Sunday, October 29, 2023

Borderline Personality Disorder (BPD)

Borderline Personality Disorder (BPD) is a long-lasting and complex mental health ailment that is associated with considerable social and vocational impairments and greater use of medical services. BPD has affective, impulsive, interpersonal, and cognitive distortion symptoms. BPD patients have a pervasive pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity. This disorder is associated with highly polymorphic symptoms and signs. 

Borderline personality disorder affects approximately 0.7% to 2.7% of adults. considerably higher rates of BPD were found in women compared with men. (nearly 75% of people diagnosed with BPD are women).  BPD is caused by a complex combination of genetic, social, and psychological factors.

The researchers have found structural brain abnormalities in borderline personality disorder. BPD has been linked to the amygdala and limbic systems of the brain, the centers that control emotion and, particularly, rage, fear, and impulsive automatic reactions. Studies have shown that the hippocampus and amygdala may be as much as 16% smaller in people with BPD.  Positron emission tomography (PET) scans have generally shown that people with BPD show hypometabolism of glucose in their prefrontal cortex and limbic system.

The term borderline personality disorder was coined in 1938 by Adolph Stern, a psychoanalyst who viewed the symptoms of BPD as being on the borderline between psychosis and neurosis. He noticed significant mood-related symptoms including masochistic behavior and psychic rigidity, indicating a protective mechanism against any perceived changes in the environment or within the individual.

Individuals with BPD show deficits across a number of domains of adaptive personality functioning. From a psychodynamic perspective, a hallmark of BPD is a lack of integration of self-representations.  Kernberg (1975) proposed that borderline phenomena follow from a failure to integrate representations of good and bad aspects of the self and others. According to Masterson (1976), borderline dynamics develop in a relationship with a caregiver who has her own tremendous difficulties with separation and emotion regulation.

Borderline personality disorder (BPD) can cause a wide range of symptoms. BPD is characterized by unstable behavior, unstable emotions, unstable relationships, and awareness problems. Borderline Personality Disorder causes disturbances of personal identity, and they view things in extremes. People with BPT have difficulty managing their emotions and often they have a loss of emotional control with anger issues, especially self-loathing.

They experience intense mood swings and volatile interpersonal relationships, and it can swing from extreme closeness to extreme dislike. Their relationships are chaotic and unstable. They have difficulty developing and sustaining trusting relationships. They have turbulent, erratic, and intense relationships. They make quick decisions and act impulsively and recklessly. They are affected by distorted and unstable self-image, unstable sense of self with chronic feelings of emptiness, and feelings of existential anguish. They experience a painful sense of incoherence. Some have stress-related paranoia. They live with constant emotional pain with psychosocial impairment.

People with BPD engage in self-destructive behavior or self-sabotage with dramatic and erratic behaviors. Cognitive distortion aka black-and-white thinking often seen in BPD. They view situations, people, and even self-perception in extreme, all-or-nothing terms. Behavioral minimization (having no accountability for actions or behaviors) can be identified in them.

An extreme fear of abandonment is a common symptom of BPD. They have an intense fear of abandonment with a sense of instability and insecurity. They experience a profound attachment insecurity with poor attachment interactions. They try to avoid real or imagined abandonment.  This fear can lead to the need for frequent reassurance and can lead to unhealthy attachments. They become, codependent or sometimes sabotage their relationships. When they feel that they are about to be abandoned, they typically become fearful and angry. The intensity of their reaction reflects their sensitivity to rejection. 

Guilt and shame play a major role in their lives.  Sometimes they are impacted by temporary paranoid thoughts. Transient, stress-related paranoid ideation is common among the patients. Moreover, they have impulsivity, disrupted interpersonal interactions (splitting behaviors of family, friends, and coworkers), low distress tolerance, emotional dysregulation, high emotional sensitivity, highly variable moods, poor boundaries between self and others, impairment in self-concept, sudden shifts in identity, alterations in self-image, maladaptive attempts at self-soothing, sexual promiscuity, chronic boredom, poor ability for self-direction, inappropriate, intense anger and depressive symptoms.

Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm and has a mean of three-lifetime suicide attempts. Up to 10% of BPD patients will die by suicide. Self-punishing and self-mutilation behaviors are common among the BPD patients. Self-harm behaviors (non-suicidal self-injury) usually present as superficial cuts to the wrists and arms.  Often, they threaten to harm themselves for manipulative purposes.

People with BPD lack insight into their disruptive behavior and thought patterns. They have an inability to move on from or process their emotions. Some of the patients have dissociative symptoms. (about 40%–50% of patients with the disorder have brief periods of psychotic symptoms or dissociation).

The Karpman drama triangle is evident in BPD. The triangle consists of the persecutor, the rescuer, and the victim. It indicates a destructive pattern of social behavior. They have an impaired ability to pursue meaningful short-term goals with satisfaction.

Some experts view BPD symptoms as a way to cope with childhood trauma. The prevalence of traumatic life events such as abuse and abandonment in childhood is high among those with borderline personality disorder. Up to 70% of people with BPD have experienced childhood trauma. In addition, borderline personality disorder runs in families. It’s estimated that 1.4% of the adult U.S. population experiences BPD.   

Common co-morbid psychiatric conditions associated with borderline personality disorder include depression, bipolar disorder, anxiety disorder, sleep disorder, and substance abuse.

Unfortunately, people living with BPD are often stigmatized and avoided by treatment providers. Often the patients sabotage the treatment interventions. Emotional manipulation is also a common factor. Furthermore, they tend to attack the therapist or make allegations against the service provider.

The central elements of treatment are psychoeducation, self-management, improved stress tolerance and awareness, emotion management, and training in social competence. Social rehabilitation can be the most important therapeutic measure. Traditional “talk” therapies have little success in Borderline Personality Disorder (BPD) and Dialectical Behavioral Therapy (DBT), schema-focused therapy (SFT) has proven more effective.  

Dialectical Behavioral Therapy (DBT) components are interpersonal (communication), distress tolerance, emotional regulation, and mindfulness. DBT provides more awareness of the current moment. Psychodynamic psychotherapy is one of the accepted treatments for BPD. Cognitive behavioral therapy (CBT) focuses on assisting the patient to see difficult experiences, interactions, or relationships more clearly. CBT helps to identify and change core beliefs and behaviors that come from inaccurate perceptions and problems interacting with others.

Many of the specialized psychotherapies help patients with BPD, but long-term functional recovery is difficult. Early identification of patients with BPD and early intervention may allow these patients to resume a healthier trajectory. However, remission is more common as people reach the middle years of life.

Written and compiled by Ruwan M Jayatunge M.D. 

Saturday, October 28, 2023

මහාචාර්‍ය නලින් ද සිල්වා හමුවීම


මහාචාර්‍ය නලින් ද සිල්වා සඳහන් කරනවා මම එතුමාගේ අදහස්වලට විරුද්ධ අයෙක් කියලා. මම මහාචාර්‍ය නලින් ද සිල්වා ගේ ඇතැම් අදහස් විවේචනය කරලා තියනවා. නමුත් කරනවා පුද්ගලයෙකු ලෙස මම එතුමා හෙලා දැකලා නෑ. මෑතකදී මට මහාචාර්‍ය නලින් ද සිල්වා  හමු වුනා එතුමාගේ නිවසේදී. 

