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A War on Nerves

Ben Shephard's superb book about the relationship between psychiatry and war in the 20th century explores a key neuropsychiatric topic that escapes many practitioners' eyes and experience, except in the form of the etiolated latecomer posttraumatic stress disorder (PTSD). A central theme of Shephard's A War of Nerves, Soldiers and Psychiatrists, 1914 to 1994 is hysteria, a concept that, in spite of the administrative attempts of committee-driven psychiatry, resolutely refuses to go away, even when covered by euphemisms such as chronic fatigue, exhaustion, low moral fiber, conversion, or dissociation. As the book documents, literally hundreds of thousands of soldiers presented to physicians at battlefronts with a wide variety of quasi-neurological symptoms and signs, including tremors, seizures, gait abnormalities, paralyses, comas, and loss of speech—the very stuff of neurology. Yet, for the majority of soldiers, neurologic examination failed to discover any underlying neurological damage. These clinical presentations were puzzling to those trained in the neurological tradition, and, notably in the Great War, there were few psychiatrists around to offer help. In reality, understanding such presentations is, at one level, simple: soldiers exposed to the horrors of war "broke down," often in this dramatic way. However, for the examining physician the problem was complicated by the neurological presentations, and diagnosis became dependent on an acute knowledge of both neurology and psychiatry. Theories of how and why soldiers presented such symptoms, initially simplified by the introduction and acceptance of the concept of "shell shock," soon waned, especially with the knowledge that many soldiers who were diagnosed with shell shock were in reality never near exploding shells and could not have received traumatic damage to the central nervous system. This interface of neurology and psychiatry, dramatically exposed by various wars of the 20th century, including those of Korea and Vietnam, remains today an enigmatic knot tied with many unsolved twists. In clinical civilian practice, such presentations seem deceptively rare and were often reported only from highly specialized referral centers; however, in reality such presentations are more common than suspected. These presentations are overwhelmingly neurological, and have recurred over time with a clinical consistency that can only reflect a recognizable syndrome with characteristic features and prognosis. Interestingly, over the century, the number of soldiers presenting with such symptoms seems to have declined, and by Vietnam, the epithet "stress" ("battle" stress as opposed to "shell shock" stress) became a dominant part of everyday vocabulary. The role of soldiers' vulnerability, always a fruitful and unresolved argument for debate, became diminished with the rise in importance of the stress suffered. The subsequent invention of the syndrome PTSD, in part a reflection of a coordinated political effort, arose essentially to account for thousands of veterans who in the aftermath of the war failed to cope with a return to civilian life, developed psychiatric symptoms, and entered what Shephard refers to as the "late 20th century culture of trauma." The relationship between soldiers' neuroses of the battlefields and PTSD is difficult to fathom, especially as somatic presentations of the former are not embraced by any diagnostic criteria. Posttraumatic hysteria is simply not allowed, despite its considerable history and continuing occurrence in military and civilian practice. Such scotoma reflects the inadequacies of the Diagnostic and Statistical Manual of Mental Disorders criteria and the division between psychiatrists and neurologists, leading now, as in the past, to many failures of diagnosis and inappropriate management of these truly neuropsychiatric problems. The whole area of nonepileptic ("pseudo") seizures is a part of this issue; thus, these clinical presentations—from classic hysteria to the refined PTSD—are not the rarities of historical texts, but still present clinically with regular frequency. The more extravagant cases continue to bear a distinctive neurological stamp that neuropsychiatry alone can unravel. Frederic Mott, pathologist at the London County Hospital, an enthusiastic dissector of the brains of "lunatics," an early supporter of the concept of "shell shock," and a model of an early 20th century neuropsychiatrist, opined, "Instead of theories, we should seek...some biochemical or biophysical explanation why sudden emotional shock or continued emotional disturbance should produce an acquired emotivity in neuropotentially sound individuals...." The rush to secure PTSD as a syndrome has seen a failure of an understanding of the full and fascinating range of trauma syndromes. Their escape into sociological, legal, and political arenas has done much to undermine the credibility of a century of war on nerves. LSffil