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The Beast on My BackGerald Weissmann
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Vol. 18 No. 11 · 6 June 1996

The Beast on My Back

Gerald Weissmann

2509 words
The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder 
by Allan Young.
Princeton, 327 pp., £28, March 1996, 0 691 03352 8
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‘Bête Noire’ is set in Piccadilly during the long winter between the Battle of Alamein and the Normandy invasion. At the time, the 24-year-old Douglas had pretty much recovered from wounds inflicted by German 88s in the Western Desert and by spring he was back in action. On 9 June, three days after landing in France, he was killed behind enemy lines. We can trace the beast to a passage in From Alamein to Zem Zem, in which he describes his escape from a blasted tank over a minefield of wrecked armour and oil-stained corpses:

Presently I saw two men crawling on the ground … I recognised one as Robin. His left foot was smashed to pulp, mingled with the remainder of a boot. But as I spoke to Robin saying, ‘Have you got a tourniquet, Robin?’ and he answered apologetically, ‘I’m afraid I haven’t, Peter,’ I looked at the second man. Only his clothes distinguished him as a human being, and they were badly charred. His face was gone: in place of it was a huge yellow vegetable. The eyes blinked in it, eyes without lashes, and a grotesque huge mouth dribbled and moaned like a child exhausted with crying.

For most combatants, the numbing effects of such battlefield nightmares are relatively short-lived; for some they last a lifetime. The more permanently affected were said in the past to have been ‘touched with fire’ (the American Civil War), suffering from ‘shell-shock’ (World War One) or afflicted by ‘traumatic neurosis’ (World War Two). In each instance the symptoms that patients displayed seemed to split along class lines. ‘Officers complain of nightmares and bellyaches, enlisted men think they’ve been paralysed,’ our psychiatry instructors told us at Fort Sam Houston after the Korean War.

The syndrome was codified after Vietnam. The beast on the back – and a grab-bag of other distressing symptoms – came to be called Post-Traumatic Stress Disorder or PTSD. According to the American Psychiatric Association, the official definition of this condition requires a traumatic event ‘outside the range of usual human experience … one that would be markedly distressing to almost anyone’, followed by such symptoms as repetitive recall of the trauma, psychological numbing, amnesia, insomnia or other forms of automatic arousal. Readers of Robert Graves, Siegfried Sassoon or Pat Barker should not be surprised that this description of PTSD turns out to have a strong resemblance to the description of shell-shock that has become part of the modern literary tradition: the psychiatrists are, after all, simply describing the same beast on different backs.

It might be argued that the beast has been there since records were kept; nightmares have been with us always. Among physicians, Hippocrates had the first look: ‘but the worst of all is to get no sleep either night or day; for it follows from this symptom that the insomnolency is connected with sorrow and pain.’ Two better-known passages suggest something resembling PTSD: Hotspur, with beads of sweat on his brow, rolls in sleep restlessly to mutter ‘Of prisoners ransomed and of soldiers slain/And all the currents of a heady fight’. Guilt after mischief leads the Macbeths to

                eat our meal in fear and sleep
In the affliction of these terrible dreams
That shake us nightly: better be with the dead
Whom we, to gain our peace, have sent to peace.

Kipling joined military to civilian motifs and added the element of class in ‘Gentlemen Rankers’:

If the home we never write to, and the oaths we never keep,
And all we know most distant and most dear,
Across the snoring barrack-room returns to break our sleep,
Can you blame us if we soak ourselves in beer?
When the drunken comrade mutters and the great guard-lantern sputters
And the horror of our fall is written plain,
Every secret, self-revealing on the aching whitewashed ceiling.
Do you wonder that we drug ourselves from pain?

Allan Young, in his scholarly study of the ‘invention’ of PTSD, would disagree with the notion that it has always been with us, arguing that ‘the traumatic memory is a man-made object. It originates in the scientific and clinical discourses of the 19th century; before that time there is unhappiness, despair and disturbing recollections, but no traumatic memory, in the sense that we know it today.’ His book is a lucid case-study of the way medicine and society have managed to build up this man-made disorder over the past century and a half. A medical anthropologist at McGill University, Young has also done some fieldwork of his own and describes his observations at the National Centre for the Treatment of War-Related Post-Traumatic Stress Disorder, located somewhere in the Midwest of the United States. He visited the Veterans Administration centre 13 years after the troops left Vietnam; his transcripts convince us that for many of those vets the battle still rages.

