On Science

Following Combat and Civilian Traumas

Now called post-traumatic stress disorder, ‘shell shock’ is still with us

By Josie Glausiusz | July 30, 2014
Artwork made by participants of the Alola Foundation's
Artwork made by participants of the Alola Foundation's "Women for Peace" conference, held in Timor-Leste in 2009. (Photo by AusAID)


In September 1917, the weekly journal Nature published a lively exchange between the authors of a book entitled Shell Shock and Its Lessons and a critic of the book. The authors—G. Elliot Smith and T.H. Pear, a professor of anatomy and a lecturer in psychology at the University of Manchester—are accused of being “out-and-out environmentalists,” and the critic, Robert Armstrong-Jones, argues that “a family history of insanity, epilepsy, paralysis, neurasthenia or parental alcoholism has been obtained in 33 percent of all cases of shell shock.” Among the soldiers suffering from shell shock are “men who before the war were the strongest, bravest, most daring, yet level-headed, members of the community, and with a clean and untainted family history,” the authors counter.

Shell shock’s symptoms ranged from diarrhea to delusions, unrelenting nightmares, and even blindness. Its cause was much debated at the time. In the early stages of World War I, shell shock was believed to result from nerve injury, perhaps due to concussion caused by exploding shells. Later, it was thought that the colossal divide between exposure to the war followed by the return to civilian life could trigger extreme psychological trauma.

A century after the outbreak of World War I on July 28, 2014, post-traumatic stress disorder (as it is now known) is still of tremendous significance. PTSD took a big toll on Vietnam-era soldiers and today affects seven to 20 percent of U.S. veterans of the wars in Afghanistan and Iraq. According to a Institute of Medicine report, treatment is often inadequate, ad hoc, or chaotic. Recent evidence suggests that a tendency of combat soldiers to develop PTSD may indeed be genetic: a 2013 study of Israeli combat soldiers showed that those predisposed to avoid threats—an inclination associated with a variant of a gene that controls the transport of serotonin, a transmitter of nerve signals—may be at greater risk of PTSD.

But two other newly published studies—one conducted in Norway, the other in Timor-Leste (the former Indonesian colony of East Timor)—show that previous exposure to abuse, violence, or war may dramatically increase the risk of the disorder.

The Norwegian study, led by Dag Ø. Nordanger of the Regional Centre for Child and Youth Mental Health and Child Welfare in Bergen, examined post-traumatic stress reactions among 10,220 adolescents after the so-called Oslo Terror events of July 22, 2011. (A right-wing extremist named Anders Behring Breivik blew up eight people with a bomb planted near an Oslo government building, then shot and killed 69 people, most of them teenagers, at a youth camp on the island of Utoeya.) Nordanger and his colleagues found that prior exposure to violence or unwanted sexual acts were predictors of post-traumatic stress among adolescents, perhaps because the Oslo Terror provided a strong reminder of earlier trauma the teens had experienced.

The perpetual menace of new bloodshed affects mental health workers, as well, according to Derrick Silove, professor of psychiatry at the University of New South Wales, Sydney, and the lead author of the Timor-Leste study. Following the country’s independence from Indonesia in 2002, he and his colleagues examined 1,022 adults in 2004 and again in 2010-11. They found that the incidence of PTSD jumped sevenfold—from two percent to nearly 17 percent—following a period of civil unrest in 2006-07. It was most likely to develop in women and in those who had witnessed murder or human rights violations during the 1975-1999 Indonesian occupation.

“There also is a toll on counselors listening to repeated trauma stories (particularly as many have been exposed to the same traumas themselves),” Silove wrote to me in an email. Treating PTSD among a poverty-stricken population, he adds, “remains a major challenge,” as intensive training of counselors is costly. Although “short psychotherapeutic interventions” are being tested around the world, Silove says, “the main ‘intervention’ continues to be ‘social,’” which he describes as “repair of conditions of safety, security and control so that there is the best chance of natural recovery.”

In September 1917—well before the armistice of November 11, 1918—Europe was still very far from any form of recovery, and the authors of Shell Shock and Its Lessons were fighting their own battle to provide treatment for shell-shocked soldiers. Whether or not the anxieties were caused “by the terrifying experiences of warfare or the worries of civil life,” they saw an “urgent need for the establishment of clinics in which patients afflicted with mental disturbance can be treated while they are still sane.”


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