Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis
Jones E, Vermaas RH, McCartney H, Beech C, Palmer I, Hyams K, Wessely S;
Commented by , 24 Feb 2003
Aim of the study
The presence of post-combat disorder can be traced back over centuries and even millennia. The current concept of post-traumatic stress disorder (PTSD) is, however, quite new. It was introduced as a diagnostic category in DSM-III.
The diagnosis has subsequently been included in DSM-III-R and DSM-IV, as well as in ICD-10, after several changes in the original diagnostic criteria. One of the major changes concerns the introduction, in DSM-III-R, of the term “flashbacks”, as one of the defining symptoms of the disorder.
Flashbacks are a form of dissociative state, characterized by involuntary, vivid images that occur in the waking state. The authors of the present study tested whether the prevalence of flashbacks has altered over the past 150 years in soldiers subjected to intense combat stress.
Method
The authors identified post-combat disorders (given diagnoses such as “shellshock” or “disordered action of the heart”) in the files of soldiers from the British Army who fought in wars from 1850 onwards (i.e. the Victorian campaigns (1854-1895), the Boer War (1899-1902), the First World War (1914-1918), the Second World War (1939-1945), Malaya (1948-1960), Korea (1951-1953), and the Persian Gulf War (1991). Subjects were selected randomly among soldiers who had been awarded war pensions for post-combat disorders.
The authors used a standardised form to collect 94 possible symptoms. The form included a description of flashbacks as well as 10 additional symptoms that are part of the current definition of PTSD.
Flashbacks were diagnosed if the subject had complained of intrusive memories, presenting as hallucinations, in particular visual or auditory hallucinations, but had no delusions, and was not psychotic.
Results
The authors examined 1856 cases of post-combat syndromes. They could not identify flashbacks in any case before the First World War. They identified flashbacks in a few soldiers with post-combat syndromes who had fought during the First World War (3 cases out of 640 or 0.5%) and the Second World War (5 cases out of 367 or 1.4%).
Flashbacks were however significantly more frequent (36 cases out of 400 or 9%) in ex-servicemen with post-combat syndrome who had fought in the Persian Gulf War.
Discussion
The present study suggests that one of the core symptoms of PTSD – flashbacks, is a new phenomenon that has become more prevalent during the last few decades. This finding raises questions about the origin and nature of flashbacks.
In the authors’ view, their findings provide support for Young’s theory according to which PTSD is a contemporary culture-bound syndrome whose expression has been influenced by the way in which information about traumatic events is broadcast (in particular through television and video recorders).
Anecdotic support for this hypothesis comes from the fact that some patients describe their flashbacks as being like the playback of a video recording.
The study presents several limitations. In particular, it is a retrospective study, and it is based on records that date back to up to more than a century. As such, the clinicians who wrote the reports may not have inquired in a systematic way about the presence or absence of the various manifestations that characterize our current understanding of the concept of flashbacks.
With this provision in mind, the present study may be considered as a highly interesting contribution to the understanding of a complex disorder (PTSD) and one of its most intriguing symptoms (flashbacks).
Reference
Young, A. Our traumatic neurosis and its brain. Science in Context, 14, 661-683.