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By Sandra L. Bloom, MD
Philadelphia, Pa., USA

Published in the International Handbook of Human Response to Trauma (2000), New York: Kluwer Academic/Plenum Publishers. Edited by Arieh Y. Shalev, Rachel Yehuda and Alexander C. McFarlane.

The Lost is Found: Post-traumatic Stress Disorder

Shatan says that he first heard that traumatic war neurosis had disappeared in 1974 as a result of a phone call from an Asbury Park, New Jersey public defender. A Vietnam veteran had been charged with violence against property and had amnesia for his behavior.

The public defender entered a plea of not guilty based on traumatic war neurosis and the judge rejected the defense because there was no longer such a diagnosis. Shatan recommended that the public defender contact the DSM-III Task Force headed by Robert Spitzer. He did so and was told that there were no plans to reinsert any form of traumatic war neurosis in the DSM-III. A reporter from the Village Voice got this word back to Shatan and he was shocked. He got together with Lifton to decide what to do. They realized they had to mobilize, and mobilize quickly (Shatan, 1985).

Their response was to form the Vietnam Veterans Working Group (V.V.W.G.), supported, in part, by the American Orthopsychiatric Association and the Emergency Ministry of the United Presbyterian Church (Shatan, Haley & Smith, 1979).

The National Council of Churches did any xeroxing that needed to be done. Amitai Etzioni provided some office space for them at his Center for Policy Research at Columbia University (Shatan, 1997a; Scott, 1993). In 1974, Sarah Haley published her landmark paper, "When the patient reports atrocities" in the Archives of General Psychiatry, one of the publications of the American Psychiatric Association, and it was widely read.

John Talbott had easy access to the American Psychiatric Association. He sponsored meetings at the New York chapter of the APA, inviting Shatan, Haley, Arthur Egendorf and others to present on "Post-Vietnam syndrome". He also helped them get access to Robert Spitzer at the 1975 American Psychiatric Association convention.

Jack Smith developed a questionnaire as part of his doctoral thesis, "American War Neurosis, 1860-1970" and Shatan sent the questionnaire to 35 members of the VVWG in 1975, many of whom had been working closely with the veterans in rap groups and individual sessions, some as far back as 1970 (Shatan, Haley & Smith, 1979). He asked them to go through their caseload with the questionnaires.

Shatan and Lifton, joined by Jack Smith and Sarah Haley, tabulated the results on 724 veterans and arrived at a classification system very close to the one Kardiner had proposed in 1941 (Shatan, 1997b, Shatan, Haley & Smith, 1979; Van der Kolk, Herron & Hostetler, 1994).

While this was going on in the psychiatric establishment, Charles Figley organized panels in 1975 at the American Sociological Association and the 1976 meeting of the American Orthopsychiatric Association. He met with Chaim Shatan, Robert Lifton, and others, while beginning to work on an edited volume which, in 1978, would become a landmark book on Vietnam. Figley, a psychologist, had served in Vietnam in 1965 with the Marines and was one of the first Vietnam veterans to return home.

He completed graduate studies and participated in Dewey Canyon III. On campus, he met other Vietnam veterans and became aware of the widespread nature of their adjustment problems. After obtaining his degree, he took a position at Purdue University where he founded and directed the Consortium on Veteran Studies and started studying the post-Vietnam effects intensively. He developed a bibliography about combat trauma and began corresponding with other people interested in similar studies (Scott, 1993).

Meanwhile, John Wilson, a conscientious objector during the Vietnam War, began working on the Forgotten Warrior project. Wilson had completed his Ph.D. in 1973 and performed three years of alternative service in a crisis intervention center. When two close friends returned from Vietnam as radically changed people, a seed was planted in his mind. His first academic position was in Cleveland where a student of his presented a report on some Vietnam veterans he had interviewed on campus.

John was intrigued. He sent out letters to the veterans on campus and more than 100 responded. He and his student, Chris Doyle, recorded narratives of their lives before, during and after Vietnam and the work became consuming. His department chairman threatened to block his tenure or promotion if he continued this work, but John was undeterred. He set up rap groups at the university and requested funding from various organizations for a study.

But only in 1976 was he able, through the assistance of a disabled veteran, to get the Disabled American Veterans to provided the money he needed to complete the study (Scott, 1993). Out of over 450 interviews he and an associate, Chris Doyle wrote The Forgotten Warrior Project (Wilson, 1977).

In 1977, Figley chaired a research symposium at the American Psychological Association conference where he was able to arrange for the presentation of three papers: Egendorf and his colleagues' first version of what would ultimately become the Legacies of Vietnam study, (Egendorf et al., 1977), his own work from the Consortium (Figley & Southerly, 1977), and Wilson and Doyle's, Forgotten Warrior Project (Wilson & Doyle, 1977).

Each separate study supported and extended the other (Figley, 1978b) and provided even more support for the efforts of the V.V.W.G. in their attempt to change DSM-III.

