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Trauma-related symptoms among veterans of military engagement have been documented at least since the time of the ancient Greeks. Since the third edition of the Diagnostic and Statistical Manual in 1980, this condition has been known as posttraumatic stress disorder, but the name has changed repeatedly over the past century, including shell shock, war neurosis, and soldier’s heart. Using over 14 million articles in the digital archives of the New York Times, Associated Press, and Reuters,we quantify historical changes in trauma-related terminology over the past century. These data suggest that posttraumatic stress disorder has historically peaked in public awareness after the end of US military engagements, but denoted by a different name each time—a phenomenon that could impede clinical and scientific progress. Keywords PTSD, history of medicine, disease names, psychiatry, culturonomics, media, New York Times Received 22 November 2017; Accepted 25 February 2018 Interface, we queried 14,138,283 articles published from Introduction 1900 to 2016 for key words in the title, byline, or body of Trauma-related symptoms among veterans of military the article. Our search criteria were as follows: articles engagement have been documented at least since the had to contain at least one military association word time of the ancient Greeks, with modern names includ- (‘‘veteran,’’ ‘‘soldier,’’ ‘‘military,’’ or ‘‘armed forces’’), ing shell shock, battle fatigue, and Post Traumatic Stress as well as a PTSD moniker of interest (selected manually 2,3 Disorder (PTSD). Historically, the experiences of vet- by the authors). To account for the fact that more articles erans have played a major role in shaping our under- are published per year now than in 1900, we focused on standing of trauma-related disorders. In parallel, the percentage of all articles each year that included each clinicians and researchers continue to debate deﬁnitions search term, rather than the absolute number of articles and diagnostic classiﬁcations of trauma-related dis- with that term. All code (github.com/HLoho/NYT- 5,6 orders, which have important implications for patients PTSD) and data (developer.nytimes.com/) from this in terms of diagnosis, treatment, insurance, disability study are available online. Note that 27 trauma-related status, and forensics. terms were queried in total, but only four of the most Mainstream news media oﬀer another lens through common are presented in these analyses (see which we can understand how this debate and accom- Supplementary Material for a full list of terms). panying renaming process has unfolded over time. Therefore, to advance the debate, we set out to quantify historical changes in trauma-related terminology over the Department of Psychiatry, Yale University, New Haven, CT, USA past century from the perspective of mainstream media. Data Science Division, Spring Health, New York City, NY, USA Laureate Institute for Brain Research, Tulsa, OK, USA US Department of Veterans Affairs National Center for PTSD, Methods VA Connecticut Healthcare System, Newington, CT, USA We examined word use in the mainstream media, as Corresponding author: reﬂected by articles in the digital archives of the New Adam M. Chekroud, Department of Psychiatry, Yale University, 300 George York Times, Associated Press, and Reuters. Using the St #901, New Haven, CT 06511, USA. New York Times Developer Application Programming Email: email@example.com Creative Commons CC-BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http:// www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Chronic Stress to talk about their experiences and of the public to listen Results to them. Figure 1 illustrates the ebb and ﬂow of trauma-related syndrome mentions in mainstream media: around the Discussion end of each major war (indicated by dotted vertical lines), a new term for PTSD comes into public conscious- Language changes as understanding changes. PTSD ness and replaces its predecessor. Shell shock gave way to symptoms were termed shell shock in the First World battle fatigue, which gave way to Post Vietnam Syndrome, War because it was thought they were caused by concus- which was ﬁnally overtaken by PTSD. The rate at which sive physical trauma due to shells used in trench warfare. terms then fade into obscurity in the post-war years per- This in turn informed the design of early experimental haps illustrates how quickly the mental health sequelae of studies that showed, for example, that veterans with war are forgotten in mainstream media. shell shock exhibited greater increases in heart and A simple factor that might inﬂuence this phenomenon respiratory rate than healthy controls when exposed to is the percentage of US population in active military gunﬁre or sulfuric ﬂame in laboratory settings (for a duty. With this in mind, Figure 2 shows the percentage review, see Krystal et al. ). During the Second World of articles each year that included a veteran term and a War, studies of irritable heart or soldier’s heart focused PTSD moniker (upper panel), alongside the percentage of on exaggerated arousal responses and sympathetic ner- the US