මහාචාර්‍ය නලින් ද සිල්වා බුද්ධිමතෙක් , ඒ වගේම විවිධ විෂයන් හදාරපු කෙනෙක්. එතුමා සමග මම මරණින් පසු විඥානය පවතිනවාද යන්න පිලිබඳව විවාද කලා. වෛද්‍යවරයෙකු ලෙස මාගේ රෝගීන් ආශ්‍රිතව NDE (Near Death Experience) මම අධ්‍යනය කලා. එසේම යෝක් විශ්ව විද්‍යාලයේ මහාචාරය වරුන් වන  Guy Bernard Proulx ,  James E Alcock සමග අදහස් හුවමාරු කර ගත්තා. මම තවමත් මරණින් පසු විඥානය පවතිනවාද යන්න පිලිබඳව අධ්‍යනය කරනවා. මහාචාර්‍ය නලීන් ගණිතය සහ Quintom Mechanics  ආශ්‍රිතව මට අදහස් ලබා දුන්නා. මහාචාර්‍ය නලින් ද සිල්වා දැණුම ආකරයක්. නමුත් අවාසනාවන්ත ලෙස ඒ දැණුම හරි හැටි සමාජගත වුනේ නෑ.  

Saturday, October 21, 2023

Leonardo da Vinci’s Art in a Psychoanalytic Perspective


By Ruwan M Jayatunge M.D   

"Leonardo da Vinci was like a man who awoke too early in the darkness, while the others were all still asleep" - Sigmund Freud   

The renaissance painter Leonardo da Vinci was a man well beyond his time. He was a genius who demonstrated skills as an architect, engineer, mathematician and a philosopher. What is so special about Leonardo da Vinci’s art? He studied nature in its finest detail. He made enormous attempts to make his art as true to life as possible. He was a passionate painter who was dedicated to his work, sometimes driven by obsessions. His art is everlasting and he expressed motions of the mind in his art. Leonardo's paintings are full of spiritual reflections.  

For centuries da Vinci’s some of the art work has become a mystifying riddle to the people. According to connoisseur opinion there are hidden messages associated with his art and the speculation led to the birth of the term da vinci code. His paintings can be called “Pictures within Pictures. He used art as a mode of communication. Perhaps some of the puzzles were not known to da Vinci himself since he depicted his art following unconsciously driven motives. A large portion of these distinctive characteristics steamed from his unconscious mind that was deeply analyzed by Dr Sigmund Freud.  

The impressive essay written by Sigmund Freud in 1910 titled Leonardo da Vinci, A Memory of His Childhood reveals the inner psyche of this great artist. Freud's essay on Leonardo was stupendous and he reconstructed the psychology of a man who was considered as the archetype of the Renaissance period. Freud had speculated on various aspects of Leonardo's personality. His life has been the subject of study, analysis and speculation. Freud has written the connection between Leonardo’s inner psyche and its role in his art. Freud examined Leonardo's life and works closely from a psychological perspective. 

Freud largely depicted Leonardo's life by factual references he had found. He mainly speculated on the two paintings of Leonardo da Vinci the Monna Lisa and Sant'Anna and the Madonna with the child. This analysis gives a detailed reconstruction of Leonardo's emotional life from his earliest years.  Leonardo da Vinci was born as the illegitimate son of a notary in 1452. He had an anxious childhood. Frequently little Leonardo was disturbed by a nightmare. He saw a kite dropped from the sky and hovered over his cradle, its tail feathers brushing his face. Although little is known about Leonardo's early life there are facts which concur that he was very much attached to his father’s young legal wife Anchiano. Young Leonardo was devastated over untimely death of Anchiano and suffered derivational symptoms. 

Freud examined the childhood of Leonardo da Vinci, to explain his psychological inclinations toward people who took care of him.  Young Leonardo was doted on by his mother, neglected by his father; hence Freud suggested that he was subjected to so called inordinate Oedipal development in which the subject took his father's domination of the mother as a "de facto" domination (therefore prohibition on the father's part). Freud applied theory on Leonardo’s prodigious genesis scientific pursuits and the fact that he left so many works unfinished. For instance one of his magnificent paintings the Madonna Litta was not completed by Leonardo da Vinci and later one of his pupils did the completion. Freud attributed that partial completion of Madonna is symbolic and it was the unconscious expression of childhood anxiety that was experienced by da Vinci following the deprivation of his mother.  

Sigmund Freud interpreted Leonardo’s childhood memories as fantasies and compares it with mythological information. He stated that Leonardo identified with his mother unconsciously as an object so he could experience self-love (narcissism) and his antagonism toward his father was specifically described in his art. Freud continues his discussion of the memory of Leonardo's mother in his analysis of Mona Lisa's smile. This ambiguous half smile is one of the striking features of the painting. Enigmatic portrait Mona Lisa which is an open text painted during the Italian Renaissance and it could be considered as the most celebrated work of Leonardo.  

Freud theorized that Leonardo’s fondness of depicting the Virgin Mary with St Anne which represents two mothers. Leonardo was raised by his blood mother and later adopted by the wife of his father hence he had two mothers. This very idea was represented in his art. Freud explained that depicting the Virgin Mary with St Anne represents protection under two mothers.  Experts claim that androgyny and eroticism manifested in a number of drawings of Leonardo da Vinci and his famous painting Virgin of the Rocks demonstrates Leonardo's interest in nature. Leonardo's most legendary painting, the Last Supper represents the last meal shared by Jesus with his disciples before his capture and death. His ability to adequately depict the faces of Christ and Judas were marvelous. The Last Supper specifically portrays the reaction given by Judas Iscariot who betrayed Christ.  Freudian psychobiography of Leonardo da Vinci scrutinizes the life and work of one of the exceptional artists of human history and for a considerable extent it helps to resolve the mystery of Leonardo da Vinci.

