Evolution and Posttraumatic Stress

Disorders of Vigilance and Defence

Chris Cantor

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781135448509
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Posttraumatic Stress Disorder remains one of the most contentious and poorly understood psychiatric disorders. Evolution and Posttraumatic Stress provides a valuable new perspective on its nature and causes.

This book is the first to examine PTSD from an evolutionary perspective. Beginning with a review of conventional theories, Chris Cantor provides a clear and succinct overview of the history, clinical features and epidemiology of PTSD before going on to introduce and integrate evolutionary theory. Subjects discussed include:

The evolution of human defensive behaviours

A clinical perspective of PTSD

Defence in overdrive: evolution, PTSD and parsimony

This original presentation of PTSD as a defensive strategy describes how the use of evolutionary theory provides a more coherent and successful model for diagnosis, greatly improving understanding of usually mystifying symptoms. It will be of great interest to psychiatrists, psychotherapists, psychologists, and anthropologists.

Part I
Posttraumatic stress disorder

An introduction

We rarely think people have good sense unless they agree with us.

François de la Rouchefoucauld, 1613–1680

Chapter 1
A brief history of PTSD

When a thing ceases to be a subject of controversy, it ceases to be a subject of interest.

William Hazlitt, 1778–1830

The long and the short

Posttraumatic stress disorder was once thought to be relatively uncommon, but recent estimates suggest that between 10 and 39 per cent of people will suffer it during their lives (Breslau et al. 1998; Kilpatrick and Resnick 1992). For many the disorder becomes chronic and disabling. In 2002 a class action suit was brought by 2000 British service personnel against the UK Ministry of Defence relating to psychological trauma sustained in conflicts including Northern Ireland, the Falklands, Bosnia and the first Gulf War. The action was largely unsuccessful, in part because of shortcomings in our factual base regarding psychological trauma prevention, but it nevertheless sounded a loud warning for the future (Bisson 2003). PTSD can no longer be ignored. In the search for knowledge there is a tendency to repeat research confirming what we already know, as opposed to probing new territory (McFarlane and van der Kolk 1996b). This book ventures into new territory. PTSD simply put is a complex and persistent reaction to severely threatening life experiences. It has an irrational or phobic quality, but unlike ordinary phobias it usually involves other elements, particularly a marked irritability or aggression. I will briefly describe two typical cases to orientate those unfamiliar with it.

An experienced policeman was called to a minor football match when the crowd of mainly intoxicated young adults became unruly. The rowdy contingent constituted over a hundred individuals. Prior experiences suggested that such youngsters generally settled down when diplomatically confronted. Unexpectedly, the policeman’s partner was struck from behind. He went to his partner’s aid and was himself struck from behind. He recalls being in a dazed state struggling with someone who was trying to remove his pistol from its holster. Eventually fourteen police officers brought the crowd under control. Subsequently, he struggled with the unexpectedness of what had transpired and his sense of powerlessness. He started shaking when called to domestic incidents. Two years later he has had to abandon his police career, he has difficulty sleeping, cannot cope with his anxiety in shopping centres, avoids watching television news because of its crime and war coverage, is highly socially reclusive, is irritable and particularly prone to automatically overreacting with uncharacteristic aggression to minor loutish behaviour in public, despite no longer carrying any policing responsibilities.

A government worker visited a remote rural household unaware of the householder’s anti-government sentiments. She was confronted by the householder with a rifle in an obviously highly disturbed state of mind. She had no doubt that the householder meant to kill her. She compassionately identified with the householder’s distress and her skilled negotiation of the situation probably saved her life. Subsequently, over several months she lost confidence in her work and eventually had to pursue medical retirement. Four years later, she remains socially avoidant and prone to fleeing from the few friends she does visit, if their voices become raised. She cannot sleep, is highly on edge when away from her home and is irritable. Minor day-to-day hassles become mountains for her. At interview she is recurrently overaroused and fragile, quite able to understand her abnormal reactions but relatively powerless to control them.

Having given you a taste of the condition, I need to make three key points regarding the history of PTSD. The first is how long it is; the second is how short it is; and the third is how blurred it is.

