The Traumatic Neuroses of War PTSD

271 Pages·1941·4.7 MB·English

by  Abram Kardiner

PSYCHOSOMATIC MEDICINE MONOGRAPH II -III
THE TRAUMATIC
NEUROSES OF WAR
COPYRIGHT, 1941, BY NATIONAL RESEARCH COUNCIL
2101 CONSTITUTION AVENUE, WASHINGTON, D.C.
PSYCHOSOMATIC MEDICINE MONOGRAPH II -III
THE TRAUMATIC
NEUROSES OF WAR
BY
ABRAM KARDINER, M.D.
//
FORMERLY ATTENDING SPECIALIST
U. S. VETERANS HOSPITAL NUMBER 8I
FORMERLY INSTRUCTOR IN PSYCHIATRY
CORNELL UNIVERSITY
AND
ASSOCIATE IN PSYCHIATRY
COLUMBIA UNIVERSITY
' I941 '
PUBLISHED WITH THE SPONSORSHIP OF THE
COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR
DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY
NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.
EDITORIAL BOARD
MANAGING EDITOR: FLANDERS DUNBAR
EDITORS
FRANZ ALEXANDER FLANDERS DUNBAR
Psychoanalysis Psychiatry
DANA W. ATCHLEY CLARK L. HULL
Internal Medicine Psychology
STANLEY COBB HOWARD S. LIDDELL
Neurology Comparative Physiology
HALLOWELL DAVIS GROVER F. POWERS
Physiology Pediatrics
ADVISORY BOARD
PHILIP BARD NOLAN D. C. LEWIS
CARL BINGER KARL A. MENNINGER
HERRMAN BLUMGART ADOLF MEYER
E. V. L. BROWN WALTER L. PALMER
WALTER B. CANNON TRACY J. PUTNAM
BRONSON CROTHERS STEPHEN WALTER RANSON
FELIX DEUTSCH SAUL ROSENZWEIG
OSKAR DIETHELM LEON J. SAUL
GEORGE DRAPER ELMER L. SEVRINGHAUS
EARL T. ENGLE EPHRAIM SHORR
LOUIS Z. FISHMAN DAVID SLIGHT
JOHN F. FULTON JOHN H. STOKES
W. HORSLEY GANTT JOSEPH STOKES, JR.
ROY R. GRINKER MARION B. SULZBERGER
WALTER W. HAMBURGER ALFRED H. WASHBURN
LUDVIG HEKTOEN EDWARD WEISS
M. RALPH KAUFMAN JOHN C. WITHEHORN
WILLIAM J. KERR HAROLD G. WOLFF
LAWRENCE S. KUBIE ROLLIN T. WOODYATT
DAVID M. LEVY EDWIN G. ZABRISKIE
PRINTED BYTHE GEORGE BANTA PUBLISHINGCOMPANY, MENASHA, WISCONSIN, U.S.A.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
FOREWORD
The traumatic neurosis has long been a troublesome medical and
forensic problem. The medical aspects are fundamental because it is
the resolution of these problems upon which all other social issues
depend. Until the war of 1914-1918 this neurosis received but little
attention. The main problem in connection with it was whether to
account for the symptoms on the basis of organic or "functional"
hypotheses. Moreover, the neurosis usually carried the name of the
provoking agent, like lightning neurosis, railroad spine, shell shock,
etc.
The neuroses incidental to the great war made the world neurosis-
minded. They were studied with more care than at any time pre
viously, and the literature is encyclopedic. Explanations of this
neurosis on a functional basis came largely from the influence of
psychoanalysis. The work of W. H. R. Rivers and William Mc-
Dougall was highly significant, aswell as that of Ferenczi, Abraham,
Simmel and Jones. Freudneverdiscussed this neurosis systematically,
but made some extremely important observations about it in 1921.
Between this work and the present time lie the experiences with
the chronic neuroses of the last war. This taught us much about
psychopathology, treatment, and the complicated forensic issues con
nected with it. Nevertheless the conclusions of this work did not get
much attention, and hardly influenced the conception of the peace
time traumatic neurosis, which is the same in structure as those pre
cipitated in war.
The current war has again brought to the foreground the problem
of the neuroses incidental to it. This time, however, the problem is
much more urgent because, owing to the widespread aerial bom
bardment of urban centers, the traumatic neurosis is now no longer
likely to be confined to combatants. In fact the traumatic neurosis
bids well to be one of the commonest neurotic disturbances in the
world. It is difficult to predict the nature and scope of the medical
vi THE TRAUMATIC NEUROSES OF WAR
and social problems that this new aspect will create, but there can be
no doubt that these problems, both psychiatric and social, will be of
prime importance. If we are not to repeat the errors made during the
last war, with its accompanying waste, important problems in organi
zation and study lie ahead. In our preparatory efforts the experi
ences of the last war and those in the current war should be our chief
guide.
This book purports to be a guide to the study, treatment and
postwar care of those neurotic disturbances which are incidental to
war. The greatest stress in this work falls on the discussion of those
principles of psychopathology necessary to make these neuroses in
telligible and to furnish a rational basis for therapy. This was re
garded as the prime objective, for without this knowledge no
intelligent program for treatment, prophylaxis, and postwar care