Among his patients Young found no Hotspur, Douglas or Siegfried Sassoon. And as might be expected from the economics of VA medicine in the US, there were certainly no gentlemen rankers. He found only hard-core remnants of the conscript army sent to Asia and written off as losers when they came home; the drifters, the violent, the addicted, the dim. Each carries his own beast on his back, which the therapists called the ‘pathogenic secret’, waiting to be confessed in a climax of relief. Yet there were few epiphanies at the VA. ‘There are occasional “disclosures”,’ Young writes, ‘since this is what the clinical ideology demands, and some of these narratives are vivid and charged with emotion. But there are no real climaxes; there is no point at which everything – narrative, affect and remission – seems to come together.’ The anthropologist found life at the centre rather monotonous, ‘full of unending hours of talk, punctuated by the incessant drip-drop of tiny signifying moments’. Some of these he recorded:

MARTIN:

Well, you gel orders to burn a village, and a gook tries to put the fire out while you’re trying to burn his hootch. He fucks with you, and you show him that you can fuck with him. You can push him away, or you can kick his ass, or you can do what we usually did: you can shoot him.

JACK:

You can’t see anything because of the smoke – awful smell – all kinds of shit burning. We entered the village and there were bodies all over the place. Near me there was a dead old woman and a young girl – but the girl was alive. She’d lost one leg and was going around in a circle on the ground, crying out but not making any sound. The marine next to me takes out a hand gun and shoots her in the head. I was completely pissed by the fucking thing, all of it. All I wanted to do was trash people and that’s what I did. I didn’t care who they were, and I’d just as well have killed US.

PETER:

In Vietnam, we didn’t have an objective. We weren’t allowed to accomplish anything. They just sent people there to fart around and to die.

Young describes how psychiatrists, psychologists, epidemiologists and military doctors have tried to understand why traumatic memories such as these have so often followed familiar patterns. He pinpoints the birth of traumatic memory to a machine-made disaster, the train crash. John Erichsen was perhaps the first physician to describe the syndrome in the 1860s while examining victims of British railway accidents; he called it ‘railway spine’, and attributed it to vaguely defined neurological mechanisms that originated in dorsal trauma. ‘Spinal irritation’ was a popular diagnosis at the time: Henry and William James acquired the disorder to sit out, as it were, the American Civil War. Their plucky sister Alice spent a lifetime in bed on account of her spinal affliction, the ‘dorsal trouble in the blood’ which William believed to run in the family. The disorder was based on Marshall Hall’s earlier description of the reflex arc, a reduction of our higher mental functions to local electrical circuits – a now archaic, if persistent, belief. The notion that our spines harbour the secret of health and disease remains at the root, literally, of such curious American practices as osteopathy, chiropractic and Christian Science.

The Continental alienists, Charcot, Janet and Freud, suggested that the syndrome need not be produced by true physical traumas: psychological wounds were sufficient. It is therefore appropriate that Freud’s heuristic theory of the dynamic unconscious should dominate the study of traumatic memory today. Young points out that in the course of the Great War the locus of the disorder shifted from Erichsen’s railway spine and Freud’s consulting-room hysteria to the battlefield, where large numbers of soldiers were now given the diagnosis of shell-shock.

A half-century after the publication of Erichsen’s first book on railway accidents, physicians serving in the Royal Army Medical Corps, like their counterparts in other combatant armies, were witnesses to an epidemic of traumatic paralyses, contractures, anaesthesias and aboulias. It was as if a hundred colossal railway smash-ups were taking place every day, for four years. By war’s end, 80,000 cases of shell-shock had been treated in RAMC medical units, and 30,000 troops diagnosed with nervous trauma had been evacuated to British hospitals. After the war, 200,000 ex-servicemen received pensions for nervous disorders.

It was during this epidemic that W.H.R. Rivers, another medical anthropologist, introduced the Freudian dynamic unconscious into the treatment of shell-shock. Young quotes the homage Rivers paid to his wartime enemy and professional colleague: ‘Instead of advising repression and assisting it by drugs, suggestion or hypnotism, we should lead the patient to resolutely face the situation provided by his painful experience. We should point out to him that such experience … can never be thrust wholly out of his life … His experience should be talked over in all of its bearings.’