The early history of PTSD has been traced back to descriptions of trauma resembling PTSD in the pre-Christian period (Parry-Jones and Parry-Jones 1994). From the nineteenth century onwards a bewildering array of labels and concepts were described. These have included: ‘spinal concussion’, ‘railway spins’ and ‘irritable heart’ from the 1860s; ‘soldier’s heart’ and ‘cardiac weakness’ from the 1870s; ‘traumatic shock’, ‘traumatic neurosis’, ‘hysterical hemianaesthesia’, ‘spinal irritation’, ‘railway brain’ and ‘nervous shock’ from the 1880s; ‘anxiety neurosis’ and ‘psychical trauma’ from the 1890s; ‘traumatic neurosis’, ‘shell fever’, ‘irritable heart of soldiers’, ‘mental shock’, ‘war shock’, ‘shell shock’, ‘neuro-circulatory asthenia’, ‘disordered action of the heart’ and ‘war psychoneurosis’ from the 1910s; ‘cardiac/war neurosis’ from the 1930s; and ‘battle fatigue/combat exhaustion’ and ‘effort syndrome’ from the 1940s (Parry-Jones and Parry-Jones 1994). Yet it was only as recently as 1980 that PTSD gained official recognition.

The above references to ‘railways’ relate to the early era of train travel, with one notable victim being the author Charles Dickens. When travelling by train, a crash had left his carriage swaying precariously from a bridge. On emerging, he saw dead and injured all around, but like a true professional went back to his carriage to get his manuscript. One year later Dickens noted, ‘I have sudden vague rushes of terror, even when riding in a hansom cab, which are perfectly unreasonable but quite unsurmountable’ (Beveridge 1997). His daughter suggested he never fully recovered. He died on the fifth anniversary of this train crash. Another British writer, Samuel Pepys, is also thought to have suffered PTSD, following the Great Fire of London in 1666. His subsequent irritability seems to have made him a boorish guest at London’s celebrity dinners (Daly 1983).

The world wars

While railways heavily influenced the study of psychological trauma in the nineteenth century, wars were the dominant influences in the twentieth century. The First World War resulted in 80,000 British soldiers presenting with symptoms of ‘shell shock’ (Beveridge 1997). This embarrassed not only the military establishment but also British psychiatry, which until then had emphasized degeneracy and feeble minds. The fact that officers were five times more likely to develop psychiatric disorders than their fellow men helped reduce such bigotry and mobilize at least transient sympathy (Shephard 2002). However, in the years following the war the economic costs of unprecedented psychological casualties of war soon eroded the British government’s sympathy. While the social intolerance of British veterans’ ‘weaknesses’ was appalling (McFarlane and van der Kolk 1996a), in Germany it was even worse. Their fallen heroes were accused of being moral invalids not only for breaking down mentally but also for having failed to return victorious (van der Kolk et al. 1996b).

Generally psychiatry has had an ambivalent orientation with the notion that psychological trauma can profoundly and at times permanently alter brain functioning. Then and subsequently, there have been periods of fascination with and sympathy for those with PTSD, alternating with disbelief and condemnation (Shephard 2002).

Reviewing the contemporary descriptions of traumatic stress reactions is confusing as the accounts are through the eyes of writers of the time, there were no reliable research studies and the timing of presentations is confused. Acute stress reactions at the source of the stress – near the front lines – inevitably will be more dramatic than those removed from it, and from those months or years later. Hysteria, rightly or wrongly, was often diagnosed. This confuses but does not negate PTSD, as there is no reason why the two should not coexist. Accounts of bizarre motionless posturing suggestive of hysteria (these days called conversion or dissociative disorders) were common in both world wars (Shephard 2002).

Hysterical disorders have as a central characteristic the inability of individuals to face the sources of their traumas. While this is readily understandable in psychological terms, it is commonly encountered in the context of other medical or psychological illnesses, which often go overlooked. One of the ‘medical’ causes that would have fuelled hysterical reactions in the hideously long trench-warfare engagements of the First World War would have simply been exhaustion. This combined with artillery shelling and mortality on a scale never before experienced would have fuelled both hysterical and PTSD reactions. The futility of some battles, such as the Somme, would have massively added perceptions of uncontrollability and hopelessness to the soldiers’ experiences. We will later see that uncontrollability is a particularly powerful inducer of anxiety states.

