Historical Perspectives

Awareness of the role of psychological trauma as a contributory factor in psychiatric disturbances has off and on been a subject of serious study since the latter part of the 19th century. At the Hopital du Salpetriere in Paris Jean Martin Charcot first suggested

Textbook of Biological Psychiatry. Edited by Jaak Panksepp Copyright © 2004 by Wiley-Liss, Inc. ISBN: 0-471-43478-7

that the symptoms of (what was then called) "hysterical" patients had their origins in histories of trauma. His colleague Pierre Janet proposed that posttraumatic reactions are caused by "vehement emotions" that interfere with coping capacities, that is, the incapacity to "process" the experience. As a result, sensory or affective aspects of the traumatic events are split off (dissociated) from everyday consciousness and from voluntary control (Janet, 1889, 1919/1925; van der Kolk and van der Hart, 1989). The imprints of these traumas tended to intrude in patients' lives, not primarily as memories of what had happened but as intense emotional reactions, aggressive behavior, physical pain, and bodily states in response to sensory or emotional reminders, reactions that could best be understood as elements of the original trauma response.

After two clinical rotations at the Salpetriere, Sigmund Freud, with Joseph Breuer, noted that in case of traumatic stress: "The ... memory of the trauma ... acts like a foreign body which long after its entry must be regarded as an agent that is still at work. ... If a [motor] reaction is suppressed [the affect] stays attached to the memory. It may therefore be said that the ideas which have become pathological have persisted with such freshness and affective strength because they have been denied the normal wearing-away processes by means ofabreaction and reproduction in states ofunhibited association" (italicized in original) (Breuer and Freud, 1893, pp. 7-11).

Contemporary studies of traumatic memories have corroborated Janet and Freud's initial observations that traumatic memories persist primarily as implicit, behavioral, and somatic memories and secondarily as vague, overgeneral, fragmented, incomplete, and disorganized narratives. Previous work by Foa (1995) and ourselves (Hopper and van der Kolk, 2001) suggest that these memories change and become more like a coherent story as people recover from their posttraumatic stress disorder (PTSD).

In The Traumatic Neuroses of War Kardiner (1941) proposed that sufferers from "traumatic neuroses" develop an enduring vigilance for and sensitivity to environmental threat, and stated. "The nucleus of the neurosis is a physioneurosis. This is present... during the entire process of organization; it outlives every intermediary accommodative device, and persists in the chronic forms." He described extreme physiological arousal in these patients: They suffered from sensitivity to temperature, pain, and sudden tactile stimuli. "These patients cannot stand being slapped on the back abruptly; they cannot tolerate a misstep or a stumble. From a physiologic point of view there exists a lowering of the threshold of stimulation; and, from a psychological point of view a state of readiness for fright reactions" (p. 95). Kardiner articulated the central issue of PTSD: "The subject acts as if the original traumatic situation were still in existence and engages in protective devices which failed on the original occasion. This means in effect that his conception of the outer world and his conception of himself have been permanently altered" (p. 82).

In 1980 the American Psychiatric Association, faced with the necessity to create a diagnosis to capture the essence of the posttraumatic problems in Vietnam veterans, created a diagnosis, posttraumatic stress disorder (PTSD) that was predicated on the notion that overwhelming experiences leave a memory imprint that may become a central organizing principle in the victim's life. While this definition (detailed later) highlighted how a particular event, or series of events, can alter a person's response to subsequent stimuli, it largely ignores the recurrent observation that following exposure to traumatic life events, the organism may reorganize the way it regulates a large array of biological and psychological functions, not only in response to particular triggers but in its basic orientation to its environment. These problems include difficulty distinguishing relevant from irrelevant stimuli; problems with arousal modulation and attention, impairment in the capacity to plan and execute actions relevant to the present, difficulties peacefully negotiating interpersonal needs, and problems experiencing playfulness and pleasure.

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