Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War (review)

This study of British Army experience, with brief synoptic accounts of U.S. Army data, is a very valuable complement to Ben Shephard's magisterial A War of Nerves (2000). Edgar Jones and Simon Wessely expand aspects of Shephard's work with useful data on screening, psychiatric theory, and the reception of psychiatry by line officers. Thorough attention is given to psychosocial issues of class and military rank, and to attempts to define physiological etiologies for behavioral dysfunction.

The World War I hospitals, physicians, and programs in England and the copying of the "forward treatment" model of the French are described; various therapies are examined; and the important psychiatrists are characterized. The American adoption and expansion of the French-British system is briefly reported. Overall, in the British Expeditionary Force (BEF) and American Expeditionary Force (AEF) about 50–60 percent of "shell shock" soldiers were returned to duty at the front—but there are no data on relapse rates.

After the war, the British military psychiatric system for war was abandoned (as it was in the United States). Royal Commissions examined the causes of shell shock ("fear," "hysteria," "malingering") and its prevention ("leadership," "esprit de corps," "discipline and training"). Pensions for psychiatric disability were expensive and hard to regulate, and the pressure to reduce or eliminate them persisted up to World War II. Otherwise, the entire wartime military psychiatric system was discarded and all the lessons forgotten.

When World War II began in 1939, the British Army was unprepared for psychiatric patients. Parliamentary pressure forced the appointment of a consultant in 1940, J. R. Rees. The authors do not note that Rees found the U.S. Army World War I medical history of psychiatry in the AEF (1929) "a complete textbook," whose lessons he applied to the British Army.¹ "Exhaustion" became the diagnosis for the symptom complex of "shell shock." After too many soldiers were evacuated from North Africa, the system of World War I was installed in 1942. More psychiatrists were assigned, though line officers' suspicion of them and their "malingering" patients was slow to recede. The return-to-duty rates rose to 60–65 percent. The U.S. Army had no forward system (system for treating psychiatric casualties at the front), and in Tunisia in late 1943 it adopted the British program and terminology—which was itself copied by the British from the AEF of World War I! The story of psychiatric care in battle is replete with irony.

Korea, Vietnam, Northern Ireland, and the Falklands came in rapid enough succession that the forward treatment or "PIE"—Proximity, Immediacy, Expectancy— system was employed: treat the soldier with combat exhaustion at the battalion or regimental aid stations, treat immediately (reassure, feed, sedate, assure one or two nights of sleep), and reinforce in discussion that he is expected to return to his unit. This is still the doctrine. Fine discussions of the major medical people, excellent statistics, and detailed accounts of the hospitals extend these chapters beyond other accounts of the programs of the British Army.

New to the literature is a detailed statistical analysis of the British pension system since the Anglo-Boer War (1899–1902). Attempts to eliminate and reduce pensions were successfully resisted by veterans' organizations. The authors argue that the prevailing cultural attitudes define etiology, diagnoses, and therapies for each war, but that there is always a postwar psychological aftereffect. The politicized PTSD (post-traumatic stress disorder) syndrome since 1980 is the present example. There is now public acceptance of PTSD for all physically and psychically stressful events. A well-documented discussion of the psychological screening of recruits shows that Britain and the United States have used various contemporary theories and models to predict success in battle; with the exception of rejection of the obviously disabled, neither army has succeeded.

A provocative chapter on "War Syndromes" is a...