One lesson had seemed to have been learnt from the First World War – that the cost of loss of fighting men by inappropriate psychological management was too great to ignore. Nevertheless, come the Second World War, it was disregarded. Winston Churchill, the British Prime Minister, was less than enamoured with the prospect of allowing psychiatrists and psychologists any chance of influencing the forthcoming torrent of casualties (Shephard 2002). The total annual cost of mental health services allocated to the British Army at that time has been estimated as the same as the cost of running the war for one hour and twenty minutes.

Whereas the First World War often involved lengthy immersion in the extreme horrors of the trenches, the Second World War generally meant briefer but at times more intense combat contacts, alternating with removal from the front line (Shephard 2002). This was most obvious in the air forces, where a pilot could wake up in relative comfort, spend the day flying while attempting to defy the high odds of being killed, to return from such hellish experiences to the comforts of home by the day’s end.

Early conceptualization of traumatic reactions

The late nineteenth and early twentieth centuries were influenced by more notable writers in the field than I can describe in this short review, but brief orientation is desirable. ‘Railroad spine’ of the nineteenth century was emphatically ‘organic’ to some and ‘psychological’ to others, reflecting an unhealthy polarity of conceptualization that is slowly receding.

Pierre Janet, the French psychologist and neurologist, suggested that emotions may make events traumatic by interfering with the integration of experience into existing memory schemes. They are stored instead as anxiety phenomena or visual images that might resemble the emergency responses, but have little bearing on the current experience (van der Kolk 1994). Janet’s work on the splitting or dissociation of conscious awareness of trauma in the early 1900s was quickly put to sleep for the middle part of the twentieth century, only to be rediscovered in the 1980s (van der Kolk et al. 1996b).

Sigmund Freud’s work emphasized the destructive effects on the psyche of early sexual trauma (van der Kolk 1994). Although he expressed hope that neurophysiology would eventually explain many of his findings, his work at a time of primitive understanding of such issues contributed to the further separation of the mind from the brain.

Abram Kardiner (1941) more than anyone else in the middle twentieth century contributed positively to the limited progress of that era (van der Kolk et al. 1996b). Kardiner noticed the enduring vigilance of those suffering traumatic neuroses. He described this as a ‘physioneurosis’, a word that implied reuniting the physiological with the conflictual. His reconceptualization is highly relevant to the theories I later propose.

Science and politics in recent times

It would be nice if it could be said that mental health could have carried on from where Kardiner left off. However, the reality is that the former appeared to be in a state of scientific slumber. When the study of trauma finally reawakened it was due more to politics than scientific progress (Shephard 2002).

The influential American Psychiatric Association (APA) classificatory series known as the Diagnostic and Statistical Manual(s) of Mental Disorders (DSM) has both reflected and helped steer trauma-related psychiatry in the second half of the twentieth century. The first and second editions of the DSM series emphasized individual vulnerability with respect to trauma (Yehuda and McFarlane 1995). These early DSM editions had moved from feeble minds to neurotic ones. It was only in the third edition of the DSM series in 1980 (DSM-III) that PTSD gained official recognition, with a more balanced orientation (APA 1980). It would be tempting to think that psychiatry had become enlightened, but the acceptance of PTSD in the DSM-III was more about political lobbying than the wisdom of the profession. The Vietnam War had generated a band of advocates among the public who were not inclined to take ‘no’ for an answer (Shephard 2002).

