Psychological Wounds of Conflict: The Impact of War
The emergence of the concept of shell shock during the First World War had focused unparalleled attention to the issue of traumatic illness.
Today, the recognition of post-traumatic stress disorder (PTSD) has established in the minds of the public, media and the health professionals that war can produce long-term and severe psychological effects. However, it was not always so.
Vulnerability to Stress
In the late nineteenth century, passengers who had been exposed to a terrifying train crash were often diagnosed with “railway spine” to explain why their psycho-somatic symptoms endured after physical wounds had healed. Medical opinion was divided as to whether these were organic effects, related to lesions in the central nervous system, or whether they were due to an inborn or acquired vulnerability to stress.
During World War One, soldiers exhibiting similar patterns of symptoms were given the label “shell shock.” The cause of their invalidity and, therefore, the appropriate form of management was the subject of considerable debate. Some hardline medical doctors, such as Gordon Holmes, believed that servicemen who broke down on the battlefield and failed to return to duty after a short period of recuperation showed a lack of resolve, which should be addressed by military discipline rather than continued hospitalization. By contrast, Charles Myers, consulting psychologist to British forces in France, argued that each soldier patient should be assessed on his merits.
Having observed the capacity of artillery bombardment to erode the morale and determination of the toughest combatant, Myers considered shell shock a legitimate illness, requiring expert treatment no less than any wound or disease. By exposing the citizen armies of Europe to prolonged and extreme danger, World War One generated psychological casualties on an industrial scale. This, in turn, created a military crisis that drew doctors from a diverse range of specialties into the field of mental health; never before had so much attention been focused on a single psychiatric disorder.
The term “shell shock” emerged in the harsh winter of 1914-15 as soldiers sought to describe how they felt when under fire. During training, they had been instructed to conceal their fears because panic was known to spread rapidly through battalions. Yet, apart from trusting to luck, there was little that an infantryman could do to protect his life when being shelled. Without regulated tours of duty and no prospect of an early end to the conflict, many frontline soldiers were worn down by the emotional demands of trench warfare.
In the aftermath of the Battle of the Somme, shell shock became a military priority as a flood of psychiatric casualties eroded the strength of front-line units. Specialist centers were set up within the sound of the guns to provide rapid treatment and to discourage soldiers from believing that they had escaped military duty. In addition, new regulations governed the use of diagnostic terms, seeking to stem the flow of casualties across the Channel.
In theory, hospitals in Britain were reserved for severe or intractable cases of shell shock. There, teams of doctors researched causation and experimented with treatment. From this concentrated effort emerged various schools of trauma therapy: At the Maudsley Hospital under the direction of Frederick Mott, “an atmosphere of cure” was emphasized through purposeful activity (graduated exercise, carpentry, gardening, games and social events), whilst at the Red Cross Hospital in Maghull clinicians used ideas borrowed from anthropology and psycho-analysis. At Seale Hayne in Devon, where Arthur Hurst had access to farmland and a pottery, occupational therapy was emphasized as a way of restoring soldiers’ self-confidence and physical function.
By the early 1950s it was recognized that all soldiers have a breaking point, however well trained and motivated. As well as the link between physical and psychological casualties, it was also established that factors such as morale, leadership, regular sleep and confidence in equipment could mediate the size of the association but not the association itself.
At least 250,000 UK servicemen suffered from some form of psycho-somatic illness related to the conflict. Many failed to recover once peace had been restored. At first, the government funded treatment for veterans. “Special medical clinics” were opened by the Ministry of Pensions in provincial towns to provide a nationwide service of out-patient psychotherapy. With shortages of doctors qualified in trauma therapy, a training school was set up under Lt Colonel R.G. Rows, medical superintendent of Maghull.
By October 1920, 29 clinics were in operation and in February of the following year, it was estimated that 14,771 ex-servicemen with shell shock were either attending boards for assessment or clinics for treatment. However, a dramatic downturn in the economy and a government committed to public sector cuts saw the clinics close. By the mid-1920s trauma psychiatry had fallen down the health agenda and it took another world war to bring the sub-specialty to prominence.
World War Two
During World War Two breakdown on the battlefield again became a priority for the Allied democracies concerned that high casualties would undermine popular support for the conflict. Military psychiatry became an essential element of medical provision. With the direct involvement of the United States and its wealth of resources, attention was turned to evaluating the nature of breakdown and the effectiveness of treatments. Towards the end of the war, large-scale investigation was conducted into the psychological demands of combat (notably Samuel Stouffer’s two-volume study The American Soldier).