population currently on active duty in the military vous system activity (e.g., Crile, 1940). After the 7–11 (lower panel). After the Vietnam War, the percentage Second World War, the Diagnostic and Statistical of PTSD mentions has broadly increased while the Manual (DSM)-I introduced gross stress reaction in number of active duty personnel decreased (and there is 1952, but omitted the term in the second edition in no signiﬁcant correlation between the two time-series 1968 during the Vietnam War. It is likely that authors overall, r(115)¼0.078, p¼ 0.40). This broad trend of the DSM II never experienced treating battle fatigue toward greater discussion of PTSD may indeed reﬂect and PTSD-like symptoms during the First World War an underlying trend toward increased discussion of and the Korean War, and respected psychiatrists working 12,13 mental illness since the 1950s, and may be explained in Vietnam felt that the mental health issues they encoun- by a generational change in the willingness of veterans tered were encompassed by other diagnoses. However, Figure 1. The ebb and flow of veterans and trauma-related syndrome mentions in mainstream media. Annual percentage of articles mentioning veterans and specific terms for PTSD. Source: Reproduced with permission from New York Times, Reuters, and Associated Press, 1900–2016. Vets*: ‘‘veteran or soldier or Military or armed forces.’’ Chekroud et al. 3 Figure 2. Media discussion of veterans and PTSD* does not simply track US Military population. Overall mentions of veterans and term for PTSD. Source: Reproduced with permission from New York Times, Reuters, and Associated Press, 1900–2016. Vets*: ‘‘veteran or soldier or Military or armed forces’’; PTSD*: any from Figure 1. with publication of the DSM-III in 1980, the idea of nomenclature represents the haphazard attempts of the trauma-related neurosis came back. The introduction of medical community to make sense of the broad range PTSD broadened the phenomena that could account for of war-related physical and psychological symptoms PTSD (including non–war-related factors, e.g., sexual that aﬄict veterans returning home from combat. These abuses), and broadened the phenomenology of the con- symptoms were historically poorly understood and dition to include reexperiencing, numbness/depression, thus poorly classiﬁed. That is why, for example, hyperarousal, and cognitive symptoms. Accumulated the mental and physical symptoms experienced by long- over decades of research, our current knowledge about term prisoners of war in the Second World War were PTSD now recruits genetic, epigenetic, and neuroscienti- never formally recognized or named by the medical com- ﬁc methods to understand fear conditioning, dysregulated munity. That is also why terms such as Vietnam syn- 18,19 circuitry, and memory reconsolidation. drome and battle fatigue may represent more than just the Along with updates in scientiﬁc knowledge, changing symptoms of what we now call PTSD. But even to this cultural and societal factors also inﬂuenced the changing day, the construct of PTSD itself is imperfect and based 3,4 nomenclature of post-war syndromes. A clear example on a consensus of symptoms, a consensus that arguably of this occurred in 1922, when the British government’s does not always move the ﬁeld forward. Thus, this War Oﬃce Committee of Enquiry into ‘‘Shell Shock’’ messy evolution of disease names occurred in the context oﬃcially declared that shell shock was not a valid battle of both scientiﬁc progress and societal evolution. casualty and recommended the term be banned. In light of this history of shifting names, we must be Perhaps the British Government and its citizens wanted careful to avoid losing the accumulated expertise and to forget and move past the pain of the war, either awareness that led to those gains in knowledge. PTSD consciously or subconsciously; regardless, whatever has a history of particularly disjointed research. social factors were in play changed the nomenclature of Promising physiological ﬁndings from the First World post-war syndromes and pushed for shell shock to be for- War and Second World War physicians were abandoned gotten. Of course, this does not mean that the renaming in favor of psychodynamic and behavioral approaches, of post-war syndromes was deliberate. The evolving only to be resumed years later in the 1960s. This 4 Chronic Stress pause in neurobiological research had clear consequences: Acknowledgments placebo-controlled clinical trials of pharmacological We are grateful to one anonymous reviewer for thoughtful and PTSD treatments lagged behind other mental illnesses detailed discussions on this topic. The authors thank Drs. such as depression and schizophrenia. Gregory McCarthy and Monica Rosenberg for their thoughts and feedback on earlier versions of the article. The renaming process could also be detrimental to improving awareness of PTSD, potentially reducing Declaration of Conflicting Interests treatment rates and increasing the overall burden of PTSD. Over time, naming iterations may contribute to The author(s) declared the following potential conﬂicts of lapses in public awareness, making it too easy to forget interest with respect to