Shrinks

by Jeffrey A. Lieberman

  “I don’t have anything,” I said calmly. “Take whatever you want, but I’m just a student, I don’t have anything.”

  “What about your roommate?” the intruder spat, motioning toward the other bedroom. My roommate, a law student, was away at class.

  “I don’t think he has much, but take everything… anything you want.” The taller man looked at me quizzically and tapped the gun against my shoulder a few times as if thinking. The two thugs looked at each other, then one abruptly yanked the thin gold chain off my neck, they hoisted up the television, stereo, and clock radio, and casually ambled out the front door.

  At the time, the home invasion was the scariest experience of my life. You might expect that it shook me up, giving me nightmares or driving me to obsess about my personal safety. Surprisingly, no. After filing a useless report with the DC police, I replaced the appliances and went right on with my life. I didn’t move to a new neighborhood. I didn’t have bad dreams. I didn’t ruminate over the intrusion. If I heard an unexpected knock on my door, I hopped up to answer it. I didn’t even flinch when, months later, I saw one of them on the street on my way home. To be honest, I can no longer recall the details of the robbery very well at all, certainly no better than the details of The Poseidon Adventure, a suspenseful but unremarkable movie I saw that same year. Though I believe the gun was large and black, it could very well have been a small metal revolver. To my youthful mind the whole experience ended up seeming kind of thrilling, an adventure I had bravely endured.

  Twelve years later, another dramatic event produced a very different reaction. I was living in an apartment on the fifteenth floor of a high-rise in Manhattan with my wife and three-year-old son. It was early October and I needed to remove the heavy air conditioner unit from my son’s bedroom window and store it for the winter.

  The unit was supported on the outside by a bracket screwed into the wall. I raised the window that pressed down onto the top of the air conditioner so I could lift the unit off the windowsill—a terrible mistake. The moment I lifted the window, the weight of the air conditioner tore the bracket from the outside wall.

  The air conditioner began to tumble away from the building toward the usually busy sidewalk fifteen floors below. The machine seemed to hurtle down through the sky in a kind of cinematic slow motion. My life literally flashed before my eyes. All my dreams of a career in psychiatry, all my plans of raising a family, were plunging down with this mechanical meteor. I could do nothing but uselessly shriek, “Watch out!”

  “Holy shit!” the doorman yelped as he frantically leapt away. Miraculously, the air conditioner smashed onto the pavement, not people. Pedestrians on both sides of the street all whipped their heads in unison toward the crashing sound of impact, but, thankfully, nobody was hurt.

  I had escaped a high-stakes situation once again—but this time I was shaken to the depths of my being. I couldn’t stop thinking about how stupid I was, how close I had come to hurting someone and ruining my life. I lost my appetite. I had trouble sleeping, and when I did I was plagued by graphic nightmares in which I painfully relived the air conditioner’s fateful plunge. During the day I could not stop ruminating over the incident, playing it over and over in my mind like a video loop, each time reexperiencing my terror with vivid intensity. When I went into my son’s room, I wouldn’t go near the window, for the mere sight of it triggered disturbing feelings.

  Even now, decades later, I can viscerally recall the fear and helplessness of those moments with little effort. In fact, just moments before I sat down to write about this incident, a Liberty Mutual Insurance commercial came on television. As the wistful song “Human” plays and Paul Giamatti’s mellifluous voice expounds upon human frailty, a man accidentally drops an air conditioner out his window onto a neighbor’s car. The ad is innocuous and witty, yet as I watched, I winced in fearful remembrance. Some part of me was instantly transported back to that terrifying moment watching my life plummet down fifteen stories…

  These are all classic symptoms of one of the most unusual and controversial of mental illnesses: post-traumatic stress disorder (PTSD). One thing that sets PTSD apart from just about every other mental illness is that its origin is clear-cut and unequivocal: PTSD is caused by traumatic experience. Of the 265 diagnoses in the latest edition of the DSM, all are defined without any reference to causes, except for substance-use disorders and PTSD. While drug addiction is obviously due to an effect of the environment—the repeated administration of a chemical substance inducing neural changes—PTSD is the result of a psychological reaction to an event that produces lasting changes to a person’s mental state and behavior. Before the event, a person appears mentally healthy. After the event, he is mentally wounded.

