209: The Invisible Wounds of War

209:  Je Suis Prest

209 title

The field hospital at which I was stationed had been shelled three times.  Even knowing that the flimsy walls of our temporary structures would not protect us, still doctors, nurses and orderlies had all dashed inside at the first alarm, huddling together for courage.  Courage is in very short supply when there are mortar shells screaming overhead and bombs going off next door.

From Outlander by Diana Gabaldon, Chapter 7

combat nurse

Claire spent six years as a combat nurse in the second World War.  In episode 209, the sights and sounds of men preparing for battle trigger terrifying flashbacks to her time in the war and she is seen reliving the trauma she has no doubt tucked away deep in her memory.  As a combat nurse, she would have spent her days caring for soldiers suffering horrendous injuries as well as the more mundane, as we see with her flashback to her time educating soldiers about trench foot.  She would be building relationships with the same men and women who would later be sick and seriously injured and in her care.  She would have witnessed innumerable tragic deaths, while often fearing for her own life.  When the war finally ends, Claire finds herself with only a brief time of peace and reunion with Frank before she is once again in harm’s way.

Since her arrival in the 18th century, Claire has suffered what seems to be a lifetime of traumas in the form of war, violence, assault, arrest and imprisonment, narrow avoidance of execution, witnessing the torture of her husband, and the devastating death of her daughter.

Claire holds deep within a long history of trauma.

claire covering ears

Shell Shock and the World Wars

The psychological distress experienced by soldiers was first dubbed “shell shock” during World War I.  Physicians used the term to describe the “dazed, disoriented state many soldiers experienced during combat or shortly thereafter.”(1)  The condition was thought to be brought on by concussion and physiological damage caused by exploding artillery shells.  However, military physicians noted that the same symptoms were seen in other soldiers who had not been in close proximity to exploding shells and opinion shifted, with many contending that shell shock was “a variety of cowardice or malingering” and those who “cracked” under the pressure of war were considered weak.

After WWI, Sigmund Freud argued that shell shock was psychological in origin, recommending psychoanalysis for treatment.  The idea that brain injury from exploding artillery shells led to these symptoms fell out of favor and the opinion that the condition affected the psychologically “weak” persisted.  During WWII, draft boards attempted to “weed out” those deemed psychologically unfit to fight, finding over 1 million men ineligible to go to war.  Despite this, in the European theater, the US military had a rate of psychiatric casualties of 102 per 1,000 troops.(1)

Overall in WWII, 25% of US military casualties were caused by psychological war trauma.  The rate was approached 50% for soldiers engaged in long, intense fighting.(2)  Seeing that so many suffered these effects, despite already excluding over 1 million men in the screening process, opinion among most in the military began to shift to the acceptance that combat fatigue was not evidence of cowardice or pre-existing mental illness.

1,393,000 soldiers were treated for battle fatigue during WWII.  Treatment was often focused on a few days of complete rest, with quick return to the front lines.  50-70% returned to combat within three days.  Other treatment modalities included the administration of sodium pentathol (dubbed “truth serum”) to induce soldiers to “re-live their repressed battlefield experiences and thus reach a catharsis.”(2)  Other physicians found that providing liquor during debriefings was beneficial to the troops.  Some were treated with electric shock in an attempt to “jolt” the veteran out of his emotional turmoil.  Others were treated with large doses of insulin which dropped their blood sugar severely and caused a comatose state.  In the 1950s, some WWII veterans were even subjected to lobotomy, or surgical severing of the frontal lobes of the brain, in an attempt to relieve their psychological symptoms.  Whether dubbed shell shock, psychoneurotic disorder, anxiety neurosis, character disorder, or combat exhaustion, very little was understood about what would come to be known Post Traumatic Stress Disorder.


Defining PTSD

In 1980, after experience with troops returning from the Vietnam War, the American Psychiatric Association defined PTSD and published diagnostic criteria.

Post Traumatic Stress Disorder, or PTSD, is now defined as a mental disorder that can develop after a person is exposed to a traumatic event, causing at least one month of symptoms including a variety of the following:

  • Re-experiencing the trauma
    • flashbacks, bad dreams, frightening thoughts
  • Avoidance symptoms
    • staying away from places, events or objects that are reminders of the trauma
    • feeling emotionally numb
    • feeling strong guilt, depression or worry
    • losing interest in activities that were previously enjoyable
    • difficulty remembering the traumatic event
  • Arousal and reactivity syptoms
    • easily startled
    • feeling tense or “on edge”
    • difficulty sleeping
    • angry outbursts
  • Cognition and mood symptoms
    • trouble remembering key features of the traumatic event
    • negative thoughts about oneself or the world
    • distorted feelings like guilt or blame
    • loss of interest in enjoyable activities

The manner in which PTSD causes these symptoms is not yet understood.  Interestingly, MRI studies have shown decreased volume in key parts of the brain in patients suffering from  PTSD.  The hippocampus is involved in creating new memories and retrieving them in response to relevant stimuli.  The amygdala helps to process emotion and plays a role in fear response.  Both have been found to be smaller in PTSD patients.  These findings have raised the question of whether PTSD causes these brain changes or if those with these differences are more susceptible to PTSD, thus opening the door to research into strategies for prevention and treatment.(3)

Location of the amygdala and hippocampus in the brain / source

Treatment today for PTSD includes cognitive-behavioral therapy, antidepressant medications, or a combination of both.  Many resort to self-medication with drugs and alcohol to dull their crippling symptoms of PTSD, only to battle addiction as well.


The Impact of PTSD Today

In the US, 3.5% adults have PTSD in a given year and approximately 9% will develop it at some point in their life.  Rates are higher in regions of armed conflict.  11-20% of veterans of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffer from PTSD in a given year.  About 12% of Gulf War (Desert Storm) veterans will have PTSD in a given year.  It is estimated that about 30% of Vietnam Veterans have had PTSD in their lifetime.(4)

Combat veterans are more likely to have suicidal thoughts, often associated with PTSD, and are more likely to act on a suicidal plan.  They are less likely to seek the help of a mental health professional for fear of social stigma or “appearing weak.”(5)

Each day, 22 US veterans take their own lives.(6)

There is significant work to be done to fully understand how PTSD works, why it happens and what we needs to be done to prevent it and help these patients.  Public awareness and understanding of PTSD and its effects is vital.   Bravo to the Outlander team for this compelling depiction of PTSD, and in a female veteran no less!

Resources for those suffering from PTSD and those who care for them:

Veterans Crisis Line

Stop Soldier Suicide

Real Warriors Campaign


Questions, comments, concerns, or suggestions for future Outlander medicine topics? I’d love to hear from you! Leave a comment here or find me on twitter @SassenachDoctor.



1.  Scott, WJ.  “PTSD in DSM-III:  A Case in the Politics of Diagnosis and Disease.”  Social Problems.  37 (1990): 294-310.

2.  http://www.pbs.org/perilousfight/psychology/the_mental_toll/

3.  Morey RA, Gold AL, et al.  “Amygdala Volume Changes in Posttraumatic Stress Disorder in a Large Case-Controlled Veterans Group.”  Arch Gen Psychiatry. 2012;69(11):1169-1178.

4.  www.ptsd.va.gov

5.  Sher L, Braquehais MD, Casa M.  “Posttraumatic stress disorder, depression and suicide in veterans.”  Cleveland Clinic Journal of Medicine. 2012. 79(2): 92-97.

6. “Office of Public and Intergovernmental Affairs.” News Releases. VA Office of Public and Intergovernmental Affairs, 1 Feb. 2013. Web. Retrieved from www.va.gov/opa/pressrel/pressrelease.cfm?id=2427.