Sunday, October 15, 2023

ජැක්සන් ඇන්තනි ගේ නික්ම යාම


ජැක්සන් ඇන්තනි යනු සහජ දක්‍ෂතා සපිරි පුද්ගලයෙකු විය​. ඔහු මුල් කාලයේදී අධි රංගනයක නිරතවූ නමුදු පසු කාලයකදී දක්‍ෂ චරිතාංග නළුවෙකු විය​. ඔහු ගාමිනී ෆොන්සේකාටත් වඩා දක්‍ෂ ලෙස විවිධ චරිත රඟපෑ බව මාගේ අදහසයි. ඔහු කෙවින් කොස්ට්නර් වැනි නළුවෙකු බව කිව හැකිය​. බොහෝ දක්‍ෂතා තිබූ නිසා ඔහු බොහෝ දෙනාගේ ඉරිසියාව මුසු වයිරයට ලක් විය​. බොහෝ දෙනෙකු ඔහුගේ සාර්ථකත්වයට ඉරිසියා කලෝය​. දැඩි සත්කාරයේ සිටියදී පවා ඔහුගේ මරණය ප්‍රාර්ථනා කලෝය​. ඔහු සාධාරණ විවේචනයට ලක් වූයේ මහින්ද රාජපක්‍ෂ බුදුන් ගේ ඥාතියෙකු බව කීම නිසාය​. ඔහු මේ කතාව කියුවේ මහින් ද රාජපක්‍ෂ රජතුමාට ඇඳ සිටි කාලයකය​. එහෙත් බොහෝ දෙනෙකුට මේ කතාවේ යටි අරුත තේරුම් ගියේ නැත​. ඉතිහාසය මනා සේ දැන සිටි ජැක්සන් මාටින් රාජපක්‍ෂ කාල්ටන් වලව්වේ හරක් බැලූ බවත්  මහින්ද බුදුන් ගේ ඟාතියෙකු නොවන බවත් දැන සිටි නමුදු  මහින් ද රාජපක්‍ෂ ක්ලෑන් එක උපහාසයට ලක් කිරීම සඳහා මේ කතාව කියූ බව උපකල්පනය කල හැකිය​. ජැක්සන් ගේ ප්‍රකාශයත් සමග මහින්ද රාජපක්‍ෂ සහ සමාගම නාය යාම ඇරඹිනි. මේ අනුව රාජපක්‍ෂවාදයට මුල්ම ගල ගසන ලද්දේ ජැක්සන් විසිනි. 

Sunday, October 8, 2023

පලස්තීනය සහ ඊශ්‍රායලය​


පලස්තීන  සහ ඊශ්‍රායල  ගැටුමේදී මට කිසිදු පාර්ශවයකට සහාය දීමට නොහැකි තත්වයක් උදාවී තිබේ. මට පලස්තීනය සහ ඊශ්‍රායලය යන දෙරටේම මිතුරන් සිටිති. එහෙත් ඊශ්‍රායල් ගුවන් ප්‍රහාර නිසා මිය යන සිවිල් වැසියන් ද  පලස්තීන හමාස් බෝම්බ කරුවන් නිසා මිය යන සිවිල් වැසියන් පිලිබඳවද කණගාටුවක් තිබේ.

පලස්තීන මිතුරන් පිලිබඳව කතා කිරීමේදී මට වෛද්‍ය පීඨයේ මා සමග ඉගෙන ගත්  පලස්තීන ජාතික මිතුරන් කිහිප දෙනෙකු පිලිබඳව සිහිපත් වෙයි. ඒ අතරින් මන්සූර් තරීෆ් සහ ඊබ්‍රහීම් අබුතීනා මාගේ මතකයට නැගෙයි. ඔවුන් දෙදෙනා ආවේ ජෝර්ධානයේ සිටය​. මා ඇතැම් දින වල රාත්‍රියේ ආහාර ගත්තේ ඔවුන් දෙදෙනා සමගය​. සූරියකාන්ත තෙල් වලින් බැද ගත් අර්තාපල් ,හරක් මස් හෝ කුකුල් මස් සමග සලාදයක් අප පාන් සමග අනුභව කලෙමු. බොහෝ විට අප ඊට ලූණු , තක්කාලි සහ බිත්තර ද දැමුවෙමු. අප කෑවේ පිඟන් වල නොව කෙලින්ම  අර්තාපල්  සහ මස් බැදගත් විශාල ඇළුමීනියම් භාජනයට ගෑරැප්පු ගසාය​. එසේ කන විට අප තිදෙනා අතර නිතැතින්ම සහෝදරත්වයක් වර්ධනය විය​.  ඔවුන් දෙදෙනා මට පල්ස්තීනය සහ ඊශ්‍රායලය පිලිබඳ බොහෝ කතා කීවේය​. එසේම ගිම්හාන නිවාඩුවෙන් පසු ජෝර්ධානයට ගොස් එන විට මන්සූර් මට අනගි සපත්තු දෙකක් සහ ඊබ්‍රහීම් ස්පෝට්ස් ඇඳුම් කට්ටලයක් තෑගි කලේය​. ඔවුන් දෙදෙනා තවමත් මාගේ හදවතේ ජීවත් වන මිතුරන් දෙදෙනෙකි.

ලෙබනනයෙන් පැමිනි රයිෆ් ද පල්ස්තීනුවෙකි. ඔහුට  ඊශ්‍රායලය මතක් කල විට කෝප වෙයි. ඔහු යුදෙව්වන්ට වයිර කරන්නෙකි. "උන් ඔක්කොම යුදෙව්වෝ" ඔහු අපගේ යුදා ජාතික ආචාර්‍යවරුන් වෙත පොදුවේ වෙන් කරමින් පවසයි. රයීෆ් ගේ යුදෙව් විරෝධය මට තේරුම් ගත හැකිය​. පලස්තීන අනාතයෙකු ලෙසට ජෝර්ධානයේ ඊශ්‍රායෙල මිලිටරි බලය සියැසින් දකිමින්  කරදඞු උස් මහත් වූ ඔහුගේ යුදෙව් විරෝධය  ලේ මස් වලටම කා වැදී තිබේ. වරක් ඈතින් එන  මහාචාර්‍ය මිකුනිස්ට " ෂැලොම් ෂැලොම් " කියා ඔහු සමච්චලයට සමාචාර කලේය​. හොඳ වේලාවට මහාචාර්‍ය මිකුනිස්ට එය ඇසුනේ නැත​.වරක් එක් ශ්‍රී ලාංකික සිසුවෙක් රයිෆ්ට උඹලා රටක් නැති අනාතයෝ කියා කී විට රයිෆ් ගේ මුහුණ කෝපයෙන් සහ ශෝකයෙන් බරිත විය​.

පලස්තීනයේ ජීවත් වූ  දියාබ් ලෙබනනයේ දියාබ් උස මහත ශක්තිමත් පුද්ගලයෙකු වූ අතර ගෝරියටද බර විය​. වරක් කැන්ටිමේදී දියාබ් පෝලිම පැනීම නිසා මම දියාබ්ව ඇද ඉවතට ගත්තෙමි. ඒ නිසා දියාබ් මා සමග දබරයට ආ අතර මමද නොබියව ඔහුට පහර දීමට අත මිට මෙලවූයෙමි. සහජයෙන් අරාබින් පහරට පහරක් ගහන පුද්ගලයන් හමුවේ පසුබා යති. එම නිසා දියාබ් පසු බැස්සේය​. මෙම මූලධර්මය ඊශ්‍රායෙලය විසින් අරාබීන් විශයෙහි යොදා ගන්නා බව මට සිතේ. එහෙත් පසු කාලයක දියාබ් සන්සුන් පුද්ගලයෙකු වූ අතර මා සමග මිතුරු විය​. ඔහු රුසියානු යුවතියක් කසාද බැන්දේය​. ඔහු පස් වන වසරේ සිටියදී පියෙකුද විය​.

