During the early stages of World War I some soldiers began to exhibit strange symptoms; for example, they were panicked, crying and fearful, and they showed the inability to reason, sleep, walk or talk.  They also experienced flashbacks of traumatic memories. Some suffered from serious tremors, amnesia, depression and were hypersensitive to noise. According to McLeod (2004) by December 1914, 7 - 10% of all officers and 3 - 4% of other ranks in the British forces suffered from nervous and mental shock problems.

At the time, this condition was not well known and some soldiers were actually executed for cowardice because they refused to go back into the front line. The condition was called 'shell shock' but it was ill-defined and it was not known why some soldiers were affected and others were not. Treatments included electric shocks, isolation and restricted diet. Arthur Hurst, one of the first psychologists to treat veterans with shell shock, took the men to the British countryside where they would "labour on the land."  In addition, men reenacted their battles on fields and then wrote diaries about their experiences. Today there is a better understanding of the symptoms that the soldiers exhibited and today some of the symptoms of  'shell shock' are found in the diagnosis of PTSD.

 Teacher only box

You may want to give students the following site to read and discuss: Voices of the First World War.

There is also a good article: What World War I taught us about PTSD.

Finally, Kramer (2018)'s The perception and treatment of shell-shocked soldiers.

PTSD or post-traumatic stress disorder is a disorder that develops in some people after traumatic events, such as combat, crime, an accident, a natural disaster or abuse. Normally PTSD lasts for more than 30 days and develops in response to a specific stressor; it is characterized by intrusive memories of the traumatic event, emotional withdrawal, and heightened autonomic arousal, which may result in insomnia, hyper-vigilance, or loss of control over anger and aggressive behaviour. Often, PTSD patients experience a decreased interest in others and a sense of estrangement.

In the USA, PTSD has a prevalence rate of 1 - 3 percent and an estimated lifetime prevalence of 5 percent in men and 10 percent in women. Davidson et al. (2007) estimate that PTSD affects 15 - 24 per cent of individuals who are exposed to traumatic events. However, it is important to say that not all individuals exposed to traumatic events develop PTSD symptoms.  The type of trauma appears to be a key factor: 3 percent of those who experience a personal attack, 20 percent of wounded veterans, and 50 percent of rape victims develop PTSD. The most frequent trauma that triggers PTSD is the loss of a loved one, accounting for one-third of all cases.

Careful research and documentation of PTSD began after the Vietnam War. The National Vietnam Veterans Readjustment Study (Kulka et al, 1988)  estimated that the prevalence of PTSD among veterans was 15.2 percent at that time and that 30 percent had experienced the disorder at some point since returning from Vietnam.

PTSD has subsequently been observed in all US veteran populations that have been studied, including those from the Second World War, the Korean conflict, the Gulf Wars, and in United Nations peacekeeping forces deployed to other war zones around the world. There are remarkably similar findings of PTSD in military veterans in other countries - for example, Australian Vietnam veterans experience many of the same symptoms as US Vietnam veterans.

PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person’s ability to function in social or family life, including occupational instability, marital problems and divorce, family discord, and difficulties in parenting.

 Teacher only box

If we use the DSM 5 to make a diagnosis, we need to ask him the following questions:

• How long have the symptoms lasted (it needs to be at least six months)
• It is unclear whether his lack of motivation can be considered "functional impairment." It may be, however, that the arguing with his wife could be considered functional impairment.

It is, however, likely that the symptoms are not due to drug use.

For diagnosis, he has to meet all five symptom criteria.

• Stressor - it is clear that he could have been exposed to high stress while fighting in Tikrit.  He was wounded, but it is not clear whether this "traumatic" or not.  The actual trauma would have to be identified.
• Intrusion symptoms - this is also not clear and would require more questions.  He does cry during the film, but a therapist would have to ask him why this happened and whether this is a common behaviour.
• Avoidance - the fact that he went to see a film on Vietnam makes it unlikely that he is showing avoidant behaviour.
• Negative thoughts and feelings - this appears to be the most relevant symptom.  He feels hopeless and he has lost interest in activities. 
• Arousal - this is not evident in the short description above - outside of the conflict with his wife.

Obviously, a therapist would want to ask Derek a lot more questions before making a preliminary diagnosis, but based on the information in this vignette, it is more likely that he is either having a difficult time transitioning to being a civilian or is suffering from depression. if he has bee home longer than six months, it is more likely to be depression than acculturative stress.

Checking for understanding

Biological approaches to PTSD