Abstract
Post-Traumatic Stress Disorder (PTSD) seems an odd duck as far as mental disorders go, a diagnosis that has the curious property of seeming both anomalous in, and emblematic of, modern psychiatry. Looked at one way, PTSD is a square peg in the round hole of the current era of biomedical psychiatry. Given that its social, environmental cause is located outside the individual brain, it appears to be a misfit in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a manual that has done more than anything to promote the ontology of mental disorders as illnesses seated in the body, or more narrowly, the brain. But looked at another way, PTSD’s ostensible ill-fitting character seems to reflect a deeper truth about the DSM. Contrary to its standardizing impulses, DSM diagnoses are a bricolage of different kinds of states. Under the rubric of mental disorders, the DSM includes your obvious mental disorders like depression and schizophrenia, but also things like developmental disorders, behavioral disorders, addiction, sexual deviations, personality disorders, and the occasional oddball like restless leg syndrome. This strange assortment reflects the colonizing pretenses that undergird the DSM project; in trying to extend psychiatry’s jurisdiction, the manual errs in the direction of over-inclusiveness, its content thus reflecting an accretion of ideas and the idiosyncratic vicissitudes of psychiatric knowledge (and ignorance). In this sense, the misfit PTSD fits right in.
All this raises a question: how much can we really learn about psychiatry and mental health from a biography of PTSD? It turns out quite a lot. In his new book, PTSD: A Short History, Allan V. Horwitz reveals just the rich insight that can be mined from the case of PTSD. Tracing its evolution from the mid-nineteenth century to today, Horwitz uses PTSD’s distinct character as an effective wedge to open and explore deep questions regarding the relationship between culture and psychiatric diagnoses and the ways in which social, political, and economic concerns have shaped how we understand trauma. The end result is a well-written, succinct history that spins out many promising threads for future scholars to pursue. Indeed, I can think of no better introduction to PTSD. Any aspiring scholar would do well to begin her explorations into the topic here. For this reason, PTSD: A Short History take its place among the must-reads on PTSD, a short list that includes Allan Young’s tour de force, Harmony of Illusions (1995), and Kenneth MacLeish’s poignant ethnography, Making War at Fort Hood (2013).
As part of the Johns Hopkins Biographies of Disease series edited by historian Charles Rosenberg, PTSD: A Short History traces the emergence of the current diagnosis of PTSD through earlier incarnations of trauma-related mental distress. As a scholar who has written definitive books on the recent history of mental illness, Horwitz is a perfect guide through this history, bringing the kind of clear prose and thoughtful analysis that has come to be expected from him. The book begins with a discussion of early manifestations of trauma-related mental distress, focusing on the American Civil War and industrial accidents, notably train accidents that led to the phenomenon of “railway spine.” Right away this period reveals two recurrent themes that drive the history of PTSD: (1) the debates over whether the source of distress should be attributed to the nature of the trauma itself or to some predisposing vulnerability of the patient experiencing the trauma and (2) the complicated imbrication of PTSD in the economics and politics of compensation (in this early era, legal compensation of railroad companies; in later eras, compensation and services for war veterans). The narrative then turns to a discussion of the two World Wars, in which psychological casualties spurred greater articulation of war-related trauma and PTSD precursors like shell shock and combat fatigue. The remainder of the book discusses more recent articulations of trauma, the emergence of the modern notion of PTSD out of anti-Vietnam activism and psychiatric reforms, and finally the dramatic expansion of PTSD in the past three decades. In tracing this history, Horwitz reveals the extent to which understandings of mental distress are shaped by extra-scientific factors, like cultural trends and professional politicking.
PTSD: A Short History represents more of a synthesis of existing research than an innovative, new take. This is not to be taken as a criticism, but rather as an acknowledgement of what type of project this is. The disease biography series from Johns Hopkins aims precisely at what Horwitz achieved here: an excellent primer that can serve as a springboard for further exploration. Mission accomplished.
With that said, there is an inherent risk to these kind of disease “biographies,” which Rosenberg himself warns of in the book’s preface. To write a biography of a disease is to imply continuity and coherence, a unified entity with a linear life course. This framework can be problematic when applied to something shape-shifting and historically specific like trauma. Does the modern form of PTSD reflect the culmination of a coherent progression through earlier proto-articulations? Or does it represent something altogether distinct? Of particular concern is the threat of mis-telling history through a presentist lens. The shifting symptomology of mental distress from trauma only heightens this concern. The symptom profile of shell shock looked quite different from combat fatigue, which itself looks quite different from PTSD. Given that we define and classify mental disorders based on their manifest symptoms, are we warranted in assuming that underlying each of these different ways of being distressed is some shared essence? And if not, is the whole idea of a biography of PTSD misguided?
I think not, but the question lingers. And, in fairness, Horwitz is sensitive to this issue. This comes through most visibly in his inclusion of a chapter on the recovered memory movement, a moral panic that focused on recovering memories from childhood trauma, which led to a number of false accusations. This movement is not part of the typical PTSD narrative. Indeed, the mental disorder most associated with the recovered memory movement is not PTSD, but Multiple Personality Disorder. By including it in the book, Horwitz is subverting the PTSD biography a bit, signaling that the story of trauma is not linear, that it has offshoots, and that trauma is more heterogeneous and sprawling than the neat and tidy PTSD criteria suggest. In other words, the history of PTSD is a messy one and even a short history must appreciate this messiness.
There is a deeper lesson within this acknowledgement, one threaded throughout Horwitz’s book, albeit as subtext. As PTSD has achieved ubiquitous acknowledgment, as the category expands to encompass more and more under its purview, and as it is exported globally to other countries, we would do well to recognize its limits and the dangers of reading all trauma through its lens. Human suffering is diverse and protean. No one diagnosis can capture the entire breadth of this suffering.