Sunday, 15 April 2018

Shell shock, malingering and PTSD

Breakdown The Crisis of Shell Shock on The Somme 1916 by Taylor Downing is a brilliant examination of the psychological effects of prolonged exposure to danger and death. Thousands of young men from all walks of life volunteered to serve in Kitcheners New Army, many of them joining what became known as the Pals regiments. And it was alongside their pals that many witnessed and experienced horrible suffering, mutilation and overwhelming fear. Is it any wonder that  many of them  developed bizarre symptoms of shaking, unsteadiness, paralysis and a variety of other effects, which baffled the medics of the day.

Downing provides a balanced treatment of a truly difficult subject. During the conflict the military authorities tended to take the view that such men might be malingerers and cowards and that the effect on colleagues would be somewhat infectious, making them unfit for battle. It resulted in what was known as 'wastage', such that numbers of fighting men were not only reduced by physical wounds inflicted but also by profound psychological damage. Hence a hard ,line was generally taken. Some of the treatments attempted were truly barbaric and callous. The opinion of medical officers attached to regiments was often ignored since it was felt that they were too sympathetic. Men who were clearly suffering from intense anxiety were forced back to the front, some of whom survived the war physically but never adapted to life after the conflict was over.

For me it raised the difficult issue of what we would now know as Post-Traumatic Stress Disorder. However this is somewhat different to the shell shock ( a term which the military wanted to stop using during there conflict) of the men of the Great War. Trench warfare, with its claustrophobia, vulnerability to shelling, being buried alive, and with dismembered rotting bodies all around,  resulted in a specific kind of anxiety neurosis. It caused an odd mix of what we would generally recognise as hysterical (conversion) symptoms and signs as well as profound fear and anxiety.  PTSD however is by definition a mix of symptoms following the index trauma, associated with flashbacks, headaches and depressive symptoms. To what extent is it a helpful diagnosis when the same experience is shared by many but only some have symptoms of PTSD? Do some of us have a predisposition or vulnerability as a result of our upbringing, genetics and personality? And how is it managed?

For the modern GP there is always the challenge of encouraging hope and optimism of recovery in our patients on the one hand, whilst empathising with the symptoms experienced on the other. In other words how do we detect and help the 'malingerer' (terrible word that it is, we all know what we mean), to move out of the adopted sick role, whilst allowing for the reality of what only the patients themnselves knows that they are feeling and thinking.

Our medical and military predecessors struggled mightily to get the balance right and its salutary to read of the various approaches in this superb book. But it is a reminder of just how difficult the management of psychosomatic illness is and probably always will be.
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A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.