  What is it about traumatic events that produce such intense and lasting effects? Why does trauma occur in some people and not in others? And how do we account for its seemingly unpredictable incidence—after all, it seems rather counterintuitive that dropping an air conditioner elicited PTSD-like effects, while a violent home invasion did not. During the latter episode I was assaulted and my life was in genuine danger; during the air conditioner’s plunge, I never faced any physical hazard. Was there some critical factor that determined how my brain processed each event?

  The unique nature and curious history of PTSD make it one of the most fascinating of all mental disorders. The story of PTSD encapsulates everything we’ve learned so far about psychiatry’s tumultuous past: the history of diagnosis, the history of treatment, the discovery of the brain, the influence and rejection of psychoanalysis, and the slow evolution of society’s attitude toward psychiatrists, from open derision to grudging respect. PTSD also represents one of the first times that psychiatry has achieved a reasonable understanding of how a mental disorder actually forms in the brain, even if our understanding is not yet complete.

  The belated unriddling of PTSD commenced in a setting that was extremely inhospitable to the practice of psychiatry but extremely conducive to the generation of PTSD: the battlefield.

  We Don’t Have Time to Monkey Around with Guys Like That

  In 1862, Acting Assistant Surgeon Jacob Mendez Da Costa was treating Union soldiers at Turner’s Lane Hospital in Philadelphia, one of the largest military hospitals in the States. He had never seen such carnage, gaping bayonet wounds and ragged limbs blown off by cannon fire. In addition to observing the visible injuries, as he slowly worked his way through the casualties of the Peninsular campaign, Da Costa noticed that many soldiers seemed to exhibit unusual heart problems, particularly “a prompt and persistent tachycardia”—medical jargon for a racing heartbeat.

  For example, Da Costa described a twenty-one-year-old private William C. of the 140th New York Volunteers, who sought treatment after suffering from diarrhea for three months and “had his attention drawn to his heart by attacks of palpitation, pain in the cardiac region, and difficulty in breathing at night.” By the war’s end, Da Costa had seen more than four hundred soldiers who exhibited the same peculiar and anomalous heart troubles, including many soldiers who had suffered no physical battlefield injuries at all. Da Costa attributed the condition to an “overactive heart damaged by ill use.” He reported his observations in the 1867 publication by the United States Sanitary Commission and named this putative syndrome “irritable and exhausted soldier’s heart.” Da Costa suggested that soldier’s heart could be treated with hospitalization and a tincture of digitalis, a drug that slows the heart rate.

  Da Costa did not believe that the condition he had identified was in any way psychological, and no other Civil War physician made a connection between soldier’s heart and the mental stress of warfare. In the official records of soldiers who refused to return to the front lines despite a lack of physical injury, the most common designations were “insanity” and “nostalgia”—that is, homesickness.

  As bloody as the Civil War was, it paled in comparison to the mechanized horrors of World War I, the Great War. Heavy artillery r
ained down death from miles away. Machine guns ripped through entire platoons in seconds. Toxic gas scalded the skin and scorched the lungs. Incidents of soldier’s heart increased dramatically and were anointed by British doctors with a new appellation: shell shock, based on the presumed link between the symptoms and the explosion of artillery shells.

  Physicians observed that men suffering from shell shock not only exhibited the rapid heart rate first documented by Da Costa but also endured “profuse sweating, muscle tension, tremulousness, cramps, nausea, vomiting, diarrhea, and involuntary defecation and urination”—not to mention blood-curdling nightmares. In the memorable book A War of Nerves, by Ben Shepherd, British physician William Rivers describes a shell-shocked lieutenant rescued from a French battlefield:

  He had gone out to seek a fellow officer and found his body blown to pieces with head and limbs lying separated from his trunk.