the research, authorship, and/or pub- lication of this article: A.M. Chekroud holds equity in Spring that veterans have likely suﬀered from PTSD for as long Care Inc., a behavioral health startup. He is lead inventor on as veterans have suﬀered from war. This lack of aware- three patent submissions relating to treatment for major ness could make it easier for governments to hide the depressive disorder [a) USPTO docket number magnitude of the problem in the aftermath of military Y0087.70116US00, b) USPTO. Provisional Appl. No. 62/ engagements, as occurred when the British government 491,660, and c) USPTO. Provisional Appl. No. 62/629,041]. banned the term shell shock. Changing the name of a He has consulted for Fortress Biotech on antidepressant drug disease or censoring its mention entirely could allow the development. M. Paulus is Associate Editor of JAMA public to forget the human cost of war. Psychiatry. He is an advisor to Spring Care, Inc., a behavioral Future investigations incorporating the rich perspec- health startup. He has received royalties for an article about tive of mainstream media publications can help to unpack methamphetamine in Uptodate, and received grant support the complex relationship between this renaming process from Janssen Pharmaceuticals. J.H. Krystal is the editor of Biological Psychiatry. He has been a consultant to the follow- and stigma. For example, it may help us to understand ing companies: Amgen, LLC, AstraZeneca Pharmaceuticals, the process by which clinical deﬁnitions become more Biogen, Biomedisyn Corporation, Forum Pharmaceuticals, well-known and either attract or reduce stigma, eventu- Janssen Pharmaceuticals, Orsuka America Pharmaceutical, ally leading patients to embrace or hide their illness. If Sunovion Pharmaceuticals, Takeda Industries, Taisho patients avoid associating with terms like battle fatigue, Pharmaceutical Co. He is on the Scientiﬁc Advisory Board the terms themselves may lose their speciﬁc meaning over of Biohaven Pharmaceuticals, Blackthorn Therapeutics, time. Other popular forms of media may oﬀer another Lohocla Research Coreportation, Luc Therapeutices, Pﬁzer viewpoint, such as war-related movies that appear some Pharmaceuticals, Spring Care, Inc., TRImaran Pharma. He years after military engagements (e.g., Apocalypse Now, holds stock in ArRETT Neuroscience and Biohaven Platoon, Hamburger Hill, Full Metal Jacket). A multifa- Pharmaceuticals Medical Sciences and stock options in ceted approach, including analyses of semantic content of Blackthorn Therapeutics and Luc Therapeutics. Dr. Krystal has the following patents and inventions: (1) Seibyl JP, these texts, could eventually help understand self-stigma Krystal JH, Charney DS. Dopamine and noradrenergic reup- relating to PTSD, and what interventions can minimize take inhibitors in treatment of schizophrenia. Patent it. #:5,447,948.September 5, 1995. (2) a co-inventor with Dr. Gerard Sanacora on a ﬁled patent application by Yale University related to targeting the glutamatergic system for Conclusion the treatment of neuropsychiatric disorders The way that we name and treat disease has developed (PCTWO06108055A1). (3) Charney D, Krystal JH, Manji tremendously over the past 100 years. With advances in H, Matthew S, Zarate C., - Intranasal Administration of digitized media archives and computational linguistic Ketamine to Treat Depression United States Application analyses, the same can now happen for how we talk No. 14/197,767 ﬁled on March 5, 2014; United States appli- about disease. These data for the ﬁrst time quantify cation or PCT International application No. 14/306,382 ﬁled on June 17, 2014. (4) Arias A, Petrakis I, Krystal JH. – the temporal dynamics—the ebb and ﬂow—of PTSD- Composition and methods to treat addiction. Provisional related terminology in the public eye, through the lens Use Patent Application no.61/973/961. April 2, 2014, ﬁled of mainstream news media since the turn of the 20th cen- by Yale University Oﬃce of Cooperative Research. (5) tury. Historically, discussion of veterans and PTSD has Chekroud, A.,Gueorguieva,R., &Krystal,JH. ‘‘Treatment peaked following US military engagements but gone by a Selection for Major Depressive Disorder’’ [ﬁling date 3rd June diﬀerent name each time. This phenomenon of cultural 2016, USPTO docket number Y0087.70116US00], a provi- forgetting can result in the discontinuity of collective sional patent submission by Yale University. H. Loho reports knowledge from generation to generation and risks no conﬂicts of interest. impeding the scientiﬁc community from reaching a Funding deeper understanding of the disease. Quantifying this phenomenon can help to contextualize ongoing debate The author(s) received no ﬁnancial support for the research, around the name of the disorder. authorship, and/or publication of this article. Chekroud et al. 5 12. Bhugra D, Ventriglio A, Bhui KS. What’s in a name? Supplemental Material Reclaiming mental illness. 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Chronic Stress – SAGE
Published: Apr 16, 2018
Keywords: PTSD; history of medicine; disease names; psychiatry; culturonomics; media; New York Times
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