මාගේ ඊශ්‍රායල මිතුරන් අතර බොහෝ මහාචාර්‍යවරු වෙති. ඔවුන් මට බෙහෙවින්ම උපකාර කොට තිබේ. එසේම මගේ පොත් වලට පෙරවදන් පවා සපයා ඇත්තේ මෙම යුදෙව් විද්වතුන් විසිනි.  මාගේ ඊශ්‍රායල මිතුරන් අතරින්   IDFහෙවත්   ඊශ්‍රායල  ආරක්‍ෂක සේවයේ නිරතව සිටි යාකොබ් එතරම් උස මහත පුද්ගලයෙකු නොවේ. එහෙත් ඔහු කුළු හරකෙකු මෙන් ශක්තිමත් ය​. එසේම යෝක් විශ්ව විද්‍යාලයේ මාගේ ගුරුවරයෙකු වූ ටෝනි ෂිම්බ්‍රි මිතුරෙකුද විය. ඔහු මා නාලන්දා විද්‍යාලයේ උසස් පෙළ කල සමයේ සිටි භෞතික විද්‍යා ගුරුවරයෙකු වූ තිලක් අල්විස් මෙන් මචං ගුරුවරයෙකු විය​.  ටෝනි අප සමග කතා කරන විට ඔහුගේ පුද්ගලික ජීවිතයේ දේවල්ද කීවේය​. අප අතර ගුරු -සිසු තාප්පයක් නොවීය​.  ඔහු මුලදී සිතුවේ මගේ මූලයන් ඉන්දියාවේ කියාය​. ඒ නිසා වරක් ඉන්ඳියාවට ගිය ගමනකදී චොක්ලට් පාට සහ කුණු සපිරි ගංගා නම් නදියේ හිස ඔබාගත් අයුරු කීවේය​. පසු කාලයක ටෝනි  ටොරොන්ටෝ විශ්ව විද්‍යාලයට ගියේය​.

බයිබලයට අනුව  පලස්තීනය සහ ඊශ්‍රායලය යනු සොහොයුරන් දෙදෙනෙකු ගෙන් ආරම්භ වූ පරම්පරාවන් දෙකක් වෙති. ඔවුන් වසර දහස් ගනනක් පුරා එකිනෙකා සමග මරා ගනිති. දෙවන ලෝක යුද්ධයෙන් පසුව ඊශ්‍රායල රාජ්‍යය බ්‍රිතාන්‍ය විසින් පලස්තීනයේ ස්ථාපිත කිරීම නිසා මේ ගැටුම් තවත් උත්සන්න විය​. ඊශ්‍රායල රාජ්‍යය බ්‍රිතාන්‍ය විසින් මුලින්ම ස්ථාපිත කිරීමට යන ලද්දේ ලංකාවේ උතුරු මැද පලාතේ බවත් ඊට විරුද්ධව හේමපාල මුණිදාස විසින් උද්ඝෝෂණය කල බවත් කියවේ. යම් ලෙසකින් ඊශ්‍රායල රාජ්‍යය ලංකාවේ උතුරු මැද පලාතේ ඇති කලේ නම් ලංකාවේ මෑත ඉතිහාසය සහමුලින්ම වෙනස්  වීමට ඉඩ තිබුණි.

Thursday, October 5, 2023

William Wordsworth: The influential Romantic Poet


Dr. Ruwan M Jayatunge
William Wordsworth, one of the most influential romantic poets in Western literature, was deeply influenced by his love for nature which inspired him since his childhood. Wordsworth presented a magnificent picture of the relationship between human beings and the natural world. For him, nothing was wonderful or mysterious other than nature. He introduced himself as a Nature’s child.

Wordsworth made an explicit connection between poetic diction and the appropriate relationship between nature and society. His poetry often rejoices the beauty and spiritual values of the natural world. Wordsworth’s poems add sunshine to the human heart. William Wordsworth saw man as a part of the natural world but felt disturbed when Industrialization broke the innate bond and created a more artificial world away from his dreams.

Strange emotions
With a melancholic feeling, he accepted the consequences of the Industrial Revolution that changed the air and terrain. Wordsworth was not against the achievements of science and technology but obviously felt gloomy when nature was replaced by man-made artificial cities. Then he wrote

The world is too much with us, late and soon
Getting and spending we lay waste our powers
Little we see in Nature that is ours
We have given our hearts away, a sordid boon
This sea that bares her bosom to the moon
The winds that will be howling at all hours
And are up gathered not like sleeping flowers

Wordsworth was a factual Romantic thinker. He revolutionized poetry by writing in simple, straightforward language. His verse represents the ideas he carried from the eighteenth century to the Victorian age. His entire life was an explosion of creative talent.

His poetry recounts the philosophy of life. Wordsworth defined poetry as the “spontaneous overflow of powerful feelings,” intense “emotion recollected in tranquility.”

He often said, “Poetry is the breath and finer spirit of all knowledge; it is the impassioned expression which is in the countenance of all Science.” As a poet, he blends his metaphysics with pictures of life and scenery. He used external symbols to speak to the human heart.

Energy and passion
Wordsworth continued to write poetry with energy and passion. Some of his poetry had radical origins. Wordsworth’s interest in both poetry and politics was exceptional. He believed in a rationalistic model of human behavior and formulated his own theory of human nature. Wordsworth grasped Rousseau’s expression: “Man is born free; and everywhere he is in chains and his illustrious slogan “Liberty, Equality, and Fraternity.”

Wordsworth came into contact with the French Revolution while living in France and was fascinated by the revolutionary activities. Revolutionary Paris boosted his young spirit. He had hailed the French Revolution with feelings of enthusiastic admiration. There was a rebel inside him. He composed many ideas on justice and morality. William was better at writing philosophical ideas in verse.

Wordsworth adopted radical intellectual and political stances. He used his inner thoughts to process the ideas of freedom and independence admiring nature and pronouncing man’s innate connection with it. He saw nothing loftier than human hopes, nothing deeper than the human heart nothing more valuable than nature, and nothing more negotiable than human freedom.

Even though the French Revolution gave him a glimpse of hope in the early stages soon he realized human freedom was not at a reachable point. The Reign of Terror connected with the French Revolution made him discontent.

The key representative of English Romanticism was against revolutionary republicanism which promoted violence.

Although he embraced the radical faith when he witnessed terror Wordsworth became a conservative public man. He was disappointed when the blossom of human freedom faded. Wordsworth lost his trust in immediate social reform. Then he devoted himself to study in seclusion. But the influence of the French Revolution on this part of his life cannot be undervalued.

His poem Guilt and Sorrow (or Incidents on Salisbury Plain) could be the testimony of his feelings. As a dejected man, he converted his personal experiences and tragedies into verse. Wordsworth explored a wider spectrum of nature and the human heart. He was one of the prominent Romantic thinkers of all time. He does not belong to one country or to one culture. William Wordsworth was a universal man who believed in human freedom, aspirations, and man’s exceptional bond with nature.

