Dr Ruwan M Jayatunge
Post-traumatic Stress Disorder (PTSD) is an anxiety syndrome that develops after exposure to traumatic life events (Pervanidou & Chrousos, 2007). Although PTSD is sometimes considered to be a relatively new diagnosis, as the name first appeared in 1980, the concept of the disorder has a very long history (Andreasen, 2010) and psychological reactions to traumatic incidents have been frequently described for more than 100 years (Thomann & Rauschmann, 2004).
In the 19th century ungovernable emotional excess or else hysteria became a major focus in the medical field. The physicians noticed that hysteria symptoms usually appear with emotional conflicts and symptoms were linked to psychological factors. Hysteria was regarded as a multi-symptomatic syndrome. During the First World War many soldiers suffered hysteria type of reactions that were called Shell Shock. Shell shock resulted from psychological trauma experienced on the battlefield. Decisive discussions and descriptions of shell shock and hysteria laid the foundation for the modern notions of dissociation and PTSD (Dayan & Olliac, 2010).
The French clinicians mainly Charcot and Janet were the first to connect traumatic events and symptoms of hysteria (Schestatsky et al., 2003). Charcot regarded traumatic hysteria as stemming not from the physical effects of the traumatic accident but rather from the idea his patients had formed of it (Pitman, 2013). Pierre Janet (1889) first described how the central issue in trauma is dissociation (van der Kolk, van der Hart, & Burbridge, 1995).
Sigmund Freud (1856-1936) developed a specific interest in hysteria after his stay with Professor Jean-Martin Charcot during the winter of 1885-1886 (Bogousslavsky & Dieguez, 2014). Freud had learned a great deal about the epistemological status of the knowledge he was deriving from hysterical patients in the years since 1895 (Pletsch, 1982). In 1895 Sigmund Freud and Josef Breuer published their book -Studies on Hysteria. Freud and Breuer concluded that the hysteric suffers mainly from reminiscences (Luckhurst, 2004). As described by Freud hysteria was not anything physical at all but an emotional, internal affliction that could affect both males and females, which was caused by previous trauma (Maines, 1999). Freud expressed the belief that many cases of hysteria had a basis in childhood incest (Stone, 1992) and he investigated the aetiology of hysteria(Löwe et al., 2006).
The concept of dissociation was proposed by Janet in 1889. According to Janet dissociation is a disruption in the normally integrated functions of memory, identity, perception and/or consciousness (Perry & Laurence, 1984). However Freud renounced the concept of dissociation (Gurevich ,2014). After visiting Janet, Freud adopted many of these concepts of dissociation as a splitting of consciousness, often associated with bizarre physical symptoms and manifestations, and ultimately attributed such symptoms in his hysterical patients to a history of childhood sexual abuse (Scaer, 2001).
In the nineteenth-century post-traumatic symptoms were described as Railway spine. The railroad accidents at the beginning of the industrial age cased a large number of PTSD victims. In 1866 Surgeon Eric Erichsen developed the influential hypotheses that psychological symptoms after railway accidents were caused by a concussion of the spine followed by "molecular changes" in the spinal cord -"railway spine syndrome" (Löwe et al.,2006). After 1900, the symptoms were generally diagnosed as a functional neurosis (Siemerink-Hermans, 1988). Sigmund Freud was interested in the nineteenth-century medical condition railway spine syndrome. Freud thought that symptoms of railway-spine lay in a deeply rooted facet of infantile sexual life.
Freud's Three Essays on the Theory of Sexuality is one of the grounding texts of 20th century European thinking (Van Haute & Westerink, 2016). Freud placed sexuality at the centre of psychic development, psychoanalytic theory and clinical work (Green, 1995). He found sexual aetiology in neuroses. Hence Freud introduced new categories of pathology.
The diagnosis of Neurasthenia appeared in 1869 and the concept was introduced by George Miller Beard. Some experts saw similarities between shell shock and neurasthenia. Neurasthenia rapidly became fashionable and highly prevalent (Taylor, 2001). At the end of the 19th century, neurasthenia and hysteria were considered distinct diseases. Specifically, neurasthenia was regarded as a disease of the body, whereas hysteria was regarded as a disease of the psyche (Paciaroni & Bogousslavsky, 2014).