In addition, Gilbert W. Beebe, a sociologist, Michael E. DeBakey, a surgeon, and Albert Glass a military psychiatrist researched the relationship between physical and psychiatric casualties. Their findings provided objective evidence on which to build policy for subsequent conflicts.
By the early 1950s it was recognized that all soldiers have a breaking point, however well trained and motivated. As well as the link between physical and psychological casualties, it was also established that factors such as morale, leadership, regular sleep and confidence in equipment could mediate the size of the association but not the association itself. Yet, it was still believed that combat was secondary to personality in terms of causation. War, it was argued, served as a trigger to underlying vulnerability. Robust individuals with no family history of mental illness were expected to recover from the trauma of battle relatively quickly with no lasting ill effects.
The political crisis created by the Vietnam War, combined with significant cultural change, inspired a new interpretation of trauma psychiatry. Anti-war campaigners argued that veterans who had been able to contain their distressing experiences whilst on active service broke down on return to the US when confronted by an unsympathetic public. They called the phenomenon “delayed stress syndrome” or “post-Vietnam syndrome.”
A campaign by veterans and clinicians led to the formal recognition of PTSD by the American Psychiatric Association in 1980. It represented a turning point in aetiological theory. In both World Wars the individual had been held responsible for his breakdown: whether his genetics, family history, up-bringing or unconscious conflict. PTSD reversed this causal explanation. The traumatic exposure, criterion A in the DSM-III definition, was now primary and everyone, whether citizen or soldier, was potentially vulnerable to the new traumatic disorder if exposed to a life-threatening event. Personality factors were now considered secondary determining, amongst other things, the speed of recovery or severity of the disorder.
Post-Traumatic Stress Disorder
Shell shock and PTSD are not the same disorder by a different name. The former was a catch-all term for any soldier who broke down and was unable to perform his duties. It was expressed through a range of psycho-somatic symptoms such as chest pain, fatigue, headache, tremor, palpitations and nightmares. PTSD has some features in common with shell shock (notably startle reaction, poor concentration and intrusive images). Both disorders arose in a context of heightened emotion conditioned by extreme threat. They can be seen as culturally determined expressions of distress.
Although there is no direct chain of events from World War One through to the recognition of PTSD in 1980, the shell shock episode had focused unparalleled attention to the issue of traumatic illness. Never before had so many soldiers suffered from psychological disorder. Furthermore, their illness could not be explained by pre-war theories of degeneration, heredity or the side effects of infectious disease. Neurologists, general physicians and even surgeons, doctors who before 1914 would not have shown any interest in psychiatry, were drawn to shell shock.
By bringing new ideas to the discipline, it gave a fresh impetus to the search for psychological understanding and, in this sense, PTSD can be viewed as a progeny of World War One. Whilst today we are better equipped to diagnose and treat psychological trauma, we seem no further forward in preventing the conflicts that are the cause of these illnesses.
PTSD in Children and Teens
This fact sheet provides an overview of how trauma affects school-aged children and teens. You will also find information on treatments for PTSD in children. To learn about PTSD in very young children, please see our fact sheet Very Young Trauma Survivors: The Role of Attachment.
What events cause PTSD in children?
Children and teens could have PTSD if they have lived through an event that could have caused them or someone else to be killed or badly hurt. Such events include sexual or physical abuse or other violent crimes. Disasters such as floods, school shootings, car crashes, or fires might also cause PTSD. Other events that can cause PTSD are war, a friend’s suicide, or seeing violence in the area they live.
Child protection services in the U.S. get around three million reports each year. This involves 5.5 million children. Of the reported cases, there is proof of abuse in about 30%. From these cases, we have an idea how often different types of abuse occur:
- 65% neglect
- 18% physical abuse
- 10% sexual abuse
- 7% psychological (mental) abuse
Also, three to ten million children witness family violence each year. Around 40% to 60% of those cases involve child physical abuse. (Note: It is thought that two-thirds of child abuse cases are not reported.)
How many children get PTSD?
Studies show that about 15% to 43% of girls and 14% to 43% of boys go through at least one trauma. Of those children and teens who have had a trauma, 3% to 15% of girls and 1% to 6% of boys develop PTSD. Rates of PTSD are higher for certain types of trauma survivors.
What are the risk factors for PTSD?
Three factors have been shown to raise the chances that children will get PTSD. These factors are:
- How severe the trauma is
- How the parents react to the trauma
- How close or far away the child is from the trauma
Children and teens that go through the most severe traumas tend to have the highest levels of PTSD symptoms. The PTSD symptoms may be less severe if the child has more family support and if the parents are less upset by the trauma. Lastly, children and teens who are farther away from the event report less distress.