Poetry Therapy



Ruwan M Jayatunge M.D. 

Poetry is a verbal art that has an aesthetic quality associated with artistic expression. Poetry has a distinctive style and rhythm and often touches physical, social, emotional, intellectual, and volitional aspects of life. Poetry is based on the interplay of words, feelings, emotions, ideas, experiences, and imagination.  It is a creative introspection and provides more connectedness. As Robert Frost elucidated poetry is when an emotion has found its thought and the thought has found words.

A poem is an emotional-intellectual-physical construct (Longo,2002). Poetry provides profound insight into human experiences and links with inner thoughts, deep feelings, and strongly held beliefs. Poetry helps to manage intense feelings. Poetic writing helps to connect with the inner self and extends to external connections with others and promotes self-reflection, facilitates introspective thinking. Writing poetry provides penetrating insights into individual experiences.

The earliest known examples of written poetry come from the Sumerian civilization, which dates to around 2,000 BCE. Poetry has been used for healing and personal growth since antiquity. The power of poetry is known for its therapeutic outcome. Writing poetry is a valuable therapeutic activity for people with mental health issues. It is an exceptional method to describe mental experiences and debrief emotions. It helps in self-expression and exploration of feelings, memories, emotions, and thoughts leading to cathartic effects. 

The therapeutic power of poetry has been known to men since the Greek Civilization. People knew the therapeutic benefits of poetry.  The ancient poet Homer: the presumed author of the Iliad and the Odyssey knew about poetry’s healing capacity. Xenophanes (570 BCE- 478 BCE) was a poet who used his poetic skills to explain his philosophy. The Greek Physician Soranus of Ephesus in the first century A.D. used poetry and drama to treat his patients. According to Holm-Hadulla et al., (2010), the German poet Johann Wolfgang von Goethe (1749 – 1832) suffered from poetic melancholy, depressive episodes, and dysthymic phases and his poetic work helped him to curb his depressive thoughts. The English romantic poet John Keats (1795- 1821) had bouts of depression and poetry helped him to combat his despair. D. H. Lawrence assumed that writing poetry leads to self-understanding. The poet T.S. Eliot (1957) identified the healing qualities in poetry.

Poetry is not only an aesthetic expression, but it also has the potential to heal and transform. Therefore, poetry can be regarded as a form of therapy, and therapists can incorporate poetry into their treatment.  As an expressive intervention in the early 1800s, Dr. Benjamin Rush introduced poetry as a form of therapy to his patients. According to Gorelick (2005), Poetry therapy appeared widely in the late 1960s. 

The use of poetry therapy continues to grow. McArdle and Byrt (2001) state that poetry therapy is the intentional use of poetry for healing. Poetry therapy falls under the remit of Art Therapy and it’s an effective form of adjunctive therapy for the treatment of mental health problems (Hankir & Zaman 2015). Poetry therapy has spiritual and psychological benefits and brings coherence. Poetry therapy is an arts-based psychotherapeutic intervention geared to achieve healing and personal growth (McCulliss, 2011).   Poetry can be used as an expressive therapy to treat depression, anxiety, pain management, grief disorder, and stress-related conditions.

Poetry therapy is a narrative technique, and it gives exposure to innermost feelings and thoughts. It is a cost-effective and client-centered treatment mode. Kerner and Fitzpatrick (2007) elucidate that poetry therapy is a strength-based technique. Moreover, poetry therapy can be used as a motivational intervention and to establish therapeutic relationships.

People find Poetry as a mental soother. The therapy appeals to the rational brain and emotions.  In poetry therapy, the patients are allowed to express their emotional experiences and help to process their past trauma increasing their sense of effectiveness, reducing distress, and uplifting self-esteem. The patient has the possibility to reach the core of their illness. The patient achieves a sense of control and finds meaning in their deplorable mental health condition. Poetry therapy is geared to obtain positive transformation and help in recovery.

Poetry therapy helps to achieve emotional catharsis, and self-affirmation and enhances mental health. Poetic ability augments creativity, mental imagery, and self-expression and increases positive emotions. Poetry helps to access metaphor and helps the patients to express their deeply repressed sensitive thoughts. This therapeutic intervention enables reflection and helps in self-disclosure. 

Writing poetry has positive therapeutic effects (Sharma, 2020). Mohammadian and team (2011) indicate the therapeutic success of poetry therapy. Poetry therapy has the potential to provide greater self-awareness, promote emotional sensitivity, cultivate a compassionate presence, and provide a space to vent, reflect, and come to terms with their respective situations (Xiang et al., 2020).

The healing effect of poetry is seen in anxiety disorders. Anxiety disorders are the most prevalent psychiatric disorders and are associated with a high burden of illness (Thibaut,2017). According to Alschuler (2006), Poetry therapy enhances insight and reduces anxiety. Poetry therapy promotes personal awareness and helps to revisit traumatic memories and process them. It empowers one’s emotional experiences, cleansing the mind and helping in self-discovery. Moreover, poetry helps to confront fear, intense feelings, and distressing memories. Poetry enhances emotional adaptation and desensitizes intrusive thoughts. Poetry therapy allows the use of symbols to express their unresolved mental conflicts, deep emotions, and distressing memories, hence providing a cathartic release. Brillantes-Evangelista (2015) proposed using poetry therapy as an adjunctive therapy in treating Post-traumatic stress disorder (PTSD).

Poetry can help to cope with Depression. Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Poetry has the ability to enhance mood. Poetry therapy can be used as a therapeutic approach to reduce symptoms of mood disorders (Asgarabad et al., 2018).  Writing poetry alleviates symptoms of depression.  Mohammadian and team (2011 indicate that poetry therapy can reduce signs of depression. Poetry therapy helps to control negative emotions and gives the opportunity to reflect on their inner thoughts.

Treasure and Whitney, (2010) argue that poetry therapy improves rational perspective and increases a sense of control. Writing poetry increases the awareness of the sensibilities creating an image of experience, articulating the image, generating new meaning of the image, accepting a new meaning, and using it for self-growth, enhancing deeper healing. Poetry can help enable the expression of individuals' deepest unspoken concerns and can bring a sense of healing (Robinson, 2004).

Poetry therapy can be incorporated into pain management, especially in Fibromyalgia. Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide (Cohen SP, Vase & Hooten, 2021). Poetry can ease emotional and physical pain via altered focus, symbolic imagery, and regulating emotions and feelings. Lepore and Smyth (20002) indicate that poetry has a beneficial effect on managing pain, coping with stressors, and improving personal well-being.  Poetry produced an improvement in pain intensity (Arruda et al., 2016) and it can be offered as a supplement to other therapy.

