Traumatic Neuroses

TRAUMATIC NEUROSES, a term first proposed by the German neurologist Oppenheim, who, at the end of the 19th century, described under this name neurotic clinical pictures observed in persons who had suffered in railway accidents. Oppenheim believed that these neuroses were based on subtle organic changes. Oppenheim's report provoked a lively discussion, in which the majority of authors spoke out against the interpretation of traumatic neurosis as an organic disease. Oppenheim's opponents saw in traumatic neurosis only one of the forms of hysteria or neurasthenia and, following Strümpell, believed that "demanding ideas" (Begehrungsvorstellungen) played a large role in the genesis of this disease. Most psychiatrists and neurologists approached "war neuroses," the picture of which bears a complete resemblance to the previously described traumatic neuroses, with the same interpretation. This gave Oppenheim reason to again come forward with an energetic defense of his views on "traumatic neurosis." Oppenheim attempted to prove that strong peripheral irritations could, by being transmitted to the brain, cause subtle organic changes in it, the expression of which is the picture of "traumatic neurosis." In the subsequent dispute, Oppenheim somewhat changed his position. Under the pressure of facts, he had to admit that at least a portion of the cases of "war neuroses" were hysteria; he began to allow for the existence of "hystero-somatic" mixed forms, in the genesis of which, along with mechanical concussion, psychic trauma and emotional disturbances also take part. He began to reduce the "organic" changes in traumatic neuroses to a disruption of pathways, to phenomena of diaschisis, which cannot be detected by a microscope but nevertheless serve as an obstacle to the proper motor and sensory functioning of the central nervous system. In this dispute, only a few specialists were on Oppenheim's side: Goldscheider, Babinski, and Sarbo. His opponents were significantly more numerous. Among them were such authorities as Gaupp, Nonne, Bonhoeffer, Binswanger, Lewandowsky, and others. Bonhoeffer and Gaupp showed that among prisoners of war and the severely wounded, traumatic neurosis is almost never encountered. Nonne pointed to the difference in morbidity between soldiers and officers. At a discussion in Munich in 1916, the majority of German psychiatrists and neurologists came to the conclusion that the functional nature of war, or rather traumatic, neuroses must be considered proven. However, this position in turn became the starting point for further disagreements. The variety of clinical pictures of traumatic neurosis contributed not a little to this. Traumatic neurosis usually arises as a result of acute psychic trauma in the form of fright experienced during some accident or catastrophe, such as an earthquake, railway wreck, shell explosion, etc. Thus, the initial stage of traumatic neurosis is a picture of psychic shock, in the pathogenesis of which the leading role belongs to damage to the autonomic nervous system. In severe cases, a picture of the so-called fright psychosis develops, first described by Miondi and Stierlin, who studied mental illnesses during the Messina earthquake. In these cases, more or less prolonged disturbances of consciousness of a delirious or twilight character, states of stupor, sometimes senseless automatic actions, states of agitation and aggression, etc., were observed. In the majority of cases, however, the matter is limited to acute fright with short-term clouding of consciousness or even without it, and subsequent autonomic disturbances. Upon the disappearance of the acute phenomena, a state of depression usually develops with hypochondriacal fears, with unpleasant sensations in various parts of the body, and reduced activity. In some cases, this state then begins to gradually smooth out and improvement occurs; in others, a fixation of the existing symptoms takes place, hysterical mechanisms appear on the scene, and the so-called traumatic development of personality begins. The most vivid picture of such traumatic development is presented by cases in which the main driving spring of this development is the unshakable conviction of the trauma victim in their rights to special attention and care on the part of the state and society, for which they allegedly lost their health and which are irredeemable debtors to them. Hence the parasitic existence of such trauma victims, the demands for monetary allowances and spa treatment, and the attitude toward irresponsibility and illness. An instrument in this litigious struggle is the proof of disease through various hysterical mechanisms. In military trauma victims, these are primarily the so-called traumatic seizures with command, often reproducing individual military episodes and arising as a rule due to external causes, usually in situations difficult for the patient. A very frequent symptom is trembling of the head, hands, or the entire body, which intensifies during agitation. Hysterical paralyses, mutism, sensory disturbances, and diverse autonomic stigmata are not rare. All this unfolds against a background of excessive affective explosiveness, and this explosiveness often has a purposeful, demonstrative character. In another group of cases, traumatic development presents a significantly less vivid picture, characterized primarily by the fixation of autonomic disturbances and hypochondriacal sensations: especially after injuries related to professional work, complaints of general weakness, sharp fatigue, headaches, dizziness, palpitations, pains in various parts of the body, weakening of memory, and depressed mood, etc., come to the fore. The patients are lethargic, tearful; all their attention is focused on painful sensations and on the desire to prove that they cannot work but must be treated for a long time. Thus, the clinical picture and course of traumatic neurosis are determined by two main factors: 1) the direct effect of psychic trauma on the organism and 2) the psychological processing of the received trauma. The role and significance of these two factors are not the same at different stages of the disease and in different patients. Observation by German and Russian psychiatrists shows that at the beginning of the World War, cases were often observed where the picture of traumatic neurosis was limited to symptoms of psychic shock and did not receive further development. Subsequently, these cases became increasingly rare. By the end of the war, when the incidence of traumatic neurosis had taken on the character of an epidemic, many cases of traumatic neurosis developed even without acute psychic trauma. At the same time, the purposeful elements in the picture of the neurosis began to appear so nakedly that the term "hysteria" became almost synonymous with simulation. This fact also coincides with the observations of Russian psychiatrists who have devoted a large number of works to traumatic neurosis (Amenitsky, Avtokratov, Rozenshtein, Segalov, Gannushkin, Khoroshko, and others). A number of authors attempt to dissect the above-described clinical picture and propose strictly distinguishing the traumatic neurosis itself from the hysteria that often complicates it. This attempt hardly deserves recognition, since hysterical mechanisms not only fix individual symptoms of shock neurosis but are closely interwoven into the essence of its clinical picture. Often, the very excessiveness of the reaction to acute psychic trauma depends on the participation of hysterical mechanisms. It is impossible to strictly distinguish the accompanying somatic phenomena of an acute affective experience from hysterical mechanisms. From this point of view, the dispute between Bonhoeffer and Kleist about the possibility of delimiting fright neurosis from hysteria appears to a significant extent fruitless. No less scholastic is the dispute between individual authors regarding the psychological interpretation of traumatic neurosis. Some authors, emphasizing the purposeful tendencies in the picture of traumatic neurosis, citing, for example, the increase in this disease in connection with insurance legislation, etc., share Strümpell's point of view and believe that the main thing in the genesis of traumatic neurosis is demanding ideas. Hence the terms "rent neurosis," "demand neurosis." Another part of the authors prefers to speak not of "rent neurosis," but of rights neurosis (Weizsäcker). Finally, others assert that in the foreground in the genesis of traumatic neurosis are hypochondriacal fears for one's health in connection with the sustained injury. These hypochondriacal complexes, in the opinion of Hoffmann, are often implanted by doctors. There is no doubt that representatives of various views can cite a large number of facts testifying in favor of the positions they defend. If it is not difficult to prove the presence of a purposeful tendency in many cases of traumatic neurosis, then, on the other hand, every psychiatrist is also aware of cases where the neurosis develops in connection with fear for one's health. All this does not solve the question of the pathogenesis of traumatic neurosis at all, and the dispute itself is conducted from incorrect positions. Firstly, all these views extremely simplify the entire complex problem of the pathogenesis of traumatic neurosis, and secondly, they attempt to resolve it in general, regardless of the specific personality and situation. In reality, however, the pathogenesis of traumatic neurosis is not the same in individual cases. Only very schematically can the following possibilities be outlined here.