Although Rivers differed from Freud on several points, arguing that the shell-shock cases he treated couldn’t reasonably be linked to replays of childhood sexual theatrics, Freud’s patient unearthing of the past was generally preferable to the heroic counter-shock treatment then fashionable in the military. The talking cures of Freud and Rivers, based on restoring the mind’s equilibrium, were – consciously or not – in keeping with the physiological principles of homeostasis described by Walter Cannon of Harvard (1871-1945). The Claude Bernard of American physiology, Cannon was a student of physiological shock and the first to show the importance of neuro-endocrinology. In ‘The Emergency Functions of the Adrenal Medulla in Pain and the Major Emotions’ he wrote: ‘The organism which with the aid of increased adrenal secretion can best muster its energies, can best call forth sugar to supply the labouring muscles, can best lessen fatigue, and can best send blood to the parts essential in the run or the fight for life, is most likely to survive’ [my italics]. And so flight or fight it was, and traumatic memory danced to the tune of adrenaline.

Young goes on to note that interest in the syndrome declined after World War One but revived during the Forties, when Abram Kardiner, an American psychoanalyst who had treated traumatised veterans in the Twenties, codified the criteria for its diagnosis and distinguished its delayed and chronic forms (Macbeth v. Hotspur, one might say). It is to him that we owe the terminology of ‘traumatic neurosis’ – and I remember distinguishing its various forms as we mustered its real and alleged victims out of service. The traumatic neuroses of World War Two were considered diseases of adaptation to relentless stress, a notion which, again, fitted well with physiological theories of the time. Hans Selye (1907-87) introduced both ‘adaptation’ and ‘stress’ to medicine, basing his work on the other major secretion of the adrenal, cortisone. Selye correctly identified cortisone as the stress hormone.

We consider the first stage [of response to sub-lethal injuries] to be the expression of a general alarm of the organism when suddenly confronted with a critical situation and therefore term it the ‘general alarm reaction’. Since the syndrome as a whole seems to represent a generalised effort of the organism to adapt itself to new conditions, it might be termed the ‘general adaptation syndrome’. It might be compared to other general defence actions such as inflammation or the formation of immune bodies.

It wasn’t long before disorders caused by physical or mental stress, like those provoked by noxious microbes, were seen as flaws of mental adaptation, an inflammation of the spirit gone awry, a splinter of the soul.

The field changed radically when the nomenclature was revised as a consequence of the American experience in Vietnam: PTSD was born in the rice paddies. But the diagnosis achieved general acceptance only in 1980 when PTSD was included in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Young is at his best in detailing the ‘political struggle waged by psychiatric workers and activists on behalf of the large number of Vietnam War veterans who were then suffering the undiagnosed psychological effects of war-related trauma’. American psychiatrists of widely different persuasions and with divergent agendas played a role in this campaign, and Young has high praise for those doctors who hammered out the names we still use today for the many forms of mental disease. He credits such pioneers of psychiatric nosology as Eli Robins, Robert Spitzer, Gerald Klerman and Myrna Weissman, while Robert Jay Lifton and Nancy Andraesen get full marks for squeezing PTSD into the canon. And when the latest revision of the code (DSM-IV, 1994) made room for all the lost Martins and Peters and Jacks, Young rightly concluded:

the publication of DSM-IV is a signifying moment. It signals the repatriation of the traumatic memory, the act of bringing it back home from the jungles and highlands of Vietnam. The collective memory of the war dims and gradually merges with the memories of older, half-remembered wars fought in Korea, Europe and the Pacific. As the veterans of Vietnam age and fade, and their patrons in government adopt new priorities, a chapter in the history of the traumatic memory draws to a close.

The story of PTSD, according to Young, suggests that medicine and society interact to frame or ‘construct’ diseases; and he himself leans toward the school of social thought that holds the facts of science contingent on their context. Young agrees that ‘the suffering is real; PTSD is real’ and goes on to ask: ‘but can one also say that the facts now attached to PTSD are true (timeless) as well as real?’ Probably not, one might reply, but even at this stage in the history of mental science, there are some facts that seem as established as the law of perfect gases; pv = nRT is no more of a fact than that general paresis is due to the spirochete of syphilis, that Alzheimer’s disease is provoked by neurofibrillary tangles in the brain, or that lead drove the hatter mad.

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Letters

Vol. 18 No. 14 · 18 July 1996

I fail to see the point of Gerald Weissman’s article about Post-Traumatic Stress Disorder (LRB, 6 June). Is he trying to say that it is a great advance to exchange one label for another (’the field changed radically when the nomenclature was revised’)? What used to be called Traumatic War Neurosis, or something similar, is now labeled PTSD – what’s the big deal?