Ironically, the decision to alter the DSM-III in relation to homosexuality may have had something to do with subsequent changes in the DSM allowing PTSD to enter the lexicon. The argument over whether or not homosexuality was a disease entity was so heated and politically loaded, that Spitzer decided it should be put to a vote. This indicated that the DSM-II could end up being completely redone, opening up negotiating room for those who wanted to reintroduce stress reactions into the classification schema.

In the summer of 1975, the V.V.W.G. invited Spitzer to lunch at Columbia Presbyterian in New York City. The group filled him on their activities and he was willing to appoint a formal committee, the Committee on Reactive Disorders, to proceed with the inquiry. He appointed himself, Dr. Lyman Wynne and Dr. Nancy Andreason to be the representatives on the committee with Andreason as chair.

She had previously worked with burn victims and knew about the long-term psychological as well as physical suffering that was involved in recovery from severe trauma. Spitzer instructed Andreason to work with Shatan, Lifton, and Smith. The appointment of Jack Smith, a non-M.D., was a highly unusual move. But the burden of proof still remained with the V.V.W.G. (Scott, 1993).

Convincing Andreason of the validity of the long-term reactions to overwhelming stress was key to the success of the venture. The Working Group reckoned that persuasion would be easier if they could show the similarities between combat stress and other forms of traumatic experience. So they recruited Harley Shands who had experience working with job-related trauma, Mardi Horowitz who was working on the physiology of stress, combined this with the research related to concentration camp victims that Niederland and Krystal had been doing, and contacted researchers working with other survivor groups to join in their mission.

Sarah Haley pointed out to Andreason that in reviewing the charts of the Vietnam veterans in the VA hospital, she had discovered that many of the clinicians were treating the patients as if there was a diagnosis of traumatic war neurosis available. This practical reality had a particularly strong impact on the discussions (Scott, 1993; Shatan, 1997a). Shatan, Haley and Smith presented their position paper at the 1977 annual meeting of the American Psychiatric Association, representing the accumulated work of the V.V.W.G. and making specific recommendations to the DSM-III Task Force for changes in the categorization system (Figley, 1978a; Shatan, Haley & Smith, 1977).

Early in 1978, Spitzer called the Working Group together to present their findings to the Committee of Reactive Disorders. Lifton, Smith and Shatan presented their evidence in a meeting with Spitzer, Andreason, and Wynne. They emphasized a wide circle of war zone victims, and the similarity between them and other victim groups. Later that month, the Committee released its decision, recommending a diagnosis of "post-traumatic stress disorder".

The DSM-III was completed and published two years later, having incorporated most of the recommendations made by the V.V.W.G., which were very similar to the observations made by Kardiner in the 1940's (Kardiner, 1941; Scott, 1993; Shatan, 1978b). Interestingly, at the same time as the V.V.W.G. were endeavoring to establish criteria for the DMS-III, another group of mental health professionals were working on a diagnostic system for dissociative disorders.

There was no communication between them and the PTSD working group, largely because very little academic conversation had yet occurred about the relationship between dissociation and trauma. As a result, a separate classification for the dissociative disorders was also entered into DSM-III and separate organizations subsequently developed to study these two related fields (Van der Kolk, Herron, & Hostetler, 1994).

In the meantime, President Carter had appointed Max Cleland as Director of the Veterans Administration and Alan Cranston assumed the chairmanship of the Senate Committee on Veterans Affairs. Cleland called a meeting with Art Blank, Charles Figley, Shad Meshad, John Wilson, William Mahedy and others to make specific recommendations for a VA readjustment counseling program.

Art Blank, a psychiatrist, had been drafted to serve in Vietnam in 1965. When he returned and got a position at Yale, one of his clinical positions was at the West Haven VA Hospital treating Vietnam vets. As a result of his own experience, he began diagnosing traumatic war neurosis in 1972, long before his colleagues were willing to see the effects of war on the returning veterans.

He made contact with Sarah Haley after reading her 1974 paper and through her, had met Figley and Shatan (Blank, 1998). Once the Vet Centers became a reality, he became the VA's Chief of Psychiatric Services. As a result of the changed political climate, at the same time as the APA was changing the DSM-III, Congress directed the Veterans Administration to create a nationwide system of specialized counseling centers (Vet Centers) for a wide range of readjustment problems in Vietnam veterans, including PTSD (Blank, 1985). The first Vet Center opened in 1979 and by 1990 there were almost two hundred around the country (Blank, 1993).

The Legacies of Vietnam study was published in 1981. In that year, Robert Laufer, the principle investigator of the study, testified before the Senate Committee on Veterans Affairs. Senator Alan Simpson wrote the Senate report summarizing the testimony and in it he said, "It does appear clear from the report that there is a continuing need for the Vet Center program and, as the findings of that study become more widely known, that need may become greater as veterans and their families come to realize that service during the Vietnam-era may have had an impact on an individual's ability later in life to adjust satisfactorily to his or her social environment" (United States Senate, 1981, p.16).

Convergence Creates a Social Movement Although the Vietnam War provided the "general tendency to change which is apparent in many spheres during wartime" (Jones, 1953), other converging and significant social forces played a role in bringing the recognition of the effects of trauma into the public consciousness in the United States and around the world.

