associated with ‘madmen,’ he is mad too, or on the way to insanity. If nobody is available to receive this man’s confidence, to knock away the false foundations of his belief, to bring the whole structure of his nightmare clattering about his ears, and finally, to help him rebuild for himself (not merely to reconstruct for him) a new and enlightened outlook on his future—in short, if he is left alone, told to ‘cheer up’ or unwisely isolated, it may be his reason, rather than the lack of it, which will prove to be his enemy…In a word, it is not in the intellectual but in the emotional sphere that we must look for terms to describe these conditions. These disturbances are characterized by instability and exaggeration of emotion rather than by ineffective or impaired reason” (Smith & Pear, 1918, pp. 2-3).
The authors go on to suggest that a thorough account of the patient’s history before and during the war is essential; while some would conclude that the common thread between all cases of shell shock was the shell explosion itself, it became clear that the symptoms of shell shock were present before the explosions, which happened to be the “last straw” (Smith & Pear, 1918). Rather, the trigger for war strain was considered to be intense emotional arousal and the subsequent suppression of sympathy for others, as well as fear (Smith & Pear, 1918). Resulting symptoms were believed to include,
“loss of memory, insomnia, terrifying dreams, pains, emotional instability, diminution of self-confidence and self-control, attacks of unconsciousness or of changed consciousness sometimes accompanied by convulsive movements resembling those characteristic of epileptic fits, incapacity to understand any but the simplest matters, obsessive thoughts, usually of the gloomiest and most painful kind, even in some cases hallucinations and incipient delusions…[These symptoms] make life for some of their victims a veritable hell” (Smith & Pear, 1918, pp. 12-13).
Another stress theory that arose during this time was “war neurosis,” proposed by Sigmund Freud. Freud did not write extensively about the topic, but his colleagues, Sandor Ferenczi, Karl Abraham, Ernst Simmel, and Earnest Jones, took interest in it and published a book entitled, “Psycho-Analysis and the War Neuroses” (1919). Freud wrote the introduction to this book. In the following passage, Freud explains his conceptualization of war neuroses as brought about by conflicts between soldiers’ “war egos” and “peace egos”:
“The war neuroses, in so far as they differ from the ordinary neuroses of peace time through particular peculiarities, are to be regarded as traumatic neuroses, whose existence has been rendered possible or promoted through an ego-conflict…The conflict takes place between the old ego of peace time and the new war-ego of the soldier, and it becomes acute as soon as the peace-ego is faced with the danger of being killed through the risky undertakings of his newly formed parasitical double. Or one might put it, the old ego protects itself from the danger to life by flight into the traumatic neurosis in defending itself against the new ego which it recognizes as threatening its life” (Ferenczi, Abraham, Simmel, & Jones, 1919, pp. 2-3).
Freud also points out that war neurosis is best treated by the cathartic method of psychoanalysis. Indeed, after the war, Freud was called upon by the Austrian War Ministry to give his opinion about the rumored brutal treatment of psychologically wounded soldiers by Army Doctors (Freud Museum London, n.d.). In 1920, he submitted a memorandum entitled, “Memorandum on the Electrical Treatment of War Neurotics.” Consistent with the views expressed in the introduction to “Psycho-Analysis and War Neuroses” (Ferenczi et al., 1919), Freud attested that war neurosis had psychical causes that were best treated with psychoanalysis rather than electrical shock treatment. The full memorandum can be read on the Freud Museum London website, found here: http://www.freud.org.uk/education/topic/10574/freud-and-the-war-neuroses/
By the end of WWI, psychiatrists began to believe that what had been known as “shell shock” was the result of emotional problems rather than physical injury of the brain. Although this realization was a step forward in the conceptualization and treatment of PTSD, psychiatrists continued to believe that soldiers who were “weak” were predisposed to the condition (Bentley, 2005). Thus, their primary aim was to use psychiatric testing to screen out those they believed would sustain psychological casualties in war (Bentley, 2005). There also continued to be doubts among some military professionals about the legitimacy of the condition. One military medical officer, Thomas Salmon, said of the disease, “War neurosis which persists is not a creditable disease to have…as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies…no one should be permitted to glorify himself as a case of ‘shell shock’” (Magee, 2006).
Bentley, S. (2005). Short history of PTSD: From Thermopylae to Hue soldiers have always had a disturbing reaction to war. Vietnam Veterans of America: The Veteran. Retrieved from http://www.vva.org/archive/TheVeteran/2005_03/feature_HistoryPTSD.htm
Ferenczi, S., Abraham, K., Simmel, E., & Jones, E. (1919). Psycho-analysis and the war neuroses. London: The International Psycho-Analytical Press. Retrieved from http://books.google.com/books?id=5tyo14DXM8AC&printsec=frontcover&dq=Psycho-Analysis+and+War+Neuroses&hl=en&ei=chLZTq-BHYXs0gHShaDTDQ&sa=X&oi=book_result&ct=result&resnum=1&ved=0CDQQ6AEwAA#v=onepage&q&f=false
Freud Museum London (n.d.). Freud and the war neuroses. Retrieved from http://www.freud.org.uk/education/topic/10574/freud-and-the-war-neuroses/
Magee, D. (2006, May 15). PTSD: Only the name has changed. WCF Courier. Retrieved from http://wcfcourier.com/news/metro/ptsd-only-the-name-has-changed/article_394eabda-6a67-5b42-ab5b-2643c4158f11.html
Scott, W. J. (1990). PTSD in the DSM-III: A case in the politics of diagnosis and disease. Social Problems, 37(3), 294-310. Retrieved from http://www.jstor.org/stable/800744?seq=3
Smith, G. E., & Pear, T. H. (1918). Shell shock and its lessons. Manchester: University Press. Retrieved from http://books.google.com/books?id=zCQ6AAAAMAAJ&printsec=frontcover&dq=shell+shock&hl=en#v=onepage&q&f=false