Poetry can provide comfort in grief and loss. Grieving people need expression for their pain and emotions. Writing and reading poetry is one of the ways to cope with grief and bereavement and it helps to explore challenging existential issues. Poetry helps the person to grow beyond the loss experience and find meaning. Poetry helps to process emotional pain by using metaphors to communicate poignant experiences and put grief into eloquent words. It provides an outlet to release thoughts and emotions and achieve the coherence of life. Poetry therapy helps the assimilation of negative experiences and achieve post-traumatic growth. Poetry therapy should be considered as an adjunctive treatment mode in prolonged grief disorder.

Poetry is a mental soother in loneliness. Site and team (2022) describe loneliness as a fundamentally, social-psychological phenomenon. Loneliness and social isolation are detrimental to mental and physical health (Miller, 2011). Xiang and team (2020) highlight the ability of poetry to combat loneliness. Poetry helps to alleviate loneliness and social isolation. Moreover, poetry facilitates meaningful shared experiences (Gilmour et al., 2019).  As described by Mood (2018) poetry helps to boost communication skills.

Poetry therapy helps in recovery from addiction. Addiction is a growing problem and has a profound impact on physical and mental health. Poetry provides a means of processing and healing and leads to a space for free association. Poetry therapy helps to build confidence provides unrestricted expression and gives an opportunity to explore negative emotions. Poetry therapy deals with distress tolerance, and individual addiction-related dynamics and helps to decrease cravings. Howard (1997) indicates the effectiveness of poetry therapy in chemical addictions. Furthermore, Springer (2006) highlights poetry writing as a therapeutic collaboration in addictions.

Poetry therapy helps to express tension and negative emotions more artistically and is useful in anger management. Poetry is an antidote for negative stimuli, irritability, and negative emotions. Poetical writing deepens a person’s ability to connect to pent-up emotions and It helps to process internal conflict and repressed feelings. People with dysregulated anger can explore underlying emotions via poetry therapy and it provides a safe outlet providing a transformative effect.

Poetry helps people to understand and confront shame and guilt. Shame and guilt are negative self-conscious emotions, and it has a negative impact on mental health.  Shame is often accompanied by a sense of shrinking, of being small of worthlessness and powerlessness, and of being exposed (Stuewig et al.; 2015). Addressing patients' experiences of shame is an important part of the culturally competent treatment of mental disorders.  (Yakeley, 2018) Poetry helps to deal with the experience of shame and guilt in a more constructive way.  Poetry therapy enriches self-compassion and self-value and lessens shame and guilt. Poetry provides a sense of self-control and pride. It helps to reshape the negative perception, self-reflection, and enhance the self-identity.  Poetry helps to explore their feelings of shame and guilt. According to Tegnér and team (2009) guided poetry writing improves emotional resilience.  Zhang (2022) points out that poetry therapy improves positive personality traits.  

Poetry is a rich textual medium and a robust avenue for self-expression and self-guided therapy. Poetry is a powerful tool for emotional stability (Heimes, 2011). Poetic narrative enhances emotional disclosure. poetry can provide a new avenue for healing (Xiang et al.,2020). Mental health clinicians are exploring the potential use of poetry in mental healthcare. It can be used as an alternative or complementary therapy.   



Writing poetry is a self-healing process and provides self-empowerment. It is an activity that is beneficial to mental health and wellbeing. Poetry therapy encourages patients to articulate complex emotions associated with their mental and physical conditions.  Positive treatment outcomes have been reported in poetry therapy.  Poetry therapy is recognized as a fruitful therapeutic tool. The research indicates that poetry therapy helps to mitigate anxiety, depression, and stress and enhances self-directed recovery. Poetry therapy should be used more extensively in clinical settings. It’s important to bring poetry therapy into evidence-based policy and practice.



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Monday, October 2, 2023

The History of Post-traumatic Stress Disorder


Dr Ruwan M Jayatunge M.D.

PTSD is a relatively newly defined disorder with an old history and historical medical literature reveals clinical symptoms similar to post-traumatic stress disorder dating back to the Egyptian civilization. In 1900 BC, an Egyptian physician eloquently described the hysterical reactions of a patient after a traumatic experience. These reports became one of the first medical textbooks ever when published in 1990 B.C. (Figley, C.R., 1993).

War Trauma described in Mahabharata

Mahabharata is an epic tale in Indian mythology originally written by Sage Ved Vyas in Sanskrit. Mahabharata illustrates the Great War of Mahabharat between the Pandavas and the Kauravas happened in 3139 BC. Although many believed, that Mahabharata was a fable the archeological discovery of the ancient city of Dwaraka, situated on the extreme West Coast of Indian territory by Dr. S.B. Rao, Emeritus Scientist of the National Institute of Oceanography provided credence to the legend of Krishna and the Mahabharata war. The great epic Mahabharata describes vivid combat stress reactions exhibited by the ancient worriers.

The horrendous combat events described in Mahabharata (translated by Dr. P.V Vartak)

On the 14th day of the Mahabharat War, i.e., on 30th October a similar phenomenon took place. Due to the October heat enhanced with the heat of the fire weapons liberally used in the War, the ground became so hot that the layers of air near it were rarefied while the layers at the top were denser. Therefore the sun above the horizon was reflected producing its image beneath. The Sun's disc which was flattened into an ellipse by a general refraction was also joined to the brilliant streak of reflected image. The last tip of the Sun disappeared not below the true horizon, but some distance above it at the false horizon. Looking at it, Jayadratha came out and was killed. By that time, the same appeared on the true horizon. Naturally, there was no refraction because the light rays came parallel to the ground. This review- analyzed the Sun at the true horizon. Then the sun actually set, but the refraction projected the image above the horizon. The sun was thus visible for a short time, which then set again.

Combat-related PTSD poetically described by Homer

The Greek epic poet Homer was an artistically gifted oral poet who had the capacity to inspire human nature in dramatic terms. Homer's great epic Iliad, which was composed may be in 730 BC narrates a series of harrowing experiences of battle stresses that were experienced by the ancient Hellenic combatants. In depicting the world of the warriors in the Iliad, Homer pays special attention to the objects of war and human relations in extreme situations.

The Iliad offers a glimpse of battle stress and the human capacity to resist such trauma. Despite the beautiful objects and environments for their aesthetic value, the Iliad expresses the ironies of war. Homer recounts the horrors of war using various expressions such as the smell of blood and sweat of slaughter and earth soaked in blood etc. Hence, Homer articulates that there is no glory in the slaughter.

The Iliad may be the most complete single metaphor for the deadly perils of warfare. Homer tells how the warriors in motion on the battlefield and their obsession with terror that create a destructive enterprise of war. Homer analytically describes the rage of Achilles the warrior.

Sing me, goddess, of the anger

of Achilles, son of Peleus,

bane that brought to the Achaeans

countless woes, and hurled to Hades

countless mighty hero spirits,

left to dogs and birds their carrion,

and the will of Zeus accomplished.

Sing from when they first made quarrel,

Agamemnon, king of peoples,

and the noble-born Achilles. (Translation by John Porter)

Achilles was utterly overwhelmed with grief when he heard the death of his friend Patroklos. Patroklos went to the battlefield wearing Achilles’s armor to fight the Trojan prince Hector. Patroklos was killed in the fight. His body was mutilated and put to vultures to eat. The Iliad describes Achilles’s survival guilt as an outcry.