As clinicians know, the DSM (Diagnostic and Statistical Manual of Mental Disorders) is a loose hodge-podge of fuzzy theories, speculations etc, paying lip service to the needs of the times. It is hardly a profound scientific document. Yet his review exclaims: ‘the publication of DSM-IV is a signifying moment.’ This must be the overstatement of the year; DSM is at best a useful rough tool for insurance forms and hospital administrators who must fit patients into neat rubrics. Weissman’s high praise for the so-called experts, ‘pioneers of psychiatric nosology’, is high nonsense. When I was a student, the DSM listed homosexuality as a disorder. These rather desultory listings are decided not on the basis of scientific research, but as a result of personal interest, the Zeitgeist, backroom lobbying, trends etc. How about Multiple Personality? Is that in this year? Or just re-labelled Dissociation?

Sheldon Litt
Stockholm

Vol. 18 No. 16 · 22 August 1996

‘What used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ This is what Sheldon Litt wants to know (Letters, 18 July) after reading Gerald Weissmann’s review of my book, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. The answer depends on the meaning that Litt wishes to give to his first ‘what’. If, as it seems, he is writing about a phenomenon that supposedly transcends the nomenclatures and practices of psychiatry, then one would have to agree that that there is nothing really new about PTSD. But as Weissmann makes clear, it is precisely this idea, that traumatic memory is a timeless essence, that the book rejects. The phenomenon that psychiatry knows as ‘traumatic memory’ is a relatively recent development, and during the century and a half of its existence the character of its symptoms and the identity of its victims have been periodically reconceived. PTSD is the most recent chapter in the history of traumatic memory. Litt is correct when he writes that PTSD shares features with the traumatic neuroses of the First World War, but he is mistaken if he supposes that there are no important differences between these disorders, and that they merely rename a constant underlying reality. The character of the traumatic hysterias and neurasthenias was shaped by the moral sensibilities, political institutions and clinical practices of the 1914-18 period; the character of PTSD has been likewise stamped by American participation in the Vietnam War, by the domestic liberation politics of the Sixties and Seventies, and by the profound technological and social changes taking place in American psychiatry during the same period.

Litt also attacks Weissmann for comments he is alleged to have made concerning the disease taxonomy that has dominated American psychiatry since the Eighties, the so-called DSM system. His argument that the DSM system is not scientific is justified only if one thinks of ‘science’ as a technology for uncovering pre-existing truths rather than as one or more distinctive systems for producing and vindicating knowledge. If science is what scientists do, then the DSM system can be said to have revolutionised the practice of psychiatric science it the United States.

Allan Young
McGill University, Montreal

Sheldon Litt’s letter commenting on the DSM reminded me of this bit of wisdom from DSM-III-R: ‘Beliefs or experiences of members of religious or other cultural groups may be difficult to distinguish from delusions or hallucinations. When such experiences are shared and accepted by a cultural group, they should not be considered evidence of psychosis.’ In short, if we’re all crazy, then we’re not crazy.

Roger House
Sebastopol, California

Vol. 18 No. 18 · 19 September 1996

Sheldon Litt (Letters, 18 July) has written a shrill response to my review of Allan Young’s book The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. This book, like my review of it, tries to explain not only the fact that doctors invent new names for old syndromes but why they do so. Young’s book describes in some detail and with a good deal of care why, as Litt puts it in his trottoir style, ‘what used to be called Traumatic War Neurosis, or something similar, is now labelled PTSD – what’s the big deal?’ Litt attributes to my review, rather than to its source, Young’s book, unqualified praise for the well-meaning attempts of psychiatrists periodically to revise the terms they use to describe mental disease. Quite often they have gone astray, but so have those of us in clinical investigation who have recently changed our minds about peptic ulcers, rheumatoid arthritis or how aspirin works. Only magical practices like homeopathy, chiropractic or ayurvedic medicine hold steadfast to their nomenclature over the centuries. Litt’s perhaps deliberate misreading of my review, and his failure to consult its source, remind me of the principle announced by Oliver Wendell Holmes in The Autocrat at the Breakfast Table (1858), which he called the hydrostatic paradox of controversy: ‘If you had a bent tube, one arm of which was the size of a pipe-stem and the other big enough to hold the ocean, water would stand the same height in one as in the other. Thus discussion equalises fools and wise men in the same way, and the fools know it.’

Gerald Weissmann
Marine Biological Laboratory

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