Países más competidores del comercio internacional

Although the etymology of the word ‘trauma’ goes back to the Greek word for ‘wound’ (Kirmayer, Lemelson & Barad 2008), van der Kolk and McFarlane (2007:3) state that trauma is an essential part of being human. They say: “History is written in blood.” Throughout history people have been through dreadful experiences.

In the 1800s scientific discussions reflected conflicting views on the etiology of trauma. The question was whether trauma is physical or psychological. The history of trauma reflects the efforts to providing medical services to soldiers and civilians in time of war.

As technology developed, new weapons brought new types of injuries and fears (Kirmayer et al. 2008).

The conflict about the physical or psychological origins of traumatic neuroses was relevant for combat soldiers in the 1900s. If trauma was physical, it is an illness and to define such an illness in the medical literature was difficult. To ascribe issues of cowardice and shirking to physical problems offered an honourable solution to the problems faced by soldiers. Cardiovascular symptoms such as rapid or irregular heartbeat, palpitation or shortness of breath were diagnosed as “irritable heart” and “soldier’s heart”. Myers (1915) was the first to use the term “shell shock”. However, it became difficult to explain shell shock in soldiers who had never been exposed to gunfire. It then became clear that the causes of trauma might have an emotional origin (van der Kolk 2007). Churchill’s doctor, Lord Moran, confessed in his memoirs of his service in World War I that it was difficult to distinguish between shell shock and cowardice. Interestingly, in World War II 2 200 British soldiers were condemned to death for cowardice and desertion, but only 200 were executed as a lesson to others.

A pioneer in the field of studying neurosis was Jean-Martin Charcot. He was a French neurologist and a professor of anatomical pathology and is known as “the founder of modern neurology”, and was specifically interested in hypnosis and hysteria. He initially believed that hysteria was a neurological disorder but near the end of his life concluded that hysteria was a psychological disease (Lamberty 2007:5). His work led to great advances into researching the relationship of the mind and body. In the 1900s Pierre Janet used the term “subconscious” to mean “The collection of memories forming the mental schemes that guide a person’s interaction with the environment” (van der Kolk & McFarlane 2007). In the case of a traumatic event, these memories are “split off” from the conscious awareness and the memory is stored in the subconscious, which reproduces the trauma over and over again. Janet proposed that when trauma is experienced, the individual gets stuck and become attached to the trauma; therefore no new learning can take place (van der Kolk 2007; Wastell 2005).

Freud (as cited by van der Kolk et al. 2007:54) agreed with the possibility of ‘splitting off’ from consciousness, but disagreed that childhood memories were the reason. Freud’s view was not that the actual memories of childhood caused the split off from consciousness, but that “It is rather unacceptable sexual and aggressive wishes of the

child that threatened the ego and motivated defences against the conscious awareness of these wishes.” Abram Kardiner worked with Freud and reassessed the meaning of symptoms of trauma. He proposed that individuals diagnosed with “traumatic neuroses” act as if the original traumatic situation was still in existence, thus being fixated on the trauma and showing chronic irritability, startled reactions and aggressive responses. He expanded on this view by stating that this is the result of the ego that dedicates itself to ensuring that the individual is safe and tries to protect itself against recollection of the trauma. Being fixated on the trauma alters the conception of the self in relation to the world. Kardiner’s view on trauma and its effect was “the beginning of integration” and influenced the definition of PTSD (van der Kolk 2007; Wastell 2005). Below is a summary, adapted from Hyman, Wignall and Roswell (1996) by Sadock and Sadock (2007:613), of the way the term PTSD as we know it today came to be classified.

Table 2.1: Eponyms and symptoms of Post-traumatic Stress Disorder in various US wars

War Disorder

US Civil War “Irritable heart”: fatigue, shortness of breath, palpitations, headache, excessive sweating, dizziness, disturbed sleep, fainting

World War I “Effort syndrome”: fatigue, shortness of breath, palpitations,

headache, excessive sweating, dizziness, disturbed sleep, fainting, difficulty concentrating

World War II “Combat stress reaction”: fatigue, shortness of breath, palpitations, headache, excessive sweating, dizziness, disturbed sleep, fainting, difficulty concentrating, forgetfulness

Vietnam War “Post-traumatic stress disorder”: fatigue, shortness of breath, palpitations, headache, muscle and joint pain, dizziness, disturbed sleep, difficulty concentrating, forgetfulness

Gulf War “Gulf War syndrome”: fatigue, shortness of breath, headache, muscle and joint pain, disturbed sleep, difficulty concentrating, forgetfulness

During these wars there were no classification criteria for symptoms such as reactions to combat stress, minor personality disturbances, psychosomatic reactions and neurotic symptoms. There was thus a need for developing diagnostic criteria for PTSD. The World Health Organisation (WHO) then included mental disorders in the sixth revision of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6) in 1948. In the ICD-6 PTSD was called “acute situational maladjustments.” The Diagnostic and Statistical Manual of Mental Disorder (DSM-I), developed by the American Psychiatric Association, called this “‘transient personality disturbance” in 1952. When revising the criteria, no changes were reported in the ICD- 7 and in the DSM-I.

The DSM-II (APA 1968) was based on the ICD-8 (WHO 1969) in the mental disorders section. Following the ICD-8 was the ICD-9 (WHO, 1977), which was revised and the term “acute reaction to stress” was used. The ICD-10 (WHO 1992) and the DSM-III (APA 1980) applied changed in the terminology. The stress disorders are no longer restricted to acute responses in healthy individuals. This means that traumatic stress can cause chronic reactions and that responses to traumatic stress are evident in those with previous and simultaneous conditions. It is interesting to note that the ICD- 10 (WHO 1992) also includes enduring personality changes after catastrophic experience as a diagnosis for traumatic reactions (Brett 2007). Upon revising the diagnostic criteria, the decision needed to be made about where to place PTSD in the new edition of the diagnostic manual. Discussions turned into heated debates between Advisory Subcommittee members of the DSM-IV and the DSM-IV Task Force. They had to take a decision on whether PTSD needs to be classified under the anxiety or dissociative disorders. The Task Force did not support the view that PTSD be placed in a new stress response category and therefore PTSD remains classified as an anxiety disorder (Brett 2007; van der Kolk 2003; Wastell 2005). In the newly published DSM V (2013:265) PTSD is now included in a new section: “Trauma- and Stressor-Related Disorders” and a separate criterion was added for children 6 years old or younger. The diagnosis for PTSD and acute stress disorder (Criterion A1) was modified and the requirement for specific subjective emotional reactions (Criterion A2) was removed. The recent diagnostic criteria for PTSD in the DSM-V is presented in Chapter One.