PTSD: A Short History by Allan V. Horwitz (review)

Post-traumatic stress disorder (PTSD) was formally recognized by the American Psychiatric Association in 1980 with the publication of DSM-III. It followed a sustained campaign by critics of the Vietnam War who sought to highlight the injurious psychological effects of the conflict, but the diagnosis was included only when the committee on reactive disorders concluded that PTSD had a general applicability and could be observed after any form of traumatic event. In this study, Allan Horwitz, author of Anxiety, a Short History, has applied his sociological insight to PTSD. He adopts a thematic approach with chapters devoted to the history of post-traumatic illness, the conceptual antecedents of PTSD, psychological casualties created by war and the campaign to persuade psychiatrists that this was a legitimate diagnosis. Horwitz also explores how the recovered memory movement offered an implicit challenge to PTSD by suggesting that some severe traumatic experiences are repressed to an extent that they leave no conscious trace. Vivid and intrusive memories, by contrast, are key symptoms of PTSD beyond the ability of sufferers to suppress. The author vividly documents the rise in the incidence of PTSD and analyzes the culture of vulnerability and compensation with which it is associated.

As Horwitz acknowledges, PTSD is but one position in the enduring debate about where to locate causality for post-traumatic illness between the poles of environmental stressor and individual vulnerability. In the late nineteenth and early twentieth centuries, people themselves, their personality and inherited characteristics, were held primarily responsible for their breakdown. To explain why only a subgroup succumbed to the psychological effects of battle, combat stress was relegated to a secondary role or that of a trigger. With evidence from casualty statistics collected after World War II and during the Vietnam conflict, psychiatrists increasingly attributed causality to the traumatic event. This reversal eroded much of the stigma associated with post-traumatic illness, though it failed to address the shame and guilt commonly experienced by those with a diagnosis of PTSD.

Shell shock is explored as part of the intellectual and clinical heritage of PTSD, though the role of Frederick Mott is overlooked. As a neuropathologist with an international reputation, he was appointed by the War Office to lead research into its causality and treatment. Based at the Maudsley Hospital with a regular influx of patients, Mott was arguably the first clinician in the UK to identify the fundamentals of the PTSD model. He observed that most cases arose from a pre-existing vulnerability and some the result of concussion or toxic exposure. However, Mott identified a third group who were healthy individuals subjected to “terrifying or horrifying conditions,” soldiers whose record demonstrated that they are “neither of a timid disposition” or possessed of “any neuropathic tendency” and for whom the event was the primary cause.¹

Although Horwitz describes the momentum behind research into the limbic system designed to identify the neuro-biology of PTSD, more detail could have been given on the hypotheses and findings in the search for an organic explanation. This research, if successful, could result in the disorder being reframed as a neurological illness with specific therapeutic targets. In sum, Horwitz draws together an impressive array of work to produce a balanced and concise analysis of PTSD that will serve as an insightful guide to the nature and evolution of the disorder.

Whilst the fourth iteration of PTSD, published in DSM-5 (2013), incorporated much additional research, a new critique of the disorder has gathered momentum. The growing interest in moral injury is, in part, driven by the idea that PTSD fails to capture the full range of emotions and cognitions that follow exposure to traumatic events. A high percentage of those with mild traumatic brain injury also report the symptoms of PTSD, prompting the hypothesis that microscopic brain lesions may account for both disorders. Horwitz’s measured history of PTSD may have come at a time when the disorder...