I would die here and now, in that I could not save my comrade. He has fallen far from home, and in his hour of need, my hand was not there to help him. What is there for me? Return to my own land I shall not, and I have brought no saving neither to Patroklos nor to my other comrades of whom so many have been slain by mighty Hektor; I stay here by my ships a bootless burden upon the earth. Iliad 18.97

Battle scenes and human suffering occupy much of the Iliad. When exposed to a combat atmosphere soldiers have feelings that become more intense and unpredictable. They may include responses that are re-awakened or amplified. Homer proficiently articulates such responses. In the Iliad, some combatants go into extreme confusion and experience feelings of insecurity. Their reactions are similar to modern-day combat-related PTSD.

The Iliad epitomizes another tragedy of war. The agony of war widows which roofed with physical and mental trauma. The page of Iliad echoes the woe and afflict of the Trojan women. Homer expounds on their snivel and helplessness comprehensively. Trojan women have become the ultimate symbol of a man-made disaster.

Homer's Iliad is a universal affirmation of combat trauma and poetically recites how the human psyche reacts to extreme situations. Based on its artistic qualities and deep analysis of human relations in a time of war, Iliad represents a great epic and a human melodrama.

PTSD in Buddhist Jathaka Stories

According to archaeological and literary evidence, the Jataka stories were compiled in the period, from the 3rd Century B.C. to the 5th Century A.D. The Khuddaka Nikaya contains 550 stories the Buddha told of his previous lifetimes as an aspiring Bodhisatta. According to Professor Rhys Davids Jataka's stories are one of the oldest fables. The Jataka stories deeply analyze the human mind. It contains a profound psychological content. The renowned Sri Lankan writer Martin Wickramasinghe once said Psychoanalysis was not initiated by Freud but by the Jataka storyteller.

In the Jataka stories, there are numerous characters who have displayed hysteric type of reactions. For instance, in the Maranabheruka Jathaka, one monk shows anxiety-based reactions that are similar to modern-day PTSD. This monk displays extreme fear, hyper-arousal, avoidance, frightful mental pictures (flashbacks?), and emotional anesthesia.

Shakespearian Work and PTSD

The eminent English poet and playwright William Shakespeare created many characters that appear to be afflicted by psychological and psychiatric disorders. Shakespeare had an exclusive ability to grasp the dynamics of the human mind and fathom the dysfunctions of the human psyche. Indeed Shakespeare was very comprehensible in his descriptions of various psychological and psychiatric symptoms. Shakespeare’s influence on psychopathology was immeasurable. Many of Shakespeare’s lead characters seem to be having mental disorders and even psychoses.

Shakespeare’s play of Macbeth probably written sometime between 1603 and 1607 reveals a misfortune filled with guilt, emotionally overwhelming, nightmares, hallucinations, and disturbing reminiscences. Macbeth was a Scottish Army General who wanted to rise to nobility and become the king of Scotland. To fulfill his ambition he was pushed to kill king Duncan by his ambitious wife. Macbeth murders his king Duncan while Duncan is a guest at their castle. After the murder, Macbeth and his wife become emotionally unstable. Lady Macbeth sleepwalks (a form of dissociation that is evident in trauma) She continuously washes and wrings her hands in an attempt to make it clean (OCD type of behavior that could be co-morbid with PTSD). Her nights were full of disturbances and she became hypervigilant. Following a distressing mental condition, Lady Macbeth commits suicide.

Samuel Pepy’s Diary describes PTSD reactions after the Great Fire

Samuel Pepys a Member of the Parliament kept a detailed private diary describing the aftermath of the Great Fire of London, which occurred in 1666. Samuel Pepys vividly wrote about the emotional reactions of the survivors who manifested nightmares and intrusive thoughts about the calamity.

Pepys Diary Entry, September 2, 1666

Some of our maids sitting up late last night to get things ready for our feast today, Jane called up about three in the morning, to tell us of a great fire they saw in the City. So I rose, slipped on my night-gown and went to her window, and thought it to be on the back side of Mark Lane at the farthest; but, being unused to such fires as followed, I thought it far enough off, and so went to bed again, and to sleep. . . . By and by Jane comes and tells me that she hears that above 300 houses have been burned down tonight by the fire we saw, and that it is now burning down all Fish Street, by London Bridge. So I made myself ready presently, and walked to the Tower; and there got up upon one of the high places, . . .and there I did see the houses at the end of the bridge all on fire, and an infinite great fire on this and the other side . . . of the bridge. . . .

So down [I went], with my heart full of trouble, to the Lieutenant of the Tower, who tells me that it began this morning in the King's baker's house in Pudding Lane, and that it hath burned St. Magnus's Church and most part of Fish Street already. So I rode down to the waterside, . . . and there saw a lamentable fire. . . . Everybody endeavouring to remove their goods, and flinging into the river or bringing them into lighters that lay off; poor people staying in their houses as long as till the very fire touched them, and then running into boats, or clambering from one pair of stairs by the waterside to another. And among other things, the poor pigeons, I perceive, were loth to leave their houses, but hovered about the windows and balconies, till they some of them burned their wings and fell down.

Having stayed, and in an hour's time seen the fire rage every way, and nobody to my sight endeavouring to quench it, . . . I [went next] to Whitehall (with a gentleman with me, who desired to go off from the Tower to see the fire in my boat); and there up to the King's closet in the Chapel, where people came about me, and I did give them an account [that]dismayed them all, and the word was carried into the King. so I was called for, and did tell the King and Duke of York what I saw; and that unless His Majesty did command houses to be pulled down, nothing could stop the fire. They seemed much troubled, and the King commanded me to go to my Lord Mayor from him, and command him to spare no houses. . . .

Although Samuel Pepys survived the Great Fire of London without any physical damage, his emotions were inundated. He wrote about his fires, sleep disturbances, fear feelings, intrusive memories and that haunted him for a long time.

PTSD victims of the Russo-Turkish War

From 1676 to 1681 series of military conflicts occurred between the Russian and Ottoman Empires. Professor V.I Buganov – a renowned Soviet Historian described unusual events that occurred during the war between the Turkish troops and the forces of the Peter the Great. According to Baranov’s historical recollections, some soldiers lost their voices (became aphonic as a result of hysteria-type dissociative reaction). Some manifested fear feelings and became insane (stress-related behavior following Acute Stress Disorder?).

Railway Hysteria

In 1800, a condition called Railway Hysteria / Railway Spine bore a remarkable resemblance to modern-day PTSD. The sufferers of Railway Hysteria / Railway Spine showed anxiety and somatoform symptoms after facing catastrophic railway accidents. Railway spine was a nineteenth-century diagnosis for post-traumatic symptoms. A large number of casualties were reported on Britain's Victorian railways between the 1840s and the 1860s. The Medical experts regarded 'Railway as a condition produced by a jolted and shaken spinal cord to one of traumatically-induced mental and nervous collapse fraught with implications of hysteria, neurasthenia, and degeneration.