In one group of cases, we are dealing with sharply expressed phenomena of psychic shock, which developed either due to the excessive severity of the psychic trauma itself or due to the inferiority of the soil upon which the trauma fell.

To this same group, apparently, should also be assigned those frequent cases where an accident was accompanied not only by psychic but also by mechanical trauma.

In a military setting, for example, during the explosion of a shell, along with phenomena of psychic shock, organic changes of the brain often develop as a result of concussion or contusion.

At the same time, these organic changes can for a very long time be so hidden that even the most thorough clinical examination does not allow one to differentiate these cases from pure Traumatic Neuroses.

In all these cases, severe vegetative disorders and the psychic changes caused by them (for example, Bonhoeffer's organic twilight states) come to the fore in the clinical picture of the disease.

Further psychological processing of the sustained trauma proceeds predominantly under the sign of hypochondriacal fears, supported by various paresthesias.

The hysterical disorders observed in these cases as well do not constitute the essence of the neurosis, but only color the deeper disturbances of nervous activity.

As mentioned above, clinical pictures of this kind were observed more often at the beginning of the war, and then they were lost in the mass of cases with a different pathogenesis.

By the end of the war, simultaneously with the increase in cases of Traumatic Neuroses, its clinical appearance also changed: goal-oriented attitudes and hysterical mechanisms came to the fore.

At the same time, in the pathogenesis of Traumatic Neuroses, such factors as the severity of the trauma and constitutional or acquired somato-psychic inferiority lost their decisive significance; that is, in many cases, they were absent.

The main role began to be played by purely psychological moments, such as disappointment in the goals of the war, homesickness, fatigue, and mechanisms of mutual induction, which facilitate escape from the traumatizing situation along the paths of hysterical disorders.

Thus appeared "traumatics without trauma."

Thus, the genesis of Traumatic Neuroses is very complex, and one should always remember this complexity, because a one-sided understanding of it leads to serious practical errors.

Overestimation of goal-oriented attitudes leads to a misunderstanding, to the identification of neurosis with simulation, and as a result, to overlooking, in a whole series of cases, serious disturbances of the nervous system hiding behind the goal-oriented tendencies lying on the surface.

This especially applies to the position of bourgeois doctors in capitalist countries regarding neuroses after industrial accidents.

German psychiatrists have put forward the proposition that the real cause of Traumatic Neuroses is the recognition of the right to compensation for the victim of an accident, and that with the abolition of this right, Traumatic Neuroses will also disappear.

