The Relationship between Trauma and "Neurosis"

Three syndromes purporting to relate the development of neurasthenia or hysteria following trauma were described during this transition period of 1890 to 1920: traumatic neurosis, shell-shock and occupation neurosis. (Table. 2)

Traumatic neurosis

With the advent of the railways in the early 19th century, the influence of trauma upon the nervous system became an important medico-legal issue in England and Germany (Page, 1891, Schuster, 1908). The term "traumatic neurosis" was used to describe both the conditions of severe psychological disturbance ("railway brain") and chronic spinal pain syndromes ("railway spine") following injuries sustained in railway collisions. In other cases pain could remain localised to the site of injury, usually involving a limb, and described as "severe nervous disturbances in the affected part" (Str|mpell, 1894) The psychological sequelae were said to have features of neurasthenia, hysteria and certain of the psychoses (melancholia and hypochondriasis).

Breuer and Freud (1893) pounced on "traumatic neurosis" as exemplifying their paradigm of (conversion) hysteria: "The experiences which released the original affect, the excitation of which was then converted into a somatic phenomenon, are described by us as psychical traumas, and the pathological manifestation arising in this way as hysterical symptoms of traumatic origin" (p 209). Ideas sufficiently powerful to cause psychic trauma ("commotion") were seen by them to act upon a nervous system which was abnormally excitable ("predisposition"). The "hysterical disposition" consisted of a higher than normal degree of suggestibility which would more easily favour the conversion of "affective excitation" into a dysfunctional state of the nervous system.

As the construct of "traumatic neurosis" evolved, the problem of distinguishing "true" injury from simulation greatly occupied the minds of those who assessed and treated the sufferers (Page, 1891; Schuster, 1908). The poorly understood symptom complexes of many patients and the difficulties which arose in deciding upon monetary compensation for their injury gave rise to considerable diagnostic scepticism amongst physicians. Injury cases could be accused of malingering, of having a personality disorder, or even of exhibiting frank psychopathology (for review see Trimble, 1981).

Shell shock

During the Great War (1914-1918), the large numbers of troops exhibiting the many bizarre neurological syndromes collectively known as "shell shock" became urgent diagnostic and therapeutic problems for those engaged in military medicine. The pathology of "shell-shock" initially included pure exhaustion and anatomical lesions of the nervous system resulting from the forces of nearby explosions combined with carbon monoxide poisoning ("commotio cerebri") (Mott, 1919). However, other thinking invoked the substrate of a "psychopathic constitution" which evolved into the concept of "emotio cerebri", or psychological reactions occurring in sensitised, neuropotentially sound individuals (Buzzard, 1916; Smith and Pear, 1917; Culpin, 1940). This last concept was apparently more helpful in the practical management of the large majority of cases (Wittkower and Spillane, 1940).

Although "true" malingering was thought to be rare, many cases of "shell shock" were thought to exaggerate their distress or artificially prolong symptoms in order to avoid a return to duty (Myers, 1940). This form of behaviour could result in more long term benefits ("secondary gain") to the sufferer, such as incapacity for service and eligibility for a pension (Trimble, 1981). In his book The Anatomy of Courage, Lord Moran (Wilson, 1945) noted that two years after the Armistice, nearly 65,000 men discharged from the British Army were drawing pensions for neurasthenia.

Next: Occupation Neurosis