The Common psychological symptoms of Neurasthenia were insomnia, lack of concentration, depression, fears and irritability (Gosling, 1987). Freud thought that neurasthenia is resulting from sexual excess, and anxiety neuroses. However in 1895 Freud removed anxiety neurosis from neurasthenia (Taylor, 2001).
Freud used the term trauma to describe abrupt events in which an individual is overwhelmed by stimuli, particularly noxious stimuli such as loss or threat to life (Witztum & Kotler, 2000). He studied the link between sexual trauma and hysterical illness (Chu, 1991). Freud hypothesized that traumatic memories unconsciously converted into the somatic manifestations of hysteria.Furthermore Freud described dissociation as a reaction to trauma (Bacciagaluppi, 2011).
Freud had characterized the memory of trauma as “a foreign body which long after its entry must continue to be regarded as an agent that is still at work ( Smelser, 2004). In Beyond the Pleasure Principle (1920) Freud described how patients suffering from traumatic neuroses often experienced a lack of conscious preoccupation with the memories of their accident (van der Kolk, 2000). Moreover Freud thought that inability to put traumatic experiences into words repression occurs (van der Kolk & Ducey, 1989).
The symptoms of PTSD fall into three clusters: reenactment of the traumatic event: avoidance of cues associated with the event or general withdrawal; and physiological hyperreactivity (Perry & Azad ,1999). Sigmund Freud observed that early memory traces can be activated by later events that cause partial reliving of earlier traumas in the form of affect states, anxiety, or re-enactments (van der Kolk, 1989).
Freud stated that that neurosis derives from deeply traumatic experiences and it is rooted in ego defense mechanisms. In 1888 Freud declared that “a neurosis in the strictest sense of the word; based wholly and entirely on physiological modifications of the nervous system” In 1896 Freud wrote that sexually abused children display hysteria later in life. This concept helped him to develop his seduction theory. Freud's seduction theory
Furthermore Freud wrote about phobic anxiety. Freud analyzed the phobia in a five-year-old boy-Little Hans in 1909. Little Hans' is one of the most highly commented cases in the psychoanalytic literature (Vives, 2012). Freud put the case as a clinical confirmation of the relative theory of infantile sexuality and the existence of an infantile neurosis based on the castration complex and oedipal conflict (Ferrara, 1982). According to Freud in phobias the id has been repressed by the ego.He further stated that the object of the phobia was not the original source of the anxiety. Moreover Freud considered agoraphobia as a defensive organization to avoid anxiety, not bound to the original conflict, but to substitutive formation(Manfredi de Poderoso & Linetzky, 2003). Freud believed that people are motivated towards tension reduction, in order to reduce feelings of anxiety.
In his writings especially, Mourning & Melancholia (1917), Beyond the Pleasure Principle (1920), and Symptoms, Inhibitions & Anxiety (1926) Freud vibrantly describes the effects of psychological trauma on psyche. Freud discovered the psychodynamic conflicts following psychological trauma. In his 1920 essay Beyond the Pleasure Principle Freud indicated trauma and its destructive effect on human psyche. Freud metaphorically defined trauma as the breaching of the ‘protective shield” by an external stimulus, its overwhelming affects pushing the individual into a state of helplessness (Dayan & Olliac, 2010).
Freud observed neuroses caused by the trauma of war. During the First World War, military physicians from the belligerent countries were faced with soldiers suffering from psychotrauma with often unheard of clinical signs (Tatu & Bogousslavsky, 2014) and there was a new surge of interest in hysteria associated with war psycho-neuroses (Bogousslavsky, 2011). The soldiers in the trenches, undergoing unrelenting artillery bombardment, suffered from similar symptoms, designated at the time as shell shock (Shively & Perl, 2012). The shell-shock experience helped to break down the distinction between the sane and the insane (Howorth, 2000). Freud treated several soldiers who returned from the WW1. Freud understood the ill effect of combat trauma on human psyche.