W. Riese argued heatedly against these attitudes, emphasizing that at the basis of every case of Traumatic Neuroses lies a real and sometimes very severe experience, into which the doctor is obligated to "empathize."

It is necessary to note that Traumatic Neuroses in capitalist countries are much more widespread than in the Soviet Union, which is why the problem has acquired greater urgency there.

Even bourgeois authors are forced to admit that a favorable soil for its development among workers is created by the consciousness of material insecurity and the fear of hunger and poverty threatening as a result of the loss of work.

Insurance legislation, being a compromise and not giving the worker any assurance that he will actually receive support in a difficult moment, creates, precisely by its half-heartedness, an additional stimulus for the emergence of neurotic manifestations in him.

In the USSR, the basic prerequisites for the emergence of Traumatic Neuroses are absent: every worker among us is provided with work corresponding to his strength, even in the case where, due to the state of his health, he is no longer suited for his former profession.

In the case of disability, our legislation ensures not the right to compensation for an injury caused at work, but only material support for further existence.

Thanks to this, Traumatic Neuroses among us represent a comparatively rare and gradually disappearing phenomenon: from the war traumatics, only isolated cases remain, almost exclusively those where an organic brain lesion is hidden behind neurotic layers, and industrial accidents cause the emergence of Traumatic Neuroses only where there is favorable soil for this in the form of, mainly, a psychopathic predisposition.

The course of Traumatic Neuroses is extremely diverse and depends on the most varied factors.

Constitutional features, the severity of the trauma, the environment in which the trauma was received, the social attitudes of the traumatic individual's personality, this or that medical approach, etc., are of significance.

One should especially mention the course of those cases where psychic trauma was accompanied by physical trauma (concussion of the brain, contusion).

According to their further course, three groups can be distinguished from these cases: in the first group, several years after the trauma, neurological signs of damage to the central nervous system appear, and at the same time, a picture of organic dementia (dementia traumatica) develops.

The second group of cases is characterized by the emergence of epileptic seizures.

Finally, in the third group, described by Kretschmer, the development of paranoid pictures is observed.

Practically, it is extremely important to differentiate a case of pure Traumatic Neuroses from those cases where Traumatic Neuroses is combined with a more serious disease of the central nervous system, such as an organic lesion, epilepsy, or schizophrenia.

At the same time, one should keep in mind that the longer the time that has passed since the epidemic of Traumatic Neuroses (e.g., war neuroses), the smaller the number of cases of uncomplicated Traumatic Neuroses.

The differential diagnosis of complicated cases is often very difficult, because the features of Traumatic Neuroses usually obscure and distort the clinical picture of the organic disease.

This also takes place in cases of the combination of Traumatic Neuroses with schizophrenia, where neurotic mechanisms simulate affective liveliness.

A correct diagnosis in these cases is possible only with the most thorough study of the structure and dynamics of the disease.

As for the treatment of Traumatic Neuroses, there exist several methods proposed by various authors according to their understanding of the essence of Traumatic Neuroses.

During the war, German and French neuropathologists introduced a number of very cruel methods of treating Traumatic Neuroses.

Thus, Kaufmann (see Kaufmann's method) applied the influence of a strong electric current, proceeding from the assumption that the innervation pathways disrupted due to the sustained shock could be restored by a repeated shock, and Kehrer and Berthold developed a method of forced military training.

All these methods were dictated by the acute need of the German army of the imperialist war era for human material.

Another extreme is the proposal by Stier to treat traumatics by satisfying their claims for a pension.

The most common method of treating Traumatic Neuroses consists of psychotherapeutic influence in combination with physiotherapeutic procedures.

When using these methods, one must, however, remember the danger of instilling in the neurotic an attitude toward the disease.

In cases where Traumatic Neuroses complicates an organic disease of the central nervous system or a physical injury, therapeutic measures must be primarily directed against the underlying disease.

The prevention of Traumatic Neuroses is of enormous importance, especially in the Red Army.

The very structure of the Red Army, built on the principle of conscious discipline and consisting of politically and technically literate fighters who have a clear goal of defending the socialist fatherland and the cause of peace, is a powerful health-promoting factor.

However, this by no means relieves doctors of the duty to deploy preventive work.

Here, the prevention of psychogenic diseases among the population in general is of significance, then psychohygienic work in the units of the Red Army, consisting of the doctor's participation in the organization of the fighters' training and rest and the timely recognition and correct assessment of neurotic reactions in individual nervously unbalanced subjects.

One has to encounter cases of Traumatic Neuroses in forensic psychiatric and labor expertise.

Here, the following provisions are determining for the attitude toward these cases: 1) Traumatic Neuroses is not a circumstance that reduces or excludes responsibility for actions committed by the neurotic; 2) Traumatic Neuroses only in exceptional cases, on the basis of a severe psychopathic predisposition, gives total disability for a long time (e.g., persistent hysterical paralyses); somewhat more often, but still in comparatively rare cases, it gives a long-term reduction in work capacity, especially in relation to professions requiring great attention and the ability for prolonged affective tension and volitional endurance.