INSPIRATIONS FROM HISTORY
Year : 2015 | Volume
: 20 | Issue : 2 | Page : 85--87
"Shell Shock": An Entity that Predated Combat-related Posttraumatic Stress Disorder
Ragul Ganesh, Siddharth Sarkar, Rajesh Sagar
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi
In the last century, numerous soldiers had been diagnosed with various post combat disorders. The terminology that has been utilized to describe such patients include combat fatigue, combat stress reaction, soldier«SQ»s heart, effort syndrome, non-ulcer dyspepsia, effects of agent orange and gulf war syndrome. The initial description of such post combat disorder was probably «SQ»shell shock«SQ» which came into vogue during the World War I. The soldiers, undergoing unyielding artillery bombardment, in the trenches suffered persistent symptoms of headache, behavioural changes and memory impairment, and was designated at the time as «SQ»shell shock«SQ». Myers and Mott, independently studied numerous soldiers to elucidate the features and aetiology of the entity. An attempt was made to restrict the usage of the term, but the psychological distress of the soldiers persisted to be addressed in some manner or the other, culminating in the genesis of Post Traumatic Stress Disorder.
|How to cite this article:|
Ganesh R, Sarkar S, Sagar R. "Shell Shock": An Entity that Predated Combat-related Posttraumatic Stress Disorder.J Mental Health Hum Behav 2015;20:85-87
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Ganesh R, Sarkar S, Sagar R. "Shell Shock": An Entity that Predated Combat-related Posttraumatic Stress Disorder. J Mental Health Hum Behav [serial online] 2015 [cited 2020 Feb 26 ];20:85-87
Available from: http://www.jmhhb.org/text.asp?2015/20/2/85/174603
Posttraumatic stress disorder (PTSD) among military personnel is a well-recognized disorder currently. However, the initial recognition of the constellation of symptoms which currently defines PTSD can be traced to a century back. We retrace the historical origins and evolution of the concept of "shell shock" to what is now considered as PTSD.
“Shell Shock”: Early Recognition and Evolution of Concept
"Shell shock" was seemingly the first term to describe the set of symptoms during the early stages of the First World War (1914-18). The British soldiers were reportedly having medical symptoms including amnesia, tremors, headaches, dizziness, tinnitus, and hypersensitivity to noise after combat. Many of those reporting sick showed no signs of head wounds though the symptoms resembled those after a physical injury to the brain.
It has been suggested that by December 1914, about 10% of British officers and 4% of enlisted men were suffering from "nervous and mental shock."  It is not known who exactly coined the term "shell shock," but the first mention may be a story published in the Times on February 6, 1915.  It was reported that the War Office was arranging to send soldiers suffering from "shock" to be treated in special wards at the National Hospital for the Paralyzed and Epileptic, in Queen Square.
Furthermore, in February 1915, the term shell shock was used by Myers, consultant psychologist to the British Expeditionary Force, in a Lancet article to describe three soldiers suffering from "loss of memory, vision, smell, and taste."  Myers based his report on these patients, admitted to a hospital in Le Touquet during the early phase of the war (between November 1914 and January 1915). These patients had been shocked by shells exploding in their immediate vicinity and presented with remarkably similar symptoms. According to Myers, these cases bore a close relationship to "hysteria."
Subsequently, those patients in the British army who presented with mental disorders after combat stress were diagnosed as cases of shell shock. The Second Battle of Ypres was fought from April to May 1915 for control of the town of Ypres in Western Belgium. During this period, the number of shell shock cases had increased to large numbers, but scant progress was made in the understanding of this clinical problem. Hence, an effective management strategy could not be formulated to tackle the issue. The British army struggled to open sufficient hospitals to accommodate the patients in Belgium or France. Hence, the patients with shell shock were transferred to base hospitals in France and Britain for observation in general wards.  In the absence of an effective treatment strategy, the disorder invalidated a considerable number of army personnel.