can be formulated. In addition, an attempt is made to discuss the
forensic aspects of the traumatic neuroses, since so many of them be
come government charges for a long postwar period. Treatment is
discussed at length only in connection with several chronic cases which
terminated successfully. This is in no way to be construed as indicat
ing that therapy in these chronic cases is universally successful.
Most of the clinical material included in this book was gathered
while I was Attending Specialist in the Outpatient Department of
U. S. Veterans Hospital Number 81 during 1922 to 1925. All but
a few of the cases were studied there. Some of them were repeatedly
demonstrated to classes in psychiatry from 1923 to 1928. The case
which is the basis for the discussion on therapy was demonstrated in
person before the New York Society for Clinical Psychiatry in Feb
ruary, 1924.
Although the purpose of the book is purely practical, the oppor
tunity was used to discuss all the accessory data necessary to a more
complete understanding of this type of neurosis, and also to discuss
some pertinent issues in psychopathology. The reader not interested
in any but the clinical and practical aspects of these neuroses can
safely delete Chapters IV and V.
The material of this book was the subject of a paper originally
published in the Psychoanalytic Quarterly (Vol. I, nos. 3-4), under
FOREWORD
the title, "The Bioanalysis of the Epileptic Reaction." In that paper
the emphasis was largely theoretical. The chief interest there was to
reconstruct the nature of the epileptic reaction. Some of the cases
there used are reproduced here. The clinical material in the present
book is much more extensive, however. As regards the psychopathol-
ogy, the conception of the traumatic neurosis is essentially the same.
However, the theoretical reconstruction has been considerably altered
and much simplified, this simplification being due to a change in the
operational concepts employed. The chief operational concept in the
first version was that of "instinct," and in order to describe the dy
namics a good many obscure concepts had to be devised which were
not very helpful. These have all been deleted. I am indebted to the
publishers of the Psychoanalytic Quarterly for permission to repro
duce some of the material published in the earlier work.
The short bibliography is no indication of the extent of my in
debtedness to other writers on this subject. I have included in this
bibliography only those references ofwhich I have been able to make
positive use.
For the consummation of this work I am indebted to: Dr. Walter
Treadway, through whom I received the opportunity to study these
neuroses; to the late Dr. George H. Kirby; to Dr. Adolph Meyer,
for discussions while the material was organized; to Dr. Sandor
Rado, for continual encouragement; and Dr. Otto Fenichel for a
very stimulating criticism of the above mentioned paper (Int.
Zeitschr. f. Psychoan., 1934).
I owe a great debt of thanks to the editors of Psychosomatic Medi
cine, especially to Drs. H. Flanders Dunbar, H. S. Liddell and
Franz Alexander, for their editorial criticism and assistance in the
preparation of the book. I am also indebted to Dr. Harold Kelman
for studying the theoretical parts of the book, for some suggestions
on organization for treatment, and on problems for future research.
His experience with civilian and war traumatic neuroses was useful
to me as a check on my observations, and discussions with him were
useful in formulatingmyopinions on many matters.
New York A.K.
November3, 1040

PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
CONTENTS
FOREWORD
PART I: CLINICAL
I. INTRODUCTION
II. SYMPTOMATOLOGY OF THE TRAUMATIC NEU
ROSES 7
Pathoneuroses—Hypochondriasis .... 7
Schizophrenia 9
Transference Neurosis 10
Defensive Ceremonials and Tics 15
Autonomic Disturbances 21
Sensory-motor Disorders 29
The Epileptic Symptom Complex .... 36
Summary ........ 66
III. ANALYSIS OF THE SYMPTOMATOLOGY . 68
War and the Traumatic Situation 68
What is a Trauma? ...... 74
The Alteration of Adaptation in . 81
1. Repetitive tics and ceremonials 81
2. Sensory-motor phenomena . 82
3. Sympathetic-parasympathetic phenomena 82
4. Syncopal phenomena ..... 83
The Organization of the Neurosis .... 84
Constant Features of Traumatic Neurosis, including 86
1. Fixation on the traumatic event . 87
2. Dream life ...... 88
3. Contraction of general level of functioning 94
4. Irritability ....... 95
5. Tendency to aggression and violence ... 96
6. Inhibitory phenomena ..... 97
Regression or Disorganization 100
Traumatic Neurosis and Epilepsy 117
Conclusion 131