In 1918 at the Fifth International Psycho-Analytical Congress that was held at Budapest Freud read a paper on The Psycho-Analysis of War Neuroses. War neuroses can be addressed as an early model of traumatic stress disorder, such as acute stress disorder or post-traumatic stress disorder. (Tölle, 2005). Just before and after the end of World War I, Sigmund Freud took on an activist role and in his writings and speeches, redirected the concept of war trauma from individual failure to a larger issue of community responsibility (Danto, 2016).
In 1919 Freud wrote; "In traumatic and war neuroses the human ego is defending itself from a danger which threatens it from without or which is embodied in a shape assumed by the ego itself. In the transference neuroses of peace the enemy from which the ego is defending itself is actually the libido, whose demands seem to it to be menacing. In both cases the ego is afraid of being damaged - in the latter case by the libido and in the former by external violence. It might, indeed, be said that in the case of the war neuroses, in contrast to the pure traumatic neuroses and in approximation to the transference neuroses, what is feared is nevertheless an internal enemy. The theoretical difficulties standing in the way of a unifying hypothesis of this kind do not seem insuperable: after all, we have a perfect right to describe repression, which lies at the basis of every neurosis, as a reaction to a trauma- as an elementary traumatic neurosis." (SE17, p210). Freud considered that fixation at the moment of the traumatic experience is the basis of a traumatic neurosis.
Freud observed somatization reactions in many of his patients. The concept of somatization takes its origin from the work of Freud who proposed the idea of conversion as a main defense mechanism (Tsukui &, Ebana, 2009). In psychodynamic theory, somatization is conceptualized as an ego defense, the unconscious re-channeling of repressed emotions into somatic symptoms as a form of symbolic communication (Sutker, & Adams, 2001). His famous case study of Fräulein Anna O (Bertha Pappenheim) had a number of somatization symptoms.
Sigmund Freud used the term Traumatic Neurosis that resembles the present day PTSD (Young, 2002). The term traumatic neurosis designates a psycho-pathological state characterized by various disturbances arising soon or long after an intense emotional shock (Gale, 2005). Freud too regarded traumatic neurosis as a fright-induced psychological phenomenon, in contrast to psychoneurosis, which he believed was caused by repressed sexual desires (Pitman, 2013).However the nosologic designation of traumatic neurosis was not consensually accepted until after World War II (Modlin, 1986).
Freud believed that neuroses arise from intrapsychic conflict and he stated that “in neurosis the ego suppresses part of the id out of allegiance to reality. Freud's original model of neurosis, known as Seduction Theory, was a post-traumatic paradigm which placed emphasis on external stressor events. In 1897, due to a confluence of factors, he shifted his paradigm to stress intrapsychic fantasy as the focus of analytic treatment for traumatic neurosis (Wilson, 1994). In Freud’s words, “The symptomatic picture presented by traumatic neurosis approaches that of hysteria in the wealth of its similar motor symptoms, but surpasses it as a rule in its strongly marked signs of subjective ailment . . . , as well as in the evidence it gives of a far more general enfeeblement and disturbance of the mental capacities” (1920g, p. 12).
Freud wrote about Seduction trauma. Seduction trauma refers to a range of phenomena currently described under the rubric of child abuse. Freud elucidated the fantasy distortion and elaboration of traumatic experience and retained the importance of actual trauma (Blum, 1996). Freud's pre-analytic concept of seduction trauma was interwoven with the emerging concepts of an unconscious pathogenic past, repression, and reconstruction (Blum, 2008). Freud’s Oedipus complex is about the incesttaboo, guilt, and aggression (Kilborne 2003). Freud's seduction theory asserts that psychoneuroses in adults are caused by reactivation of forgotten recollections of gross sexual abuse (involving the genitals) that had taken place prior to the age of 8 to 10 years (Figueroa, 2014).
Freud knew the ill effects of childhood trauma. Childhood maltreatment increases the risk for PTSD (Price et al., 2017). Freud revealed the horrors of incest. Incest is emotionally devastating to a child as it involves betrayal, and the irretrievable loss of trust in the adults in the child's life (Godbey & Hutchinson, 1996). Post traumatic stress disorder, dissociative disorders, major depression and borderline personality disorder can be seen in the victims of childhood sexual abuse ( Erdinç et al.,2004). Freud pointed out that childhood sexual abuse could cause psychic damage in the later years.
