Photograph by Universal History Archive, UIG/Getty
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A Canadian soldier surveys the aftermath of the 1917 Battle of Passchendaele in Belgium. Hundreds of thousands of people who served in WWI survived with what would now be called post-traumatic stress disorder (PTSD).

Photograph by Universal History Archive, UIG/Getty

How PTSD went from ‘shell-shock’ to a recognized medical diagnosis

The symptoms of post-traumatic stress disorder have been recorded for millennia, but it took more than a century for physicians to classify it as a disorder with a specific treatment.

The battles were over, but the soldiers still fought. Flashbacks, nightmares, and depression plagued them. Some slurred their speech. Others couldn’t concentrate. Haunted and fearful, the soldiers struggled with the ghosts of war.

Which war? If you guessed Vietnam, the U.S. Civil War, or even World War I, you’d be wrong. These soldiers’ symptoms were recorded not on paper charts, but on cuneiform tablets inscribed in Mesopotamia more than 3,000 years ago.

Back then, the ancient soldiers were assumed to have been hexed by ghosts. But if they were treated today, they would likely receive a formal psychiatric diagnosis of post-traumatic stress disorder (PTSD).

Although the diagnosis has its roots in combat, the medical community now recognizes that PTSD affects civilians and soldiers alike. Patients develop PTSD after experiencing, learning about, or witnessing a traumatic event—defined as “actual or threatened death, serious injury, or sexual violence”—and their intrusive symptoms affect their ability to cope in the present.

Nearly seven percent of American adults will likely experience PTSD during their lifetimes, but it took hundreds of years, and the dawn of industrial-scale warfare, for society to recognize the deleterious physical and mental effects of experiencing, witnessing, or becoming aware of traumatic events.

"Traumatic hysteria"

Medical historians have documented many early accounts of what would now be classified as PTSD. There’s Herodotus’ description of an Athenian soldier who became blind after witnessing the Battle of Marathon in 490 B.C., and a Shakespearean monologue in Henry IV, Part 1 in which Lady Percy describes her husband’s sleeplessness and inability to enjoy life after fighting a battle. Then there are more modern descriptions, like accounts of Civil War combatants who developed what their doctors called “soldier’s heart.”

But though early physicians looked for a physical cause, it wasn’t until the 1880s that psychiatrists connected the symptoms to the brain. At the time, women who expressed vehement emotions were labeled with “hysteria,” a condition that supposedly arose from the uterus. When French neurologist Jean-Martin Charcot saw similar symptoms in men, he chalked them up to traumatic events—rather than biological destiny—and the term “traumatic hysteria” was born.

“The concept of trauma was entangled with feminine weakness from the beginning,” says MaryCatherine McDonald, a historian of PTSD who works as an assistant professor of philosophy and religious studies at Old Dominion University. And when World War I blasted onto the scene, it challenged a common conviction that psychological steadiness was a matter of personal character, masculinity, and moral strength.

Shell shock and combat fatigue

From aerial combat to poison gas, WWI introduced terrifying new combat technology on a previously unimaginable scale, and soldiers left the front shattered. Seemingly overnight, the field of war psychiatry emerged and a new term—shell shock—appeared to describe a range of mental injuries, from facial tics to an inability to speak. Hundreds of thousands of men on both sides left World War I with what would now be called PTSD, and while some received a rudimentary form of psychiatric treatment, they were vilified after the war. As historian Fiona Reid notes, “shell-shock treatment was constantly entwined with discipline” in militaries that had trouble aligning their beliefs in courage and heroism with the reality of men who bore invisible wounds.

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An American soldier in WWII suffering from "battle shock" is given a sedative by a medic. Terms like "battle shock," “psychiatric collapse,” “combat fatigue,” and “war neurosis” were used to describe PTSD symptoms during World War II.

By World War II, psychiatrists increasingly recognized that combat would have mental health ramifications—and concluded that too many men who were prone to anxiety or “neurotic tendencies” had been selected to serve in the previous war. But though six times as many American men were screened and rejected for service in the lead-up to the World War II, military service still took its toll. About twice as many American soldiers showed symptoms of PTSD during World War II than in World War I. This time their condition was called “psychiatric collapse,” “combat fatigue,” or “war neurosis.”

Military officials assumed that removing men from combat situations or treating them with injections of drugs such as sodium amytal would relieve their psychiatric distress. It didn’t work: Nearly 1.4 million of the 16.1 million men who served in World War II were treated for combat fatigue during the war, and the condition was responsible for 40 percent of all discharges.

Post-Vietnam syndrome

A growing recognition of the ubiquity of psychiatric injury during war prompted more compassionate approaches to traumatized veterans. “The soldier suffers in the modern war situation a privation hard to equal in any situation in civilian or even primitive life,” wrote psychiatrist Abram Kardiner, whose 1941 book The Traumatic Neuroses of War helped change views of what is now known at PTSD. But despite a growing recognition of the unique stresses of combat, as well as studies that showed the effects of war could last for decades, soldiers continued to face out-of-date views on their ability to bounce back from combat-related psychiatric distress.

