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Book Reviews   |    
A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century
Reviewed by Sally L. Satel, M.D.
Psychiatric Services 2003; doi: 10.1176/appi.ps.54.3.405
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by Ben Shephard; Cambridge, Massachusetts, Harvard University Press, 2001, 487 pages, $27.95

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British military historian Ben Shephard has written a sweeping and authoritative book on the history of combat trauma. A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century should be required reading for every clinician who works with military personnel or veterans. One of Shephard's fundamental points—that the default position among individuals who have been exposed to extreme stress is actually resilience, not psychic damage—is enormously important. Unfortunately, it is one that is underemphasized in the literature and in clinical culture.

In 27 detailed and meticulously documented chapters, Shephard, a former journalist, explores the psychological problems soldiers developed in World Wars I and II, the Vietnam War, and other conflicts.

Combat stress is nothing new, of course. But sometimes it has been eclipsed. The matter, as American psychoanalyst Abram Kardiner once wrote, "alternate[s] between being the urgent topic of the times and being completely and utterly neglected." Indeed, important ideas about combat-induced stress—variously called shell shock, war neurosis, battle fatigue, and posttraumatic stress disorder (PTSD) over the years—and about its treatment seem to have required reinvention as new generations of psychiatrists attended to new generations of soldiers. (This is a shame, because, as Shephard points out, war neurosis was apparently quite well handled during World War II.)

Although shell shock has always been with us, the threshold for its expression has undoubtedly dropped several notches as society has become more tolerant of personal disclosure of psychic pain and PTSD has become admissible in the forensic and disability arenas. As Shephard says, "Every war is different. Every time there is a war, different social attitudes to fundamental questions like fear, madness, and social obligation will redefine the role of military psychiatry in a different way."

We have certainly come a long way from the electric shock "treatment" delivered by European psychiatrists to catatonic World War I soldiers. In fact, today's military is so sensitive to overwhelming recruits that trainees carry little colored cards in their pocket during boot camp so they can signal the sergeant when they are feeling "stressed." Along the way, military psychiatrists have grappled with several seemingly timeless dilemmas. Most wrenching was the moral conundrum: protect and treat a shattered soldier, or fortify him just enough so that he can be sent back into battle. Effective treatments for chronic war stress were a matter of debate too: Should a psychiatrist help the patient bring traumatic memories to the surface, or encourage suppression? There was also the question of compensation. The effect of pensions on so-called war neurotics was noted as early as World War I: "As men got better, the thought of losing their allowance would cause their hysterical symptoms to return or new ones to appear," wrote a British psychotherapist in the early 1920s.

I was particularly drawn to Shephard's last chapters on the Vietnam War. As psychiatrists are aware, the story of PTSD as we know it starts with Vietnam veterans. In the late 1960s, a band of self-proclaimed antiwar psychiatrists formulated a new diagnostic concept to describe the psychological wounds sustained in the war. The original proposal was "post Vietnam syndrome" (PVS), but the DSM-III task force, headed by Robert Spitzer and Nancy Andreasen, would not permit such specificity. In the end, all agreed on "posttraumatic stress disorder." The PVS campaign was spearheaded by psychiatrists Robert Jay Lifton, well known for his work on the psychological damage wrought by Hiroshima, and Chaim Shatan. Along with a handful of other outspoken psychiatrists and psychologists, these two individuals would shape the dramatic image of the Vietnam veteran as the kind of walking time bomb immortalized in modern classics such as Taxi Driver and Apocalypse Now.

Shephard brings a welcome skepticism to the discussion of PTSD. He emphasizes the role of individual differences in response to stress, a concept that challenges the post-Vietnam model championed by Lifton, Shatan, and others—namely, that prolonged war stress is a common and normal reaction to combat in almost everybody, everywhere. Shephard underscores the tendency of clinical psychiatry to medicalize normal distress in response to catastrophe.

This is not to say that Shephard denies the reality of PTSD—again, he clearly documents its manifestations in other wars—but he properly acknowledges the extent to which certain diagnoses flourish in an environment that offers incentives to shape distress according to a particular narrative. Examples of questionable cases of PTSD abound in the courtroom, in the benefits claims arena, and in the clinic.

Having worked in a Department of Veterans Affairs (VA) hospital for several years, I have developed a healthy skepticism about the virtue of PTSD wards. These intensive inpatient units often encouraged patients to view themselves as disabled war victims. Either deliberately or unconsciously they maintained themselves in a state of dysfunction so that they could collect service-connected disability.

Thankfully, the units have been dismantled, and the emphasis for patients with chronic PTSD today is present-oriented rehabilitation. Shephard's account of the history of the PTSD diagnosis, which appeared in DSM-III in 1980, vividly illustrates this category's significance as representing both a legitimate mental condition and a political artifact of the Vietnam War intended to validate the suffering of Vietnam veterans.

The last chapter of the book, "The Culture of Trauma," is an insightful treatment of the ways that stress-related disorders have shaped our thinking about human response to adversity. These disorders have fueled the victim culture. They have turned pathos into pathology. People may perceive extreme crisis in three ways: as a threat, as a loss, or as a challenge. The emotional correlate of threat is fearful anticipation and that of loss is depression. Challenge, by contrast, is marked by optimism.

Today, the expectation of the mental health profession—and many other professions—is that threat and loss will predominate. As we saw after September 11, 2001, professionals presumed that the nation would be overwhelmed by stress. Experts would be required. The trauma industry of crisis counselors and debriefers—mobilized in full force after September 11—justified their work, without any evidence of its effectiveness, as an effort to prevent the development of PTSD. Hundreds of millions of dollars, private and federal, rained down on New York City to treat the expected legions of psychically damaged persons.

Since the mid-1990s, a number of outstanding cultural analyses of combat PTSD have been published, all by historians or anthropologists: Shook Over Hell: Post Traumatic Stress, Vietnam, and the Civil War, by Eric Dean, Jr. (1); Harmony of Illusions: Inventing Post Traumatic Stress Disorder, by Allan Young (2); and The Politics of Readjustment: Vietnam Veterans Since the War, by Wilbur Scott (3). The prodigiously researched A War of Nerves completes this superb contemporary tetralogy on the interface of war and psychiatry.

Dr. Satel is staff psychiatrist at Oasis Drug Treatment Clinic in Washington, D.C., and lecturer in psychiatry at Yale University School of Medicine in New Haven, Connecticut.

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