Goodwin on Horwitz, 'PTSD: A Short History'

Author: 
Allan V. Horwitz
Reviewer: 
Christopher Thomas Goodwin

Allan V. Horwitz. PTSD: A Short History. Baltimore: Johns Hopkins University Press, 2018. 256 pp. $28.95 (paper), ISBN 978-1-4214-2639-6

Reviewed by Christopher Thomas Goodwin (University of Illinois Urbana-Champaign) Published on H-War (September, 2022) Commissioned by Margaret Sankey (Air University)

Printable Version: https://www.h-net.org/reviews/showpdf.php?id=57495

Allan V. Horwitz offers a compelling overview and summary of the existing literature on post-traumatic stress disorder (PTSD), and he argues that the history of PTSD shines light on a disorder rooted in “social and cultural forces to an unusually great extent among mental illnesses” (p. 3). As the excellent foreword by Charles E. Rosenberg claims, “disease has always been a social and linguistic as well as a biological entity” (p. ix). Horwitz traces this categorical imbrication from the mid-nineteenth century to the present day, following the contours of debates among specialists and the public. He follows the concept’s trajectory from its infancy as “railway spine” to modern PTSD, from a male (and then female) disorder to a more gender-neutral condition, and from its spread away from specialists to its ubiquity in the public consciousness (p. 11). And he examines the tortuous debating concerning PTSD’s root causes as physical or environmental. More specifically, Horwitz argues that, while psychiatric specialists haggled over a scientifically rigorous definition in the early days of the profession, the modern definition arose from the “socio-political climate of America in the Vietnam era” (p. 93). In the moral pursuit of a definition encompassing the broadest segment of veterans traumatized during an unjust war, veterans’ advocates, psychiatrists, and the authors of the Diagnostic and Statistical Manual of Mental Disorders III (DSM-III) initialized the broadening of the term “trauma.” This broadening has continued to such an extent that we now live, the author claims, in a “culture of trauma” where PTSD is ubiquitous (p. 137).

Horwitz locates the origins of PTSD in the American Civil War with the first tentative steps to recognize war-related disabilities that were not purely physical, visual wounds. A more decisive impetus coincided with the advent of railroads and the psychological trauma resulting from train crashes. Landmark court cases established juridical liability by linking “physical shocks ... to purely mental problems” (p. 31). Horwitz covers well-trodden territory when he charts the familiar beginnings of psychiatry with Jean-Martin Charcot, Pierre Janet, and Sigmund Freud. Likewise, historians have extensively covered the manifestation of shell shock in the First World War. Unfortunately, in a mere handful of pages, the author dispenses with PTSD during the Second World War and confines most of the discussion to the United States. A rather large and developed literature on psychology and psychiatry in Nazi Germany—a history with numerous consequences for the postwar era’s conception of mental illness and ethical treatment of patients—fails to appear. His coverage of the United States in the Second World War and its immediate aftermath would have significantly benefited from the disability history literature. This critical field has grown considerably in the past several decades, particularly regarding disabled veterans. The oversight is indicative of a broader issue within Horwitz’s work, namely, that the extensive history of disabled veterans before the Vietnam War rarely appears in his sources. The issue is doubly strange considering that a large portion of his work and his central argument revolve around the role of advocacy groups for disabled veterans in the modern definition of PTSD.

Although the bibliography is thin on historical sources at times, Horwitz’s strongest sections cover the postwar years when disabled veterans take center stage. He narrates the vicissitudes in the debates surrounding PTSD within a psychiatric community broadly hostile to the war raging in Southeast Asia and the agitation of veterans’ groups, such as Vietnam Veterans Against the War. The definition of PTSD that appeared in the DSM-III in 1980 and its revision in 1986, the DSM-III-R, focused entirely on environmental causes, ostensibly laying to rest the long debate between physical and environmental causes of PTSD. That the individual did not suffer PTSD due to any inherent vulnerability or defect became a moral principle; instead, victims had been placed or found themselves in situations that could cause anyone psychological damage. Horwitz follows the de-professionalization of the PTSD concept through the 1980s and 1990s with the recovered memory movement, which shifted the focus of mental trauma from men, soldiers, and veterans to women, sexual assault victims, and abused children. While Horwitz notes that the movement was eventually largely discredited, he sees a sea change in sociocultural control of the PTSD concept away from professional groups toward laypersons.

The shift away from professionals also finally decoupled gender and trauma, and Horwitz pays special attention to the role of gender in the history of PTSD. While medical professionals linked masculinity, cowardice, and mental trauma during the American Civil War, the rise of psychiatric theory generated the nebulous diagnosis of female hysteria. Later, the naming and treatment of shell shock in the First World War and combat fatigue in the Second World War arose partially as rebuttals to the notion that men might succumb to a feminine mental disorder. Horwitz argues that this divide broke down during the postwar era to the point where there exists little stigma for men seeking treatment or accepting a diagnosis of PTSD. Yet he cites studies where “women reported about twice as much PTSD as men,” although men experienced more traumas (p. 145). There is the occasional slippage of concepts here, indicating the tension throughout the book between subjective and objective definitions of trauma. One suspects that the gendered character of PTSD has not broken down quite as much as Horwitz claims. The book’s scope further complicates his treatment of gender: coverage of the United States and Western Europe dominate the book. Horwitz notes that “different cultures draw lines in different places between events that expectably lead to pathological symptoms and those that do not; events that are traumatic in one place or time might be habitual in others” (p. 4). Historians and sociologists have shown the validity of this statement in the burgeoning field of cultural trauma. Therefore, readers should note that this book is a history of PTSD in the United States and, to a much lesser extent, Western Europe from 1861 to the present day.

The narrative culminates with modern PTSD culture in the United States: psychiatrists and the public diagnose “trauma” with a social, cultural, and subjective looseness, leading to skyrocketing numbers of PTSD diagnoses. The question really seems to be: where do we draw the line between PTSD’s universality and its relativity? Horwitz does an admirable job of ensuring that this question does not simply become yet another iteration of the old physical-environmental debates. While highlighting the recent rise of neurobiological explanations, he offers other factors, such as cultural symptom pools: after suffering through legitimately traumatizing events, victims draw symptomatic presentations from a repertoire culturally shaped by other victims’ symptoms and those that doctors expect patients to exhibit. Modern explanations of mental illness no longer cleanly divide the physical from the environmental, the organic from the cultural. PTSD: A Short History is an excellent and concise introduction to a concept that has resisted—and continues to resist—definitions over nearly two centuries.

Citation: Christopher Thomas Goodwin. Review of Horwitz, Allan V., PTSD: A Short History. H-War, H-Net Reviews. September, 2022. URL: https://www.h-net.org/reviews/showrev.php?id=57495

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