  From that time he had been haunted at night by the vision of his dead and mutilated friend. When he slept he had nightmares in which his friend appeared, sometimes as he had seen him mangled in the field, sometimes in the still more terrifying aspect of one whose limbs and features had been eaten away by leprosy. The mutilated or leprous officer of the dream would come nearer and nearer until the patient suddenly awoke pouring with sweat and in a state of utmost terror.

  Other symptoms of shell shock read like a blizzard of neurological dysfunction: bizarre gaits, paralyses, stammering, deafness, muteness, shaking, seizure-like fits, hallucinations, night terrors, and twitching. These traumatized soldiers were shown no sympathy by their superiors. Instead, shell-shocked soldiers were castigated as “gutless yellow-bellies” who couldn’t stand up to the manly rigors of war. They were often punished by their officers—and occasionally executed for cowardice or desertion.

  During World War I, psychiatrists were virtually absent from the military medical corps; military leaders did not want their soldiers exposed to the mental frailty and emotional weakness associated with psychiatry. The whole purpose of military training was to create a sense of invulnerability, a psychology of courage and heroism. Nothing could be more antithetical to that psychic hardening than the exploration and open expression of emotions encouraged by psychiatrists. At the same time, shell shock could not easily be ignored: roughly 10 percent of all soldiers serving in the Great War became emotionally disabled.

  The first description of “wartime psychic trauma” in the medical literature was in a 1915 Lancet article written by two Cambridge University professors, psychologist Charles Myers and psychiatrist William Rivers. In the article, they adapted Freud’s new psychoanalytic theory to explain shell shock in terms of repressed memories from childhood that became unrepressed by war trauma, thereby producing neurotic conflicts that intruded upon conscious awareness. To exorcise these neurotic memories, Rivers advocated the “power of the healer” (what Freud called transference) to lead the patient to a more tolerable understanding of his experiences.

  Freud himself testified as an expert witness in a trial of Austrian physicians accused of mistreating psychologically wounded soldiers, and concluded that shell shock was indeed a bona fide disorder, distinct from common neuroses, but that it could be treated with psychoanalysis. Soon, psychiatrists applied other treatments to shell-shocked soldiers, including hypnosis and hearty encouragement, reportedly with favorable results. Still, there was nothing approaching consensus when it came to the nature or treatment of combat trauma.

  While the horrors of the Great War were unprecedented, somehow World War II was even worse. Aerial bombardment, massive artillery, flamethrowers, grenades, claustrophobic submarines, and vicious landmines conspired with diabolical enhancements of World War I weaponry to produce even more frequent incidents of soldier’s heart, now dubbed battle fatigue, combat neurosis, or combat exhaustion.

  At first, the military believed that combat neurosis occurred only in cowards and psychological weaklings, and it began screening out recruits thought to possess deficiencies in their character; by these criteria over a million men were deemed unfit to fight because of perceived susceptibility to combat neurosis. But the military brass was forced to revise its thinking when the psychological casualty rate was still 10 percent of “mentally fit” soldiers. Moreover, some of these casualties were seasoned soldiers who had fought bravely.

  The deluge of emotionally disabled soldiers compelled the military to reluctantly acknowledge the problem. In a startling reversal of attitude, the American army sought out the assistance of the shrinks who were just gaining prominence in civilian society. At the start of World War I, there were no psychiatrists in the military. At the start of World War II, the presence of psychiatrists in the American military was minimal: Out of the 1,000 members of the Army Medical Corps in 1939, only 35 were so-called neuropsychiatrists, the military’s term for psychiatrists. (The term is misleading, since almost every neuropsychiatrist was a psychoanalyst who knew practically nothing about the neural architecture of the brain.) But as the war progressed and increasing numbers of soldiers came back physically whole but emotionally crippled, the military realized it needed to adjust its attitude toward psychiatry.