The two most significant, and war-related events, of course, were the Nazi Holocaust and Hiroshima-Nagasaki. Robert Lifton had published an extensive study of Hiroshima victims (1967) a subject few people wanted to address, no more than they really wanted to confront the problems of Vietnam veterans or Holocaust survivors, all "politically incorrect survivors of atrocities" (Milgram, 1998).

William Niederland (1968) had already devoted twenty-five years to working with concentration camp survivors, noting that the same delay preceded their "survivor syndrome" as was being recognized in the work with Vietnam veterans. (Shatan, 1974).

Niederland, who Shatan had known for a long time, and Henry Krystal, who had also studied concentration camp survivors (Krystal, 1968), organized a conference on victimization at Yeshiva University in 1975 and joined the V.V.W.G. (Scott, 1993). Shatan, Lifton, and others working with the Vietnam veterans had already made international contacts as early as 1974 with other professionals working with veterans - in Canada, Switzerland, and Australia as well as Israel (Shatan, 1974).

In the early 70's, Shatan traveled to Israel and met with military psychiatrists there (Scott, 1993). In a letter to the director of the American Orthopsychiatric Association in 1978, Shatan reported that a liaison had been established with the National Institute for Research in the Behavioral Sciences of Israel (1978b). There, Dr. Rappaport and an American consultant, Dr. Israel Charny, were working on a project called the "Genocide Early Warning System", hoping to isolate and identify features in a society which prefigure the later development of genocide (1978b).

Studies also began to be published and conferences held in Israel on the effects of war stress there, a logical occurrence given the unremitting nature of warfare in the region (Benyakar & Noy, 1975; Milgram, 1978; Moses et al., 1975; Noy, 1978; Sohlberg, 1975; Steiner & Neumann, 1978). Noach Milgram organized the first of four international conferences on psychological stress and coping in time of war and peace in January, 1975 in Tel-Aviv, a year after the Yom Kippur War, and the second in June, 1978 in Jerusalem.

Both were attended by Israeli and U.S. participants (Milgram, 1998). Israel was naturally the home for a large number of Holocaust survivors, yet there was a "conspiracy of silence" in Israel about listening to their stories (Danieli, 1981), similar to the phenomenon Neff had described in reference to the Vietnam veterans with his observation that Vietnam veterans were invisible patients with an invisible (nonexistent) illness (1975).

Danieli and Solomon have both provided a framework for understanding the gradual transformation of Israeli society towards a willingness to comprehend the magnitude of post-traumatic problems (Danieli, 1981; Solomon, 1995a; b, c, d).

Yael Danieli had served in the Israeli Defense Forces before emigrating to the United States, where she founded the Group Project for Holocaust Survivors and their Children. During this period she had already begun her life work, exploring the intergenerational transmission of victimization, styles of adaptation to victimization, survivor guilt, and the attitudes and difficulties of mental health professionals working with survivors and children of survivors of the Nazi Holocaust (Ochberg, 1988b).

She would later go on to establish strong connections with the United Nations and become instrumental in bringing the concepts of traumatic stress to a wider international audience (Danieli, Rodley, & Weisaeth (1996). Ellen Frey-Wouters, a specialist in international law, and originally from the Netherlands, co-authored, with her husband, Robert Laufer, the third volume of the Legacies of Vietnam study while also writing about survivors of the Nazi Holocaust and working on social policy issues around the area of traumatic stress.

Many studies of concentration camp survivors were being conducted in Europe as well, including comprehensive long-term follow-up studies from Denmark, the Netherlands, and Norway (Bastiaans, 1974; Eitinger 1961, 1964; Thygesen et al, 1970). Meanwhile, also in Norway, Askevold studied the effects of prolonged stress on men who had served in the Merchant Marine in World War II (1976).

For the European community, Nazi occupations and the terrorism perpetrated by the Gestapo played a significant role in sensitizing them to the long-term consequences of excessive stress (Malt, Schnyder & Weisaeth, 1996).

Another effect of World War II was the vast movement of refugees. Eitinger began studies of refugees in Norway as well as studying concentration camp survivors (1960). The Vietnam War and the fall of Saigon in 1975 brought a flood of Vietnamese and Cambodian refugees to the United States. As early as 1979 reports began to be published about the adjustment problems they were having (Lin, Tozuma, & Masuda, 1979), opening up a discourse on how Westerners could most effectively intervene and help refugees from the East (Kinzie, 1978).

Independent of the DSM-III process and the effects of war, a number of other significant developments took place during the 1970s. One was Mardi Horowitz' Stress Response Syndromes (1976), which, building on Selye's earlier work (1956), began to provide a psychophysiological basis for understanding the body's responses to overwhelming experience and how that response connected to psychological processes.

Charles Figley (1978), edited the first significant collaborative book on Vietnam War veterans, and in doing so, introduced a new psychosocial series for Brunner/Mazel that by 1990 would grow to eighteen volumes of literature spanning every victimization category.

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