Other factors can also affect PTSD. Events that involve people hurting other people, such as rape and assault, are more likely to result in PTSD than other types of traumas. Also, the more traumas a child goes through, the higher the risk of getting PTSD. Girls are more likely than boys to get PTSD.
It is not clear whether a child’s ethnic group may affect PTSD. Some research shows that minorities have higher levels of PTSD symptoms. Other research suggests this may be because minorities may go through more traumas.
Another question is whether a child’s age at the time of the trauma has an effect on PTSD. Researchers think it may not be that the effects of trauma differ according to the child’s age. Rather, it may be that PTSD looks different in children of different ages.
What does PTSD look like in children?
School-aged children (ages 5-12)
These children may not have flashbacks or problems remembering parts of the trauma, the way adults with PTSD often do. Children, though, might put the events of the trauma in the wrong order. They might also think there were signs that the trauma was going to happen. As a result, they think that they will see these signs again before another trauma happens. They think that if they pay attention, they can avoid future traumas.
Children of this age might also show signs of PTSD in their play. They might keep repeating a part of the trauma. These games do not make their worry and distress go away. For example, a child might always want to play shooting games after he sees a school shooting. Children may also fit parts of the trauma into their daily lives. For example, a child might carry a gun to school after seeing a school shooting.
Teens (ages 12-18)
Teens are in between children and adults. Some PTSD symptoms in teens begin to look like those of adults. One difference is that teens are more likely than younger children or adults to show impulsive and aggressive behaviors.
What are the other effects of trauma on children?
Besides PTSD, children and teens that have gone through trauma often have other types of problems. Much of what we know about the effects of trauma on children comes from the research on child sexual abuse. This research shows that sexually abused children often have problems with
- Fear, worry, sadness, anger, feeling alone and apart from others, feeling as if people are looking down on them, low self-worth, and not being able to trust others
- Behaviors such as aggression, out-of-place sexual behavior, self-harm, and abuse of drugs or alcohol
How is PTSD treated in children and teens?
For many children, PTSD symptoms go away on their own after a few months. Yet some children show symptoms for years if they do not get treatment. There are many treatment options, described below:
Cognitive-Behavioral Therapy (CBT)
CBT is the most effective approach for treating children. One type of CBT is called Trauma-Focused CBT (TF-CBT). In TF-CBT, the child may talk about his or her memory of the trauma. TF-CBT also includes techniques to help lower worry and stress. The child may learn how to assert himself or herself. The therapy may involve learning to change thoughts or beliefs about the trauma that are not correct or true. For example, after a trauma, a child may start thinking, “the world is totally unsafe.”
Some may question whether children should be asked to think about and remember events that scared them. However, this type of treatment approach is useful when children are distressed by memories of the trauma. The child can be taught at his or her own pace to relax while they are thinking about the trauma. That way, they learn that they do not have to be afraid of their memories. Research shows that TF-CBT is safe and effective for children with PTSD.
CBT often uses training for parents and caregivers as well. It is important for caregivers to understand the effects of PTSD. Parents need to learn coping skills that will help them help their children.
Psychological first aid/crisis management
Psychological First Aid (PFA) has been used with school-aged children and teens that have been through violence where they live. PFA can be used in schools and traditional settings. It involves providing comfort and support, and letting children know their reactions are normal. PFA teaches calming and problem solving skills. PFA also helps caregivers deal with changes in the child’s feelings and behavior. Children with more severe symptoms may be referred for added treatment.
Eye movement desensitization and reprocessing (EMDR)
EMDR combines cognitive therapy with directed eye movements. EMDR is effective in treating both children and adults with PTSD, yet studies indicate that the eye movements are not needed to make it work.
Play therapy can be used to treat young children with PTSD who are not able to deal with the trauma more directly. The therapist uses games, drawings, and other methods to help children process their traumatic memories.
Special treatments may be needed for children who show out-of-place sexual behaviors, extreme behavior problems, or problems with drugs or alcohol.
What can you do to help?
Reading this fact sheet is a first step toward helping your child. Learn about PTSD and pay attention to how your child is doing. Watch for signs such as sleep problems, anger, and avoidance of certain people or places. Also watch for changes in school performance and problems with friends.
You may need to get professional help for your child. Find a mental health provider who has treated PTSD in children. Ask how the therapist treats PTSD, and choose someone who makes you and your child feel at ease. You, as a parent, might also get help from talking to a therapist on your own. Please see our Where to Get Helppage for treatment resources.
This fact sheet is based on a more detailed version, located in the “Professional” section of our website: PTSD in Children and Adolescents.