In 1869, the neurologist George Beard called a group of symptoms neurasthenia that appeared in Beard's Neurasthenia As a Cause of Inebriety (1879) characterized by chronic fatigue and weakness, loss of memory, and generalized aches and pains, formerly thought to result from exhaustion of the nervous system.

Soldier’s Heart

In 1876 US Civil War Physician Dr Mandez Da Costa introduced the term Soldier’s Heart which illustrated the physical and emotional symptoms displayed by the Civil War veterans. These symptoms included startle responses, hypervigilance, dyspnea, palpitation, chest pain, fatigue, faintness, and heart arrhythmias. Soldier heart or Da Costa's syndrome is considered the manifestation of an anxiety disorder and treatment is primarily behavioral, involving modifications to lifestyle and daily exertion.

Pierre Janet

In 1889, Pierre Janet published L''Automatisme Psychologique, his first work to deal with how the mind processes traumatic experiences. Pierre Janet coined the word ‘dissociation and explained the effects of dissociation of the traumatic memories and their return as fragmentary reliving experiences

Effort Syndrome

Effort Syndrome was introduced in 1900. This condition was characterized by chest pain; dizziness; fatigue; palpitations; cold, moist hands; and sighing respiration. The condition is often associated with soldiers in combat but occurs also in other individuals. The pain often mimics angina pectoris but is more closely connected to anxiety states and occurs after rather than during exercise.

Chronic Fatigue Syndrome (introduced in 1900)

Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that may worsen with physical or mental activity but doesn't improve with rest. Although there are many theories about what causes this condition — ranging from viral infections to psychological stress.

Jean-Martin Charcot

In 1901 the Parisian clinical neurologist Jean-Martin Charcot better known as "the founder of modern neurology” described traumatic memories as parasites of the mind. He formulated a comprehensive, neurogenic model of ‘the great neurosis’. For Charcot, hysteria was strictly a dysfunction of the central nervous system. In Charcot's view, traumatic hysteria and male hysteria were identical. Charcot acknowledged the relevance of psychological traumas, dissociated from the patient's consciousness, in determining the nature of its symptoms. Jean-Martin Charcot's views immensely affected Sigmund Freud's early theory of hysteria and the notion of psychical trauma.

Sigmund Freud and PTSD

Sigmund Freud used the term Traumatic Neurosis which resembles present-day PTSD. The term traumatic neurosis designates a psycho-pathological state characterized by various disturbances arising soon or long after an intense emotional shock. Freud specifically wrote about the effects of traumatic memories and traumatic shock.

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’s understanding of trauma was well represented in his works mainly in Mourning & Melancholia (1917), Beyond the Pleasure Principle (1920), and Symptoms, Inhibitions & Anxiety (1926). Freud assumed that the negative emotional energy associated with traumatic memories was unconsciously converted into the somatic manifestations of hysteria. Freud’s lectures in 1917–1918 eloquently described the broad clinical picture of PTSD.

In one of his famous lectures- Fixation Upon Trauma / the Unconscious which was conducted in America 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 course, similar cases occurred before the war, after railway accidents, and other terrifying experiences involving danger to life. The traumatic neurosis is not fundamentally the same as those which occur spontaneously…..

….. The traumatic neurosis demonstrates very clearly that a fixation on the moment of the traumatic occurrence lies at the 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.

In 1910 Freud stated that hysterical patients suffer from intrusive reminiscences. There is much suggestive evidence to prove that Sigmund Freud knew the spacious clinical picture of PTSD.

Shell shock

By 1918, British Military Doctors identified a group of symptoms including tiredness, irritability, giddiness, lack of concentration, and headaches among the soldiers who fought in World War I. A British Pathologist Col Fredrick Mott coined the term Shell Shock and he considered shell shock as an organic condition produced by miniature hemorrhages of the brain. Between 1914 and 1918, the British Army identified 80,000 men as suffering from shell shock. Shell shock was generally seen as a sign of emotional weakness or cowardice.

Wilfred Owen was a Captain of the British Army and witnessed the atrocities of WW 1 firsthand. He wrote his famous anti-war poem "Dulce et Decorum Est" while receiving treatment for shell shock in Craiglockart.

Bent double, like old beggars under sacks,

Knock-kneed, coughing like hags, we cursed through sludge,

Till on the haunting flares we turned our backs

And towards our distant rest began to trudge.

Men marched asleep. Many had lost their boots

But limped on, blood-shod. All went lame; all blind;

Drunk with fatigue; deaf even to the hoots

Of tired, outstripped Five-Nines that dropped behind.

Gas! Gas! Quick, boys! – An ecstasy of fumbling,

Fitting the clumsy helmets just in time;

But someone still was yelling out and stumbling,

And flound'ring like a man in fire or lime . . .

Dim, through the misty panes and thick green light,

As under a green sea, I saw him drowning.

In all my dreams, before my helpless sight,

He plunges at me, guttering, choking, drowning.

Combat Fatigue

World War 2 was a global military conflict, that began in 1939, and 110 million persons were mobilized for military services. In 1939, the term Combat Fatigue was introduced to describe the combat trauma reactions that occurred during WW2. Combat Fatigue is characterized by hypersensitivity to stimuli such as noises, movements, and light accompanied by overactive responses that include involuntary defensive jerking or jumping, easy irritability progressing even to acts of violence, and sleep disturbances including battle dreams, nightmares, and inability to fall asleep.

Following a battle in WWII, 17% were afflicted with acute PTSD. A longitudinal study of Harvard University alumni found that 56% of World War II veterans who experienced heavy combat were chronically ill or dead by age 65 (Lee, Vaillant, Torrey & Elder, 1995).

1952 DSM 1 – Neurotic Reaction (Stress Response Syndrome)

The Diagnostic and Statistical Manual of Mental Disorders (DSM 1) was published in 1952 by the American Psychiatric Association and provided new diagnostic criteria for Neurotic Reaction (Stress Response Syndrome).

1968 DSM 2 Transient Situational Disturbance

Transient Situational Disturbance is defined as a form of maladaptive reaction to identifiable psychosocial stressors occurring within a short time after the onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor.

1980 DSM 3 PTSD

In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience.

In 1993 WHO recognized PTSD as a Separate Diagnostic Entity

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as classified by the World Health Organization (WHO).ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States. The ICD is the international standard diagnostic classification for all general epidemiological, health management purposes, and clinical uses.

1994 DSM 4

The Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (American Psychiatric Association, 1994) defines PTSD as a constellation of symptoms and behaviors that includes three core clusters. Re-experience the trauma in the form of intrusive thoughts, dreams, and images, avoidance of thoughts or reminders of the trauma, together with emotional numbing and withdrawal, and signs of increased central and autonomic arousal.

PTSD in ICD - 10 (2019) 

Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks"), dreams or nightmares, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0).

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