Freud introduced the concept of repetition compulsion (Freud, 1920). The concept of the repetition compulsion
Repetition compulsion is a maladaptive behavior (Bowins, 2010). The tendency of victims of physical or sexual childhood abuse to become re-victimized in later life has well been documented empirically (Wöller 2005). Freud saw Repetition as a means of abreacting the trauma by seeking to bind the enormous quantity of excitations that cannot find discharge (Casoni 2002). Modern empirical findings confirm Freud's clinical hypotheses regarding the repetition compulsion (Slipp, 2000). According to Van der Kolk repetition compulsion is a re-enactment or re-victimization of past traumatic experiences (Shoda & Kato, 2007). Compulsion to repeat can be viewed as a posttraumatic stress response (Levy, 2000).
In Three Essays on the Theory of Sexuality (1905) Freud introduced the term –Fixation. According to Freud fixation is the manifestation of very early linkages. Fixation has been compared to psychological imprinting (Malcolm, 1988).
In 1909 Freud came to the Clark University USA and delivered several lectures. In these lectures Freud eloquently described the broad clinical picture of PTSD. In one of his famous lectures- Fixation upon trauma - the unconscious Freud states thus…..
…..The closest analogy to this behavior in our nervous patients is provided by the forms of illness recently made so common by the war – the so-called traumatic neurosis. Of courses, similar cases have occurred before the war, after railway accidents and other terrifying experiences involving danger to life. The traumatic neurosis are not fundamentally the same as those which occur spontaneously…..
….. The traumatic neurosis demonstrates very clearly that a fixation to the moment of the traumatic occurrence lies at their root. These patients regularly produce the traumatic situation in their dreams, in case showing attacks of a hysterical type in which analysis is possible; it appears that the attack constitutes a complete reproduction of this situation. It is as though these persons had not yet been able to deal adequately with the situation, as if this task were still actually before them unaccomplished……….
……. a person is brought so completely to a stop by a traumatic event which shatters the foundations of
his life that he abandons all interest in the present and future and remains permanently absorbed in mental concentration upon the past……..
Freud treated a number of patients who had traumatic neurosis or modern day PTSD. For instance his Hungarian patient Anton von Freund had persistent neurosis. The soldier of Dardanelles had war neurosis. In the Studies on Hysteria (1895) Freud describes Frälein Elisabeth von R‘s (Ilona Weiss) traumatic memories. Freud wiped out her traumatic memories under hypnosis (Hurst, 1983).
Freud used psychoanalysis to treat Traumatic Neurosis (PTSD). He made an attempt through psychoanalysis to recover repressed traumatic memories through free association (freie Einfalle) with introspection to the patient. The method Freud contributed to Medicine is the interpretative listening to discourse on two planes (simultaneous and superimposed) with which this divided subject expresses the intra-psychic conflict (Sanchez Lazaro ,1993). This method helped his patens with psychological trauma.
Although some of Freud's theories are obsolete today, many parts of his work appear to be astonishingly modern, even in the light of current neurobiological research (Hartmann, 2009). He eloquently wrote about psychological trauma. Freud's thinking influenced both the DSM-I and II classification of stress response syndromes as transient reactive processes (Wilson, 1994). Freud's concept of the anxiety neurosis was used as a major organizing principle in DSM-I and DSM-II (Frances et al., 1993).He was able to recognize not only the importance of implicit unconscious learning but also the way it currently impacts on the patient in psychoanalytic therapy (Slipp, 2000). There is much suggestive evidence to prove that Sigmund Freud knew the spacious clinical picture of PTSD.
Acknowledgements
· Prof. Richard A A Kanaan Chair of Psychiatry,
Austin Health University of Melbourne
· Prof. Dr. Paul Verhaeghe Department of psychoanalysis and clinical
consulting Ghent University Henri
Dunantlaan Ghent Belgium
· Dr. Tom Dalzell School of Psychotherapy, St Vincent's University
Hospital, Elm Park, Dublin 4, Republic of Ireland
· Dr. Thomas Lepoutre -Centre for Research on Psychoanalysis, Medicine and
Society University at Sorbonne Paris
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