Psychiatric legacy of World War I remains unclear 100 years later

Although World War I has been frequently viewed as the starting point of military psychiatry, the lasting effects of the psychiatric work done during this time are not clear, according to a series paper published in The Lancet.

In particular, shellshock was first identified as a disorder during World War I, and a treatment known as forward psychiatry was introduced to address it. However, shellshock was a broad category that was not a true predecessor of post-traumatic stress disorder, and forward psychiatry’s effectiveness may have been exaggerated, the researchers wrote.

In the paper, researchers from King’s Centre for Military Health Research, Institute of Psychiatry at King’s College London, reviewed contemporary publications, classified military reports and casualty returns to reevaluate conventional thinking regarding the long-term importance of these discoveries to psychiatric practice.

Shellshock was first given validation in the medical literature in a 1915 paper by CS Myers published in The Lancet. The disorder was broadly defined to include symptoms such as exhaustion, palpitations, shortness of breath, tremor, joint/muscle pain, dizziness and headaches, along with nightmares, ongoing anxiety and insomnia. According to the current report, the term was used as a “catchall label” for physical manifestations of trauma, rather than a specifically defined condition. Early attempts to understand causation of shellshock concluded that the most important factor in shellshock is “an inborn or acquired tendency to emotivity.”

A group of clinicians later met at Maghull Military Hospital near Aintree, Liverpool, to discuss theories on the causes of shellshock. During this discussion, an anatomy professor and a psychologist suggested shellshock could be anthropological in origin. Because the military psychology is based on controlling and suppressing vulnerable emotions while emphasizing loyalty and fighting spirit, these clinicians theorized, the only acceptable outlet for fear or emotional breakdown (and possible escape from active duty) would be a physical illness.

The concept of forward psychiatry arose after the Battle of the Somme, which resulted in the death or injury of 419,600 British soldiers between July and November of 1916. With so many wounded, the issue of shellshock became increasingly problematic. During this time, the British Expeditionary Force needed to maintain its military forces by returning soldiers to the front line as quickly as possible. To facilitate this, the British used a French model to create four specialist units known as not yet diagnosed nervous (NYDN) centers. These facilities were specifically designed to diagnose and treat psychosomatic conditions without the need for referral to base hospitals. The three mandates of these centers were expressed in the acronym PIE: Proximity (close to the battlefield); Immediate referral from the frontline; and Expectation of recovery. These centers appealed to commanders because soldiers evacuated from the trenches were less likely to return to the frontline. Soldiers were fed, allowed to rest, and then placed on gradually increasing exercise regimens, eventually culminating in route marches. However, the effectiveness of this approach was called into question in the absence of follow-up data, and ultimately, the intervention did not address the issue of psychiatric casualties.

According to the researchers, interpretations of the effectiveness of this treatment were culturally influenced and inflated. They wrote, however, that the significant psychiatric data gleaned from World War I may still be relevant and useful to the treatment of soldiers in modern conflicts.

“The vigorous debates that arose in response to controversy about the nature of psychiatric disorders and the discussions about how these disorders should be managed remain relevant to the trauma experienced by military personnel who have served in Iraq and Afghanistan,” the researchers wrote. “The psychiatric history of World War I should be thought of as an opportunity for commemoration and in terms of its contemporary relevance — not as an opportunity for self-congratulation.”

Disclosures: Jones is employed by the Institute of Psychiatry and is the programme leader for an MSc in war and psychiatry. Wessely is an honorary civilian consultant adviser in psychiatry to the British Army and a trustee of Combat Stress, a UK charity that provides service and support for veterans with mental health problems.