  To combat the shortage of neuropsychiatrists, the military began to provide intensive psychiatric training to nonpsychiatric physicians. This training was authorized in an October 1943 letter from the Office of the Surgeon General addressing the “Early recognition and treatment of Neuropsychiatric Conditions in the Combat Zone,” which may represent the first time the American military formally acknowledged the importance of “mental health” in active soldiers: “Because of the shortage of neuropsychiatrists, the attention of all medical officers is asked to attend to the responsibility for the mental as well as physical health of military personnel.”

  At the start of the war, the Office of the Surgeon General had two divisions: medicine and surgery. Now, because of need for more battlefield psychiatrists, a new division was added: neuropsychiatry. The first director of the new division was William C. Menninger, who would soon be assigned to produce the Medical 203, the direct forerunner of the DSM-I; he also became the first psychiatrist ever to hold the rank of brigadier general. In 1943, 600 physicians from other specialties were trained in neuropsychiatry and 400 neuropsychiatrists were directly recruited into the army. By the war’s end, 2,400 army physicians had either been trained in neuropsychiatry or were neuropsychiatrists. A new role had been carved out for the psychiatrist: trauma physician.

  Menninger’s Medical 203 included a detailed diagnosis of what was termed “combat exhaustion,” but instead of viewing the condition as a single disorder, the 203 broke it down into a variety of possible neuroses stemming from wartime stress, including “hysterical neuroses,” “anxiety neuroses,” and “reactive depression neuroses.” In 1945, the Department of Defense created a fifty-minute film that trained military physicians in the nuances of combat exhaustion. Despite its conspicuous psychoanalytic perspective, the training film takes a surprisingly progressive attitude toward the condition. It portrays a roomful of dubious military physicians who question the authenticity of combat exhaustion. One declares, “We’re going to be dealing with soldiers who are really shot up, we won’t have time to monkey around with guys like that.” Another claims, “That soldier must have been a misfit from the start to break down.” Then the instructor patiently explains to them that combat exhaustion can afflict even the most courageous and battle hardened of men and insists the condition is just as real and debilitating as a shrapnel wound.

  Such a perspective was a striking turnaround for the military; it would have been simply unimaginable in World War I, when European and American militaries wanted nothing to do with psychiatry and shell-shocked soldiers were regarded as suffering from defects of character. Even so, many officers still scoffed at the idea of combat exhaustion and continued to dismiss soldier’s heart as ordinary cowardice. During the Sicily campaign in 1943, General George Patton infamously visited wounded soldier
s in an evacuation hospital when he came across a glassy-eyed soldier who didn’t have any visible injuries. He asked the man what was wrong.

  “Combat exhaustion,” murmured the soldier.

  Patton slapped him in the face and harangued him as a spineless malingerer. Afterwards he issued an order that anyone who claimed they could not fight because of combat exhaustion should be court-martialed. To the military’s credit, Patton was reprimanded and ordered to apologize to the soldier by General Dwight D. Eisenhower.

  Combat exhaustion turned out to be one of the few serious mental conditions that psychoanalytic treatment appeared to help. Psychoanalytical neuropsychiatrists encouraged traumatized soldiers to acknowledge their feelings and express them, rather than keeping them bottled up as military training and masculine self-discipline dictated. They observed that soldiers who openly talked about their traumas tended to experience their battle fatigue less severely and recover faster. While the psychoanalytic reasoning behind this remedy was dubious—military neuropsychiatrists purported to be uncovering and alleviating buried neurotic conflicts—the effects were not, and today it is standard practice to provide empathic support to traumatized soldiers. Their apparent success in treating combat exhaustion with Freudian methods increased the self-confidence of military shrinks and motivated many of them to become enthusiastic proponents of psychoanalysis when they returned to civilian practice after the war, thereby aiding the Freudian conquest of American psychiatry.

  Russian soldier (left) and American soldier (right) exhibiting the “1,000-yard stare” characteristic of battle fatigue or combat exhaustion in World War II. (Right: U.S. Military, February 1944, National Archives 26-G-3394)