Toward Etiological Understanding
Efforts were made to identify the etiology of shell shock. The British army recruited Frederick Mott, then Britain's leading neuropathologist to discover the etiology of this condition. By the end of 1915, after first-hand contact of numerous service patients, Mott suggested that the forces of compression released by an exploding shell could cause a concussion or "commotio cerebri."  Alternative etiology suggested by Mott was that the disorder resulted from damage to the central nervous system from carbon monoxide released by the partial detonation of a shell or mortar. It was suggested that in extreme cases, these effects might be fatal if intense commotion affected "the delicate colloidal structures of the living tissues of the brain and spinal cord," arresting "the functions of the vital centers in the medulla." Shell shock was formulated as an organic problem even though the pathology remained unclear.
However, further research conducted in 1915 and 1916 by Myers led to promulgation of a new hypothesis. Myers observed that many shell-shocked soldiers had been nowhere near an explosion but had identical symptoms to those soldiers who had been in the vicinity of a shell explosion. Myers suggested a psychological explanation and proposed the term "emotional" rather than "commotional" shock.  The psychological explanation gained ground over the neurological. The distinction between various etiologies of shell shock gathered attention, in part because it offered the British army an opportunity to return shell-shocked soldiers to active duty. The British army in France was instructed that shell shock and shell concussion cases due to enemy should have the letter "W" (for Wounded) prefixed; while those of a person's breakdown without a shell explosion, or when thought not due to the enemy should have the label "S" (for Sickness) prefixed. The type of privileges including that of wound stripe and pension depended upon whether a person was given the label of "W" or "S."
In November 1916, Arthur Sloggett, Director General of Army Medical Services, authorized two new classifications.  The "effects of explosion (wound)" was meant for those who were unable to perform their duties as a soldier as a result of direct contact with "a specific explosion without producing a visible wound." However, "nervousness" was reserved for those soldiers whose symptoms were characterized by anxiety after the combat experience. Four dedicated units were set up in France close to the front line for acute cases of soldiers experiencing symptoms of shell shock. Furthermore, specialist base hospitals were established for those already suffering from chronic effects. Considerable resources were diverted toward the investigation and clinical management of this apparently novel disorder. If symptoms persisted after a few weeks at a local Casualty Clearing Station (which would normally be close enough to the front line to hear artillery fire), the personnel might be evacuated to one of four dedicated psychiatric centers which had been set up further behind the lines for subsequent evaluation. Apart from these efforts of the army to reduce the emergence of shell shock, efforts were also made to treat the sufferers of shell shock using hypnosis, with some degree of success. 
The chronic form of shell shock was expressed by medically unexplained symptoms, in particular, tics, paresis, tremor, contractures, fatigue, headache, difficulty sleeping, nightmares, memory loss, and poor concentration together with aches and pains. In addition, sufferers felt fatigued and were often unable to complete routine tasks.  By the end of the first world war, approximately 80,000 British soldiers had been diagnosed with shell-shock. Efforts were made to limit the use of the diagnosis of shell shock, and the use of the term was censored, even in medical journals. 
At the beginning of World War II, it was expected that the cases of shell shock may rise as the war stretches and casualties mount. Preemptively, the term "shell shock" was banned by the British army, though the phrase "post-concussion syndrome" was used to describe similar stress-related responses among those exposed to combat.  Subsequently, other terms made their entry to describe the symptoms experienced by those military personnel who experience trauma related to war conditions. These terms have included "soldier's heart" and "war neurosis."
Introduction of Posttraumatic Stress Disorder in Psychiatric Classificatory System
The term PTSD made its first appearance in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. This diagnosis came to limelight after the Vietnam War, which saw a considerable number of veterans suffering through symptoms of hyperarousal, re-experiencing phenomenon, and avoidance of war-related cues to avoid distress. Initially, envisaged to convey distress associated with combat-related war exposure, the diagnosis of PTSD had extended its purview to include any exceptionally threatening trauma.
Though the journey from the recognition of shell shock to advocacy of PTSD has been long and arduous, the progression shows that perceptive and inquisitive clinical acumen, can lay foundations for discerning the best ways to help individuals in distress, especially when individuals are in a position where expression of distress may be construed as a sign of weakness.
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Conflicts of interest
There are no conflicts of interest.
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