In 1952, the American Psychological Association published the Diagnostic and Statistical Manual of Mental Disorders (DSM), the closest thing psychiatry has to a bible. The handbook helps professionals diagnose mental illnesses and strongly influences everything from research to public policy to health insurance. But veterans’ symptoms were categorized under disorders like depression or schizophrenia instead of being recognized as a distinct diagnosis.

Enter “Post-Vietnam syndrome,” a term coined in 1972 by psychiatrist Chaim Shatan. By then, Vietnam veterans had been returning home for years, and many were beset by emotional numbness, volatility, flashbacks, and rage. In part because many experienced delayed symptoms, veterans had trouble accessing treatment and benefits despite their invisible wounds.

With Horses' Help, Army Veteran Finds Healing in Yellowstone Green Beret and Army veteran Ray Knell was a broken man with PTSD and severe anxiety when he returned home from Afghanistan. His trust in humans was gone. A friend introduced him to backcountry horsemanship, and the wilderness and animal relationship gave him hope and peace of mind. To inspire others to use wilderness and horses to overcome their struggles, Knell embarked on a 1,000-mile ride along the Continental Divide with Mustang Sally and two mules, Top Gun and Magic. Filmmaker Ben Masters joined Knell through Yellowstone to see the grandeur of our country’s first national park and to witness the importance of conserving wilderness to heal ourselves.

Increasingly, veterans turned to what psychiatrist Robert Lifton called “street corner psychiatry”—veteran self-help communities who often combined their healing with anti-war protests. Along the way, they met clinicians and researchers like Lifton and Shatan, who began to advocate for the DSM to include some kind of post-combat stress diagnosis. In 1980, “post-traumatic stress disorder” became a formal diagnosis in the DSM’s third edition. Twelve years later, it was also adopted in the World Health Organization’s International Classification of Diseases.

Invisible wounds

Today’s definition of PTSD is more inclusive than ever—and the condition is recognized among survivors of sexual abuse or assault, health crises and surgeries, natural disasters, bereavement, mass shootings, accidents, and more. PTSD is associated with everything from flashbacks and nightmares to hypervigilance, problems concentrating, amnesia, dissociation, and negative beliefs about themselves or others.

With every passing year, researchers develop new treatments for PTSD and learn more about how trauma affects the brain and body. They are also grappling with the possibility that the effects of trauma and stress can be passed from one generation to the next through chemical changes that effect how DNA is expressed. A 2018 study, for example, found high mortality among the offspring of men who survived Civil War prison camps in the 1860s. Scientists are still sparring over an earlier study that suggested the offspring of Holocaust survivors inherited a different balance of stress hormones than their peers.

Other researchers, like Jessica Graham-LoPresti, push against the limitations of the official PTSD diagnosis itself. A clinical psychologist and assistant professor at Suffolk University, Graham-LoPresti studies the effects of systemic racism on African-Americans. “People of color experience a lot of symptoms in response to the frequency and pervasiveness of racism that mirror the symptoms of PTSD,” she says, noting that watching footage of police brutality can exacerbate the fears and stresses of lives already touched by pervasive racist experiences. “This is not new, but [this imagery is] causing a lot of hypervigilance, emotional responses of stress and anxiety, and feelings of helplessness and hopelessness.”

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School children warily eye "Rudy," an emotional support dog brought in on the first day of school following the devastating Kincade Fire in northern California in 2019. Many of the children suffer from PTSD symptoms due to the frequency of the fires in the area.

But though the current definition of PTSD considers experiencing or witnessing a single incident of racialized terror an inciting incident, it doesn’t allow for the microaggressions and intergenerational dynamics African-Americans experience every day. “It’s a complicated conversation,” says Graham-LoPresti. “It is so new, and researchers of color are starting to get a lot of pushback because the field is so overwhelmingly white.”

As Graham Lo-Presti works to connect the dots between racism and PTSD, her colleagues are considering the potential effects of another pandemic: COVID-19. Psychiatrists are bracing for a flood of patients traumatized both by surviving the illness and losing their loved ones to it. In the wake of the SARS epidemic in Hong Kong in 2003, some patients and healthcare workers developed PTSD—and in a variety of studies, people who were quarantined exhibited more signs of post-traumatic stress than people who were not.

But that doesn’t mean that everyone who lives through a traumatic event will develop PTSD—or that those with post-traumatic stress disorder can’t find healing and joy. As with other chronic illnesses, PTSD can go into remission—and as the study of PTSD matures, researchers have come to appreciate the brain’s heroic attempts to heal itself after traumatic events.

“It’s such a destructive idea to think that PSTD is dysfunction,” says McDonald. “We’re getting it fundamentally wrong when we think it’s a sign of brokenness. It’s the sign of the impulse to survive.”