While the DSM-III was a genuine milestone from both human rights and scientific perspectives, the phenomenologically symptom-based (as opposed to a basis in theory) orientation of the DSM series has decontextualized psychiatry. The multiple squabbling and divergent factions in mental health could not agree on causation of the many disorders, so the DSM largely banished causal factors from its diagnostic schemes. Agreement on symptom patterns was elevated to a far higher status than understanding what their underlying causes might be. Generally in medicine causation forms the basis of diagnostic classification. ‘Chest disease’ might have been acceptable as a diagnosis a few millennia ago. These days, specific subcategories based on causes such as tuberculosis, cancer, asthma, etc. are required. Mental health is yet to have the confidence necessary for consensuses on causation. Research was sorely needed and temporarily this seemingly bizarre atheoretical approach was probably justified. In time the DSM series will surely self-destruct or evolve into an aetiologically based system.

While causative factors are mostly banished from DSM diagnostic criteria, PTSD is one of the few disorders in which a partial causal attribution is recognized – i.e. massive trauma causing the problem. Nevertheless, an uneasy tension between those emphasizing trauma and those emphasizing individual vulnerability continues (van der Kolk and McFarlane 1996).

Within, between and beyond psychiatry, psychology and sociology there has been conflict between those wishing to normalize the status of victims and those wishing to define their states as abnormal (Yehuda and McFarlane 1995). Advocates of human rights and feminism have been reluctant to accept notions of damaged individuals, especially in the contexts of political oppression (for example, torture victims). This makes great political sense, provided one’s priority is ‘the Cause’, as opposed to helping the suffering individuals. The fact that following most severe traumas, the majority of victims do not develop PTSD, suggests individual vulnerability, including genetic, familial, personality factors, past trauma problems and deficient supports. Achieving the correct balance between the responsibility of society and that of the individual is far from straightforward, especially when it comes to compensation.

Normality is often a confusing and unhelpful concept in mental health. In a statistical sense PTSD at times may emerge as ‘normal’ in the contexts of extreme traumas such as severe torture where the majority of those exposed may develop the disorder. With lesser stressors the same symptoms would be statistically ‘abnormal’. Fortunately, in clinical practice it is all too obvious that PTSD is a psychological state associated with high levels of suffering and psychosocial disability. Many psychological disorders for which there is no controversy about ‘normality’, for example other anxiety disorders, may be less disabling. I suggest to patients that the debate about normal/abnormal mental health is frivolous. If their suffering is worth the effort of their consulting a mental health practitioner, it will be very rare that they would be wasting anyone’s time. Ample stigma remains, deterring people from presenting for mental health care. Psychiatry is one of the last medical disciplines to recognize the benefits of early intervention. Even mild PTSD meets the threshold for legitimate health care need by a country mile.

There is one aspect of normality that I must strongly emphasize. PTSD is not a normal response to ordinary stressors. This is most important when considering results from animal experiments. There are ethical constraints on what mistreatments may be inflicted on animals for scientific purposes. Stressing them is permitted, but stressing them to the levels associated with PTSD generally is not. Hence, animal experiments at times confound the issue of normal stress responses and PTSD.

Muddy waters

A further confounding issue in the study of trauma is the blurring of boundaries between fear and loss-related phenomena. I will illustrate this with the most appalling and remarkable early case study I know of in the whole of mental health literature.

Parry-Jones and Parry-Jones (1994) described the observations of Dr Nicolai of Demonte and Professor Ignazio Somis.

The peasant family of Joseph Roccia were engulfed by an avalanche in the Italian Alps in 1755. Joseph Roccia (aged 50) and his son James (aged 15) saw their home engulfed by a huge avalanche, with Joseph’s wife (aged 40), daughter (aged 11), son (aged 2) and sister-in-law (aged 24) within it. Thirty-seven days later Joseph’s wife, daughter and sister-in-law were dug out alive, although his infant son was dead. They had been confined for over five weeks in a space said to be 6 by 4 by 2½ feet, within a hay manger partly protected by a beam. They had survived on a few chestnuts in one of their pockets, milk from two goats trapped with them, and snow. A donkey and two fowls died early in the drama. On the sixth day, Joseph’s 2-year-old son was writhing in agony. Four d...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgements
• Introduction
• PART I Posttraumatic stress disorder: an introduction
• PART II Evolution and posttraumatic stress disorders
• Epilogue: PTSD in other species?
• Glossary
• References
• Index